key: cord- -dwmfayaz authors: saad, neil j. title: the al hol camp in northeast syria: health and humanitarian challenges date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: dwmfayaz nan with the world in the grip of covid- pandemic other emergencies risk drifting to the back of people's minds. one longstanding emergency is the war and conflict in syria, which has claimed at least lives and left an estimated million people in need of humanitarian assistance. in the northwest of the country, in the idlib and northern aleppo governorates, four million people, of which two-thirds are displaced from other parts of syria, are currently in the midst of a humanitarian crisis due to a military campaign by syrian and russian government forces. in the northeast, the plight of many in detention and refugee or internally displaced people (idp) camps appears forgotten. to compound this complex situation further, covid- has now also arrived in syria, including in the northeast. at the time of writing, in syria, cases and deaths have been reported. here, i aim to describe the situation in one of the refugee/ idp camps in northeast syria, the al hol camp, based on my experiences there from may to august as an epidemiologist with médecins sans frontières (msf), to raise awareness about the health and humanitarian situation. the islamic state of iraq and syria (isis) occupied large parts of syria and iraq and terrorised hundreds of thousands of iraqis and syrians living under their occupation. a coalition emerged in september to uproot isis, with kurdish and iraqi forces slowly reclaiming lost territory in a drawn-out war. in march , the last isis enclave, baghouz, was overrun by kurdish troops and the caliphate was declared defeated. during the retreat of isis and after the fall of the caliphate, refugee and idp camps were established across the northeast to shelter those who had recently lived under isis's control or were perceived to be the partners, children and relatives of male isis members. three of these camps, of which the largest is the al hol camp, also contained foreign nationals, including europeans who joined isis. the al hol camp, close to the syria-iraq border, was initially set up by the united nations high commissioner for refugees during the gulf war for approximately people and it expanded further during the us invasion of iraq in the early s. in , the camp hosted roughly iraqi refugees but this grew to approximately , between december and march , largely surpassing the capacity, due to a mass influx of refugees and idp. when i arrived in may , an estimated of the were third-country nationals, defined as neither syrian nor iraqi, and over % were women and children. between december and march , the new arrivals to the camp were transported from the deir al-zour area, which was previously controlled by isis, through a series of security screening points. at the screening points, all men of fighting age, including adolescents above - years, were separated from their families and imprisoned. only, women and children were allowed passage to the camp. generally, newcomers first stay at a reception area and remain there until allocated a shelter and being summary box ► al hol camp is the largest refugee/internally displaced people camp in northeast syria. it currently contains approximately individuals, of which an estimated are foreign non-iraqi nationals. ► the current situation for those living in the camp is untenable due to abhorrent living conditions and restriction on medical care or access to care. ► international humanitarian and human rights law should always be respected in the camp and foreign governments should not forget the plight of their own nationals in the camp. provided with documentation. however, the mass influx resulted in approximately people living in rub halls, large warehouse-style tents meant to store supplies and hundreds living in open air in the reception area, exposed to the cold-barren syrian winter. ultimately, the people living in the reception area and rub halls were allocated a shelter. also, some of the men were released later and allowed to join their families in the camp. currently, the camp is divided into three large parts based on the nationality/ethnicity; one part for iraqis, one part for syrians and one part, fenced off, for thirdcountry nationals, which includes europeans, north americans and central asians. it is controlled by the syrian democratic forces (sdf), an alliance of militia which is dominated by the kurdish people's protection forces, with services provided by several united nations agencies and international non-governmental organisations (ngos), including msf. however, refugee/idp camp is, in reality, a euphemistic term for the al hol camp as severe movement restrictions are imposed and camp residents are not accorded the rights and dignity under international humanitarian and human rights law. the initial health conditions of the people arriving in the camp between december and march were dire. many of them were in need of healthcare; children suffered from malnutrition, people were wounded or suffering from illnesses, such as acute diarrhoea. at least people, mostly children, had died during the long journey on the trucks or on arrival at the camp due to malnutrition and hypothermia as a result of the horrendous conditions and winter temperatures. moreover, the vulnerable state of the people arriving, who had survived without sufficient food or medical care at the frontlines, was exacerbated by the displacement as, during the long journey, security measures were deemed more important than provision of healthcare. this rapid influx of vulnerable people led to a humanitarian crisis, with insufficient food, water, shelter or healthcare available. several months on, during my time there from may to august , camp residents continued to suffer from poor water and sanitary conditions. the minimum emergency standards set by sphere, for water, which are l per person per day, were not met in the camp. many residents had to survive with l of water daily, a third below minimally required, after queuing for hours. moreover, water quality was commonly not suitable for drinking, exacerbating diarrhoea and other waterborne diseases among camp inhabitants. of the nearly consultations in camp health facilities, % were for acute diarrhoea, during the period of may to july . to compound the complex health situation, a measles outbreak and malnutrition crisis plagued the camp. moreover, mental health problems, such as depression, anxiety and post-traumatic stress disorder, due to the conflict, strife and isis occupation were not addressed for the majority of the residents, due to the paucity of mental health services available. access to medical care, particularly in the evenings, was very difficult for camp inhabitants due to the movement restrictions imposed by camp authorities. it was commonplace for women to give birth in their tents and referrals to an outside referral hospital were complicated and sometimes denied, even for urgent medical cases. the annex, the fenced off part of the camp, where third-country nationals (non-syrian and non-iraqi nationals) are confined has worse health and sanitary conditions than the other parts of the camp. the people in the annex are also subject to harsher movement restrictions and more regularly denied access to healthcare by camp authorities, the sdf, due to their perceived isis affiliation. there was no full-time permanent health structure in the annex but healthcare referrals outside of the annex to either health facilities located in other parts of the camp or to the referral hospital were commonly denied. pregnant women in the annex so commonly gave birth in their tents that clean delivery kits were handed out because security services would refuse referrals. inhabitants of the annex were initially given l of water per person per day for both drinking and cleaning purposes, which is a negligible amount. oftentimes the water was not clean, with worms or other debris floating in it. furthermore, the annex is an environment solely composed of women and children (all third-country national men are imprisoned) and yet it lacked a single school or child-friendly space. in an environment with such desolate circumstances, it is difficult to imagine what will become of the camp residents in the future. in the harsh conditions of the al hol camp, international ngos, united nations agencies and local authorities worked towards improving people's living conditions and supporting their basic needs. the turkish military operation in the northeast syria in october forced several ngos to evacuate their international staff and halt the majority of activities due to the volatility and uncertainty of the situation. since december , health actors have slowly returned to the al hol camp with some healthcare provision and essential services resuming in the camp. however, in january , the united nations security council decided to reduce the international border crossings in opposition-controlled territory, used for the delivery of humanitarian aid, from four to two, which further complicates humanitarian assistance. this precarious context is now further disrupted by covid- . medical services remain scarce and facilities are insufficiently equipped; for example the kurdish authorities only have ventilators for the entire northeast syria. bmj global health conclusion nine years on in the syria conflict, the humanitarian crisis will only worsen further due the covid- pandemic. particularly problematic is the restriction on medical care and access to care for people within the al hol camp based on their perceived isis affiliation, which is unjust and immoral. no person should be denied essential and potentially life-saving care, regardless of their background, nationality, religion or perceived affiliation. while countries decide on the appropriate long-term answer, international humanitarian and human rights law should always be respected. countries, including european ones, should take responsibility for their nationals in these camps rather than simply refusing to repatriate them. as long as national governments continue to grapple with the situation in the al hol camp and some governments attempt to forget the plight of their nationals, people will continue to suffer and struggle for dignity and survival. united nations office for the coordination of humanitarian affairs. humanitarian update syrian arab republic syrian revolution nine years on: , persons killed and millions of syrians displaced and injured united nations office for the coordination of humanitarian affairs. syrian arab republic-recent developments in nortwest syria-flash united nations office for the coordination of humanitarian affairs. syrian arab republic: covid- humanitarian update no international crisis group. fighting isis: the road to and beyond raqqa joint statement on behalf of the global coalition to defeat isis on the first anniversary of isis's territorial defeat united nations office for the coordination of humanitarian affairs security checks delaying urgent healthcare for syrians fleeing islamic state: un official united nations office for the coordination of humanitarian affairs. syria: humanitarian response in the women and children continue to suffer in northeast syria's al hol camp unicef-supported facilitators work around the clock to provide lifesaving assistance in al-hol camp syria: dire conditions for isis suspects' families al hol camp at 'breaking point' as , women and children arrive in hours paulo sérgio pinheiro, chair of the independent international commission of inquiry on the syrian arab republic at the st session of the un human rights council the sphere handbook -humanitarian charter and minimum standards in humanitarian response united nations office for the coordination of humanitarian affairs. syria: humanitarian response in the world health organization. health sector bulletin united nations security council resolution who warns of pandemic's 'catastrophic impact' on syria virus fears spread at camps for isis families in syria's north east syria confirms first covid- case amid fears of catastrophic spread international crisis group. women and children first: repatriating the westerners affiliated with isis acknowledgements i acknowledge support from the german research key: cord- -opvs ejd authors: masiira, ben; antara, simon n; kazoora, herbert b; namusisi, olivia; gombe, notion t; magazani, alain n; nguku, patrick m; kazambu, ditu; gitta, sheba n; kihembo, christine; sawadogo, bernard; bogale, tatek a; ohuabunwo, chima; nsubuga, peter; tshimanga, mufuta title: building a new platform to support public health emergency response in africa: the afenet corps of disease detectives, – date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: opvs ejd public health emergency (phe) response in sub-saharan africa is constrained by inadequate skilled public health workforce and underfunding. since , the african field epidemiology network (afenet) has been supporting field epidemiology capacity development and innovative strategies are required to use this workforce. in , afenet launched a continental rapid response team: the afenet corps of disease detectives (acodd). acodd comprises field epidemiology graduates and residents and was established to support phe response. since , afenet has deployed the acodd to support response to several phes. the main challenges faced during acodd deployments were financing of operations, acodd safety and security, resistance to interventions and distrust of the responders by some communities. our experience during these deployments showed that it was feasible to mobilise and deploy acodd within hours. however, the sustainability of deployments will depend on establishing strong linkages with the employers of acodd members. phes are effectively controlled when there is a fast deployment and strong linkages between the stakeholders. there are ongoing efforts to strengthen phe preparedness and response in sub-saharan africa. acodd members are a competent workforce that can effectively augment phe response. acodd teams mentored front-line health workers and community health workers who are critical in phe response. public health emergence response in sub-saharan africa is constrained by inadequacies in a skilled workforce and underfunding. acodd can be utilised to overcome the challenges of accessing a skilled public health workforce. to improve health security in sub-saharan africa, more financing of phe response is needed. the risk that infectious agents will continue to kill humans in the st century is highest in africa. according to the who, africa experiences more than disease outbreaks and other health emergencies annually. from the beginning of , african countries have been facing one of the greatest challenges: the covid- pandemic. the covid- pandemic started in china in december and rapidly spread across the globe. such public health emergencies (phes) expose the fragility of emergency response systems in africa. for example, the ebola virus disease (evd) epidemic in west africa claimed > lives and cost billions of us dollars in socioeconomic losses. for an effective phe response, the global health security agenda recommends countries to have at least one field epidemiologist (trained at the advanced or intermediate levels) per population. other authors have suggested a coverage three to five field epidemiologists per million population. however, data at the african field epidemiology network (afenet) show that the sub-saharan region summary box ► innovative strategies can be applied to leverage the inadequate public health workforce to address public health challenges including emergencies. ► acodd was established to support ministries of health to overcome the challenges of rapidly mobilising and deploying adequate and skilled public health workforce. ► public health emergency response in sub-saharan africa is still constrained by underfunding. ► it is feasible to mobilise and deploy acodd member within hours to support ministries of health to respond to emergencies. ► lack of effective community engagement can result into violence against the rapid responders. ► psychosocial support can be a game changer in addressing difficult situations faced by rapid responders such as distrust. has only % of the required number of field epidemiologists. afenet was established in to support field epidemiology workforce development in sub-saharan africa. during the ministerial round acodd's organisational structure is summarised in figure . there are three levels of acodd management; the afenet secretariat, regional and country levels. at the afenet secretariat, the head of afenet (who reports to the afenet board of directors) provides overall strategic leadership, the head of programmes provides overall technical leadership and the acodd focal person (fp) coordinates operations across the network. at regional level, acodd operations are led by the afenet regional technical coordinator (rtc). at country level, the acodd operations are led by the country fp who is the fetp resident advisor. details of the acodd management team responsibilities are summarised in table . acodd has supported response to several emergencies including disease outbreaks, mass gathering event-based surveillance, polio surveillance and natural disasters such as cyclone idai in the southern africa region. outlined below are the key disease outbreaks where acodd members were deployed. the ninth ebola virus disease outbreak in the democratic republic of the congo, may-july soon after acodd was launched, afenet received a request from the drc ministry of health to support the response to the evd outbreak in Équateur province. this evd outbreak had been declared on may . between may and july , afenet, in collaboration with the us centres for disease control and prevention (cdc), deployed a team of acodd members to support the national rrt contributing a total of person-days of deployment. acodd members investigated alerts of which were confirmed with evd, identified contacts of which were followed up, mentored front-line health workers and conducted a total of community sensitisation sessions. other acodd members were involved in screening of passengers at five priority points of entry (poes) and points of control (pocs) to identify suspected cases of evd surveillance. the acodd conducted data analysis and compiled and presented daily updates that helped inform the outbreak response strategies. this outbreak was quickly contained and the minister of health announced its end on july . the outbreak had a total of evd cases of which were confirmed, were probable, died (case fatality ratio: %). of the cases, occurred in bikoro health zone, occurred in iboko health zone and occurred in wangata health zone. as part of the mohcc rrt, acodd teams investigated cholera cases, identified cases through active cholera case search and participated in outbreak data analysis. acodd members with clinical background supported case management teams at health facilities and assessed compliance to treatment protocols by case management teams. a team of acodd participated in conducting risk communication, community a total of acodd members were deployed in rotations for days contributing a total of person-days. once in the field, acodd members had a meeting with the field incident commander and the district health leadership to get an understanding of the outbreak and to finalise the terms of reference. acodd teams investigated alerts none of which was confirmed with evd and listed contacts of which ( %) were followed up and tested negative after completing the follow-up period. the acodd reviewed medical records at health facilities to identify suspected evd cases and out of these records nine suspected cases were identified and all tested negative for evd. in addition, the acodd screened travellers at poes, participated in community-based and event-based surveillance, community sensitisation, psychosocial support and data analysis. the response team initially found surveillance and contact tracing difficult due to community mistrust and false information. for example, there was information that suspected patients with ebola admitted to the etu and their contacts are killed by a 'lethal injection' in order to prevent further transmission of evd. these rumours made one of the high-risk contacts to go into hiding. when the high-risk contact was traced in one of the remote locations, he rejected ebola vaccination despite several visits by the teams. however, after days of counselling by the psychosocial team, the high-risk contact eventually accepted evd vaccination. because of the community mistrust and misinformation, the rrt adopted a community-led surveillance and contact tracing strategy. under this approach, community health workers known as village health teams (vhts) were trained. the vhts conducted contact tracing under the close supervision from the contact tracing teams. during field activities, acodd teams mentored health workers and vhts. this evd outbreak involved three confirmed cases, all of whom died (case fatality ratio, cfr: %) and all had an epidemiological link to a confirmed case who died in drc. many of the acodd teams faced community resistance and constant security challenges, amidst the increase in the spread of the outbreak, which had a negative impact on the response. on july , who declared this outbreak as a public health emergency of international concern. afenet received grants from the us cdc and the world bank to enhance response efforts. these funds were used to implement surveillance training to enhance ebola response and readiness (steer) for the front-line health workers, community health workers and acodd deployment. steer focused on building the capacity in evd surveillance, ipc and risk communication. a total of health workers and community health workers in evd affected health areas were trained. by december , the rrts were starting to register success with new evd cases reported during the week of november to december compared with cases during the week of - september . by march , there was no new confirmed evd case since february , and a total of evd cases had been reported of which were confirmed cases, probable cases and cases had died (case fatality ratio of %). as of march , there were signs that the epidemic had been contained with the last cases all reported from a small geographical area within beni health zone. acodd response to the covid- pandemic as soon as the chinese government declared the covid- outbreak, countries on the african continent activated their emergency preparedness and response mechanisms. by january , who declared the pandemic a phe of global emergency of international concern. in early february , the acodd fps started working with afenet to mobilise acodd members to be on stand-by to support ministries of health and technical bmj global health agencies/networks such as the who, us cdc, global outbreak alert and response network and africa cdc. acodd teams across afenet member countries supported various activities including ( ) coordination and planning, ( ) development of the national response plans, ( ) adapting the who covid- case definition to country contexts, ( ) investigation of suspected cases, ( ) poe screening, ( ) contact tracing, ( ) training of rrts and screeners at poes, ( ) risk communication and ( ) supporting the development of protocols and standard operating procedures (sops). afenet supported africa cdc to recruit acodd epidemiologists to strengthen covid- capabilities among african countries. these volunteers supported coordination and planning, building capacities for surveillance, laboratory, ipc and case management, policy development and provided technical support to public health emergency operation centres to develop incident action plans and sops. acodd teams faced four key challenges during deployment and these are highlighted below. the bulk of afenet operations are supported by the us cdc and the united states agency for international development. between august and march , afenet received requests for acodd support from member countries of which ( %) were funded. acodd deployments were largely supported using the funds generated from indirect project costs while some deployments received direct support from the us cdc. although afenet uses a cost-effective model for acodd deployment, available funding has been insufficient to meet the growing demand for acodd support. a more sustainable strategy for funding of phe response should be led by the african governments. however, investigations have shown that the majority of countries in africa allocate below % of their total budget to the health sector. availability of acodd for deployment because majority of acodd are not employed by afenet, their availability to support phe response depends on their release by employers. during deployments, some of the acodd members could only serve a short duration in the field which presented a challenge of recruiting and orientation of new volunteers. although afenet has been able to mobilise adequate numbers of acodd members during emergencies, mobilisation is anticipated to be difficult in large-scale phes which require a bigger workforce. the safety of rrts is one of the critical elements for an effective response. overall, acodd and other responders operated in a safe and secure environment in most of the deployments. however, the response to the evd outbreak in drc was substantially hampered by insecurity. acodd teams in insecure areas always operated in constant fear of being attacked by the armed groups. on april , a doctor who was deployed by who was brutally murdered at the butembo university hospital. on the night of november , armed rebel forces attacked a camp at biakato mines and killed four health workers. the deteriorating security situation led to the evacuation of several rrt members, including acodd members, to goma city on december . resistance to interventions and distrust of the responders although the acodd participated in community sensitisation during the tenth evd outbreak in drc and the sixth evd outbreak in uganda, community resistance and distrust remained a key challenge. in both outbreaks, lack of trust was primarily driven by false information, misperceptions and ignorance about control strategies. whereas in uganda the distrust was easily controlled through community engagement, the responders in drc faced a more complex situation. a mob attacked one of the etus in drc resulting into patients and caregivers fleeing and one of the caregivers was killed. activities such as identification of new cases and safe, dignified burials were dangerous to implement in some areas because of violence from the residents. community resistance and distrust was also documented during the response to the west africa evd outbreak. lessons learned although fetps started over two decades ago in sub-saharan africa, the region is still faced with a scarcity of field epidemiologists. during acodd launch, the participants were engaged in discussions about the anticipated challenges related to acodd deployment. the key anticipated challenges elicited from participants included difficulty in mobilising adequate numbers of acodd members, lack of interest in responding to outbreaks due to highly infectious pathogens such as evd, and delays or non-release of the acodd members by their employers. our experience showed that its feasible to mobilise and deploy adequate numbers of acodd members within hours after receiving requests from ministries of health. many acodd members felt motivated to participate in rapid response within their countries and beyond. the acodd members employed within government ministries were easily released compared with those in the private health sector. all acodd deployments were approved and effected by the ministries of health. before field deployment, predeployment briefings were conducted with a special focus on discussing the terms of reference. acodd members were integrated into the national rrt and their daily operations were under the direct supervision of ministries of health. although the deployments were largely successful, sustainability will rely on establishing strong linkages with organisations that employ the acodd members. afenet is continuously sensitising and engaging the organisations that employ the acodd members to ensure that they release them during emergencies. the final key lesson learnt was that phes were effectively controlled when the responders were rapidly deployed and when there was strong collaboration between the key stakeholders. an analysis of the evd outbreak in west africa showed that a well-coordinated faster response would have halted the propagation of the outbreak. opportunities considerable efforts are ongoing in the sub-saharan africa region to strengthen preparedness and response to phes. from its founding in afenet, in collaboration with the us cdc, universities and other technical partners, has been contributing to health systems strengthening. acodd members are a skilled workforce that can be utilised to support emergency response. the afenet cost-effective strategy for acodd deployment is centred on in-country field epidemiologists; with recruitment from other countries only done once the in-country acodd have been exhausted. the recruitment strategy provides an added advantage in that the acodd members are well versed with the country context and can easily communicate to the target populations as opposed to recruiting external acodd members. during deployments, acodd teams interacted, worked with and learnt from other experienced responders. furthermore, in areas where the acodd members were deployed, they were involved in mentoring the front-line health workers and community health workers. effective public health preparedness and response in sub-saharan africa is constrained by inadequate skilled human resources and underfunding. the acodd platform is afenet's innovative strategy to deploy the existing field epidemiology workforce to support phe response. experience from these deployments has shown that the acodd can be rapidly mobilised and deployed to the field. the contributions of the acodd since its establishment is a clear demonstration of leveraging the existing workforce to solve the complex public health challenges that threaten health security in sub-saharan africa. the deficiencies in financing the health sector in sub-saharan africa emphasise the need for african governments to devote more financial support and resources for phe response. african field epidemiology network, kampala, uganda global public health solutions, atlanta, georgia, usa african field epidemiology network, harare, zimbabwe twitter notion t gombe @gombent contributors bm participated in conception of the manuscript, supervision of acodd deployments, synthesis of field experiences and writing all the drafts of the manuscript. sa participated in conception of the study, supervision of deployments, writing and reviewing of the manuscript and approval of the manuscript. hbk participated in conception and supported manuscript writing at all stages. on wrote the field experiences from the uganda acodd deployment and participated in reviewing and writing of the manuscript at all stages. ntg wrote the field experiences from zimbabwe, supervised acodd deployment and participated in writing of the manuscript at all stages. anm wrote the field experiences from drc acodd deployments and participated in writing of the manuscript at all stages. pmn participated in writing and reviewing of the manuscript at all stages. dk wrote supervised acodd deployment in drc and participated in writing of the manuscript at all stages. sng, ck, bs and atb participated in writing and reviewing of the manuscript at all stages. co participated in conception of the study, supervision deployments and reviewing of the manuscript. pn participated in study conception, writing and reviewing of the manuscript at all stages. mt participated in conception of the study, supervision deployments, writing and reviewing of the manuscript and gave final approval of the manuscript. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests none declared. patient consent for publication not required. provenance and peer review not commissioned; externally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. ben masiira http:// orcid. org/ - - - x emerging infectious diseases in africa in the st century world health organization. who health emergencies programme in the african region: annual report available: http:// apps. who. int/ ebola/ current-situation/ ebola-situation-report the economic and social burden of the ebola outbreak in west africa global health security agenda: ghsa workforce development action package (ghsa action package detect- ) strengthening public health surveillance and response using the health systems strengthening agenda in developing countries afenet. ministerial resolutions on african field epidemiology network (afenet) democratic republic of congo: ebola virus disease -external situation report ebola virus disease democratic republic of congo: external situation report / democratic republic of the congo. external situation report promoting equitable health care financing in the african context: current challenges and future prospects world health organization. state of health financing in the african region responder killed in attack on the butembo hospital armed groups kill ebola health workers in eastern dr congo msf suspends congo ebola effort after deadly clinic attacks an epidemic of suspicion -ebola and violence in the drc social and cultural factors behind community resistance during an ebola outbreak in a village of the guinean forest region the health impact of the - ebola outbreak field epidemiology training programmes in africa -where are the graduates? post-ebola reforms: ample analysis, inadequate action key: cord- - vetk jd authors: shayo, elizabeth; van hout, marie claire; birungi, josephine; garrib, anupam; kivuyo, sokoine; mfinanga, sayoki; nyrienda, moffat j; namakoola, ivan; okebe, joseph; ramaiya, kaushik; bachmann, max oscar; cullen, walter; lazarus, jeffrey; gill, geoff; shiri, tinevimbo; bukenya, dominic; snell, hazel; nanfuka, mastula; cuevas, luis e; shimwela, meshack; mutungi, gerald; musinguzi, joshua; mghamba, janneth; mugisha, kenneth; jaffar, shabbar; smith, peter g; sewankambo, nelson kaulukusi title: ethical issues in intervention studies on the prevention and management of diabetes and hypertension in sub-saharan africa date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: vetk jd nan the incidence of diabetes and hypertension has risen sharply in sub-saharan africa alongside a continuing high burden of hiv infection. in many settings, the prevalence figures among adults are %- % for diabetes, above % for hypertension and %- % for hiv infection. [ ] [ ] [ ] all these conditions require lifelong treatment, and they have increased substantially the demand for chronic care services in africa, where health systems have, until recently, focused on tackling acute infectious diseases. there is considerable inequity in service provision for chronic diseases. hiv services, including antiretroviral therapy, are available widely for free and are organised typically in stand-alone clinics. over % of people estimated to be living with hiv infection are in regular care. in contrast, this figure is only about %- % for people living with diabetes or hypertension. a major challenge is that medicines for diabetes and hypertension are generally not provided free of charge and have to be purchased by patients. even in those countries that do provide free medicines for hypertension and diabetes, shortages are common and patients then have to purchase the medicines from private suppliers. our research collaboration is evaluating a biomedical diabetes preventive intervention in people living with hiv infection in a placebocontrolled randomised trial and, separately, evaluating integrated healthcare provision compared with standard care for people living with hiv, diabetes or hypertension in a clusterrandomised controlled trial. there are no data on the effectiveness of these approaches from africa. therefore, these trials have clinical and health economic endpoints and the research is underpinned by an implementation research approach, which, for example, requires strong engagement with health policy makers . [ ] [ ] [ ] [ ] we discuss the implications of a limited supply of medicines and potential solutions to track the equity of medicine supply. in particular, we consider what should the ethical approach be for a research programme in terms of provision of a steady and sustainable supply of medicines for patients with diabetes and hypertension when alternative affordable and accessible supplies are unavailable? possible solutions and lessons from other contexts should the research be conducted in realworld conditions where medicines supply for hypertension and diabetes is patchy? if we conduct the research within the context of real-world conditions, then, under the ► conducting intervention studies in africa, where medicines supply for chronic conditions is inequitable and patchy, raises major ethical issues. ► here we discuss what should the ethical approach be for a research programme in terms of provision of a steady and sustainable supply of medicines for patients with diabetes and hypertension. integrated care model that we are testing, patients with different conditions would sit together in the same clinic and have consultations with the same healthcare providers. it will be morally challenging for clinical staff and researchers to turn away one group of patients because of a lack of medicines while for others, with hiv infection, treatment is available freely. in the past, in the vertical stand-alone models of care, the ethical dilemma was less stark because hiv and diabetes/hypertension clinics operated at different locations, sometimes on different days and involved different clinicians. as well as the issue of inequity, observing people living with diabetes and hypertension unable to access medicines, which are both low-cost and effective, could break the ethical principle of beneficence, which states that researchers should have the welfare of the participants as a goal. also, if the research is conducted to real-world conditions, it may be of limited relevance by the time it is completed. this is because the provision of medicines for chronic disease management in africa is likely to increase in the next few years with the increased pressure that is now on donors and governments to support these treatment programmes. if drug shortages decrease, then the findings of our research programme, which would be available in a few years' time, would be of very limited relevance when they are published. thus, in our view, there are both moral and scientific reasons for ensuring patients entering such intervention studies have access to uninterrupted supplies of medicines for the duration of the research. should the research programme purchase the medicines for participants to enable the research to run smoothly? if the study identifies a model of care that is costeffective, it could give impetus to government health services to strengthen their medicine supply chains. on the contrary, by carrying the cost that should be met by governments and donors, it could potentially reduce the pressure on health authorities to find solutions, weaken the advocacy for patients' rights and inhibit the public from demanding their rights to access treatments. advocacy for the right to access antiretroviral therapy was crucial in hiv control in africa and will likely play a major role in enhancing access to medicines for diabetes and hypertension. if the research programme provides the medicines for study participants, it would not be sustainable beyond the duration of the research programme and would mean that patients who access treatment services today may have to stop taking their medicines when the study finishes. while the study is running, provision of free drugs would be a strong incentive for participants to join the study. patients will have the right to decline and to receive the care they would otherwise have received, but if this means a less reliable supply of medicines (than in the research programme), then patients are very likely to join the research. the issue is whether or not this is undue coercion. in our view, the ideal situation here is that access to medicines is strengthened for all, ideally by ministries of health. for this to happen, researchers must work in partnership with policy makers and disease control managers, that is, policy makers and disease control managers must have ownership of the research. researchers should be prepared to purchase medicines for short-term use to cover any gaps that might occur. where ministries of health cannot achieve a reliable supply, even with the support of research programmes, then research in those settings may not be feasible. is there an obligation to provide medicines to non-trial participants? another ethical dilemma arises because the research programme will include only a fraction of all the patients with the target conditions attending the clinics and patients not in the research studies will not have access to any enhanced treatment. although the costs of treatment for diabetes and hypertension are relatively low, it is most unlikely that a research programme could bear the costs of treating large numbers of non-study participants and a requirement to do so would make the research nonviable. not providing medicines to non-study participants will cause inequity between patients in the trial and those who are not. it could compromise outcomes if participants share their medicines to spread the benefits, for example, with relatives with chronic conditions not in the study. it may also endanger community support for the study if this sends the message that we do not care about family members. there is no precedence with provision of drugs to large numbers of non-study participants. when combination antiretroviral therapy for hiv was introduced in high-income countries, it was not available in public health clinics in africa because of its high cost. research in africa at that time will have faced similar dilemmas but wide-scale provision only occurred more recently. at that time, there were also some calls that the standards in clinical trials around treatment and access to medicines should be the same in africa as in high-income countries. however, the standardisation would have inhibited hiv research in africa and was opposed by global health researchers. this enabled the research to be conducted quickly and at relatively low cost, and research on the prevention and management of diabetes and hypertension may need similar considerations. thus, although not ideal, priority of medicines for research subjects will be essential in some settings where the supply of medicines cannot be strengthened for all. should the health facilities be encouraged to procure a greater supply of medicines to facilitate the research? in some circumstances, health facilities might be able to procure a greater supply of medicines to facilitate the bmj global health research. in countries such as tanzania and uganda, under district fiscal decentralised systems, health facilities have flexibility in how they spend their resources. however, if the supply of medicines for diabetes and hypertension was augmented in this way, this could be at the expense of service provision for other conditions, raising further ethical concerns. moreover, there are clear ethical issues if health facilities procure medicines to support a research programme without ensuring that this supply will be maintained after the study. the ideal solution here is that health facilities are supported to strengthen all medicines supply, not just for diabetes and hypertension. research to inform strategies for the prevention and management of diabetes and hypertension is vital in africa. however, such research raises complex ethical issues relating to the limited supply of medicines and a pragmatic approach specific to the african context is needed. it is clear that the research would likely produce meaningless results if the supply of medicines was erratic, but equally, the research programme cannot just purchase the necessary drugs for its trial participants. a solution to this conundrum has to be through discussion and working in partnership with the key stakeholders: the policy makers, disease control managers, healthcare providers, patient groups and community representatives. indeed, a fundamental ethical requirement is meaningful engagement with the key stakeholders. similar issues arose in the early years of research on hiv treatment in africa when antiretroviral therapy was prohibitively expensive and not available widely. the research that was conducted in these situations precipitated later pressure on the international community to ensure that life-saving medicines were made freely available to people living with hiv. hiv care and prevention would not have reached its current level without overcoming the initial obstacles to research on treatment. there is a pressing need to take on board the lessons from the progress made with hiv control to develop and expand research on diabetes and hypertension control. we have used our studies on three specific diseases-hiv infection, diabetes and hypertension-to highlight the ethical dilemmas, but the ethical challenges are likely to be common to other diseases. global, regional, and national age-sex specific mortality for causes of death, - : a systematic analysis for the global burden of disease study unaids. global hiv and aids statistics diabetes in sub-saharan africa: from clinical care to health policy world health organisation. global health observatory data: raised blood pressure redesigning primary care to tackle the global epidemic of noncommunicable disease world health organisation. global health observatory data. antiretroviral therapy coverage among all age groups hypertension in sub-saharan africa: a systematic review integrated care for human immunodeficiency virus, diabetes and hypertension in africa developing the ethics of implementation research in health implementation research: what it is and how to do it implementation research: new imperatives and opportunities in global health world health organisation. ethical considerations for health policy and systems research. geneva: world health organization the history of aids exceptionalism the ethics of clinical research in the third world ethics of hiv trials provenance and peer review not commissioned; externally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. marie claire van hout http:// orcid. org/ - - - max oscar bachmann http:// orcid. org/ - - - jeffrey lazarus http:// orcid. org/ - - - luis e cuevas http:// orcid. org/ - - - shabbar jaffar http:// orcid. org/ - - - contributors es, ag, jb and sj wrote the first draft. mcvh made substantial contributions following the review by the journal. all the authors contributed to many iterations.disclaimer the views expressed in this publication are those of the author(s) and not necessarily those of the nihr or the uk department of health and social care or the european union.competing interests none declared.patient consent for publication not required. key: cord- -rw keyos authors: tao, wenjuan; zeng, zhi; dang, haixia; lu, bingqing; chuong, linh; yue, dahai; wen, jin; zhao, rui; li, weimin; kominski, gerald f title: towards universal health coverage: lessons from years of healthcare reform in china date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: rw keyos universal health coverage (uhc) is driving the global health agenda. many countries have embarked on national policy reforms towards this goal, including china. in , the chinese government launched a new round of healthcare reform towards uhc, aiming to provide universal coverage of basic healthcare by the end of . the year of marks the th anniversary of china’s most recent healthcare reform. sharing china’s experience is especially timely for other countries pursuing reforms to achieve uhc. this study describes the social, economic and health context in china, and then reviews the overall progress of healthcare reform ( to present), with a focus on the most recent ( ) round of healthcare reform. the study comprehensively analyses key reform initiatives and major achievements according to four aspects: health insurance system, drug supply and security system, medical service system and public health service system. lessons learnt from china may have important implications for other nations, including continued political support, increased health financing and a strong primary healthcare system as basis. universal health coverage (uhc) is driving the global health agenda and is now an ambition for many nations at all stages of development. uhc is a means for achieving improved equity, health, financial well-being and economic development, ensuring that everyone has access to quality, affordable health services when needed. most countries have made uhc a key global health objective through the united nations' resolution, and move towards uhc following the sustainable development goals (sdg) set in . at the beginning of the st century, the push for uhc seems stronger than ever. the new who director general, dr tedros, emphasised that uhc is the 'top strategic priority' in the road map for who's renewal. accordingly, who's general program of work for - has set an ambitious goal of benefiting more than billion people from uhc by . who states that there is 'no one size to fit all'-there are different ways to attain uhc. an increasing number of low and middle-income countries (lmic) are actively pursuing policies to achieve uhc and share their implementation experience from different political settings, such as turkey, indonesia, thailand and bangladesh. according to the world bank report, the march to uhc in china is unparalleled. also, yip et al commented that 'china's reform goals and systemic strategies are exemplary for other nations that pursue uhc.' in early , the chinese government launched a new round of health system reform with the goal of providing affordable and equitable basic healthcare for all by , which is in line with the basic concept of uhc defined by who. this year marks the th anniversary of china's most recent healthcare reform. evidence from china is especially timely for countries pursuing uhc. however, much of the early research focused solely on the first -year reform after in china, summary box ► continued political support is the most important enabling condition for achieving universal health coverage (uhc). china has shown clear political willingness to make uhc achievement a more countryled process. ► increasing health financing is necessary, and the investment from both government and private sector is considered. ► a strong primary healthcare system should be regarded as a core component in realising uhc. the chinese government has made primary healthcare a priority in its 'healthy china ' strategy. ► some lessons providing reform experiences for other countries include the pilot reform and systematic reform strategy. without addressing the issue of the reform evolution and progress during the past decade. there is inadequate understanding of how china moves towards uhc step by step. we undertook a literature review, and analysed policies and secondary data from governmental sources. we aim to share the complete experience and strategy about china's healthcare reform, and provide the critical lessons for other nations, especially for lmics. the people's republic of china (prc) covers approximately . million km , and is now the most populous country in the world with . billion people. the urban population accounts for . % of the total population. prc was founded on october . at the time, china had one of the world's poorest healthcare delivery systems due to an economy weakened by war. today, china is an upper middle-income country whose gross domestic product has grown substantially at an average annual rate of . % over the past years, and has lifted more than million people out of poverty. with the rapid economic growth, china has made great efforts to achieve uhc. for example, china has devoted increased public funding to health-the largest increase among brazil, russia, india, china and south africa countries. china has almost achieved all of the millennium development goals (mdg) by , making a major contribution to the achievement of the mdgs globally, and is now moving towards sdgs to achieve uhc by . table illustrates a summary of key socioeconomic and health indicators in the country from to , as well as the comparable data in the other emerging (e ) countries (india, brazil, mexico, russia, indonesia and turkey) in . china has experienced remarkable improvements in economic conditions, human development and health outcomes, such as life expectancy and mortality. compared with other e countries, china is at a relatively good level in both its economy and population health. since the founding of the prc in , china has experienced dramatic changes in its healthcare system. like many other countries, china's healthcare reform has also undergone a difficult exploratory process. therefore, it is necessary to briefly review the progress of reform of the healthcare system over the past years. we divide the progress of china's healthcare reform into three stages. stage : years after the founding of people's republic of china ( china ( - at the founding of prc, with a weak foundation, the state developed a centrally planned socialist system, emphasising public ownership and welfare, mass-based collectivism and egalitarianism. in the health sector, the government managed a centrally directed health delivery system, and defined four principles to guide health and medical work: ( ) serve the workers, peasants and soldiers; ( ) put prevention first, in particular through the patriotic health campaigns; ( ) integrate traditional chinese medicine with western medicine; and ( ) combine health work with mass movements. these principles of healthcare delivery reform contributed to rapid improvement in the health of the population, creating some reform models (eg, 'barefoot doctors', 'cooperative medical system' and 'threetier health service delivery system') that were highly valued by the who. during this period, despite a shortage of healthcare resources, china's healthcare bmj global health system achieved almost universal access to healthcare and preventive services, producing impressive health gainsfor example, dramatically increased life expectancy and decreased infant mortality. stage : years after the 'reform and opening up' policy beginning in , china began its 'reform and opening-up' policy, ushering in a socialist market economy that encouraged a free market and focused on economic growth. this led to a fundamental transformation of the chinese healthcare system and had a profound impact. with privatisation and marketisation, the changes in the healthcare system included: a shift from public financing to private sources; a reorganisation of public hospitals and clinics into commercial enterprises; decentralising healthcare governance to local governments; and a pricing policy that enabled facilities to gain profits. these changes helped expand healthcare resources and improve medical technology and equipment, but also posed many problems (eg, reduced government expenditure on healthcare, less emphasis on rural areas and public health, and overutilisation of unnecessary or expensive care), - resulting in a series of adverse effects, such as increased disparities between rural and urban residents, a decline in public health, rising healthcare costs and sharp decreases in insurance coverage. in , the severe acute respiratory syndrome epidemic revealed weaknesses in china's health system and focused a domestic and international spotlight on those weaknesses. this wake-up call opened a window of opportunity for a new round of healthcare reform. it is an unprecedented health system transformation towards uhc, aiming to provide universal coverage of basic healthcare by the end of . following extensive interagency consultation and public debates, this launch emphasised a return to government-led, people-centred healthcare and healthcare as a public good. the latest round of healthcare reform adopted the 'best fit' with the existing institutional and policy frameworks towards achieving uhc by an incremental approach (step by step), which was recommended by the who team. the 'opinions on deepening the health care system reform' that were promulgated by the central committee of the communist party of china (cpc) and the state council marked the start of china's new healthcare reform. the comprehensive reform plan can be summarised as 'one goal, four beams, and eight columns' (figure ). under the goal of achieving uhc, china concentrated on establishing the four systems (ie, public health service system, medical service system, health insurance system, and drug supply and security system), based on the eight functional mechanisms that could provide essential supports. accordingly, three sequential phases of healthcare reform plans were to be carried out to achieve the overall goal by : the - phase, the - phase and the - phase (figure ). bmj global health the - phase the first -year reform plan laid a foundation for the goal. there were five reform priorities: ( ) accelerating the establishment of a basic health insurance system; ( ) establishing a preliminary national essential drug system; ( ) improving the primary care delivery system to provide basic healthcare; ( ) making basic public health services (bphs) available and equal for all; and ( ) piloting public hospital reforms. reforms during this first phase focused on strengthening primary care. this phase of reform obtained positive evaluations and was confirmed to be heading in the right direction by who and others. the - phase the second phase of healthcare reform, china's ' th five-year plan', continued in the same general direction. the reforms were promoted and deepened during this period, and clarified three tasks: ( ) basic health insurance for all; ( ) consolidation and improvement of the essential drug system; and ( ) reform of public hospitals. the focus of reform gradually shifted from primary care to the public hospitals, especially county public hospitals. the county public hospitals lead the reform of public hospitals through subsidising medical services with profit from drug sales, and comprehensively promoting the reform of the management system, compensation mechanism, personnel distribution, procurement mechanism and price mechanism. the - phase following the reform tasks specified at the third plenary session of the th central committee of the cpc in , the ' th five-year plan on deepening the health care system reform' marked the beginning of the third phase, a comprehensive drive for deeper reform. the reform of this phase focuses on the transitions from: ( ) laying a solid foundation to improving quality; ( ) framework formation to system construction; and ( ) singlearea breakthroughs to system integration and comprehensive promotion. 'tripartite system reform (tsr)', which refers to the linkage reform of the medical care, main reform initiatives achievements expanding the population coverage of the basic health insurance schemes. more than % of the population covered by social health insurance schemes in . extending the health service package of the basic health insurance schemes. the number of pharmaceuticals on the drug list was expanded to in ; government subsidies per capita for the urbmi and nrcms have increased more than fivefold in compared with . developing the mfa for people living in extreme poverty. in , a total of ¥ . billion was spent from medical assistance funds nationwide to subsidise . million people to participate in basic medical insurance, and . million people received outpatient and inpatient assistance. developing the cmi for those people with catastrophic medical expenditure. since , cmi has covered . billion people in china and benefited more than million people ( % of whom are rural residents), and reimbursement payments have exceeded ¥ billion. integrating basic health insurance systems of rural and urban residents: merging nrcms and urbmi into the urrmi. unifying insurance coverage, funding policies, insured treatment, reimbursement catalogues, management of contracted medical institutions and fund management: for example, the number of drugs covered in the insurance drug list is unified to in , and the per-capita premium is unified to ¥ in . reforming the payment system. % of public hospitals above the second level have carried out reforms of the disease category-based insurance payment in ; announcing a list of pilot cities for drg payment reform in . zero mark-up policy on drug sales. all public hospitals nationwide have removed the medicine mark-ups in . formulating and expanding the neml. issuing a revision of the neml in including a list of essential medicines, and expanding the list to medicines in and medicines in . supplying and evaluating the generic drugs. publishing the first list of generic drugs on june ; as of august , product specifications have passed the generic drug consistency evaluation. reforming the drug tendering and procurement system. pilot provinces and pilot cities have implemented the 'two invoice policy' tendering system by the end of ; the drug procurement costs of the corresponding varieties in pilot cities fell from ¥ . billion to ¥ . billion, and the cost dropped by . %. promoting rational use of essential drugs. rates of antibiotic use in inpatient and outpatient care decreased by % in selected tertiary hospitals. increasing investment in the primary healthcare system, including strengthening the infrastructure of phc facilities. government subsidies to phc institutions have increased substantially: from to , subsidies as a proportion of total phc income increased from . % to . %. expanding human resources for primary care through incentives and supporting projects. compared with , the total number of primary healthcare workers in increased by . % to . million, and the number of general practitioners per population increased from . to . . developing a tiered service delivery system by establishing hcas and providing family practitioners contracted services. implementing telemedicine to improve the delivery of services to people living in remote and lowincome areas. more than medical institutions implemented telemedicine services, which have covered all national poverty counties. providing basic public health service package to all people through government subsidies. increased government public funding was invested to expand the services (from categories in to categories in ) and availability of the basic public health package to almost everyone; an average of ¥ was allotted per capita in and was increased to ¥ in . supporting programmes to control the main public health problems. figure illustrates the priorities and relationship among the three healthcare reform plans. main reform initiatives and achievements of the past decade health insurance system reforming the health insurance system is essential and critical since it has served as the major source of financing for the healthcare delivery system. basic health insurance in china, including the urban employee basic medical insurance, the new rural cooperative medical scheme (nrcms) and the urban resident basic medical insurance (urbmi), laid the foundation for universal insurance coverage. priority was given to expanding the scope and health service package of the basic insurance coverage, improving provider payment mechanisms, as well as increasing the financing level, fiscal subsidies and reimbursement rates. to improve equity in access to healthcare between rural and urban areas and efficiency in operation of the schemes, the chinese government consolidated the fragmented health insurance schemes by merging nrcms and urbmi into the urban and rural resident medical insurance in , and then established the national healthcare security administration in to implement unified management for these insurance schemes. in addition, the government launched medical financial assistance in and catastrophic medical insurance in as supplementary medical insurance to provide funds for patients with poverty and catastrophic illness. the moves, parts of 'health poverty alleviation (hpa)' (a critical element of the national poverty alleviation project), are significant steps towards 'healthy china' and uhc, protecting people with low incomes from impoverishment due to exorbitant healthcare costs, and breaking the cycle of poverty and illness. the payment reform is being implemented to modify the behaviour of providers and to control the unreasonable growth of medical expensesreplacing fee-for-service payment with comprehensive payment methods based on disease category. drug supply and security system as the base of drug supply and security system, the national essential medicines system reform is comprehensive and includes but is not limited to the following: the selection, production and distribution of essential medicines; quality assurance; reasonable pricing; tendering and procurement; a zero mark-up policy on sales; rational use and reimbursement; and monitoring and evaluation. the government issued a revision of the national essential medicines list (neml) in including a list of essential medicines, and constantly expands the list to fully meet the needs of basic healthcare. these on-list medicines should be available at all primary care institutions. to improve access to medicines, china boosted the research and development of generic drugs, and required the evaluation of generics to prove they are equivalent to the originator products in terms of quality and efficacy. a 'two invoice policy' tendering system was developed to avoid higher mark-up and reduce circulation during the process of distribution. all medicines in the neml are included in health insurance reimbursement lists, which are reimbursed at higher rates compared with non-essential medicines. medical service system establishing a strong primary care delivery system is an ongoing priority in china. the government has increased bmj global health investment in primary care, with initiatives that include strengthening the infrastructure of primary healthcare (phc) facilities, expanding human resources for primary care through incentives and supporting projects, establishing a general practitioner system and improving the capacity of phc personnel through training and education, such as general practice training and continuous medical education programmes. public hospital reforms focus on removing drug mark-ups as a source of financing, and rationalising medical service pricing (eg, improving the price of medical services that can reflect the value of medical staffs' technical services, and piloting the removal of medical consumable mark-ups). additionally, the priority task is establishing a tiered healthcare delivery system by developing healthcare alliances to improve intersectoral coordination and integration and providing family practitioners contracted services. the development of private hospitals is encouraged to increase the supply of healthcare resources. further, telemedicine is promoted to improve the delivery of services to people living in remote and poverty areas. public health service system the 'equalization of basic public health services' policy implemented the national bphs programme and the crucial public health service (cphs) programme. it aims to reduce major health risk factors, prevent and control major communicable diseases and chronic diseases and improve response to public health emergencies. this policy seeks to achieve universal availability and promote a more equitable provision of basic health services to all urban and rural citizens. the bphs set out the minimum services for all citizens, including health management and monitoring. the service package can be expanded by local governments according to local public health issues and financial affordability. cphs seeks to fight important infectious diseases (eg, prevention and control of tuberculosis, aids and bilharziasis) and meet the needs of vulnerable groups (eg, breast and cervical cancer screening for rural women, cataract surgery for low-income patients). with a focus on public health and prevention, the state council announced a series of recommended actions to achieve 'healthy china ' on july , which include 'intervening in health influencing factors, protecting full-life-cycle health, and preventing and controlling major diseases'. during the past years since the latest round of healthcare reform, china made steady progress in achieving the reform goals and uhc. table showed the summary of the main reform initiatives and achievements. lessons from china's experience achieving uhc is a tough and long-term task that is not unique to china and confronts many other countries. when pursuing uhc, china adopted the general strategies recommended by who, and also developed a pathway with chinese characteristics through healthcare reform. the experience from china may provide invaluable lessons for other countries. first, continued political support is the most important enabling condition for achieving uhc. efforts through national-level initiatives of different governments show that the political will to drive better healthcare is crucial, such as the national health policy in india and rwanda's vision . china's commitment to uhc remains unchanged since the healthcare reform in , and progress through three phases step by step focusing on the overall goal. cpc and governments at all levels have shown clear political willingness to reach the goal by , making uhc achievement a more country-led process. in , president xi jinping announced 'healthy china blueprint', a national long-term strategy in health sector that sets ambitious targets for china. second, increasing health financing is necessary, and the investment from both government and private sectors is considered. at the initial phase of the healthcare reform, on the basis of limited financial fund, chinese government increased investment in healthcare infrastructure and greatly increased the coverage of health insurances, achieving the universal coverage maximally. after years of exploration during the reform process, it was realised that china should strike a proper balance between the government and the market-play the government's leading role in providing basic health services, and at the same time, introduce appropriate competition mechanisms to energise the market in nonbasic health services, encouraging the private sector to provide multilevel and diversified medical services. third, a strong phc system should be regarded as a core component in realising uhc. along with the new declaration of astana, phc for health as a global priority is the pathway to reach the sdgs and uhc. in the early days, some experience in phc in china demonstrated that 'health for all' is a practical possibility, for example, the 'patriotic health campaign' and 'barefoot doctors'. the 'patriotic health campaign' encouraged everyone to participate in public health activities, and aimed to improve sanitation, hygiene, health education, as well as combat infectious diseases. engagement of civil society is necessary to promote uhc. the 'barefoot doctors' model used limited medical resources to provide common disease diagnosis and prevention services to a large rural population. however, the chinese healthcare system created adverse consequences after market-based reforms, in part due to a weakening of support for phc. today, recognising the importance of revamping its phc system, the chinese government has made phc a priority in its 'healthy china ' strategy. in addition to these general lessons, there are also some lessons with chinese characteristics, providing reform experiences for other countries: ( ) china's health reforms are usually piloted and then rolled out nationwide, such as the public hospital reform; or the reform started from the grass level and then refined for the nation, such as the sanming model. ( ) in the latest phase of reform, china is paying more attention to the systemic and linkage reform (ie, tsr). this innovative strategy can help promote the dynamic balance among medical care, medical insurance and medicine, and construct a coordinating healthcare system to achieve uhc. a strength of our study was that we systematically and comprehensively assessed healthcare reform in the past decade moving towards uhc in china, including evolution, initiatives and achievements. the lessons learnt from china could help other nations improve uhc in sustainable and adaptive ways, including continued political support, increased health financing and a strong phc system as basis. the experience of the rapid development of uhc in china can provide a valuable mode for countries (mainly lmics) planning their own path further on in the uhc journey. universal health coverage and public health: a truly sustainable approach the world health report : research for universal health coverage participants at the bellagio workshop on implementing pro-poor universal health coverage. implementing pro-poor universal health coverage universal health coverage, health systems strengthening, and the world bank offline: who-a roadmap to renewal? universal health coverage: realistic and achievable? universal health coverage in turkey: enhancement of equity universal health coverage in indonesia: concept, progress, and challenges health systems development in thailand: a solid platform for successful implementation of universal health coverage cooperative societies: a sustainable platform for promoting universal health coverage in bangladesh the long march to universal coverage: lessons from china. universal health coverage studies series (unico) no. early appraisal of china's huge and complex health-care reforms monitoring and evaluating progress towards universal health coverage in china world population dashboard-china china: human development indicators reforming health care in china: historical, economic and comparative perspectives the world bank in china an assessment of progress towards universal health coverage in brazil report on china's implementation of the millennium development goals the great reversal: transformation of health care in the people's republic of china health in china. from mao to market reform health care in china after mao the health sector in china policy and institutional review barefoot doctors in china china's universal health care coverage. towards universal health care in emerging economies. social policy in a development context people's republic of china health system review. manila: who regional office for the western pacific an exploration of china's mortality decline under mao: a provincial analysis, - transformation of health care in china privatization and its discontents--the evolving chinese health care system china's healthcare system and reform towards universal health care in emerging economies: opportunities and challenges health care systems in transition: people's republic of china. part i: an overview of china's health care system health care system reform in china: issues, challenges and options. citeseer: china economics and management academy evolution of health provision in pre-sars china: the changing nature of disease prevention china's health system and its reform: a review of recent studies evolution of china's health-care system china's latest health reforms: a conversation with chinese health minister chen zhu how to attain the ambitious goals for health reform in china dilemmas of access to healthcare in china advancing universal coverage of healthcare in china: translating political will into policy and practice opinions of the central committee of the communist party of china and the state council on deepening the health care system reform implementing health care reform policies in china -challenges and opportunities: the center for strategic and international studies (csis) health care transformation in contemporary china-moral experience in a socialist neoliberal polity china's health care system reform: progress and prospects launch of the health-care reform plan in china current major project on health care system reform early results of china's historic health reforms: the view from minister chen zhu. interview by tsung-mei cheng the world health organization and others made positive evaluations of the phased results of china's health care reform notice of the state council on printing and distributing the planning and implementation plan for deepening the health care system reform during the th five-year plan period notice of the state council on printing and distributing the th five-year plan for deepening the reform of health care system the central committee of the communist party of china and the state council issued the the governance of china volume -chapter: promote a healthy china consolidating the social health insurance schemes in china: towards an equitable and efficient health system state council's opinions on integrating the basic medical insurance system for urban and rural residents enhancing financial protection under china's social health insurance to achieve universal health coverage guiding opinions of the general office of the state council on further deepening the reform of basic medical insurance payment methods essential medicine policy in china: pros and cons edition): background, differences from previous editions, and potential issues opinions of the general office of the state council on reforming and improving the policy of supply and use of generic drugs the reform of the essential medicines system in china: a comprehensive approach to universal coverage state council's guidance on establishing a general practitioner systems what can we learn from china's health system reform? guidance on the promotion of family practice contract service opinions on promoting the gradual equalization of basic public health services strengthening public health services to achieve universal health coverage in china the state council's opinions on implementing healthy china action achieving high-quality universal health coverage: a perspective from the national health service in england how primary health care can make universal health coverage a reality, ensure healthy lives, and promote wellbeing for all who. primary health care-the chinese experience. geneva: world health organization an introduction to the patriotic health work the primary health-care system in china an evaluation of systemic reforms of public hospitals: the sanming model in china catastrophic medical insurance in china the latest generic drug evaluation drug summary rational use of antibiotics in the context of china's health system reform years of health-care reform in china: progress and gaps in universal health coverage key: cord- - w j authors: hung, yuen w; law, michael r; cheng, lucy; abramowitz, sharon; alcayna-stevens, lys; lurton, grégoire; mayaka, serge manitu; olekhnovitch, romain; kyomba, gabriel; ruton, hinda; ramazani, sylvain yuma; grépin, karen a title: impact of a free care policy on the utilisation of health services during an ebola outbreak in the democratic republic of congo: an interrupted time-series analysis date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: w j background: during past outbreaks of ebola virus disease (evd) and other infectious diseases, health service utilisation declined among the general public, delaying health seeking behaviour and affecting population health. from may to july , the democratic republic of congo experienced an outbreak of evd in equateur province. the ministry of public health introduced a free care policy (fcp) in both affected and neighbouring health zones. we evaluated the impact of this policy on health service utilisation. methods: using monthly data from the national health management information system from january to january , we examined rates of the use of nine health services at primary health facilities: total visits; first and fourth antenatal care visits; institutional deliveries; postnatal care visits; diphtheria, pertussis and tetanus (dtp) vaccinations and visits for uncomplicated malaria, pneumonia and diarrhoea. we used controlled interrupted time series analysis with a mixed effects model to estimate changes in the rates of services use during the policy (june–september ) and afterwards. findings: overall, use of most services increased compared to control health zones, including evd affected areas. total visits and visits for pneumonia and diarrhoea initially increased more than two-fold relative to the control areas (p< . ), while institutional deliveries and first antenatal care increased between % and % (p< . ). visits for dtp, fourth antenatal care visits and postnatal care visits were not significantly affected. during the fcp period, visit rates followed a downward trend. most increases did not persist after the policy ended. interpretation: the fcp was effective at rapidly increasing the use of some health services both evd affected and not affected health zones, but this effect was not sustained post fcp. such policies may mitigate the adverse impact of infectious disease outbreaks on population health. abstract background during past outbreaks of ebola virus disease (evd) and other infectious diseases, health service utilisation declined among the general public, delaying health seeking behaviour and affecting population health. from may to july , the democratic republic of congo experienced an outbreak of evd in equateur province. the ministry of public health introduced a free care policy (fcp) in both affected and neighbouring health zones. we evaluated the impact of this policy on health service utilisation. methods using monthly data from the national health management information system from january to january , we examined rates of the use of nine health services at primary health facilities: total visits; first and fourth antenatal care visits; institutional deliveries; postnatal care visits; diphtheria, pertussis and tetanus (dtp) vaccinations and visits for uncomplicated malaria, pneumonia and diarrhoea. we used controlled interrupted time series analysis with a mixed effects model to estimate changes in the rates of services use during the policy (june-september ) and afterwards. findings overall, use of most services increased compared to control health zones, including evd affected areas. total visits and visits for pneumonia and diarrhoea initially increased more than two-fold relative to the control areas (p< . ), while institutional deliveries and first antenatal care increased between % and % (p< . ). visits for dtp, fourth antenatal care visits and postnatal care visits were not significantly affected. during the fcp period, visit rates followed a downward trend. most increases did not persist after the policy ended. interpretation the fcp was effective at rapidly increasing the use of some health services both evd affected and not affected health zones, but this effect was not sustained post fcp. such policies may mitigate the adverse impact of infectious disease outbreaks on population health. what is already known? ► evidence from previous outbreaks of ebola virus disease (evd) and other infectious diseases suggests that the use of primary health services usually declines among the general public, which can lead to important declines in population health. ► to our knowledge, there have been no evaluations of policies or strategies implemented to mitigate the impact of evd outbreaks on the use of health services in any international context. ► the introduction of user fee exemption or other free care policies (fcps) to incentivise health service utilisation have been evaluated in a number of sub-saharan african countries contexts, however, none have been evaluated in the context of an outbreak of evd or other infectious diseases. what are the new findings? ► our findings provide strong evidence that utilisation rates of many primary health services increased with the implementation of the fcp, although most increases were not sustained after the fcp ended. ► total visits and treatments for pneumonia and diarrhoea saw the largest increases while some services, such as those involving needles and blood, were not affected by the fcp. what do the new findings imply? ► the available scientific evidence suggests that fcps may be an effective strategy to mitigate the impact of evd outbreaks on the use of health services among the general public, even in resource poor settings. ► further research is needed to understand how such policies can be better implemented and additional strategies should also be explored. ► routine health information system data can be a useful tool to study the impact of fcps and other short-term policies in low income country settings. introduction widespread disruption to health systems has been observed during previous major outbreaks of infectious diseases. for example, during the - outbreak of ebola virus disease (evd) in west africa, the use of health services greatly declined in heavily affected countries. communities were fearful and lacked trust in the health system, which not only impeded response efforts, but also deterred health seeking behaviour. overall use of health services decreased by % during the peak of the outbreak. reductions were seen for maternal and child health services, as well as treatments for priority diseases such as malaria and hiv. it has been estimated that reductions in the use of health services led to mortality increases similar in magnitude to those directly attributable to evd. moreover, studies have shown that patterns of health seeking behaviour were disrupted for months after the outbreak. as a result, implementing policies to mitigate these impacts should be a priority. in africa, user fee exemption policies or other free care policies (fcps) have been a popular approach to incentivise health service utilisation, especially in the use of maternal and child healthcare services. however, studies have shown mixed evidence with regards to their effectiveness in various contexts. [ ] [ ] [ ] [ ] weak study designs, many of which lacked an adequate control group, may partially explain the mixed evidence. an evaluation of a previous fcp introduced in the democratic republic of congo (drc) in , unrelated to an evd outbreak, also demonstrated mixed results and the programme was not sustained. while fcps have been implemented in previous evd outbreaks in drc, to date, there have been no evaluations of their impact, where in addition to the usual concerns, additional challenges may further limit the effectiveness of such policies. fcps could provide benefits in two ways during an outbreak. first, it could encourage early identification and treatment of the disease itself-a factor that is believed to be a key predictor of ebola survivorship. second, it could help increase or maintain the use of other beneficial health services among the general population. based on the intervention theory of health user fee exemption policies developed by robert et al, a fcp should allow households to obtain health services that were previously unaffordable. however, in the context of an evd outbreak, fear of infection or a lack of trust in the health system may limit the demand for these services. in the evd outbreak in the equateur province of drc, the ministry of public health quickly implemented a temporary fcp in the three evd affected health zones as well as in four neighbouring health zones, primarily motivated by the first of the benefits described above. the implementation was supported by the ongoing health system strengthening for better maternal and child health results project funded by the world bank. in this paper, we evaluate the effect of the fcp on the use of health services at primary health centres (phcs) in equateur province using routinely collected administrative data. the drc is among the largest and most populous countries in africa and also has some of the worst health indicators in the region. the health system is highly decentralised and is challenged with very low levels of funding. to compensate, the health system relies heavily on user fees for financing. however, as over % of the population live in poverty, user fees represent a major barrier to health service utilisation. the drc has provinces which are subdivided into health zones. each health zone is further subdivided into health areas, each of which is equipped with health centres to provide primary health services. in , the drc experienced two separate evd outbreaks: the first happened in equateur province, followed by a second in the eastern region of the country a few months later. the first, which was declared on may , initially began in the ikoko-impenge health area in the bikoro health zone, where two cases of fever were confirmed to be evd and community deaths had been reported. by may , a total of cases and deaths were reported, including probable cases from the iboko and wangata health zones, a distance of nearly km, raising concerns of widespread transmission. in response to the outbreak, the drc ministry of public health, in partnership with the who, established a social awareness campaign and delivered personal protective equipment to the region by may . on may , vaccination campaigns were launched targeting front-line health workers, individuals exposed to confirmed evd cases and contacts of these individuals. additionally, to encourage people at risk to seek medical care and improve surveillance in the community, the ministry of public health implemented a temporary fcp in the health areas affected by the evd epidemic as well as in nearby health zones, beginning in june . the outbreak infected a total of people and led to deaths, including two health workers, before being declared over on july , with cases remained localised to the three health zones. we conducted a retrospective, controlled interrupted time-series (its) study using monthly data to estimate changes in the level and trend in the rate of health service utilisation between january and january at phcs during the equateur province outbreak. controlled its is a very strong quasi-experimental study design that can be used with routinely collected health system data. within equateur province, cases of evd were reported in of the health zones: bikoro (rural), iboko (rural) and wangata (urban). along with these affected zones, four neighbouring health zones (bolenge, ingende, ntondo and mbandaka) also received the fcp, bmj global health which was in effect between june and september (figure ). fcp covered consultations and medications for evd and other health conditions in the targeted areas. payments were made from the government to public health facilities (health centres and hospitals) to support the health workers and the maintenance of the facilities, using an existing payment platform that had previously been established to support a results-based financing programme in the area. the government also distributed medicines covered by the fcp to public facilities. we confirmed the enactment and implementation dates of the fcp with both provincial health administrators and local healthcare workers in equateur province. we extracted monthly data from the health management information system (hmis), an national electronic data collection system based on the district health information system (dhis ) platform. data in this system are input from health facilities' monthly health service use reports at district health offices. significant efforts have been launched in the drc to improve the quality of hmis data, including continual quality assessment activities at both the health zone and facility levels and incentives for report submission and completion. hmis data have been used to retroactively evaluate the impact of the west african evd outbreak on health service utilisation, and to evaluate the impact of other policies in other low-income and middle-income countries contexts using its analysis. for each phc, we extracted the number of visits for the following health services: . overall: ( ) total clinic visits. each health facility reported each of the indicators on a monthly basis. to enable comparisons between health zones, monthly counts were modelled as per-capita monthly rates using the estimated catchment populations for each facility reported in the hmis. these indicators were selected as they represent the majority of health services delivered in phcs ( % of total visits) and had the highest level of data completeness. although routine immunisations and malaria rapid diagnostic testing had been curtailed during the outbreak due to evd transmission concerns, we included these indicators to monitor the overall use of health services in the general population in the context of the evd outbreak. the research protocol was approved by the ethics committees at wilfrid laurier university (canada) and kinshasa school of public health (drc). we tested the following hypotheses: ( ) was the fcp associated with significant changes in health services utilisation at phcs in both evd affected and non-evd affected health zones? if so, what were the magnitude of these changes? ( ) were the changes in health service utilisation sustained throughout the period of the fcp bmj global health implementation and afterwards? ( ) were there any differential effects of the fcp in evd vs non-evd health zones? ( ) were some health services more affected by the fcp than others? our analysis included the phcs in two intervention groups that received the fcp: three evd affected health zones (evd and fcp), as well as in the four neighbouring health zones that received the fcp but were not directly affected by evd (fcp only). phcs in the remaining health zones within equateur province were included as the control group (neither). we fit our models using a two-level mixed-effects negative binomial model to adjust for the clustering of observations from the same health centres over time, and to correct for over-dispersion. all of our models included random intercepts for clinic in order to account for heterogeneity of clinic visit volumes, and an autoregressive structure of one period to account for potential correlation between observations over time. we defined three time periods: pre-intervention (january -march ), intervention (june-september ) and post-intervention (october -january ) based on the timing of the fcp. we excluded the first months of the outbreak (april and may ) from our analysis, as the time period between the onset of the outbreak and the implementation of the fcp was too short to independently test for time trends. each indicator was analysed for level and slope over time, changes in immediate (level) and gradual (slope) in the intervention and post-intervention period, and the interaction of these changes with the different study groups (evd and fcp, fcp only, neither). phcs were excluded from each analysis if data were missing for two or more consecutive months in either the pre-fcp (october and march ), or during evd and fcp (april and september ) periods. thus, we excluded phcs from one health zone (makanza) that had neither evd nor fcp due to lack of consistent reporting. we identified outliers and excluded a phc for a specific indicator if their reported data exceeded eight sd from the mean time trend (< . % of the sample). due to this rule about missing data, number of phcs included in each study group varied by indicator. the samples of phcs for each indicator is included in online supplementary table s a and s b. we then conducted separate controlled its analysis for each of the nine indicators. missing data were accounted for using standard maximum likelihood estimation in the mixed-effects models. additionally, in order to estimate the absolute change of each outcome compared to the counterfactual estimate without the fcp, we used the non-linear (exponential) combination of estimate parameters from the two-level mixed-effects negative binomial model and applied bootstrapping method to construct confidence intervals around the predicted absolute changes in outcome. we simulated data based on the estimates with normally distributed error using bootstrap statistics with resamples within each group. all analyses were conducted using sas v. . . this research was done without patient involvement. patients were not invited to comment on the study design and were not consulted to develop patient relevant outcomes or interpret the results. patients were not invited to contribute to the writing or editing of this document for readability or accuracy. as shown in table , we found that the fcp was associated with changes in the utilisation of many types of services, majority were similar in both the health zones with evd and in neighbouring health zones with fcp only. overall relative to control health zones, rates of total clinic visits increased substantially in fcp health zones following the start of the evd outbreak and we see similar increases in both the evd and fcp health zones and the fcp-only health zones. as shown in figure , visit rates increased more than twofold in evd and fcp health zones (incidence rate ratio ( similar to overall clinic visits, the fcp was associated with a large increase in visits for pneumonia and diarrhoea, and to a smaller extent for malaria visits. figure shows the model results for the rate of clinic visits for pneumonia. compared to facilities in control health zones, clinic visits for pneumonia doubled at the beginning of fcp in evd and fcp health zones (irr: . , % ci: . - . , p< . ) and quadrupled in fcp-only health zones (irr: . , % ci: . - . , p< . ). during the implementation period, visits for pneumonia in evd and fcp health zones had no significant change (irr: . , % ci: . - . , p= . ) while the rate decreased over time in fcp-only health zones (irr: . , % ci: . - . , p< . ). following the end of the fcp, the level of pneumonia visits decreased by % in evd and fcp health zones (p= . ), with no significant difference in the trend in subsequent months (irr: . , % ci: . - . , p= . ). the % decrease in fcp-only health zones was not statistically significant (irr: . , % ci: . - . , p= . ) and the trend reversed after the end of the policy (irr: . , % ci: . - . , p< . ). changes in the levels and trends of visits for diarrhoea following bmj global health the fcp had a comparatively moderate effect on the utilisation of maternal health services both in the evd and fcp health zones and the fcp-only health zones which varied by service type. figure shows vaccination figure shows the results for the administration of first doses of the dtp vaccine. reporting of routine immunisation in the evd and fcp health zones was predominantly from the wangata health zone. compared to control health zones, dtp immunisation had no significant change in the evd and fcp health zones (evd and fcp: irr: . , % ci: . - . , p= . ) and marginal increase in fcp-only health zones (irr: . , % ci: . - . , p= . ). no significant changes were found in the trends nor level after the fcp ended. discussion during disease outbreaks, maintaining the use of health services is important both for diagnosing diseases and ensuring continuity of care for other health issues. we found strong evidence that a fcp implemented in the drc during an ongoing evd outbreak associated with large increases in the rate of utilisation of health services in phcs. the magnitude of this increase was similar in the evd zones compared to neighbouring zones with the fcp but no evd. our findings are consistent with previous studies that found short term effects of fcps in other african contexts, but in stark contrast to the finding that fear and a lack of trust greatly curbed health service utilisation in the west african evd outbreak. despite the increase in the use of health services, the fcp was not equally effective for all indicators. the largest increase was observed in curative visits for pneumonia and diarrhoea, while increases in the treatment of malaria were observed only in the fcp-only zones. preventative services such as first antenatal visit and institutional delivery showed more modest increases. this pattern generally aligns with other fcp studies that have shown greater effectiveness for curative services than preventative services. studies from west africa also suggest the use of curative services recovered and rebounded earlier in the post-outbreak period, compared to preventative services. due to the concern of evd transmission, health facilities may have curbed the delivery of services that involved needles or blood extraction. indeed, the chief medical officer of bikoro health zone reported that evd responders recommended that, during the epidemic, routine immunisation, elective surgeries and malaria rapid diagnostic testing be curbed in the epicentre health zones (dr b loleka, oral communication, may ). the restriction in routine immunisation in the epicentre may have also contributed to reduced reporting on immunisation and malaria diagnosis during the evd outbreak. although these services were not targeted by the fcp, we found some evidence that dtp vaccination and malaria diagnosis did not decrease during the evd period in the reporting phcs, suggesting that such activities were maintained in areas outside of the evd epicentre. our findings also highlight some potential challenges in implementing fcps. the rapid increases in the use of services following the implementation of the policy attenuated over the following months which may be a result of the disruption of the fcp on the local health system. in particular, the sudden increase in demand for primary health services may have overstretched the limited human resources, or disrupted regular operations due to the changes in reimbursements paid to health workers and budgetary constraints during the fcp implementation. these impacts should be considered in future uses of fcp-type policies designed to mitigate the impact of infectious disease outbreaks. our findings also provide some insights that could be useful to decision-makers contemplating setting up similar policies in other infectious disease outbreak contexts, for example, countries currently deciding how to respond to the pandemic of covid- . first, we demonstrate that the policy was effective soon after implementation which was likely due in part to the presence of an existing payment structure that had previously been established in the region and that could quickly be leveraged for this programme. without such a platform, it may be challenging for other countries to implement such a policy in a rapid manner. second, while the intent had always been for the policy to be temporary, our findings suggests that the effectiveness of the policy began to wane soon after implementation, potentially as a result of the lack of longer-term planning. decision-makers should try to better balance the need for short-term effectiveness with the sustainability of the policy, in particular when it is uncertain at the onset how long an outbreak will last. our study has a number of limitations that should be considered when interpreting our results. first, our sample included only health centres and did not include all health facilities. as health centres are the formal health system structure that provide primary health services, we did not include health posts, which provide mainly community health services and health promotion activities. our sample also excluded hospitals and private health facilities. as private facilities are not directly governed by the ministry of public health, their reporting of routine health data is limited. it was not possible for us to include hospitals as their reporting in some health zones was very inconsistent during the outbreak. however, in the appendix we present data from select hospitals and note that similar increases in use of health services were also observed. second, there was a small increase in missing data during the first few months of the evd outbreak, particularly in vaccination and malaria diagnosis. as we excluded health centres with consecutive missing data in this period, our samples for these two indicators did not include all evd health zones. hence, our findings on vaccination and visits for malaria diagnosis may not be generalisable to the entire evd outbreak area. third, we were unable to include an estimate of the level and trend changes following the ebola outbreak as there were only months between the outbreak and the start of the fcp. finally, it is possible that the intervention may have had led to some spillover effects into neighbouring health zones which we are not able to fully control for in our analysis. however, the challenging terrain and large distances to health facilities may have limited spillover effects. plus, if such spillover effects had happened, it is unclear which direction they would have gone, and could have even made it less likely that we were to find an effect. in conclusion, our study demonstrates that the introduction of a fcp was strongly associated with rapid increases in the use of health services, in particular in zones with both the policy and evd. this is in contrast to prior evd outbreaks, wherein countries did not implement fcps at scale and saw large declines in the use of health services, suggesting that such policies may be effective at mitigating the impact of future evd outbreaks. however, the increases were not uniform across all health services and the rapid increases in the use of health services did not continue over the full fcp period. fcps may be an effective way to mitigate the impact of future outbreaks, including the current pandemic of covid- that is now threatening many countries including the drc, on population health, however, more research is needed to better understand the impact in different contexts and how such policies can be effective over time. access to all the data in the study and had final responsibility for the decision to submit for publication. disclaimer the funders of the study had no role in study design, data collection, data analysis, interpretation of data, or writing of the report. map disclaimer the depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of bmj (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. this map is provided without any warranty of any kind, either express or implied. competing interests mrl has consulted for health canada, the health employees' union, the conference board of canada, and provided expert witness testimony for the attorney general of canada. bluesquare has ongoing contracts with a variety of organisations in drc including the ministry of health and the world bank. si, la-s, smm, and hr were paid as individual consultants as part of their collaboration with this project. patient and public involvement patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. provenance and peer review not commissioned; externally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. orcid ids the - ebola virus disease outbreak and primary healthcare delivery in liberia: timeseries analyses for - the impact of the sars epidemic on the utilization of medical services: sars and the fear of sars women and babies are dying but not of ebola': the effect of the ebola virus epidemic on the availability, uptake and outcomes of maternal and newborn health services in sierra leone health-care access during the ebola virus epidemic in liberia patterns of demand for non-ebola health services during and after the ebola outbreak: panel survey evidence from community-based reports of morbidity, mortality, and health-seeking behaviours in four monrovia communities during the west african ebola epidemic utilization of non-ebola health care services during ebola outbreaks: a systematic review and metaanalysis counting indirect crisis-related deaths in the context of a low-resilience health system: the case of maternal and neonatal health during the ebola epidemic in sierra leone effect of ebola virus disease on maternal and child health services in guinea: a retrospective observational cohort study effect of the ebolavirus-disease epidemic on malaria case management in guinea, : a cross-sectional survey of health facilities malaria morbidity and mortality in ebola-affected countries caused by decreased healthcare capacity, and the potential effect of mitigation strategies: a modelling analysis retention in care for hiv-infected patients in the eye of the ebola storm: lessons from impact of the ebola epidemic on general and hiv care in macenta, forest guinea reduced vaccination and the risk of measles and other childhood infections post-ebola a scoping review of the literature on the abolition of user fees in health care services in africa the impact of user fees on access to health services in low-and middle-income countries assessing the communitylevel impact of a decade of user fee policy shifts on health facility deliveries in kenya how effective and fair is user fee removal? evidence from zambia using a pooled synthetic control picking up the bill -improving health-care utilisation in the democratic republic of congo through user fee subsidisation: a before and after study building a middle-range theory of free public healthcare seeking in sub-saharan africa: a realist review brève situation de la riposte l'épidémie de la maladie virus ebola (mve) dans la province de l'equateur, république démocratique du congo au e jour [brief situation of ebola virus disease (evd) response in equateur province, democratic republic of c. kinshasa, democratic republic of congo repubique democratique du congo ministere de la sante publique plan national de development sanitaire - : vers la couverture sanitaire universelle [democratic republic of the congo ministry of public health national development plan assessing out-of-pocket expenditures for primary health care: how responsive is the democratic republic of congo health system to providing financial risk protection? bmc the ongoing ebola epidemic in the democratic republic of congo outbreak of ebola virus disease in the democratic republic of the congo world health organization. ebola virus disease democratic republic of the congo: external situation report world health organization. ebola virus disease democratic republic of the congo: external situation report segmented regression analysis of interrupted time series studies in medication use research mapping the stages of measure evaluation's data use continuum to dhis : an example from the democratic republic of the congo data quality assessments stimulate improvements to health management information systems: evidence from five african countries the impact of an mhealth monitoring system on health care utilization by mothers and children: an evaluation using routine health information in rwanda effect of pentavalent rotavirus vaccine introduction on hospital admissions for diarrhoea and rotavirus in children in rwanda: a time-series analysis immediate and sustained effects of user fee exemption on healthcare utilization among children under five in burkina faso: a controlled interrupted time-series analysis impact of the ebola outbreak on health systems and population health in sierra leone a literature review of the disruptive effects of user fee exemption policies on health systems the free health care initiative: how has it affected health workers in sierra leone? planning for post-ebola: lessons learned from dr congo's th epidemic republique democratique du congo evaluation des presentations des services de souns de sante epss - rapport final [democratic rebublic of congo evaluation of health services epss acknowledgements we acknowledge that this manuscript was prepared on the haldimand tract, traditional territory of the neutral, anishinaabe and haudenosaunee peoples. we are grateful to all of our key informants, including those in the democratic republic of congo (drc) and elsewhere to helping us obtain information on key parameters related to the outbreak. we also acknowledge qamar mahmood and sofia rossell at international development research centre for their support, jess wilhelm's research assistance on the project, and nicolas de borman's facilitation in facilitating the project and data access.contributors mrl, si, smm and kg conceived the idea. ywh, mrl, si, la-s, gl, smm, hr and kg developed the protocol and contributed to the study design. gl and ro provided study data and assisted with data management. ywh and lc managed and analysed the data, in collaboration with mrl. ywh and kg drafted the manuscript. all authors reviewed the manuscript and contributed to the revision of the manuscript, and approved its final version. the corresponding author had full michael r law http:// orcid. org/ - - - sharon abramowitz http:// orcid. org/ - - - lys alcayna-stevens http:// orcid. org/ - - - grégoire lurton http:// orcid. org/ - - - romain olekhnovitch http:// orcid. org/ - - - gabriel kyomba http:// orcid. org/ - - - hinda ruton http:// orcid. org/ - - - x karen a grépin http:// orcid. org/ - - - key: cord- -fa mxvc authors: svadzian, anita; vasquez, nathaly aguilera; abimbola, seye; pai, madhukar title: global health degrees: at what cost? date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: fa mxvc nan in theory, global health, as a field, takes pride in principles such as equity, fairness, reciprocity and bidirectional partnerships. in practice, many aspects of global health are dominated by individuals and institutions in high-income countries (hics) who seem to benefit more than their counterparts in low-income and middle-income countries (lmics). [ ] [ ] [ ] global health organisations are mostly head-quartered in hics, and run by people, primarily men, from hics. further, authorship of global health publications is dominated by people in hics, [ ] [ ] [ ] as well as editorial boards of global health journals. what about global health education? in the past two decades, global health has become very popular among students in hics. in response to higher demand and availability of increased funding, many hic universities invested heavily in global health programmes. although dozens of degree programmes in global health emerged as a consequence, it remains unclear who the target audience really is, and what it might cost to earn one of these degrees. are these degree programmes aimed at lmics, where training gaps are enormous, or are they primarily for the benefit of hic trainees and institutions? to answer this question, we identified academic programmes that offer either a master's of global health or a master's of international health degree. we used the academic global health programmes database maintained by the consortium of universities for global health (cugh), supplemented by online searches for universities not included in the cugh list (see box for details). we focused on master's of global or international health programmes (on campus or online), rather than related degrees such as master's of public health (mph) which might offer global health concentrations, options or tracks. in all, out of global or international health master's degrees identified, we were able to gather information for degree programmes, as of march . table outlines details for each degree programme considered for this analysis. as shown in figures , ( %) were located in north america, ( %) in europe, ( %) in western pacific, ( %) in asia and ( %) africa. nineteen ( %) of the degree programmes were -year programmes, and the rest could be completed over a longer period. of the degree programmes, five ( %) were entirely on-line (distance education), while the rest were on-campus. results for average tuition fees for master's degrees in global or international health are displayed in table . on average, across all degree programmes, the mean tuition fee was us$ for international students-usually defined as students who undertake studies outside their country of residence-and us$ for domestic students-usually defined as students who undertake studies in a country where they hold citizenship or other documented residency status. most programmes in our analysis ( %) were based in hics, with an average tuition of us$ . the mean tuition fee for online-option degrees (degrees which can be completed either in part or in full away from the traditional campus setting) was us$ vs us$ for on-campus programmes. on average, tuition for programmes in privately funded schools were considerably higher than for public schools, us$ and us$ , respectively. for the programmes in the usa, the average tuition fee for all students was us$ . there was little difference between domestic and international student fees (us$ for domestic vs us$ for international students). for programmes in the uk, the average tuition fee was us$ for domestic vs us$ for international students. in nordic countries (i.e., sweden and norway), the tuition was us$ for domestic students but an average of us$ for international students. interestingly, the degree programmes in asia and africa were associated with a high cost, with the master's in global health delivery in rwanda costing us$ , and degrees in asia costing, on average us$ . as previously mentioned, there is a large divide between tuition fees at public vs private institutions. this is underscored by the fact that the least expensive programme was at the university of bergen where tuition fee is us$ since, as stated on their webpage, public universities in norway do not charge students tuition fees, regardless of the student's country of origin. it is within their mandate as an institution and part of the country's general ethos to provide quality education to its students and future leaders at no cost. this philosophy is quite different from their counterparts in the usa where of the private schools are located and where the most expensive programme identified is based at duke university (us$ ). table compares the tuition fees for domestic vs international students. it shows that on average hic programmes charged higher fees for international students ( . times higher on average), while lmic countries charged the same for both international and domestic students. however, by looking at table , it can be noted that american schools generally charged the same for both categories of students. figure provides data on relative costs of living in each location as a function of the cost of attendance for international versus domestic students. using the united nations postadjustment multiplier as a proxy for cost of living, the scale of the circles is relative to the cost of living of each city; smaller circles represent locations that are less expensive to live in relative to its headquarters in new york city. while cost of living is relatively expensive for many european locations, these costs are offset by less expensive tuition fees. the same cannot be said about north american schools; many are located in cities with similarly high costs of living, yet tuition fees are much higher than for european schools. figure box lack of transparency: the approach and limitations to our analysis data were extracted by two authors (as and nav) with any discrepancies in double entry agreed on by consensus. for each degree programme we identified, we visited websites of these programmes and collected data on the tuition fees for international versus domestic applicants. we also emailed coordinators of the degree programmes to request clarifications or additional data, if needed. we focused on tuition fees for the entire degree programme rather than the annual tuition fees, since duration of degree programme varied from to years, with some degrees structured in such a way that students' graduation time was tied to their experiences and training garnered prior to programme entry. thus, it should be noted that when the final cost was calculated this was based on the typical time to graduation indicated either on the website itself or by the respective school's programme coordinator. in most european schools, fees are fixed regardless of how long a student takes to complete their degree. however, in north america time to graduation can be quite variable and students usually pay tuition for each semester or credit. this is particularly true of the us system where a degree cost can vary substantially between students. we chose to calculate total tuition based on a typical student's experience as suggested by either the school's website or the coordinator. in addition, some programmes require a project (eg, summer practicum) be conducted in elsewhere (typically, a low-income and middle-income countries (lmic)-the costs for these were not always absorbed by the tuition fees. while some students had their costs for projects abroad covered by a supervisor and others could apply for scholarships, the remainder would have to pay for the additional costs out of pocket. this information was not transparent across degree programmes. given the difficulty in collecting data on tuition itself, we did not quantify cost of living directly for each school. rather, we aimed to account for differences in living costs for any given school using an adjustment measure used by the international civil service commission (icsc), established by the united nations (un). the un postadjustment system is designed to ensure that the net remuneration pay of un staffers garners an equivalent purchasing power to that same staffer at the base of the system, new york city, regardless of their posting location. post adjustment multiplier considers differences in prices between the city in question and new york; local inflation; exchange rate of local currency relative to the usd; and average expenditure pattern of staff members currently at a given location. the multiplier is adjusted periodically to reflect changes in the cost of living in a given city. we used the multiplier from the march update. all cost information was converted into us dollars using the icsc conversion factor (march update) to make international comparisons possible. our analysis has several limitations. first, although we did an extensive search, it is possible we missed a few degree programmes. our search was limited to schools which were explicitly master's of global or international health rather than master's programmes with an option of a global health concentration. future iterations of this analysis could include other types of global health degrees (eg, master's of public health with a global health concentration). second, while efforts were made to contact each school if the tuition was not clearly listed on their webpage, it is possible that errors were made when calculating the tuition for fluctuating fees (eg, based on number of credits where the per-credit fee changes each year). for programmes which did not have a fixed total fee, it was difficult to gauge exactly how much a degree would cost in its entirety and despite seeking clarification, many schools could not give an exact number. in addition, while tuition was calculated based on the fees posted on a school's website in march , fees may have changed for the fall cohort. there was a lack of transparency both on the websites themselves and after contacting the universities. in addition, many programmes were reluctant to disclose the exact duration of a degree, since the duration depended largely on the profile of the incoming trainee and how quickly they could meet programme requirements. third, we used a simplistic marker for cost for living established by the un. while it would have been ideal to have gathered information of the average cost of living for a typical student in any given year, this information was not usually available for most schools, with some exceptions. fourth, we could not get data on diversity of the students who are in these global health degree programmes. thus, we do not know what proportion of the student body is made up of high-income country versus lmic trainees. lastly, we also do not have data on how many lmic trainees receive tuitionfee waivers or scholarships to complete global health degrees. also shows that many schools charge the same amount to domestic and international students (with the exception of western pacific and nordic schools), and that there is a wide dispersion in costs of tuition by region. despite limitations (see box ), we can make some key inferences from this analysis. the data presented suggest that there may be a disconnect between where global health training is needed most versus where the degree programmes are currently offered. it would thus be useful to apply the health labour market framework to better understand this discrepancy between demand and supply and the mechanisms behind this apparent divide. one potential explanation for this disconnect is that the idea of 'global health training' is itself an hic phenomenon; much of what is taught in such programmes in hics are likely typically covered in mph and related programmes (eg, community health) in lmics. another explanation, which we discuss later, is that global health degrees are a revenue-generating activity for the universities, which seek to take advantage of growing student interest in global health. tuition fees are high for most programmes. these costs will be even higher if we added costs beyond tuition (eg, travel, living expenses, accommodation, health insurance and summer practicum). without substantial external support, these degrees, we believe, would be unaffordable to trainees in lmics. additional research is needed to calculate fully loaded costs for global health degrees. this would vary a lot, depending on the country and cost of living and what financial aid or fellowships to this extent, we hope global health degree programmes will be transparent about diversity in their student body and provide information on what proportion of their lmic students receive tuition waivers or fellowships. we need data on diversity among global health students. we also need data on what proportion of the lmic students in these degrees get full tuition fee waivers. we know almost all schools offer such fee waivers, but cannot provide data on how many. this could be a topic of future research. tracking and improving this could help enhance reciprocity in global health. if students are paying high fees to get global health degrees, it is unclear what their job prospects are after completing such degrees. to recover the costs, they would need to find high-paying jobs (which might not be in the field of global health) and/or work in hics. we need to further study whether and to what extent global health degrees actually help build global health capacity and address the massive healthcare workforce shortage in lmics. in making the decision on fee waiver, another consideration should be the provenance of global health knowledge. the cost of global health training programmes for lmic students should reflect the fact that lmics are the origin of much of the knowledge that gets shared (or should ideally be shared) in hic global health training programmes. this is one of many reasons why lmic candidates should, as a matter of fairness, receive fee waivers. fee waivers may also represent a form of reparation, given the colonial and extractive origins of many hic universities and global/ public health schools. based on where global health degrees are offered and the high fees charged, we infer that most degrees might be catering to hic students and students from elite and privileged backgrounds in lmics, thus privileging a student group that is already privileged. the current leaders of global health organisations are drawn from this same limited pool. the pattern of global health training serves to perpetuate lack of diversity, a huge problem in global health that risks perpetuating colonial approaches and structures. if global health schools in hics truly care about making global health training accessible to lmics and believe in equity and reciprocity, then we should expect to see tiered tuition fee structures. we found that most schools, especially those in the usa, charge the same for domestic and international students, suggesting a lack of lower and affordable pricing for lmic trainees. this may be because the degree programmes are meant to generate revenues and be 'self-supporting' or 'self-financing.' but this explanation also suggests that, contrary to using global health degrees to enhance equity and reciprocity, many hic universities, especially medical schools, (including private universities with billions in endowments) apparently see global health training as a mechanism to generate revenue. to democratise global health education and improve equity, fairness and reciprocity, hic universities can and must allocate a certain proportion of their slots for lmic students, offer full funding support (including accommodation), and support with travel and visas. the fogarty international center training programmes by the us national institutes of health (nih) is a good model for all hics to replicate, as it has helped train over scientists worldwide, spending a small fraction of the overall nih budget. we are not surprised that there are few degree programmes in global health in lmics, since nationals of lmics do not see their day-to-day public health or clinical work as 'global health.' but we are puzzled as to why the few degree programmes based in asia and africa are priced so high. so, even within lmics, these degree programmes may be serving the privileged and elite. while these schools have indicated that they offer scholarships to candidates from lmics it is unclear how much funding is given to each student and how many students are granted these awards. this transparency would be useful. because of the covid- pandemic, more global health degrees might move to remote or distance education. it is disappointing that distance education global health degrees still cost about us$ for international students. if tuition fees were more affordable for lmic trainees, then thousands of students can be trained. but beyond affordability, there are other major barriers for lmic trainees, including the struggle to get visas to enter countries such as the usa and uk, especially with brexit and us visa bans. by working with lmic experts to create affordable, quality, online training programmes for lmic students, hic universities can demonstrate that they can deliver on reciprocity and equity. in conclusion, even if hic universities made their degrees more accessible, we should still ask why an african trainee must go to london or boston to learn about control of sleeping sickness or malaria (and pay top dollars for such training)? the traditional mindset in global health that expertise flows from north to south, is reflected in research, training, consultancy and technical assistance. this colonial model is ripe for disruption. building top-notch institutions in lmics is critical, to reduce dependence on hics, and to improve the overall quality, depth and relevance of global health training and research. someday, we hope hic trainees will earn global health degrees from such lmic universities, and learn directly from experts who are closest to the problems and closest to the solution. twitter seye abimbola @seyeabimbola and madhukar pai @paimadhu acknowledgements we are grateful to all the universities that responded to our request for information about their degree programmes in global health. errors, if any, are our own. contributors mp and sa conceived the study. as and nav collected and verified the data. as and mp wrote the initial draft. all authors revised and approved the final version. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. disclaimer the depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of bmj (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. this map is provided without any warranty of any kind, either express or implied. competing interests mp is on the editorial board of bmj global health. sa is editor-in-chief of bmj global health. they are from india and nigeria, respectively, but had the privilege of training in hic universities. they are currently based in hic universities, and are aware of their obligation to address the inequities discussed in this paper. patient consent for publication not required. provenance and peer review not commissioned; internally peer reviewed. towards a common definition of global health global health research needs more than a makeover on the meaning of global health and the role of global health journals global health needs to be global & diverse. usa: forbes global health / . the global health / report : power, privilege and priorities the foreign gaze: authorship in academic global health stuck in the middle: a systematic review of authorship in collaborative health research in africa who is telling the story? a systematic review of authorship for infectious disease research conducted in africa diversity in the editorial boards of global health journals global health journals need to address equity, diversity and inclusion consortium of universities for global health world health organization. the labour market for human resources for health in low-and middle-income countries a comprehensive health labour market framework for universal health coverage offline: the case against global health teaching global health from the south: challenges and proposals reciprocity in global health: here is how we can do better. forbes. usa: forbes on the coloniality of global public heath ebola and the narrative of mistrust global health still mimics colonial ways: here's how to break the pattern our role in global health. bethesda: national institutes of health the lancet global h. passports and privilege: access denied international civil service commission. the post adjustment index key: cord- -l d rgt authors: turcotte-tremblay, anne-marie; fregonese, federica; kadio, kadidiatou; alam, nazmul; merry, lisa title: global health is more than just ‘public health somewhere else’ date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: l d rgt nan ► global health can be anywhere as it often focuses on large-scale health inequities that are rooted in transnational determinants. ► some global health initiatives and actors aim to find solutions to domestic problems. ► king and koski's definition of global health may exacerbate inequities by reserving the right to call oneself a global health researcher to those who are privileged and have access to funding that enables them to travel to other settings. ► an inadequate definition of global health based on a 'here' vs 'somewhere else' dichotomy could result in less funding for a field already characterised by limited resources. ► the decolonisation of global health requires promoting and valuing reflexivity, critical approaches, equitable partnerships and accountability. king and koski recently published a bold commentary in bmj global health that defines global health as 'public health somewhere else'. it raises important concerns about the justification, scope, efficiency and accountability of the field. we appreciate that the commentary compels us to reflect on the definition of global health, its application and how the field could be improved. we also agree that many of the issues highlighted by the authors (ie, political priorities driven by the north, expertise from the north being overvalued) do exist in some global health interventions. many of us have heard of or witnessed disastrous situations caused by seemingly wellintentioned people. however, the problems described are not unavoidable or intrinsic characteristics of global health. moreover, we believe the proposed definition of global health is not adequate to conceptualise the field. rather than prompting improvements, it could result in mistrust towards global health and be a step backwards for the field. in the following, we contend that global health is more than just 'public health somewhere else' and argue that an inadequate definition entails risks for the field. . the populations of interest in these instances can be anywhere (low, middle and high-income countries) and include anyone affected and facing health inequities due to these transnational or global issues. the solutions can also be global or transnational in nature. the coronavirus pandemic is an example of a global health problem that is affecting people everywhere, especially vulnerable groups. due to the ever-increasing movement of people across borders, viruses like covid- can spread easily and quickly around the world and affect anyone, irrespective of whether they are in the global north or south. a global health response involving most countries that includes data sharing and coordinated efforts to stop the spread, find treatments and a cure as well as protect vulnerable groups (eg, elderly, migrants, prisoners, homeless) is therefore necessary. second, we disagree with king and koski's statement that 'a person engages in global health bmj global health when they practice public health somewhere-a community, a political entity, a geographical space-that they do not call home'. to us, this is an oversimplified statement. several of our colleagues, and we as well, have received funding to engage in global health in places we call home. for example, kk has conducted research on social protection policies in burkina faso, her home country. similarly, na has conducted research on the health of migrant workers in bangladesh, where he lives. we should be applauding and valuing global health initiatives that are led by local researchers/practitioners rather than excluding them from the definition. moreover, king and koski's definition is not adequate because some global health initiatives are aimed at finding solutions to domestic problems, whether it be in a high, middle or low-income country. for example, grand challenge canada funded the adaptation and transfer of innovations from low and middle-income countries to make a difference in canada. while the innovations come from abroad, the primary focus or end goal of such initiatives is quite local. this also highlights the fact that solutions for health problems in the north and south sometimes stem from expertise in the south. according to syed et al, global health partners are increasingly seeking a mutuality of benefits across countries. third, there are many public health researchers and practitioners working 'somewhere else', in a place that 'they do not call home', whose work does not qualify as global health. they do not view themselves as part of the global health community, nor do they actively participate in global health activities. their practice and research would also not be eligible for global health funding. for example, a canadian medical student's clinical placement in a public health unit in belgium is not automatically considered training in global health simply because it is done in another country. therefore, referring to global health merely as public health 'somewhere else' is not useful. fourth, we consider that king and koski's commentary and definition discredit the field of global health and fail to recognise its added value. while it is crucial to reflect on limitations, it is also important to highlight the field's strengths, best practices and success stories. there are examples of global health research and interventions where countries and communities have worked collaboratively and shared expertise, cultural knowledge and other resources to develop appropriate and effective solutions. [ ] [ ] [ ] moreover, while global health is considered one of the multiple branches of public health, the literature does suggest there are differences among them. for example, global health tends to have a broader focus (ie, health for all worldwide), a greater emphasis on health inequities, more interdisciplinarity and more 'bridging' between cultures and communities. practitioners and researchers working in global health also face unique ethical challenges (eg, power differentials between parties) and require that some key competencies be further developed (eg, cultural safety and inclusion, partnership development). recognising global health as a field in its own right is crucial to ensure there are dedicated resources for training and forums where the global health community can exchange and share knowledge, so that best practices can be further promoted, especially among students and emerging researchers and practitioners. it is also vital that global health be recognised as a distinct field so that resources will be made available to support global health initiatives that can promote the human right to health and help meet the global pledge to 'leave no one behind'. the proposed definition by king and koski entails several risks. first, accepting the definition proposed would mean that global health initiatives led by local actors or community leaders in low or middle-income countries, or by indigenous or migrant communities in high-income countries, would not be acknowledged and considered global health. this in turn could lead to devaluing their contribution as global health actors and limiting their access to resources to support their work, despite there being significant needs. therefore, rather than moving us 'towards an eventual decolonisation of global health', the definition by king and koski might actually reinforce the problems they highlight in their article, including inefficiency, lack of accountability and uncritical faith in western expertise, because only 'foreigners' would be acknowledged as doing global health. second, the definition may exacerbate inequities by reserving the right to call oneself a global health researcher, and the related expertise, exclusively to those who are privileged and have access to funding that allows them to travel and practise or conduct research in other settings that they do not call home. third, the definition would limit the scope of problems and solutions considered, possibly neglecting global and transnational issues. fourth, if global health is conceptualised as public health elsewhere, what interest would countries and communities have in investing in global health? this could result in less funding for a field that already faces the challenge of limited resources. lastly, the definition and commentary imply that working somewhere else is somewhat problematic and negative. we are concerned that this view is divisive and dangerous. it could contribute to ethnocentrism and ultimately limit the sharing of knowledge and expertise across groups. a 'here' versus 'somewhere else' dichotomy seems counterproductive. we live in a globalised world, and more than ever we are interconnected and interdependent. everyone in high, middle and low-income settings has a vested interest in attaining health for all and reducing health inequities. concerns over pandemics (covid- !), global warming, environmental degradation bmj global health and potential misuse of technological advances (the easy spread of fake news!) affect us all. protecting the most vulnerable is beneficial for everyone-for our economic, social, mental and physical well-being. as a burkinabé saying goes, 'we are together'. currently, global health may not be perfectly practised, but we need inclusive definitions, frameworks and training programmes that set the standards towards which we should all strive. we can have transparent discussions and be critical of global health academic programmes, research and practices, while sharing an adequate definition. we should condemn bad practices, rather than condemn the whole field. true partnerships across disciplines and geographic boundaries, which have resulted in meaningful projects, exist and can be further promoted. we need to promote the strengths and best practices of the field and value success stories while learning from failures. ultimately, the decolonisation of global health requires training programmes that teach reflexivity, critical approaches, equitable partnerships and accountability. such training programmes, and all global health initiatives more broadly, should include participatory approaches and ensure there are benefits for all stakeholders involved. resources should also be expended equitably. these are all good practices that are attainable. this is the morally 'right way' to do global health, and also a more effective way to achieve 'health for all'. contributors amtt conceived the main idea presented. all authors contributed to the conception and writing of the commentary. funding we thank the quebec population health research network for its contribution to the financing of this initiative. moreover, amtt received a training bursary from the canadian institutes of health research (cihr). lm was supported by a research scholar junior award from the fonds de recherche du québec-santé (frqs). competing interests none declared. patient consent for publication not required. provenance and peer review not commissioned; internally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. anne-marie turcotte-tremblay http:// orcid. org/ - - - defining global health as public health somewhere else towards a common definition of global health rethinking the 'global' in global health: a dialectic approach developed-developing country partnerships: benefits to developed countries? reverse innovation" could save lives. why aren't we embracing it? in: the new yorker the global health research capacity strengthening (ghr-caps) program: trainees' experiences and perspectives the what works working grouplevine r. millions saved. proven successes in global health emergence and robustness of a community discussion network on mercury contamination and health in the brazilian amazon ngo-researcher partnerships in global health research: benefits, challenges, and approaches that promote success lessons from developing, implementing and sustaining a participatory partnership for children's surgical care in tanzania public health and global health definitions beyond procedural ethics: foregrounding questions of justice in global health research ethics training for students l'évaluation qualitative, informatisée, participative et inter-organisationnelle (equipo) key: cord- -nkrw sad authors: khosla, rajat; allotey, pascale; gruskin, sofia title: global health and human rights for a postpandemic world date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: nkrw sad nan historically, pandemics have forced humans to break with the past and imagine their world anew. this one is no different. it is a portal, a gateway between one world and the next. -arundhati roy inspired by these words, we try to imagine 'another world'; one which puts everyone's health and human rights at the centre. for us to do that, we need to start with introspection about the world we wish to leave behind and ask ourselves some tough questions. for we, those working on health and human rights in global spaces and beyond, need to reflect on our values, our standards, our institutions, our mechanisms, and ask if we are fit for purpose. can we seize this opportunity to rebuild anew, without first taking a mirror to the sheer savagery of the injustice on display around the world-and our role in it? the obvious answer is-no. unless we realign our values, we risk dragging 'the carcasses of our prejudice and hatred' into the new world. with the waning of, or growing ennui from the shock of the pandemic, the world seems ready to slip back into 'avarice' with little thought. the reversal of the temporary but refreshing drop in carbon dioxide levels is evident, as is the greed of big pharma, and the onslaught on the global commons. are we going to continue with the absurdity of our present or '…walk through lightly, with little luggage, ready to imagine another world'? in the who constitution, world leaders proclaimed 'the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being.' the true meaning and purpose of this statement while never fully realised have never seemed more distant. it took just a few weeks of the covid- pandemic for the gains of decades to begin to erode. in the past months, millions have been pushed back into poverty; catastrophic consequences have been borne by the elderly; women and girls have suffered unspeakable levels of violence and been denied essential services, and we are witnessing what could well be a lost generation of children. all of which is needless and all of which was preventable. the question, therefore, is how did it all go so horribly wrong? over the last several decades, there have been significant, though uneven, advances in recognising health as a human right. addressing discrimination and inequality have largely been accepted as critical for people to attain and maintain their human rights to health. there is a general acknowledgement, at least discursively, that an individual's ability to manifest their human rights has a direct bearing on their health and vice versa. consequently, there have been significant strides in the development of normative aspects, on a range of global health topics, as well as tools for monitoring health from a human rights perspective. these advances have, however, been paralleled by regressive tendencies. the operationalisation of health within countries is often undermined by arguments that the specificities of national contexts justify the abdication of human rights responsibilities, resulting in policy incoherence and uneven implementation of international norms and standards. macrolevel politics and ruling ideologies have had profound impacts on the provision of services, and ultimately individual realisation of health. patterns of financing and funding for global health significantly determine not only normative developments but the implementation of interventions on the ground. global health work continues to pay lip service to human rights in setting global and national development priorities. yet the structures do not embrace health as a human right, as intrinsic to the capability of individuals to achieve a life they value. in failing to embrace what human rights offer, we lean towards simplistic solutions to otherwise complex bmj global health global health issues, rooted deeply in social, cultural, religious contexts. covid- is a stark example of this failure, both in the events leading up to the pandemic as well as in the responses. but covid- is not unique in revealing an ecology of sickness and mortality based on social determinants of health. failing to explicitly address human rights concerns not only continues to jeopardise the response to this pandemic, but the future of global health. the time is now to rethink health as a human right, that is premised not just on our collective conscience, but our collective responsibility. to rethink global health, we have to start by reimagining health as a 'global common'. so much of our world is premised on the notion of the individual that we have trouble understanding that some of the most crucial wealth we own is collective and social. many scholarly writings, reflecting on the determinants of the current pandemic, point to our failure to approach global health as 'commons' as the beginning of our collective descent. market structures and capitalistic models of development which justified everything, from fracking to unfathomable use of fossil fuels, to the systemic perpetuation of inequities, have systematically unravelled the concept of the 'commons'. add to that the abandonment of global leadership and the withering trust of populations in political leaders, the very glue that might have held the commons together, has been relinquished. sad as this may be, it is not new. for at least a generation, the archetype of 'commons' has been tainted by the narrative that it is invariably a tragedy. this view argues that commons would fall apart, as eventual overuse would destroy the resource. the pandemic, and the litany of failures that led to it, is evident. this pessimism may persist, in part, because the notion of the commons is frequently confused with an open-access regime, in which a resource is essentially open to everyone without restriction. therefore, without the 'social infrastructure' that defines the commons-the cultural institutions, norms and traditions-the only apparent value left is private profit for the most aggressive appropriators without any incentive to invest in the resource because someone else may gain from the returns. the same is true for global health. healthcare systems are held and managed under different property regimes, often with complete disregard of the basic tenet, that global health foremost is a 'global common right' and healthcare systems a 'common pool resource'. as we strive to create another world, we must start by challenging how we understand 'commons', and build a narrative for the collective, recognising the power of exogenous variables such as moral and social norms, and the significance of the commons to those who do not hold the strings of power. equally importantly, we must rebuild public trust, because it is not just addressing the pandemic that is at stake, but the whole future of global health. to ensure we are fit for purpose for a new world, we need to take a deeper look at our institutions, our mechanisms. the questions that arise are not about a single institution or mechanism, but about multilateralism as a whole, and about the member states who are the 'masters' of these institutions and the bedrock on which multilateralism is premised. the history of the united nations (un), and the league of nations that preceded it, provides critical context. many blame the failure of the league of nations, on general weaknesses within the organisation, such as the voting structure, and incomplete representation among world nations. the league was also paralysed by the absence of the usa, already a significant power. as paradoxical as it may be, the same pivotal country is now systematically disengaging from multilateral institutions and agreements. the situation for the un today, however, is more complicated. not only is this a time of rising nationalistic demagogues as leaders, with narratives restricted to 'me' first; the system also struggles with structural weaknesses, block politics and a voting structure which privileges certain countries over others. member states can rightly be criticised for reducing the un to a fig leaf that they hide behind, but also a whipping mule. despite rallying calls for global solidarity, as covid- has shown, we are not all in this together. siloed and isolated positions do not work. no one is insulated, and no issues are unconnected. the pandemic has brought into sharp focus the interconnectedness, the indivisibility and inalienability of the human rights agenda from the global health, global development and global peace agendas. time is now to show real leadership, seize the opportunity and bring these agendas together to deliver a truly sustainable future, one that truly leaves no one behind. the need for an in-depth review of these institutions today is more acute than ever because the way we strengthen and reshape them will not only determine our collective future but that of generations to come. for any such review to be genuinely transformative, however, it must start with a review of the member states and their conduct domestically and within these institutions. john locke explained the notion of the social contract as one 'where people in the state of nature conditionally transfer some of their rights to the government to better ensure the stable, comfortable enjoyment of their lives, liberty, and property'. the pandemic has shown people around the world willing to give extreme deference to the state and readily accepting severe restrictions to their freedom of movement for weeks and months at bmj global health a time. however, hundreds and thousands of lives have been lost, sometimes because of authoritarian leadership and their inability to accept scientific evidence and willingly subject people to needless suffering and death. the question becomes, therefore: is the current social contract tenable? from the grass roots to the national to the global level, as governments fail to provide 'stable, comfortable enjoyment of their lives, liberty, and property', this question is now universal. as the elite went into their burrows and hid for months largely unscathed, the 'common person' not only bore the burden as 'essential workers' but many died needlessly. the demand for an equal social contract premised on the fundamental values of human rights for all human beings, equal participation and voice and not deference, is required. we need collectively to answer the question: is it time to renegotiate the social contract? the stakes are high, and we cannot afford to get it wrong. we go back to our original question: are we ready to imagine a new world? to answer yes, we must first fathom the courage to 'shed the baggage', the prejudices of the past and reimagine a narrative which puts our collective health and human rights at the centre. through this essay, we hope to initiate a discussion that can help us build back for the better. in the words of jonathan mann, 'time is now for us to come together as "equal partners in the belief that the world can change".' twitter pascale allotey @pascaleallotey contributors the manuscript is a result of discussions towards foundational work on the future of human rights in health. the initial draft was written by rk and subsequent versions jointly developed with contributions from pa and sg. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests none declared. patient consent for publication not required. provenance and peer review not commissioned; internally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. pascale allotey http:// orcid. org/ - - - the pandemic is a portal world health organization. constitution of the world health organization. basic documents, forty-firth edition supplement global commission on hiv and the law. risks, rights and health leading the realization of human rights to health and through health: report of the high-level working group on the health and human rights of women, children and adolescents interpreting the international right to health in a human rights-based approach to health health and human rights at a crossroads building a transformative agenda for accountability in srhr: lessons learned from srhr and accountability literatures capability and well-being addressing human rights as key to the covid- : response silent theft: the private plunder of our common wealth the tragedy of the commons whose common future: reclaiming the commons health care as commons: an indigenous approach to universal health coverage second treatise of government health and human rights: a reader key: cord- -jgw nat authors: srinivas, prashanth nuggehalli; henriksson, dorcus kiwanuka; s gordeev, vladimir; decoster, kristof; topp, stephanie m; abimbola, seye title: “together we move a mountain”: celebrating a decade of the emerging voices for global health network date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: jgw nat nan it was otherwise an unremarkable november bus ride from antwerp to montreux; cold, but in the rather warm company of early career researchers who were to soon become the first cohort of emerging voices for global health (ev gh; http://www. ev gh. net). on that ride, early career health system researchers from countries began a journey. little did they know it would continue for over a decade, gathering in its wake, more early career researchers from countries, overwhelmingly from the global south. the ev gh programme has come a long way, from the first meeting at the annual colloquium of institute of tropical medicine, antwerp, belgium, and the subsequent road trip from antwerp to the first global symposium on health systems research at montreux, switzerland. ev gh began as a leadership and capacitybuilding programme incubated within the institute of tropical medicine, antwerp (itm-a) by a team led by professor wim van damme. with an explicit commitment to switching the poles (between the global north to the global south), the team at itm-a sought to design a unique programme to provide early career researchers with communication skills to critically examine global health agendas and events, and more importantly to not become passive consumers of evidence in global health events (such as the one that was, at the time, coming up in montreux). this was a disruptive idea. early career researchers typically enter global events in awe of the authoritative and prominent names featured in keynotes and panels. indeed, the first ev gh programme began by acknowledging the elderly white male high-income country dominance of the global health agenda. the programme wanted to do something about it, beginning at that first symposium in montreux. this year, , marks the th year of this programme and offers an opportunity to look back and look within. in this editorial, alumni and members of the ev gh globally representative elected governance entity share a brief historical overview of the network and subsequently summarise reflections of alumni across all six cohorts till date. the ev gh programme deliberately selects a cohort of - early career researchers in health systems, living or working in lowincome and middle-income countries and with an interest to engage critically on global health issues that have local relevance within their country/local health systems. while scientific merit and excellence have shaped the selection, ev gh peer reviewers and selection committees have rarely relied purely on scientific achievements. an explicit eye for candidates who have a history of critical policy and/or community engagement and ensuring a mix in each cohort of gender, geographical regions and nature of experience with health systems has guided the selection in addition to academic excellence and achievements. each ev gh cohort receives - weeks distance learning programme. participants get to know each other and engage in vibrant discussion and debates on global health topics related to the upcoming health systems research symposium. they also receive interactive online training designed to improve communication skills in oral presentations and posters through design inputs and critical peer review. the ev gh programme has bmj global health built skills that are often not part of university curricula, especially focusing on effective communication in oral presentations, panel discussions and framing and posing questions in meetings and global health events. rather than being taught, often, what participants have found beneficial is the opportunity to develop these skills within an engaging peer-steered learning environment that the programme offers. after going through the ev gh programme, participants have often continued to engage with fellow ev gh alumni in collaborative blogs and opinion pieces often in the international health policies newsletter or on one of several blog platforms offered by international global health journals. these pieces have often sparked critical discussions in countries or regions which participants find to be a strength of the network. participants' skill to confidently speak on global health issues on social media platforms or among colleagues in-country improved through the programme. at the time the ev gh programme was being birthed, the health systems research community was actively involved in field-building activities, trying to raise the profile of what has today come to be recognised as a coherent field-health policy and systems research (hpsr). under the leadership of various global health actors and the who alliance for health policy and systems research, efforts were being made to bring together a society of practitioners of health policy and systems research. the global hpsr community grew from strength-tostrength and eventually launched a society of its own, health systems global (hsg). a biennial global symposium is hosted by hsg as a platform for exchange and community-building, with an explicit focus on peoplecentred health systems, action on social inequalities by addressing the social and political determinants of health, engaging with a wide variety of biomedical, social science and humanities approaches to strengthening health systems and leadership embedded in the global south. ev gh had begun to organically coalesce around these values, such that when hsg announced the possibility of becoming one of its thematic working groups in , ev gh found a home within hsg, while retaining its identity. as the global symposia on health systems research was being hosted from one hpsr centre of excellence to another (beijing, cape town, vancouver and liverpool), ev gh invited universities and institutions, many of them in the global south, to become member organisations of the ev gh network. with a desire to further acquire a more global character and egged on by itm-a to not feel rooted within one high-income country institution, between and , the ev gh established a globally representative governance structure. this governance structure has ev gh representatives from each of the six who regions in a governance committee and with a secretariat established at one of the ev gh member institutes, the institute of public health, bangalore. following each biennial ev gh venture, participants join an email discussion group that serves as a common platform to be in touch with participants from all cohorts. other interested global health researchers are also welcomed to join this open email discussion group. the discussion group serves as a bulletin board for tracking global health events and commentary. it is often the place where collaborative opinion pieces and blogs by ev gh alumni begin. ev gh alumni work with peers rather than with supervisors and this improves their confidence and enables collaborative and multidisciplinary engagements. for many ev gh alumni, being a member of this network has helped them to raise their voice locally and speak with confidence on how global forces could be influencing local change within their settings. the collective engagement every years during the biennial global health systems symposia enables community-building and several ev gh alumni have taken on leadership roles within our network and within the broader hpsr community and beyond. some have become elected members of the hsg board, and others have taken the lead in managing other thematic working groups within hsg, and many others participate actively in other regional and global events while coordinating with fellow ev gh alumni in such fora, leveraging the membership in the network to seek wider change in the health systems and global health community. possibly, the most important take-away message for the ev gh has been the emphasis on the nature of change that the network seeks at local, national, regional and global levels. over the years, the network has nurtured a focus on equity and action on social determinants of health. an equity focus has been embedded in the programmes of various cohorts, including through application of a gender and power lenses, and a more recent focus on climate change and on fragile and conflict affected states. ev gh alumni have continued to apply these lenses to their work in other aspects of health, and as part of a larger advocacy goal that they take on after the programme. given its growth over the years, many ev gh alumni from early cohorts are today established researchers themselves (with a few practitioners, policymakers and advocates as well). there are therefore increasing opportunities for mentorship in-house. either because of a lack of secure funding commitments, or due to the organic nature of its growth, it is likely that the ev gh network will remain informal, even as several alumni identify this as a possible weakness of the network. finding solutions for funding of ev gh without losing bmj global health its inherent flexibilities and getting co-opted to the extent that it becomes one of the usual suspects in global health is a challenge facing the ev gh leadership and a tension that needs to be worked out over the next years. the premise for developing the ev gh programme a decade ago was that global health symposia were plagued by presentations of poor quality and with limited attention to communicating messages to a truly global audience. to enliven, energise and make global health events more vibrant, to improve the global health dialogue and to ensure that they are participatory and truly inclusive of voices from the global south, ev gh programme and its diverse participants challenged head on the text-heavy powerpoint and expert-driven presentation formats, by integrating community voices and prioritising participatory formats like fish-bowls, helping foreground real-world issues and provide a global-south orientation. and indeed, hsg itself, and the organising leadership of subsequent global symposia on health systems research-in beijing ( ), cape town ( ), vancouver ( ) and liverpool ( )-welcomed this changing format. as we prepare for the next symposium in dubai ( ), it is clear that the global hpsr community has come a long way in accepting the need for debate and dialogue on the best ways for challenging the norms and structures that shape social inequalities from the global to the local. with the covid- pandemic continuing unabated in many parts of the globe, the unfinished agenda on multiple fronts ranging from health systems to the sdgs casts a shadow on the response. amid such uncertainty, there is one clear agenda still waiting on the other side of this pandemic; in an era of physical distancing, how to stick together is an important challenge facing the health research community. looking back at the past decade of ev gh, we seek to reaffirm its promise of continuing to incubate disruptive and critical early career leadership within global health. together we move a mountain. long may it continue! contributors all authors participated in the conceptualisation of the article. nsp, dkh, vsg and kd wrote the first draft, and smt, kd and sa reviewed and provided comments. all authors reviewed funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors competing interests all authors (except kd) are alumni of the emerging voices for global health network. nsp, dkh and vsg are either current or earlier elected members of the governing group of the network. all authors have been earlier or currently involved in supporting the network in voluntary capacities provenance and peer review not commissioned; internally peer reviewed. data availability statement no additional data are available open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial health systems global, the new international society for health systems research acknowledgements the ev gh network ( www. ev gh. net) is very grateful to prof. wim van damme and david hercot, who initiated the venture years ago, the many people (aka 'friends of ev') who have generously supported the programme over the years in various ways, the ev secretariat staff at iph in recent years (pragati hebbar, ketki shah, diljith kannan), secretariat staff of partner institutes and co-hosts, including itm (and annelies de potter in particular). the authors would like to thank nityasri sn from the ev gh secretariat in iph, bangalore for steering the process towards this article. the authors would also like to thank generous funders and supporters over the past years, with a special mention for the belgian development cooperation (dgd) and hsg who have been very supportive throughout these years. last but not least, the ev network would not be what it is now without the enthusiasm of the many ev alumni who have together 'moved a mountain' over the past years, and will no doubt continue to do so in the future. key: cord- -ivhr no authors: richardson, eugene t title: pandemicity, covid- and the limits of public health ‘science’ date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: ivhr no nan ► mathematical models of infectious disease transmission are merely fables dressed in formal language (that therefore create the illusion of being scientific). ► for the most part, such models serve not as forecasts, but rather as a means for setting epistemic confines to the understanding of why some groups live sicker lives than others-confines that sustain predatory accumulation rather than challenge it. ► pandemicity-which we might conceive of as the linking of humanity through contagion-may bring about the dawning of a relational consciousness in the descendants of colonialists, especially in the global north. "no man is an island, entire of itself; each is a piece of the continent, a part of the main. if a clod be washed away by the sea, europe is the less, as well as if a promontory were, as well as if a manor of thy friend's or of thine own were. each man's death diminishes me, for i am involved in mankind. and therefore never send to know for whom the bell tolls; it tolls for thee." john donne wrote these lines in as part of a series of meditations conducted during a period of what we would now term social distancing, while he suffered from a relapsing febrile illness. whatever the pathogen, donne's musings on being part of a greater whole were not conceived during an epidemic or pandemic, since these words did not exist as nouns in the english language until and , respectively. in , the quasi-inexorable spread of severe acute respiratory syndrome coronavirus (sars-cov- ) has brought the interconnectedness of humankind back to the forefront of many a consciousness. yet it has not brought clarity to the blurred boundary between epidemics and pandemics. this was made manifest by the who's hesitancy over employing the latter designation in march . and while 'expert' epidemiologists have been climbing over themselves to brandish their latest forecasts (a phenomenon i have described as #willtopunditry), it seems worth asking, are their ways of parsing health phenomena useful? moreover, if one accepts that the boundaries between disease outbreaks and their political economic determinants/sequelae are blurred, the same question should also be asked of other 'expert' modelers, economists in particular. the modern epidemiologist is essentially an accountant (and this is a compliment). they tally up data, present graphs and tables, and make suggestions about investments (in intervention measures such as social distancing, for example). when it comes to forecasting epidemic trends, however, their contributions-from specious metrics like the global health security index to kaleidoscopic computational models of communicable disease transmission-have limited predictive power (as experience in global health has repeatedly shown). during the - , ebola virus outbreak in west africa, modelers devised a dizzying array of forecasts, ranging from the who's supposition early on that the outbreak would be contained at a few hundred cases to the us centers for disease control and prevention's estimate of up to . million cases by january . interestingly, this latter model was least consistent with the observed epidemic; at the same time, however, it was claimed to be the most useful (as an advocacy tool to muster a robust international response). this is not quite what the statistician george e. p. box had in mind when he wrote his famous dictum, 'all models are wrong but some are useful.' more recently, suppositious models of the sars-cov- outbreak in the uk posited that half the country (some million people) might already be infected (as of march ) and that the 'herd immunity' approach initially adopted by the uk government was defensible. in the usa, health economists bendavid and bhattacharya upped the ante questioning whether universal quarantine measures were worth their costs to the economy. the duo's neoliberal proclivities, coupled with this current offering in the wall street journal, underscore the ideological presumptions intrinsic to any modeling exercise. as the israeli economist ariel rubinstein notes: ( ) mathematical models are merely fables dressed in formal language (that therefore create the illusion of being scientific) and ( ) economics is an academic discipline which tends towards conservatism and helps the privileged in society maintain their dominance. the same can be said for epidemiology, where bourgeois empiricists build fable-models whose assumptions are usually conjured from the standpoint of dominant interests. in the case of ebola outbreak in west africa, epidemiologists attributed amplified transmission to local populations' beliefs in misinformation or their 'strange' funerary practices-in essence, diverting the public's gaze from legacies of the transatlantic slave trade (or maafa), colonialism, indirect rule, structural adjustment and extractive foreign companies as determinants. these ways of parsing health phenomena are indeed useful for those in protected affluence, since epidemiologists filter out information vital for demonstrating the global north's complicity in producing planetary health inequities-weakening the disposition of social resistance to such inequity (and demands for reparations) as a result. for the most part, mathematical models of infectious disease transmission serve not as forecasts, but rather as a means for setting epistemic confines to the understanding of why some groups live sicker lives than others-confines that sustain predatory accumulation rather than challenge it. similar to the role philanthropy plays in occulting ecnonomic exploitation, the modest improvements in well-being offered by the right hand of public health 'science' often disguise what global elites and their looting machines have expropriated with the left. that being the case, the field is in clear need of decolonising; however, it is producing some potentially useful, although structurally naïve, work to support the containment of sars-cov- within countries. but epidemiology's abetting function as an ideological apparatus can manifest at any time. in the wall street journal article mentioned above, bendavid and bhattacharya, both academics based at stanford university, may have, unwittingly, given the trump administration the stanford imprimatur to trade people's lives for profits. as such, does it make sense to speak of such fabulists-given that their models are fables-as experts? the fable-model i would propose prioritizes people's lives and has radical wealth redistribution as its moral. such a model requires expertise in solidarity. the same solidarity that kwame nkrumah called for as an antidote to neocolonialism. the same lack of solidarity that allows the descendants of colonialists-those whose power and privilege have often shielded them from pandemicity-to continue proffering conservative fables under a veil of scientism, which for the most part serve to conceal violently seized privilege, thus maintaining transnational relations of inequality. [ ] [ ] [ ] [ ] covid- has the potential to change this. pandemicity-which we might conceive of as the linking of humanity through contagion-may bring about the dawning of a relational consciousness in the descendants of colonialists. as their bubbles of protected affluence are burst by sars-cov- and tnv (the next virus) and they gain insight into global human interconnectedness, they may also begin to see that the same disproportionate mortality they are seeing around them due to covid- is the quotidian experience of much of the global south, where nearly children die daily from preventable causes. as they start to sift back through the determinative web of human rights abuses-that is, the pathologies of power that set the stage for these health inequalities, they may begin to see that they contribute a great deal to the production and reproduction of structural injustice because of the social position they occupy and the violence that has been committed in their names. and with this should come the realisation that every local outbreak is a pandemic, since they are involved in (hu)mankind. or they will continue their retreat intro militarisation, xenophobia, necropolitics and fascism, and the bell will be deafening. for as donne wrote, '…never send to know/for whom the bell tolls;/it tolls for thee.' contributors etr is the sole author of this work. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests none declared. provenance and peer review not commissioned; internally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. eugene t richardson http:// orcid. org/ - - - pandemic' vs did the hesitancy in declaring covid- a pandemic reflect a need to redefine the term? the symbolic violence of 'outbreak': a mixed methods, quasi-experimental impact evaluation of social protection on ebola survivor wellbeing metrics: what counts in global health covid- gives the lie to global health expertise mathematical modeling of the west africa ebola epidemic estimating the future number of cases in the ebola epidemic -liberia and sierra leone cdc's top modeler courts controversy with disease estimate ebola: a big data disaster robustness in the strategy of scientific model building covid- : experts question analysis suggesting half uk population has been infected mathematics of life and death: how disease models shape national shutdowns and other pandemic policies. science magazine is the coronavirus as deadly as they say? on the coloniality of global public health economic fables. cambridge: open book the political ecology of disease in tanzania epidemic illusions let the circle be unbroken: the implications of african spirituality in the diaspora discourse on colonialism indirect rule redux: the political economy of diamond mining and its relation to the ebola outbreak in kono district dying for growth: global inequality and the health of the poor how europe underdeveloped africa. london: bogle-l'ouverture understanding west africa's ebola epidemic: towards a political economy facts, power and global evidence: a new empire of truth essays on the sociology of knowledge postcolonial though and social theory silencing the past: power and the production of history violence: six sideways reflections winners take all: the elite charade of changing the world the looting machine: warlords, oligarchs, corporations, smugglers, and the theft of africa's wealth the divide: global inequality from conquest to free markets covid- and circuits of capital ideology and ideological state apparatuses the foreign gaze: authorship in academic global health neo-colonialism, the last stage of imperialism latin american critical ('social') epidemiology: new settings for an old dream decolonising the mind: the politics of language in african literature decolonizing methodologies: research and indigenous peoples tracking covid- responsibly children: reducing mortality pathologies of power: health, human rights, and the new war on the poor responsibility for justice biosocial approaches to the - ebola pandemic key: cord- -umlqh q authors: wenham, clare; kittelsen, sonja k title: cuba y seguridad sanitaria mundial: cuba’s role in global health security date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: umlqh q cuba has been largely absent in academic and policy discourse on global health security, yet cuba’s history of medical internationalism and its domestic health system have much to offer contemporary global health security debates. in this paper, we examine what we identify as key traits of cuban health security, as they play out on both international and domestic fronts. we argue that cuba demonstrates a strong health security capacity, both in terms of its health systems support and crisis response activities internationally, and its domestic disease control activities rooted in an integrated health system with a focus on universal healthcare. health security in cuba, however, also faces challenges. these concern cuba’s visibility and participation in the broader global health security architecture, the social controls exercised by the state in managing disease threats in cuban territory, and the resource constraints facing the island—in particular, the effects of the us embargo. while cuba does not frame its disease control activities within the discourse of health security, we argue that the cuban case demonstrates that it is possible to make strides to improve capacity for health security in resource-constrained settings. the successes and challenges facing health security in cuba, moreover, provide points of reflection relevant to the pursuit of health security globally and are thus worth further consideration in broader health security discussions. ► debate on global health security has focused on how we collectively respond to outbreaks, including what role and responsibility states have in supporting response efforts to health crises beyond their borders, and in strengthening domestic public health capacities to detect and contain disease risks. ► cuba's history of medical internationalism and its domestic disease prevention and control activities speak directly to these debates; yet, cuba is largely absent within global health security academic and policy discourse. cuba's international medical activities focused on routine health provision and crisis response, alongside its domestic disease control activities and universal health system demonstrate that cuba has a strong health security capacity. ► health security in cuba also faces challenges, however, particularly with respect to the trade-off between civil liberties, regime preservation and security in protecting the state and its population from diseases threats, and with respect to resource constraints, exacerbated by the us embargo. ► cuba does not frame its disease control activities within a discourse of health securitywhich impacts cuba's visibility and participation in the global health security regime. cuba demonstrates that it is possible to make strides to improve capacity for health security in resource-constrained settings facing multiple challenges, although within a particular political context where social controls exercised by the state raise questions of civil liberties. ► the successes and challenges that characterise cuba's health security activities speak to broader global health security debates and are thus worth engaging with more explicitly in contemporary health security discourse and practice. cuba has been largely absent in academic and policy discourse on global health security, yet cuba's history of medical internationalism and its domestic health system have much to offer contemporary global health security debates. in this paper, we examine what we identify as key traits of cuban health security, as they play out on both international and domestic fronts. we argue that cuba demonstrates a strong health security capacity, both in terms of its health systems support and crisis response activities internationally, and its domestic disease control activities rooted in an integrated health system with a focus on universal healthcare. health security in cuba, however, also faces challenges. these concern cuba's visibility and participation in the broader global health security architecture, the social controls exercised by the state in managing disease threats in cuban territory, and the resource constraints facing the island-in particular, the effects of the us embargo. while cuba does not frame its disease control activities within the discourse of health security, we argue that the cuban case demonstrates that it is possible to make strides to improve capacity for health security in resource-constrained settings. the successes and challenges facing health security in cuba, moreover, provide points of reflection relevant to the pursuit of health security globally and are thus worth further consideration in broader health security discussions. in the wake of this epidemic, academic and policy debate has turned to how the system for global health security can be reformed. [ ] [ ] [ ] this has included a focus on how national and global capacities can be enhanced to rapidly respond to health emergencies and how we can connect global health security activities to broader health system strengthening efforts, including the movement towards universal health coverage (uhc), as championed by who director-general tedros adhanom ghebreyesus. cuba's activities in global health security speak directly to these debates. indeed, cuba has made considerable strides in infectious disease control, comparable to that of high-income countries, doing so in a low-income setting beleaguered by a struggling economy, and facing resource and access challenges from the us embargo. these activities are embedded within a strong integrated health system, of which a key constituent part is preventative medicine (including vaccination for infectious disease) and uhc free at the point of care. through its work internationally, moreover, cuba has moved towards supporting sdg .d by assisting other countries in meeting their core capacities for surveillance and response for disease control. importantly for the global health audience, cuba demonstrates that it is possible to make strides to improve capacity for health security in resource-constrained settings facing multiple competing challenges, although this has been in a context of an authoritarian state where civil liberties have been questioned. given these achievements, it is interesting that cuba has not been referenced in broader global health security debates; yet cuba's lack of visibility in health security academic and policy discourse is noticeable. this could be attributed to cuba's isolation geopolitically, as a small island state, and given that the health security policy field has traditionally been western (us) dominated. the cuban government may not have wanted to engage in this debate, or been able to participate, based on political tensions, ideological differences and/or the us blockade of the island. alternatively, the geographical focus of health security discourse (and associated pragmatic efforts) has shifted temporally and geographically as the perception of 'next big one' has expanded from being focused solely on the threat of pandemic influenza in south-east asia to include haemorrhagic fevers in low-income and middle-income countries (lmics) in africa. cuba might have been absent from global health security narratives, similar to most of latin america, because it had not been prey to a major epidemic that has put its health system surge capacity in the spotlight. however, with the spread of zika across the caribbean and to cuba, despite the government's denial of the outbreak, this may not be an adequate explanation. we suggest a third consideration for the lack of cuban visibility in discussions of health security: that cuba does in fact demonstrate key traits which we understand to be health security, but it does so in the name of solidarity and part of a socialist project which seeks to export the strengths of the cuban regime internationally. we argue that health security is alive and well in cuba and offers insights into how we might strengthen health security globally, particularly in lmics which is vital to future preparedness efforts, although we consider these questions cautiously, recognising the particular political context in cuba and the trade-offs of civil and political liberties which come at the costs of such a strengthened health security position. to demonstrate our argument, we focus on what we consider the key traits of cuban health security, conceptualised as falling into two main categories: cuban medical engagements internationally, and cuban health provision domestically. we then consider some of the challenges for health security in cuba, notably the tension between providing complete security from the threat of disease and protecting civil rights within the state, and the impact of the us embargo on cuban health security, before reflecting on what we can learn from the cuban experience in improving health security globally. this paper uses a case study methodology to understand how cuba exhibits tendencies in global health security. the empirical material for this paper was drawn from a series of semistructured elite interviews conducted in havana in december with policymakers, medical professionals and other infectious disease control experts working in cuba. these data were subsequently transcribed, and thematic analysis was conducted to identify key trends that appeared in the qualitative material. we further undertook documentary analysis of policy documents from a range of sources, including the ministry of public health (minsap), cubacoopera (a government department responsible for medical internationalism) and the who/pan american health organization (who/paho), along with media sources both from cuba (granma) and internationally. these documents were sourced both in english and in spanish, and where necessary, translations are the authors' own. this material was triangulated against secondary literature including academic literature on health policy, international relations and cuban/latin american studies. these sources were identified through medline, google scholar and snowballing from these and international and cuban contacts. this latter step was important for two reasons: first, having undertaken interviews with policymakers from a one-party state that has worked hard to control information, we wanted to ensure that we were not solely reproducing the narrative that the cuban government wished us to voice, but that this was contextualised amid other research and findings within health and/or security analysis of the island. second, as hollander states, short-term research visits to socialist countries can be wholly misrepresentative, so we wanted to ensure that our findings were reflective of broader debates and narratives within the literature on the cuban health system. cuba's medical internationalism cuba's programme of medical internationalism has been well documented by latin-american scholars and anthropologists. [ ] [ ] [ ] [ ] medical internationalism involves sending medical brigades on missions abroad to offer routine health services, respond to crises as well as bringing medical students and patients back to cuba for education and/or treatment. we consider this to be the most apparent embodiment of cuban health security activities internationally, where the state appears to be supporting response efforts for emerging pathogens by providing human resources and technical expertise within outbreak response, and health systems capacity-building elsewhere in the world, such as the training of international medical professionals. particularly significant from the standpoint of global health security is the role that these cuban doctors, particularly the henry reeve brigade, have played in supporting responses to a number of epidemic outbreaks. brigades were deployed to el salvador, ecuador, nicaragua and honduras between and to support dengue fever response efforts. moreover, the cuban government was one of the first to respond to the ebola outbreak in west africa and its henry reeve brigade constituted the largest international bilateral support to arrive in the region. this stands in contrast to the criticism that the global community as a whole has faced for its delayed and inadequate response to the crisis. the cuban delegation, under who, was particularly involved in direct care to patients in ebola centre modi (liberia), kerry town and port loko (sierra leone) and supported the establishment of the coyah ebola treatment centre (guinea). to do so, cuban brigadistas received comprehensive training at the tropical medicine institute, instituto pedro kouri (havana), demonstrating the significant health security competency and capacity within cuba. this training included the use of personal protective equipment, biosecurity standards for patients and staff, treatment and diagnostic techniques, and risk scenario activity planning, and can now be used to launch a response to other diseases (interview, instituto de medicina tropical pedro kouri). more routinely, cuba deploys up to % of all its medical professionals to a number of non-crisis settings. this has involved medical teams totalling over health personnel, in over countries, including within the who and the g states. these cuban medical teams have tended to work in rural communities or in urban slums, areas that often have not had state medical provision prior to cuban arrival due either to an inability to recruit medical practitioners to live and work in these areas, or a lack of monetary motivation to establish provision where the local community has not been able to afford associated care costs, such as out-of-pocket payments. as routine access to health professionals facilitates the detection of diseases sooner, such activity can be considered to directly contribute to increased global health security, although notably this has not necessarily been the aim of any such brigade's mission. indeed, despite these efforts to support the development of health systems and respond to health crises, cuba does not frame these activities within the discourse of health security. rather, cuba's medical internationalism is framed as the embodiment of international solidarity and considered an extension of cuba's national health policy within the socialist framework. interviewees cited 'serving a global population' rather than protecting cuba's citizens against pathogen spread as reason for crisis interventions. recent media coverage of the closure of the mais medicos programme in brazil has focused on the political determinants of these overseas medical missions, where cuban doctors are sent to provide healthcare in exchange for oil or hard currency. political motivations have also been suggested as standing behind cuba's provision of over half of the medical professionals for mission barrio adentro in venezuela, chavez's (now failing) health and social welfare programmes focused on delivering universal healthcare across poorer neighbourhoods. such activities have spurred discussion on the motivation for this cuban international activity, whether driven by international prestige, goodwill, soft power, solidarity or economic gain. cuba's medical missions have also been criticised for violating the (labour) rights of those deployed. there is some suggestion, for example, that these doctors may not have autonomous decision-making regarding whether they want to deploy on these international missions, but rather are forced to do so by the government. recent legal proceedings in brazil, moreover, have sought to show that the cuban model of exporting physicians for economic gain violates the international labour organization's agreement on the protection of wages. this is based on the findings from the mais medicos programme that suggest that cuban medics received significantly less in wages than their international counterparts, with the majority of the wages paid directly by brazil to cuba for its doctors being retained by the cuban state. discussions about the profit-making nature of these overseas medical missions suggest that cuba's medical internationalism may be less about a notion of international solidarity or global health security, but rather functions as a form of income generation for the government within a failing economic system. in this respect, the contribution of these missions to global health security might be overegged and simply a by-product of government financing. nevertheless, we suggest that this activity could be considered part of a cuban contribution to global health security and may offer lessons for strengthening national and global rapid response capacities for disease emergence, as the deployments and training of the henry reeve brigade suggests. indeed, the global response to the - ebola epidemic was criticised as being 'hampered by a lack of trained and experienced personnel willing to deploy to the affected countries'. aside from important concerns regarding the rights bmj global health of medics deployed, cuba's medical brigades and the training they receive offer insights into how such a rapid response capacity might be achieved. moreover, the focus of cuba's medical internationalism in strengthening the provision of routine health services in resourceconstrained settings speaks to a broader vision of health security than disease containment and response alone-a focus of current debates concerning how global health security activities can be integrated in a more sustained way into broader health system strengthening and uhc aims. yet, this deployment of cuban teams has also raised concerns of taking jobs away from locally qualified physicians and healthcare workers, which raises further questions of sustainability within health systems as a cornerstone of uhc. discussions on cuban healthcare tend to focus on its government-run, integrated health system, rooted in a fundamental right to health as part of the socialist project; to provide a range of preventative and curative services free of charge to all. these services have produced worldleading health outcomes and demonstrate what is possible to accomplish in a resource-poor setting, allowing cuba to demonstrate a strong domestic health security position, although the veracity of some of these claims has been disputed. in particular, critiques have highlighted that the cuban image of a high-performing system appears to be almost exclusively based on infant mortality rates-an explicit point of focus of cuban government policy-at the cost of other health indicators, including maternal mortality, disability, disease exposure and life expectancy, and underinvestment in the social determinants of health more broadly. moreover, even this infant mortality rate has been questioned with regards to its accuracy, relative to the counterfactual and potential case-definitional differences to routine practice making cuba dramatically outperform its regional (and global) neighbours. focusing on infectious disease in particular, there are three key components to cuba's domestic health security: disease surveillance and control, cuba's biotechnology industry and universal healthcare. first, cuba has focused considerable efforts on reducing or eliminating disease threats from its territory. this has included decades of work reducing hiv/aids infection, including eradicating mother-to-child transmission of hiv, through prevention and destigmatisation campaigns, although this has come at a cost of human rights through the compulsory testing and indeed quarantining of those infected (interview, biosecurity expert). similarly, cuba eliminated malaria on the island in , and maintains this status, although through mandatory prophylaxis of those returning (or indeed arriving) in cuba from endemic regions. the country has also managed to eliminate diseases since , including measles, rubella, mumps, tetanus, meningitis b and c, and hepatitis b. (interview, ministerio de salud publica). when the threat of zika spread across the americas, cuba was quick to take proactive moves to stop the introduction of the disease within its borders. this included mass fumigation campaigns, the deployment of the military to clean civic spaces where mosquitoes may grow, and an appeal to citizens enforced by law, to support control efforts and ensure that private dwellings remained clear from mosquitoes and therefore, disease. such procedures are rooted in disease-specific action groups for health concerns; for example a dengue task force, empowered at multiple levels of governance from the municipality to the minsap and deployed in the case of a dengue outbreak with the exclusive task of bringing about the outbreak's end (interview, pan american health organization (paho)). this provides cuba with surge capacity to systematically respond to and manage health security concerns that occur within its borders. these groups work alongside the routine health service, and with civil defence units to respond to crisis events and mobilise quickly to minimise any potential threat to the population (interview, pan american health organization (paho)). more systematically, cuba has a distinct focus on rigorous point-of-entry controls. indeed, the main role of minsap's health surveillance unit is to prevent the introduction of infections to cuba (interview, ministerio de salud publica). when cuban nationals return to cuba from states that have endemic infectious diseases, they are subject to rigorous airport screening. this information is passed to their neighbourhood doctor for daily or weekly follow-up to ensure that individuals are not experiencing unusual symptoms and if they are, to facilitate rapid treatment, including if necessary, mandatory treatment and/or quarantine to avoid further disease transmission (interview, instituto de medicina tropical pedro kouri). the ability of the health system to facilitate such personalised follow-up, to ensure rapid treatment and to limit further infection is remarkable, and from a public health perspective, it far outperforms any health system in the global north, if not from a human rights perspective. these point-of-entry protocols are enforced for every flight and include airport scanners and in-airport medical professionals. if necessary, those arriving in cuba may be taken directly to a doctor and/or the tropical medicine institute, ipk (interview, instituto de medicina tropical pedro kouri). this quarantine and prophylaxis procedure at instituto de medicina tropical pedro kouri (ipk) includes all medics returning to cuba from ebola-infected or malaria-infected locations, who are subject to a mandatory days stay at ipk. second, cuba has a booming biotechnology industry, with significant investment made by the cuban state into research and drug development to ensure access to medicines should an outbreak emerge. as cuba is unable to purchase many global biomedical products, owing to the strict embargo placed on the country by usa, the bmj global health strides taken to ensure indigenous production of these medicines, treatments and future research represents demonstrable activity in maintaining cuba's health security to ensure a healthy and productive population. for example, this has included development of a vaccine for dengue fever, meningitis b, hepatitis b and many more besides. moreover, a biosecurity level laboratory (interview, ministerio de salud publica) and the development of other biomolecular diagnostic laboratories that can do diagnosis incountry mean that cuba does not have to send virus samples elsewhere (interview, ministerio de salud publica). third, cuba maintains almost uhc. uhc has been championed as a key mechanism to developing health systems resilient to disease outbreaks. cuba demonstrates how the mechanisms and processes for providing uhc to the population also provide the foundation for effective infectious disease control. cubans can seek medical advice through free and easily accessible consultations with health professionals through the consultorio (neighbourhood health clinic), established 'on every block' with a doctor and nurse in each communitywith approximately one consultorio per people. this has only been possible through significant government investment in healthcare as a priority since the revolution (although the motives for this are in part because the majority of doctors in cuba fled at that time (interview, pan american health organization (paho)). for more specialist care, patients are referred to a policlinico (polyclinic), particularly specialising in maternal and child health, chronic disease support and minor surgeries. the initial aim of this family centred programme was to decentralise hospital activities, to free up space in the system to manage the most serious of cases and to allow for surge capacity in the event of an emergency. yet the medics, and importantly nurses, who work in these consultorios and policlinicos who offer general medical provision also play a decisive role in epidemiology and disease prevention. in terms of epidemiological surveillance, the 'doctor on the corner' functions to record any epidemiological changes in the community. for example, dengue outbreaks, which occur with some frequency across cuba, are rapidly detected and within a matter of days integrated vector control activities will have begun due to the epidemiological reporting of the local consultorio. the close contact between the nuclear family and the doctor on every corner facilitates this rapid detection and response, ensuring that infections do not become major outbreaks and that infection control protocols are implemented (interview, ministerio de salud publica). this is in spite of no automated infrastructure and a paper-based surveillance system in a resource-poor setting. this infectious disease surveillance also pre-empts disease outbreaks through annual health checks on all members of the community (dispensarizacion). through this process, the consultorio preclassifies potential 'at risk' citizens based on social factors which may make them predisposed to infectious disease should it arise (interview, ministerio de salud publica; interview, pan american health organization (paho)). this preventative approach to disease control also relies on preventative care through increased vaccination coverage and health awareness among the population, reducing the chances of an outbreak taking hold in the country, the latter evidenced by the successful management of the hiv/ aids crisis on the island. thus, cuba demonstrates how the mechanisms and processes for providing uhc to the population also provide the foundation for effective infectious disease control, although this has been in a political context where the components of disease surveillance, biotechnology and universal healthcare form part of a broader narrative of regime preservation. indeed, if the goal of the cuban state is to preserve its borders and political narrative, then ensuring that its population has protection from infectious disease and access to routine healthcare functions also to reassure citizens in an effort to avoid internal sedition and lack of faith in the socialist project. nevertheless, while learnings from cuba must be considered within an instrumentalist paradigm and recognise that cuba's health security activities may not be as portable to different political and social environments, cuba's integration of community-based healthcare and disease surveillance and control activities does provide a pertinent example for broader global health security/ uhc debates as to what this might look like in practice, and how effective uhc can be for ensuring global health security. despite cuba's strong health security position, cuban health security activity is not framed as such, and this framing may well have an impact on cuban visibility within this global policy space. in turn, there are further impediments to cuban participation and recognition as a leader within the global health security architecture. for example, cuba claims to have met all the core capacity requirements for disease surveillance and control under the international health regulations (ihr) ( ), but has yet to agree to undergo a joint external evaluation (jee) to externally verify these capacities. although interviewees stated that plans were afoot for a jee in , we were unable to find evidence of this at the time of writing. this lack of clarification over the status of the jee is also mirrored in cuba's failure to report outbreak events to who, as required under the ihr ( ), including during the zika outbreak and rumoured cholera outbreaks across the island. where reports have been made, the case numbers reported have sometimes been manipulated so as not to reveal the full extent of the outbreak (interview, pan american health organization (paho)). thus, while cuba may demonstrate achievements in global health security, it also appears to be a reluctant player in the global health security regime. cuban health security activity, moreover, is not without its own challenges. as highlighted above, the ability for the state to mandate prophylaxis or quarantine for those potentially infected by a particular virus, not to mention pre-emptive activity on citizens deemed to represent risks to collective health security on the island, raises questions of civil liberties and human rights within the cuban health sector. much has been written about cuba's abuse of human rights and tight authoritarian control in other sectors, so this may not be of surprise from a broader cuban structural perspective. yet, within the health sector, there is no right to privacy in the physicianpatient relationship, no right to informed consent and no right to refuse treatment. these challenges point to an inherent tension within health security between the protection of civil liberties and public health, as encapsulated by the siracusa principles. the social control exercised by the cuban state thus raises questions of where the line between liberty and security lies and what rights governments have to restrict individual freedom in the name of public health-a debate that has also played out in other contexts, such as in the handling of patients with multidrug-resistant tuberculosis globally. a further challenge to cuba's health security is the level of underdevelopment that remains across much of the island. vast swathes of the island live in poverty, without routine access to water or sanitation services, with open sewers or water that is unable to drain because of poor civic planning (interview, pan american health organization (paho)). this can have a direct influence on susceptibility to vectorborne or waterborne disease. failure to maintain sewage systems in a civic infrastructure struggling to financially support itself has led to an increase in diarrhoeal disease and cholera. this lack of investment in the socioeconomic determinants of health, potentially as a consequence of the decisive focus on infant mortality within the health sector, poses a contradiction to so much of the success that cuba can show in terms of an exemplary health security capacity in such a resource-poor setting. it also demonstrates the inequalities across the system; while the consultorio model and thus 'health security' may work in urban areas, this may not be replicated across the system in poorer zones (interview, pan american health organization (paho)). thus, socioeconomic development and indeed, resources remain a key limitation of health security in cuba. lack of government funds means that in the event of a major outbreak there may be limitations on equipment, deployment activities elsewhere, and research and development achievements. these resource constraints are exacerbated by the us embargo, which has been almost continuously in place since . this has wide-ranging effects across areas of domestic policy, and despite having little impact on life expectancy, we propose that the embargo does have a potential impact on the health security strengths of the system. for example, the embargo on us goods means that pharmaceutical ingredients or products produced in usa or with a patent held by a us company are not available in cuba. this means that cuban access to newer international drugs is limited and may directly impact on the health security of the nation if a newly emerging pathogen appears and a drug is developed that cubans are not able to access (interview, ministerio de salud publica). this also extends to medical equipment. there have been efforts by cuban medics to circumvent this medical embargo, through sourcing medication from third party states, but this has been met with indignation and legal challenge by the usa. while it is impossible to imagine a replication of the cuban health system in other resource-poor settings owing to the uniqueness of the political situation, this is not to say that meaningful lessons cannot be ported. in particular, cuba demonstrates how a health system that is prevention-oriented and community-based contributes to reducing infectious disease threats-a key point of focus in contemporary global health security debates. here cuba provides a much needed example of how disease surveillance and control efforts can be integrated with community-based primary healthcare to provide for health security in low-income settings. cuba's medical internationalism, moreover, demonstrates the effectiveness of frequently offering national doctors for international disease control efforts, allowing for a welltrained and readily deployable medical corps to respond to disease both within cuba and abroad. the training provided to the henry reeve brigade in responding to the ebola outbreak is particularly illustrative of how national and global surge capacity to respond rapidly to health crises might be achieved. the focus on strengthening routine healthcare as well as health crisis response in cuba's medical internationalism, moreover, opens up space to reflect on how global health security activities might be integrated into longer-term health interventions. despite these activities, however, cuba remains largely at the margins of global health security policy and debate, with implications for cuba's engagement with the global health security regime, as encapsulated by the ihr ( ), and for cuba's visibility in global health security policy and practice. indeed, the us embargo, cuba's development and resource challenges, and the tight social controls exercised by the state in managing disease threats in its territory also speak to broader global health security issues. these concern global access to essential medicines and commodities, the development of sectors beyond health alone in reducing vulnerability to disease, and the trade-off between civil liberties and public health in disease control efforts. the cuban case thus offers opportunity for more in-depth reflection as to the strengths and weaknesses of contemporary health security practices, although with the caveat that lesson learning should be applied cautiously in this context given bmj global health the tensions within the cuban political system in relation to civil and political freedoms, the critiques concerning cuba's instrumentalist promotion of its health system and the trade-offs which had been decisively made for the prioritisation of disease control and infant mortality. correction notice this article has been corrected since it published online to reflect the correct author names in reference . twitter clare wenham @clarewenham microbial threats to health: emergence, detection. and response toward a common secure future: four global commissions in the wake of ebola sustainable development goals will ebola change the game? ten essential reforms before the next pandemic. the report of the harvard-lshtm independent panel on the global response to ebola sierra leone's response to the ebola outbreak report of the ebola interim assessment panel geneva: who all roads lead to universal health coverage the political economy of health transitions in the third world. health and social change in international perspective global health security: security for whom? security from what? exclusive: cuba failed to report thousands of zika virus cases in political pilgrims: western intellectuals in search of the good society healthcare without borders: understanding cuban medical internationalism where no doctor has gone before: cuba's place in the global health landscape healing the masses: cuban health politics at home and abroad cuban internationalism, che guevara, and the survival of cuba's socialist regime the cuban response to the ebola epidemic in west africa: lessons in solidarity medical internationalism in cuba cuban medical internationalism: origins, evolution, and goals cuba's international health cooperation cuba is pulling doctors from brazil after 'derogatory' comments by bolsonaro. the new york times cuba's greatest export? medical diplomacy mission barrio adentro: the right to health and social inclusion in venezuela the dark side of cuba's health system: free speech, rights of patients and labor rights of physicians cuba's doctors-abroad programme comes under fire protecting humanity from future health crises: report of the high-level panel on the global response to health crises. in: nations u, ed. a/ / . global health and foreign policy the curious case of cuba cuban infant mortality and longevity: health care or repression? cuba's health system: hardly an example to follow infant mortality in cuba: myth and reality the cuban revolution and infant mortality: a synthetic control sida: confesiones a un medico casa editora abril aids in cuba: a model for care or an ethical dilemma? a regime's tight grip on aids. the new york times mosquito guns and heavy fines: how cuba kept zika at bay for so long an appeal to our people the cuban biotechnology industry: innovation and universal health care: pan american health organization world health organization. cuban experience with local production of medicines, technology transfer and improving access to health redefining universal health coverage in the age of global health security health systems strengthening, universal health coverage, health security and resilience disease diplomacy : international norms and global health security cuban civil society during and beyond the special period cuba en la comunidad internacional en los noventa: soberanía, derechos humanos y democracia re-examining the cuban health care system: towards a qualitative critique siracusa principles on the limitation and derogation provisions in the international covenant on civil and political rights failing siracusa: governments' obligations to find the least restrictive options for tuberculosis control an evaluation of four decades of cuban healthcare effect of the u.s. embargo and economic decline on health in cuba acknowledgements the authors thank lse latin american and caribbean centre including helen yaffe, gareth jones and alvaro mendez for their discussions during the research phase of this study. contributors cw and skk conceived, designed and undertook the research. they both wrote the final paper. competing interests none declared.patient and public involvement patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.patient consent for publication not required.ethics approval ethical approval was obtained from lse ethics committee ( ).provenance and peer review not commissioned; externally peer reviewed. key: cord- -ria v p authors: mcdarby, geraldine; reynolds, lindy; zibwowa, zandile; syed, shams; kelley, ed; saikat, sohel title: the global pool of simulation exercise materials in health emergency preparedness and response: a scoping review with a health system perspective date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: ria v p simulation exercises (simex) are an established tool in defence and allied security sectors, applied extensively in health security initiatives under national or international legislative requirements, particularly the international health regulations ( ). there is, however, a paucity of information on simex application to test the functionality of health systems alongside emergency preparedness, response and recovery. given the important implications health services resilience has for the protection and improvement of human life, this scoping review was undertaken to determine how the publicly available body of existing global simex materials considers health systems, together with health security functions in the event of disruptive emergencies. the global review identified articles from literature and products from institutional sources. relevant screening identified materials suitable to examine from a health system lens using the six health system building blocks as per the who health system framework. eight materials were identified for further examination of their ability to test health system functionality from a resilience perspective. simex are an effective approach used extensively within health security and emergency response sectors but is not yet adequately used to test health system resilience. currently available simex materials lack an integrated health system perspective and have a limited focus on the quality of services delivered within the context of response to a public health emergency. the materials do not focus on the ability of systems to effectively maintain core services during response. without adjustment of the scope and focus, currently available simex materials do not have the capacity to test health systems to support the development of resilient health systems. dedicated simex materials are urgently needed to fill this gap and harness their potential as an operational tool to contribute to improvements in health systems. they can act as effective global goods to allow testing of different functional aspects of health systems and service delivery alongside emergency preparedness and response. the work was conducted within the scope of the tackling deadly diseases in africa programme, funded by the uk department for international development, which seeks to strengthen collaboration between the health system and health security clusters to promote health security and build resilient health systems. ► simulation exercises (simex) are established, practised in defence and security sectors which are later recognised in national and international regulations (e.g international health regulations, ). ► the importance of simex as an improvement tool has yet to be identified to test capacities for health system resilience alongside emergency preparedness. what are the new findings? ► currently available global pool of simex materials lack an integrated health system perspective with a limited focus on the maintenance of routine quality health services delivered during response to a public health emergency. ► without adjustment of the scope and focus, currently available global pool of publicly available simex materials do not have the capacity to test health system resilience. what do the new findings imply? ► participation of health system authorities or stakeholders in the development, conduct of simex and accountability of findings for improvement in health system strengthening is needed. ► dedicated simex materials are urgently needed to fill gaps identified in global resources to harness the potential of simex as an operational tool to contribute to improvements in health system strengthening. simulation exercises (simex) are an established tool in defence and allied security sectors, applied extensively in health security initiatives under national or international legislative requirements, particularly the international health regulations ( ) . there is, however, a paucity of information on simex application to test the functionality of health systems alongside emergency preparedness, response and recovery. given the important implications health services resilience has for the protection and improvement of human life, this scoping review was undertaken to determine how the publicly available body of existing global simex materials considers health systems, together with health security functions in the event of disruptive emergencies. the global review identified articles from literature and products from institutional sources. relevant screening identified materials suitable to examine from a health system lens using the six health system building blocks as per the who health system framework. eight materials were identified for further examination of their ability to test health system functionality from a resilience perspective. simex are an effective approach used extensively within health security and emergency response sectors but is not yet adequately used to test health system resilience. currently available simex materials lack an integrated health system perspective and have a limited focus on the quality of services delivered within the context of response to a public health emergency. to disease outbreaks. health workers were significantly more likely to be infected than the general population, with this increased risk largely attributable to the poor quality of infection prevention and control (ipc) practices and emergency preparedness. [ ] [ ] [ ] guinea, liberia and sierra leone lost between . % and . % of their country's doctors, nurses and midwives to evd, translating into significant reductions in the healthcare provision. ineffective surveillance systems enabled evd to spread locally as well as across borders. during an outbreak, as with any public health emergency (phe), the resilience of a country's health system is tested in real time. the capacity to respond to an outbreak and maintain essential services creates a surge in demand for critical resources. health system resilience has been defined as 'the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganize if conditions require it.' resilient health systems protect human life and are linked with positive health outcomes during a phe as well as in its aftermath. a lack of health system resilience is associated with excess morbidity and mortality due to the phe as well as from other causes, which can be at least partially attributed to a reduction in access to quality health services. [ ] [ ] [ ] it has been estimated that a % reduction in access to healthcare services during the west african evd resulted in increased child and maternal mortality as well as increased mortality from other infectious diseases. these indirect deaths- -were not insignificant. thus, it is critical that a mechanism exists to test and build resilient health systems in order to reduce excess morbidity and mortality from future phes. national and international preparedness for phes has long been discussed on a global scale, especially in health security forums that seek to address challenges and gaps in meeting core international health regulations (ihr) ( ) capacities. one component of the revised ihr ( ) monitoring and evaluation framework includes simulation exercises (simex), which are defined by the who as 'forms of practice, training, monitoring or evaluation of capabilities involving the description or simulation of an emergency, to which a described or simulated response is made.' simex have historically been an established tool in defence and allied security sectors, with recent adaptation to health security efforts in the context of disruptive emergencies, natural and man-made. they are now being used as a tool to assess compliance with national-for example, the uk civil contingencies act -and international legislative requirements, notably ihr . there is, however, a paucity of information on the application of these exercises to test the functionality of health systems alongside emergency preparedness, response and recovery. simex are also an ideal opportunity to test preparedness of the various functions of the health system, particularly health service delivery, in response to phes. this would contribute to the development of strong linkages between health systems and health security sectors supporting an integrated approach towards building resilient health systems. given the important implications health services resilience has for the protection and improvement of human life, this scoping review was undertaken to determine how the body of existing global simex materials considers the testing of health system resilience, together with health security preparedness, and response functions in the event of acute and/or protracted phes. recognising the dispersion of simex materials, a scoping review of academic literature as well as an institutional search was undertaken. a wide search strategy was employed to identify all relevant materials. searches of different hazard types, exercise types and subject areas were combined (online supplementary appendix ). the initial search returned articles for screening with an additional identified through bibliography review. titles and abstracts were reviewed against inclusion and exclusion criteria (table ) , reducing the number for fulltext review to . for the institutional search, institutions involved in the development, implementation or evaluation of simex were identified by experts in the field, as well as through relevant articles. their websites were searched for applicable materials. ultimately, institutions, ranging from academic to national response agencies, were reviewed (online supplementary appendix ), identifying materials which were reduced to following the screening of aims and objectives (figure ). the final materials identified (n= ; online supplementary appendix ) ( emerging from the literature and emerging from institutional review) were analysed by two independent reviewers for their scope to test aspects of health systems using the who health system framework, consisting of six independent but inter-related building blocks (table ) . resilience was considered to be addressed if materials demonstrated evidence of an integrated emergency response, maintenance of essential functions or reorganisation of services within the context of a phe. a smaller number of materials (n= ) were bmj global health ► does the material look at aspects of health service delivery in the event of a simulated event? ► does the material test a function of specific building blocks of a health system in consideration of other related building blocks? ► does the material test preparedness and response of healthcare facilities alongside national incident management system? ► does the material look at impact of emergencies on provision of routine essential health services? ► does the material look at how phes impact health service delivery at subnational and district-level facilities? ► does the material examine the standard of care during phe? identified for examination of their scope to test resilience from a functional perspective (figure and box ). materials were excluded from this portion of the analysis if they did not report either an exercise or objectives in sufficient detail to support this analysis. this portion of the analysis (n= ) involved five journal articles and three guidance materials (online supplementary appendix ). a library of publicly available materials to support the development of simex was compiled in parallel to the review process. there was no involvement of patients or the public in this study, in either the design of the methods or in the conduct of the study. results simex consideration of health system building blocks the majority ( %) of the materials (n= ) identified exclusively tested preparedness and response to a phe, without considering them as typical functions of a resilient health system (figure ). a limited number were identified that tested aspects of health system resilience or recovery (figure ). the categorisation of the scope of material was based on the research bmj global health team's interpretation, that is, if the exercises dealt with preparing and responding to a phe or if they dealt with aspects of recovery or response. a few materials self-identified as testing health security or testing for contingency, and so warranted extra categories. the materials identified looked at aspects of health security across different geographical levels (international, national, regional and facility); they more frequently examined the regional/ district ( %) and facility levels ( . %) ( figure ) . the most frequent hazard type ( %) simulated was biological which included pandemic influenza and other emerging infections ( figure ) . though often not the explicit focus, all reviewed materials (n= ) tested at least one building block or an aspect of a health system building block (figure ). a functional approach was apparent, though functions were generally tested in a narrow way both within and across relevant building blocks, rather than integrated across all relevant health system building blocks. ipc was the most commonly tested service delivery function with adherence to case management guidelines and standard operating procedures (sop) being a frequent focus of testing. the quality of health services provided in the context of the response or measures of the maintenance of essential health services were lacking. surge capacity was the most frequently tested function of health workforce, though a narrow approach was often apparent. exercises tested aspects of surge capacity such as staffing, however, this was not addressed within other building blocks in relation to the invariable increased demands on services and supplies. a narrow approach to health information systems was also apparent, with three materials (out of ) focusing on surveillance systems and only limited aspects of risk communication tested. only one identified material tested the triggering of a response plan using a surveillance system. leadership and governance (from a security perspective) was the most frequently addressed building block, with many materials testing aspects of this building block such as response plans and roles and responsibilities of responders. however, alignment with national structures and guidelines was not apparent, nor was consideration given to decision in risk identification. while access to medicines and supplies was frequently alluded to, testing of access to mechanisms or supply chain resilience was infrequent. financing was alluded to in only % of materials (n= ), but testing of mechanisms to access funding in the event of phes was not identified. tabletop exercise/discussion was the most frequent approach identified (figure ). they are less expensive and faster to execute, particularly when considering large groups of stakeholders. the limitation with this approach bmj global health is limitation in scope to adequately simulate phes and test the individual and integrative aspects of health systems. simex consideration of health system functionality and system underpinning eight materials were identified for further analyses on the functionality/system aspect of the six building blocks, using a set of questions (box ). most materials tested activation of appropriate emergency response mechanisms and structures within the respective administrative levels tested, for example, a facility-level exercise testing activation of all appropriate response mechanisms within the health facility. some materials tested activation across different levels within the system, for example, a health facility responding to an outbreak activating regional or national response systems. emergency response systems were generally assumed to have been activated, without testing system triggering. as was apparent with the building block analysis, healthcare functions were generally not tested in an integrated way. for example, a mass dispensing drill had no regard for the parallel response structures with which they would have to integrate during a response. similarly, a facility response to a sarin attack failed to integrate with national response agencies. reporting of alignment with national command and control structures or response plans was limited as was evidence of consideration of the impact of the phe on other health system-level facilities or management structures. materials to test the impact of emergencies on primary healthcare (phc) or its response were extremely limited and community resilience materials, where identified, failed to link with health systems. [ ] [ ] [ ] the materials were limited in their focus on testing the quality of services delivered in the context of response to a phe. where present, measures tended to focus on clinical aspects of care rather than system and process measures. measures to test the maintenance of essential services from a quality perspective were not identified in any of the eight selected materials. limitations of the review the application of the health system framework to review simex materials introduced a degree of subjectivity. in reality, it is the same health system that provides routine healthcare, emergency-specific healthcare and response to a shock impacting public health. this was addressed through discussion as well as with input from health system and security experts in who. similarly, the approach to the analyses conducted required sufficient detail in the identified materials in relation to exercises or objectives, which led to the exclusion of a number of relevant materials as they were not present either with sufficient details or as a package (written narrative, scenario, injects and postexercise report). both the academic literature and institutional materials were analysed using the same approach. this likely led to an underestimation of effect in relation to academic literature as not all that was tested may have been reported, and an overestimation in relation to institutional materials as objectives may not have been applied effectively within exercises. a publication bias also likely exists in relation to health security exercise reports and materials given the sensitive nature of findings as well as in relation to materials developed and delivered by private companies. while multiple institutions and organisations (n= ) known to be involved in simex were contacted to identify unpublished materials, it is likely that there remains a pool of materials not made available as they were considered proprietary and/or sensitive. however, the objectives of the exercise are based on publicly available materials that are accessible and can be used as global resources, as such access-restricted materials fall beyond the scope of this review. in general, materials identified were from countries with developed capacities for emergency preparedness and response-materials from other settings may not have percolated the literature and may not have an institutional home where materials are placed. however, the inclusion of institutions known to support simex within low income settings is likely to reduce the impact of the bias towards high-income countries within the findings of the work. the exclusion of non-english materials has the potential to introduce a cultural bias, although materials in the review included materials from most continents (north america, europe, africa, asia and australia). the extent of any cultural bias is therefore limited, and unlikely to affect the findings of the work. despite these limitations, there is no reason to suspect that materials not included in this review differ systematically from those included in such a way as to negate the findings. discussion while all materials identified tested aspects of health systems, there was limited evidence of an integrated health system approach. health system building blocks were touched on from a preparedness perspective, and often tested in a fragmented and isolated way without addressing interlinkages. ipc was frequently tested in the context of response to a pandemic or other emerging infection, with a focus on governance structures and adherence to case management and sops. ipc is central to the response to any emerging infection as was highlighted within the evd outbreak in west africa where poor ipc practices contributed to significant health worker transmission, leading to reductions in response as well as essential healthcare delivery. in a similar instance, a lack of strict adherence to ipc guidelines was associated with ongoing healthcare facility transmission during the severe acute respiratory syndrome outbreak in both toronto and taiwan in . an integrated approach to ipc as a critical function of quality health service delivery in these simex materials is thus required. the availability and timeliness of emergency financing is critical in determining the timeliness and effectiveness of coordinated efforts in any emergency response. despite this, limited consideration was given to the supply of resources required to meet the surge in demand, including staff, diagnostics, medicines or personal protective equipment, and to accessing the financing necessary to meet these demands. it is therefore of utmost importance that the rapid mobilisation of financing should be regularly tested in simex, taking into account the response required as well as consideration of maintaining quality essential health services. health information systems, though often alluded to, were rarely tested in a robust and integrated way, with a lack of focus on surveillance systems in particular. the only material identified that tested activation of an emergency plan using syndromic surveillance failed to trigger activation of the response plan. the pivotal role played by data and information systems in routine healthcare delivery is even greater in the context of emergencies. a strong and reliable health information system ensures understanding of the epidemiology of disease, and is critical in coordination, communication and management of response efforts. testing this functionality should be an integral part of simex conducted at any level. consideration of the integration of preparedness and response across health system levels was lacking, with services and facilities tending to test their own response capabilities in isolation. phc, despite being the likely first point of care in many phes, was rarely considered in the simex materials reviewed either in terms of supporting preparedness capacity or in terms of the effect of the phe on phc. phc plays a central role in surveillance which was highlighted within the evd outbreak in west africa, where failure to identify evd when it first presented within the community in guinea led to a significant delay in response with a concomitant lack of containment. despite evidence from evd west africa that community linkages can support health system response in the face of phes, the current global pool of simex materials were unlikely to link with community aspects and where community preparedness materials existed they rarely linked with health systems. the importance of integrating private healthcare facilities into emergency preparedness and response capabilities was highlighted by the recent dengue outbreak in khyber pakhtunkhwa in . a private health facility, unfamiliar with emergency response protocols, failed to activate emergency response mechanisms in a timely manner. this, alongside a lack of case management guidelines, contributed to prolonged community transmission. no evidence of integration of private healthcare facilities into health system preparedness and response was identified within the current pool of global simex materials. while there is international consensus of the need to focus on quality in healthcare, the focus on the quality of services delivered in the context of a phe was lacking. where materials did focus on service quality, they tended to focus on clinical aspects of care. system and process measures were only identified in drills that tested mass dispensing capabilities in the context of a pandemic or biological attack. these capabilities represented parallel bmj global health response structures and their linkages with appropriate health system structures were not tested, nor was the communication required to divert individuals from normal health services tested. no materials identified included measures to test the maintenance of or quality of essential health services during the response to a phe. evidence from west africa shows that the indirect mortality and morbidity associated with discontinuity of health services as well as poor quality health services was significant across the three countries, with the biggest impact on maternal and child health. the current global pool of simex materials are limited in its ability to test health service resilience alongside preparedness and response. this in turn limits the opportunity to practically bridge health security and health systems at different administrative levels. special attention is required in using simex approaches to drive sustainability of investment in health security preparedness or disease-specific programmes to proactively position available scarce resources into sector-wide development of health systems for all public health hazards per ihr ( ). simexercises are a well-practised method of testing and promoting emergency preparedness and response for local, national and global health threats. while much experience exists globally in this area, the proprietary nature of some of the materials creates a missed opportunity for the sharing of knowledge across global health security and preparedness communities. it would be in the interest of the global community to develop a mechanism to support sharing of lessons learnt that respects the integrity of private organisations involved in simex development and delivery. the effectiveness of simex has been demonstrated in identifying gaps in emergency response plans, skills and associated resources. the lack of an integrated health system perspective in the current global pool of simex materials limits their ability to support health system functionality and strengthening in the context of phes. this, along with their lack of focus on the quality of response and the maintenance of quality essential health service functions, means that they do not have the capacity to support health system resilience. the incorporation of a health system perspective into simex materials has the potential to enhance health system strengthening and the development of resilience alongside emergency response and health security capabilities. an integrated approach to simex including health security, emergency preparedness and health systems is required to address the gap identified by this review. as a result of these findings, an off-the-shelf simex package that addresses health system aspects within the context of response to a phe is being developed, which will be freely available for all countries, particularly low-income countries. this could be further supported through the cross involvement in ongoing exercises and after-action reviews to enhance connectivity and support the development of shared ownership of improvement recommendations. these new-generation simex materials could be collated in a global repository that could be accessed by national authorities. such a collaborative approach would allow the leveraging of the considerable expertise in simex present within health security and emergency preparedness sectors. lessons learnt from this integrated approach will allow health systems to be built better, function better, which will ultimately lead to the protection and improvement of human life. world health organisation. health worker ebola infections in guinea, liberia and sierra leone: a preliminary report health-care worker mortality and the legacy of the ebola epidemic ebola virus disease in health care workers--sierra leone what is a resilient health system? lessons from ebola building resilient health systems: a proposal for a resilience index effects of response to - ebola outbreak on deaths from malaria, hiv/aids, and tuberculosis, west africa the ebola outbreak and staffing in public health facilities in rural sierra leone: who is left to do the job? counting indirect crisis-related deaths in the context of a low-resilience health system: the case of maternal and neonatal health during the ebola epidemic in sierra leone world health organisation. development, monitoring and evaluation of functional core capacity for implementing the international health regulations ( ): concept note world health organisation. after action reviews and simulation exercises: under the international health regulations monitoring & evaluation framework (ihr mef) what is the value of health emergency preparedness exercises? a scoping review study a test of syndromic surveillance using a severe acute respiratory syndrome model the planning, execution, and evaluation of a mass prophylaxis full-scale exercise in cook county sarin exposure: a simulation case scenario emergency preparedness toolkit for primary care providers academic-community partnership to develop a novel disaster training tool for school nurses: emergency triage drill kit whole community: planning for the unthinkable tabletop exercise sars in healthcare facilities the financial logistics of disaster: the case of hurricane katrina who paints grim picture of anti-dengue preparedness. reliefweb high-quality health systems in the sustainable development goals era: time for a revolution delivering quality health services: a global imperative for universal health coverage ready or not: analysis of a no-notice mass vaccination field response in philadelphia hospital emergency preparedness: push-pod operation and pharmacists as immunizers a scoping review of evaluation methods for health emergency preparedness exercises contributors ssa conceptualised the study. ssa, gm and zz designed the methods. gm, lr and ssa conducted the literature search. gm and lr collected the data. gm, lr and zz developed the figures. gm, lr, ssa, zz, ek and ssy all contributed to data analysis, data interpretation, manuscript writing and reviewing.funding this study was funded by world health organization.competing interests none declared. provenance and peer review not commissioned; externally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. key: cord- - n i b o authors: panigrahi, sunil kumar; pathak, vineet kumar; kumar, m mohan; raj, utsav; priya p, karpaga title: covid- and mobile phone hygiene in healthcare settings date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: n i b o nan ► covid- is now a global pandemic. there is some evidence to suggest possible fomite transmission. hence, inanimate objects play a significant role in their transmission. ► in this commentary, we discuss 'mobile phones' as a potential vector of severe acute respiratory syndrome-cov- spread. the use of mobile phones has not been restricted in hospital and other healthcare settings. hence, mobile phones could be a missing link in controlling the covid- pandemic. ► we recommend, as part of efforts to control the covid- pandemic, awareness of 'mobile phone hygiene'; restriction of mobile phone use in healthcare settings; avoiding the sharing of mobile phones, headphones or headsets of any kind; and widely disseminated advice from mobile companies, governments and who on how to disinfect mobile phones. hospitals and other healthcare settings can facilitate the spread of infectious diseases. the recent outbreak of covid- is the third documented spillover of animal coronavirus to humans in the past two decades, after severe acute respiratory syndrome (sars) in and the middle east respiratory syndrome in . it has brought the focus of disease epidemiology to the healthcare institutions. the index case which sets the motion of outbreak investigations and subsequent control measures are initiated only after coming in contact with the healthcare institutions. hospitals without proper infection control measures are a liability during an epidemic. they may become sources of hospital-acquired infections. they may initiate a vicious cycle of new disease diagnosis and newly acquired infections, both simultaneously occurring in the same hospital. for any infectious disease, it is the mode of transmission that bridges the source or reservoir with a susceptible host. it is this point which needs to be interrupted to prevent and control further disease transmission. healthcare professionals are a bridge between infectious patients in hospitals (core population) and the general population in transmitting the disease. the things they use within the hospital premises may facilitate such disease transmission. these include mobile phones. globally, there are . billion mobile phone users. there are almost . billion users in india alone; % of mobile phone users globally are in india. based on mobile phone usage, india is placed second only next to china. it is important for healthcare professionals to use mobile phones in the hospital and other health and care settings, especially for communication. there have been recent discussions on curbing the use of white coats as a way of preventing hospital-acquired infection. however, mobile phones are arguably much more commonly and extensively used by healthcare professionals compared with white coats. apart from social media use, health professionals use mobile phones to follow health-related news; communicate with one another; look up updated guidelines, drug interactions, adverse events and health research; for photography, sharing medical documents, conducting teleconsultations and patient tracking; all resulting in extensive use of mobile phones. the self-reported use of mobile phones among health workers ranges from once in every min to once in hours. mobile phones are one of the most highly touched surfaces according to the centers for disease control and prevention (cdc), along with counters, tabletops, doorknobs, bathroom fixtures, toilets, keyboards, tablets and bedside tables. during the ongoing covid- pandemic, hand hygiene has been recommended as a mainstay of infection control by all prominent health societies, including bmj global health who. hand washing not only reduces the individual risk of transmission but also interrupts the community transmission of sars-cov- , the virus that causes covid- . however, mobile phone surfaces are a peculiar 'highrisk' surface, which can directly come in contact with the face or mouth, while talking over phone, even if hands are properly washed and clean. in their tendency to come in direct contact with the face, nose or eyes in healthcare settings, mobile phones are perhaps second only to masks, caps or goggles. however, they are neither disposable nor washable like these other three, thus warranting disinfection. mobile phones can effectively negate hand hygiene, as there can often be seemingly compulsive and frequent use of mobile phones immediately after hand washing or hand rubbing with alcohol-based sanitizers. there is growing evidence that mobile phones are a potential vector for pathogenic organisms. a recently published literature review showed that mobile phone contamination rates range from % to %. coagulase-negative staphylococcus and s. aureus were the most frequent bacteria ( %- %), and most of them were methicillin resistant. there is evidence of mobile phones getting contaminated by viruses in hospital settings. in a study, % of phones which were tested had viral pathogens. studies have also reported medical students to have four times higher odds of having heavy growth of microbes on their mobile phones. these findings are particularly important, given the evidence in a recent review, which included studies, that coronavirus can survive on inanimate surfaces like metal, glass or plastic surface for hours to days, and that high temperature such as °c or °c reduced the duration of persistence. mobile phone hygiene: better said than done sars-cov- , the virus that causes covid- , is only months old, and so our understanding of the disease epidemiology is continuously evolving. however, there are many significant guidelines from various health organisations (eg, who and cdc) focusing on prevention and control of disease spread. however, there is no mention of or focus on mobile phones in these guidelines, including the who infection control and prevention guideline, which recommends the use of hand washing as being of the highest importance of universal precautions. it is the need of the hour to address a proper hygienic use of mobile phones in healthcare settings. in a study in india, almost % of health workers of a tertiary care hospital used mobile phones in the hospital, but only % of them had at any time wiped their mobile phones clean. there seems to have been some initial agreement that more than % of alcohol damages mobile screen, whereas many microorganisms, including sars-cov- , do not respond to concentrations below % of alcohol. two of the biggest mobile phone companies (apple and samsung) do not recommend any chemical or spray to clean the mobile phone screen prior to covid- . however, amidst the ongoing pandemic of covid- , both apple and samsung have revised their user support guidelines, saying that % isopropyl alcohol or clorox disinfecting wipes can be used to gently wipe the exterior surface of phones in switched-off mode. however, in doing so, the use of bleach or entry of moisture through any of the openings must be avoided, and any harsh chemical may damage the oleophobic screen, leading to damage in the touch screen sensitivity of the phone. mobile phone hygiene: the way forward we recommend mobile phone use restrictions in healthcare institutions especially in hospital wards, operating theatres and intensive care units. disposable/washable transparent polythene mobile phone covers may be mandated for mobile phones that are brought into and used in hospital premises. use of headphones or headsets (wired/wireless) should be promoted to prevent contact with the face while talking on mobile phones. there should be no sharing of mobile phones, headphones or headsets of any kind. in addition, where available, the use of interdepartmental intercom facility though telephones may be promoted as a strategy for reducing excessive use of personal mobile phones inside hospital premises. further, organisations such as the who and cdc should mobilise mobile manufacturing companies to issue advisory on the choice of disinfectants in view of product damage. compulsory hand washing with soap and water or alcohol-based hand rubs should be practised after unavoidable mobile phone use. organisational research should be promoted through identification of bacterial or viral flora on mobile phones, and appropriate use of disinfectants according to the culture and sensitivity pattern should be included in hospital infection control measures. there has never been any concrete evidence that mobile phone hygiene has reduced disease transmission. having said that, minimising mobile phone use, hand washing, disinfectant wipes, headphone use and washable covers should be encouraged. complete mobile phone restriction in the current situation would be near impossible and may contribute to a breakdown of communication in a time when swift and open lines of communication are crucial. the available recommendation from the mobile phone industry is to use biocide ( % isopropyl alcohol or clorox disinfecting wipes) for cleaning mobile phones routinely, in the following steps: ► before starting to clean, turn off the phone and remove the case, accessories and cables, if any. ► use a soft, lint-free, waterproof and dust-proof wipe, such as a camera lens wipe, to gently wipe the surface of the device. ► lightly dampen a corner of a washcloth with a small amount of biocide and gently wipe the front and back of the phone. ► avoid entry of moisture through any openings and do not use liquid directly on the phone. ► do not use the compressor and do not use or spray bleach or any cleaning solutions directly on phone. ► do not use bleach. the cdc recommends hand hygiene before and after contact with every patient, and an estimated one-third of hospital-acquired infections are caused by lack of adherence to established infection control practices such as hand hygiene. although hand hygiene and mobile phone use by a person are not mutually exclusive, it is high time to acknowledge the potential role of mobile phones in disease transmission cascade and to take evidence-based appropriate actions. this is especially important, given the ongoing covid- pandemic. to this end, it is necessary for government agencies and the who to generate public awareness and to formulate suitable information, education and communication material on mobile phone hygiene, especially in healthcare settings. contributors all the authors were involved in the concept, design, literature search, manuscript preparation, manuscript editing and manuscript review, and acted as guarantors. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests none declared. patient consent for publication not required. provenance and peer review not commissioned; externally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. orcid id vineet kumar pathak http:// orcid. org/ - - - principles of epidemiology: lesson , section , self-study course ss world health organization. hospital preparedness for epidemic oxford textbook of global public health providing information through smart platforms: an applied study on academic libraries in saudi universities telecom regulatory authority of india white coats as a vehicle for bacterial dissemination doctors and medical students in india should stop wearing white coats cellphones as reservoirs of nosocomial pathogens mobile phones as a potential vehicle of infection in a hospital setting preventing -ncov from spreading to others infection prevention and control during health care when novel coronavirus (ncov) infection is suspected is your phone bugged? the incidence of bacteria known to cause nosocomial infection on healthcare workers' mobile phones mobile phones: reservoirs for the transmission of nosocomial pathogens healthcare workers mobile phone usage: a potential risk for viral contamination. surveillance pilot study persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents mobile phones in healthcare setting: potential threat in infection control should you clean your phone to combat coronavirus? definitely. maybe cleaning your iphone galaxy note : how to clean dirty glass/ screen key: cord- - n jp l authors: baatiema, leonard; sumah, anthony mwinkaara; tang, prosper naazumah; ganle, john kuumuori title: community health workers in ghana: the need for greater policy attention date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: n jp l from the s to the s, the who, united nations and other agencies mooted the idea of formally training and recognising community health workers (chws) to complement efforts to improve primary healthcare delivery in low and middle income countries. recently, chws have been recognised as important players in the achievement of the health-related millennium development goals (mdgs). despite this recognition, little understanding exists in ghana about the activities of chws: who they are; how they are recruited; what they do; level of health policy support; contribution to healthcare delivery and the challenges they face. based on a rapid scoping review of the existing literature, and our experience working in ghana, this paper reflects on the role of chws in healthcare delivery in ghana. we argue that chws have played critical roles in improving health service delivery and outcomes, including guinea worm eradication, expanded immunisation coverage, maternal and child health, and hiv/aids treatment and management. however, these achievements notwithstanding, chws face challenges which prevent them from being optimally productive, including capacity problems, neglect by the healthcare system, high attrition rates and inadequate supervision. policymakers in ghana therefore need to give increased attention to chws, provide remuneration for their activities, create career opportunities and other means of motivations to boost their productivity and sustain gains associated with their activities. the concept and role of community health workers (chws) have enjoyed renewed interest in global health since the alma-ata declaration in . [ ] [ ] [ ] [ ] [ ] [ ] chws have evolved over the past decades with its antecedence in the 'feldshers' in th-century russia, the barefoot doctors programme in china during the early s, and the who seminal work 'health by the people' in . recent recognition that chws are important players in global efforts to achieve the health-related millennium development goals (mdgs) highlights this attention. in , the one million chws campaign project worth us$ . billion was announced to boost the capacity of chws to deliver healthcare in sub-saharan africa. this current drive to recruit more chws is a recognition of their role in sustaining the mdg gains, as well as in ultimately achieving the more recent sustainable development goals (sdgs). a surge in the evidence of their contribution has recently been acknowledged in a cochrane review on maternal and child health. evidence in several low and middle income countries (lmics) suggests that marked reductions in child and maternal mortality through health promotion interventions, immunisation campaigns and other community driven initiatives could be attributed in part to the role played by chws. [ ] [ ] [ ] [ ] [ ] key questions what is already known about this topic? ▸ the contributions of community health workers (chws) to healthcare delivery have been recognised globally. ▸ there is a lack of global consensus on chws' scope of practice. ▸ there is inadequate health policy support for chws in low and middle income countries. what are the new findings? ▸ this analysis presents systematic and comprehensive evidence of chws' contributions and health policy gaps in ghana. ▸ it has contributed in clarifying the various classification of chws and their scope of practice. ▸ it has also highlighted evidence of inadequate health policy support for chws. ▸ the formulation of a national policy on chws. ▸ the establishment of a professional and regulatory body to regulate the standards and practice of chws. ▸ the development of a long-term strategy that will see the gradual replacement or absorption of chws into the formal health service in ghana. with the current ageing population and wave of epidemiological transition globally (the impact of which is projected to be felt more by populations in lmics), studies suggest that chws are rising to the task of ensuring that the impact is less felt by communities and health systems. [ ] [ ] [ ] the potential contributions of chws to tackling the current global health security threat posed by the zika virus, yellow fever, middle east respiratory syndrome (mers) and influenza, especially in the area of surveillance, cannot be overemphasised. despite the general consensus about the importance of chws among the global health community, health policy interventions to recognise and support optimal delivery of healthcare by chws are lacking, especially in lmics. in ghana, although a number of studies and reports have highlighted chws' activities, there is inadequate health policy support for them. to the best of our knowledge, no studies currently exist in ghana to have systematically profiled chws and their contribution to healthcare delivery. there is yet no consensus or comprehensive assessment of their roles, scope of activities and constraining factors to their productivity in ghana. this analysis paper therefore addresses this knowledge and policy gap. to analyse the activities of chws and the extent of health policy support in ghana, we conducted a literature review of published and unpublished works, including reports on the activities of chws in ghana (see box for search strategy deployed to search and retrieve relevant literature for this study). this paper also incorporates insights from our experiences of working in ghana as community health services researchers, affiliates of the ghana health service and development workers who have contributed to the design and implementation of numerous community-driven health interventions in collaboration with chws. despite an international consensus about the importance of chws to healthcare delivery, a universal definition of chws remains evasive. ambiguity further abounds in the mainstream literature on the characterisation of chws. however, during the recent united states agency for international development (usaid) chw evidence summit, there was some consensus that a chw is "a health worker who receives standardized training outside the formal nursing or medical curricula to deliver a range of basic health, promotional, educational, and mobilization services and has a defined role within the community system and larger health system". we find this definition to be insightful and thus will significantly support our analysis of chws in this paper. in ghana, two complementary types of chws are notable. the first category are an informal, poorly trained health service-supporting chws. in this category, chws are informally a part of the health system, and the health authorities or collaborating development partner (non-governmental organisation, ngo) takes responsibility for their recruitment, training, incentives and/or remuneration. the second strand of chws exists where chws are representatives of the community and act in the interest of the community. chws under this category have no or limited affiliation with the formal healthcare system, and mainly spearhead community-driven preventive health activities. despite this distinction, we admit that many chws might be combining both roles in practice. from our experiences and in our view, a 'hybrid' form of chws (a mix of the two categories) can be found in ghana. similar to the international trend, chws are diversely named in ghana, including but not limited to names such as community health volunteers (chvs), traditional birth attendants (tbas), village health volunteers, community health champions, peer health educators, community child growth promoters, community nurses, community health committee members, community-based surveillance volunteers (cbsvs), community-based agents and lay health workers. - these different characterisations generally reflect the diverse and ambiguous identities of chws in the international health literature and in health policy programmatic interventions. - for the purpose of clarity, we refer to chws in this paper as any of the above category of health workforce who, though not formal employees of the health system in ghana, are either a health service-supporting chw or community representatives, who have been identified, a rapid literature review of both published and unpublished works was conducted in academic science complete, cinahl, embase, global health medline, google scholar, isi web of knowledge, popline pubmed, psycinfo and web of science. no year limit was included in the search. we also undertook a review of reports on the activities of community health workers (chws) in ghana. the search sought to retrieve relevant documents ( programmatic and scholarly reports) on the activities of chws, especially in ghana, using key words such as community health workers, chw, village health worker, community health volunteer, lay health worker, traditional birth attendants, tbas, health promoters, ghana, remuneration, financing, health policy, impact, activities, training, practice and training. relevant papers and information were retrieved and reference lists screened for more relevant studies. studies which discussed the activities of chws with particular reference to ghana were critically assessed for relevant information. in order to establish the activities of chws in the context of the globe, works related to chws in general were included based on relevance to the study aim. in addition, the scope of the literature included in this paper was confined to works which reported, described, analysed and synthesised the activities of chw in the context of ghana. importantly, the paper incorporates insights on the activities of chws through anecdotes, authors' personal experiences and field reports. trained or untrained, and assigned roles in the community for which they receive no or some form of formal remuneration. historically, chws such as tbas have operated in most ghanaian communities. however, attempts to formally organise and recognise them came after the alma-ata declaration on primary health care (phc). village health workers (vhws) provided the first semblance of chws in ghana. these were local community representatives whose actions and activities were mostly based on altruism. although their roles such as community mobilisation, health awareness creation and immunisation campaigns were critical to the modest gains ghana achieved from implementing the phc strategy, their activities were short-lived such that by the s, vhws were no longer used. lack of coordination and inadequate supervision of their activities were among the reasons why the vhws programme was discontinued. as a result, community health nurses (chns) were introduced to deliver healthcare in mostly deprived parts of ghana. unlike the vhws, chns were recruited, provided professional training in nursing training colleges, deployed into mostly rural parts of ghana and formally remunerated to provide healthcare. however, the relatively long period needed to train them and funding challenges limited adequate training and deployment of chns. consequently, the activities of vhws were reinvigorated in the early s. central to their re-emergence was the navrongo experiment, a pilot project which culminated in the current community-based health planning and services (chps) concept. since then, chws have continued to evolve both in name and role. currently, cbsvs form the majority of chws in ghana. however, there is still lack of clarity on their contribution, recruitment, scope of practice and remuneration. chws: contributions to healthcare in ghana evidence of the success of a plethora of community health interventions supported and delivered by chws exists in the international health policy and systems research literature. although chws are involved in many domains of healthcare delivery in ghana, our review identified four important areas where chws' contributions have been immense. these four areas are examined in this paper. the navrongo experiment is one of the areas where chws' contributions to healthcare delivery have been acknowledged globally. the navrongo community health and family planning project, popularly referred to as the navrongo experiment, which culminated in the birth of the current chps programme in ghana, sought to improve access to healthcare in deprived communities using mostly community-driven resources and structures. the intervention was conceptualised under the assumption that by recruiting, training and deploying community health officers to rural communities, inequities in access to healthcare services between urban and rural settings could be bridged. under the navrongo experiment, chws played several critical roles, including outreach services, community mobilisation for health educational talks and referral to health facilities. the navrongo experiment resulted in increased access to healthcare services, immunisation coverage, reduced child and maternal mortality while improving the rural population's overall health. for example, within a period of years of its implementation, the results pointed to a % reduction in childhood mortality rate and % reduction in fertility rate. given this landmark success, results from this experimental intervention led to the conceptualisation and implementation of the chps programme as the country's main policy enactment aimed at improving access to health services in rural ghana. owing to its overall success, ghana's chps programme has been acclaimed as among the most successful community-based health programmes globally. [ ] [ ] [ ] [ ] guinea worm eradication without the diverse contributions of cbsvs, ghana's current success in eradicating the guinea worm (dracunculiasis) would have been unlikely. ghana was ranked second globally in among the guinea worm endemic countries. currently, however, ghana is guinea worm free. studies and reports from the ghana health service and non-state actors (ngos) have underscored the critical roles played by chws in eradicating the guinea worm in ghana. [ ] [ ] [ ] [ ] their roles included community mobilisation for awareness raising campaigns on the spread of the guinea worm, administration of palliative care, door-to-door distribution of drugs, referral to health centres for treatment, and distribution of water filters in communities. indeed, their role was so critical that both the national guinea worm eradication programme and some development partners (eg, carter center) have acknowledged it as being the most important factor in ghana's guinea worm eradication campaign. promotion of maternal and child health globally, chws have been acclaimed as having played a tremendous role in decreasing childhood illnesses and mortalities. notably, case management of childhood illness is one area where their contribution has been highly commended by the who and unicef. a study in ghana reported that chws were instrumental in establishing community health post, making home visits to provide healthcare services such as administration of antibiotics, oral rehydration solution and zinc to treat childhood illnesses such as pneumonia, diarrhoea and malaria. similar results have been reported by other studies globally. again in ghana, the role of tbas has been reported to double the number of women referred to clinics and hospitals for potentially life-saving care and support. indeed, in several communities in bolgatanga, kassena nankana and bawku west districts of ghana, oxfam has trained and evaluated the work of some tbas. the evidence from oxfam's work has shown positive results. in each of the communities where oxfam trained and worked with tbas, the number of women being referred by tbas to clinics and hospitals for potentially life-saving care doubled. maternal mortality has similarly reduced by %. further, between and , one of the authors ( jkg) was involved in a community-based pilot health project in communities in nadowli district, upper west region, ghana. this project was implemented by world vision ghana in partnership with ghana health services. the project trained cbsvs and tbas to perform a number of tasks, including recording births and deaths, and reporting disease outbreaks. several tbas also got trained to detect danger signs during pregnancy and labour and to make quick referral of pregnant women to health facilities to receive skilled care. the tbas were all provided basic consumables such as hand gloves, hand sanitisers, new packs of cutting blades and kerosene lanterns (to be used in the night when there is no electricity). the main aim of the project was to improve tbas' skills and resource them adequately to conduct normal deliveries, particularly in hard-to-reach rural communities. in mid- , an initial evaluation was done. the evaluation results showed that antenatal care attendance in some communities had increased twofold (ie, % in to % in ). qualitative interviews with women and tbas suggested that many tbas who received the training and essential consumables actively encouraged and referred pregnant women to healthcare facilities. also, among women who delivered at home with tbas, infections resulting from the use of bare hands and other unhygienic practices by tbas (such as the same blade being used to sever the umbilical cords of two babies) during labour were reported to have reduced. the women and tbas who participated in the interviews largely attributed the increase in the number of referrals to health facilities for skilled delivery and a reduction in infections during labour to the training tbas received and the supply of hand gloves, hand sanitisers and new blades. in fact, these positive results from ghana are supported by evidence from other low income contexts. [ ] [ ] [ ] [ ] [ ] notwithstanding these evidences, tbas' activities in maternal healthcare until now are still surrounded with controversies because the who official position only permits tbas to make referrals and not conduct home deliveries. however, based on this evidence from the upper east region and the fact that in ghana only % of births are attended to by a skilled attendant (defined here as a doctor, nurse or midwife), and % by tbas, we consider the who position on tbas as untenable in lmics such as ghana where the capacity to provide skilled and supervised delivery is limited. in other parts of the world especially in sub-saharan africa, the role of chws has been important in the fight against the spread of hiv/aids. - in ghana, the literature suggests that chws were recognised as a conduit to providing voluntary counselling and testing services. a cross-sectional survey conducted in northern ghana reported an overwhelming acceptance ( . %) of the use of lay health counsellors to provide community-based voluntary counselling and testing services. we noted, however, that only a few studies have covered the activities of chws in hiv/aids prevention and treatment in communities. our experience in working at the community level in ghana shows that chws are a key cadre of health staff working closely with chos and ngos in raising hiv/aids awareness, mobilising communities against stigma and discrimination and providing a culturally acceptable or a community-competent context for people living with hiv/aids. despite this, the district health information management system (dhims), a comprehensive database which reports on all aspects of services delivered by the ghana health service, does not report on chws' contribution to hiv/aids prevention and management. this suggests that even in contexts where their contribution is not in doubt, the healthcare system has not adequately documented or recognised their role. prior to the inception of the one million chw campaign (to which we return later), there was no national framework to guide the recruitment of chws in ghana. as a result, their recruitment was dependent on the community, the health programme, and the donor agency or development partner (ngo) involved. from the international literature and our experiences in ghana as well, chws are generally recruited from their own communities based on their level of acceptability in their respective communities, previous involvement in community-driven initiatives, high sense of dedication to duty and literacy (education) level. although these considerations are important, they are no doubt subjective and may affect the objective assessment and recruitment of chws. our experience in some communities shows that the lack of clearly defined recruitment criteria and strategy has often generated tensions among community members. indeed, some earlier studies have indicated how recruiting chws from local communities often served to generate tension and/or perpetuate gender inequalities. an important dimension regarding the recruitment of chws in ghana is the active role of ngos and other non-state actors. many ngos and other non-state actors who operate and/or implement parallel or vertical healthcare programmes in ghana often recruit parallel chws. in most cases, this parallel recruitment is often without regard for existing structures. from our experience, the ngos' style of engagement with chws can be problematic because recruiting chws without recourse to already existing structures can breed conflicts, duplication of efforts, lack of community participation and ownership of a particular health intervention and redundancies following the completion of the programmes of such organisations. comparable to the global situation, the scope of practice for chws lacks clarity and remains undefined in ghana. there has been a long-standing debate as to what exactly their roles should be and to what extent they are supposed to act in providing healthcare. according to a report by unicef, in south asia, one chw can provide healthcare services to about to households. generally, chws tend to provide more preventive and promotive healthcare, rather than curative. in other settings, the roles of chws have been observed to vary from community mobilisation for immunisation campaigns, health talks, first aid, creating awareness on disease control and health promotion to activities such as registration of births and deaths. in ghana, owing to the acute shortage of health personnel, chws' scope of practice has broadened beyond prevention and health promotional activities to encompass some curative care such as treatment for malaria and diarrhoea. generally, the scope of practice of chws in ghana varies widely, including serving as aids to community health officers, home visits, disease surveillance, maintaining environmental sanitation, nutrition education, home management of minor ailments like uncomplicated malaria, social mobilisation, and providing a limited range of reproductive and child health services. while this varied and flexible scope of practice may be a unique strength, it is therefore to be inferred that the lack of clarity on the operational mandates of chws in ghana has often undermined the effectiveness and efficiency of their roles in healthcare delivery at the community level. as observed by some researchers, a reasonable involvement of chws in limited activities has the tendency to enhance outcomes in community-based health interventions compared with an unlimited scope of practice. remuneration of chws is a controversial subject that has eluded consensus among stakeholders. internationally, the discourse is suggestive of the need to compensate their services in the form of a fee or in kind by the beneficiary communities. some other nonmonetary incentives such as providing bicycles, certificates or free healthcare to chws are also common. as a result, the who has underscored the need to pay chws reasonable wages in order to enhance their productivity, sustain community-driven interventions and reduce their attrition rates. [ ] [ ] [ ] the available literature has copiously cited the positive correlation between incentivising chws and lower rates of attrition. in ghana, chws are not remunerated by governments, and a spirit of volunteerism and altruism is rather emphasised. chws are required to draw satisfaction from community recognition, ability to gain skills and experience and the opportunity it presents to them to build social capital and access other job opportunities. this contradicts the who position and existing literature, which recommend the remuneration of chws. for instance, in the work of lehmann and sanders, the non-payment of chws under the premise that they were volunteers and offered services based on altruistic motives failed to motivate the chws to support the sustainability of community-based health interventions. our experience suggests that contrary to the government's view that chws activities should be inspired by altruism, chws usually have high expectations of rewards in the form of regular wages, stipends and some form of career opportunities to eventuate them into the health system. while chws are gaining increasing attention as important players in healthcare delivery in ghana and elsewhere, they are beset with multiple challenges. chws face capacity problems as they receive little or no formal training. one author noted this as a fundamental concern among chws as most of the experience they require for their job are gathered on the job. quite notably, the ghana health service recently attempted to address this challenge by developing training guides for some categories of chws. however, from our experience, there has been limited uptake of these training guides. we have also observed the inadequate supply of basic equipment such as wellington booths, bicycles, hand gloves and the first aid kit that some chws use to facilitate their work. neglect or inadequate recognition of chws is another fundamental challenge. as noted earlier, the absence of a policy directive on chws lends credence to our position. the current policy position of the government, which does not remunerate chws for contributing to deliver community health service, only exacerbates the dwindling enthusiasm of chws and the time they commit to their duties. this, to a large extent, affects negatively their productivity and retention. further, this has the potential to increase their attrition rates as has been reported in other settings to vary between . % and %. also, the attendant long-run effect of this situation is the high costs involved in selecting and training new chws as replacements. the inadequate recognition of chws has further led to the lack of a framework to regulate their practices as evidenced in the varying roles chws assume as espoused in earlier sections of this paper. the situation creates an inherent ambiguity and varying expectations of their roles which affects the optimum engagement of chws. in ghana, there are neither mechanisms nor a framework to regulate their practice or certify chws as having the requisite competencies to practice as in the case of other health professionals such as medical doctors, nurses or chns. to be able to attain standardisation and integration of the services of chws into the health system, a form of oversight is required. this may take the form of a regulatory or professional body which will provide some form of certification or licensing to duly recognise their competencies and standardise their practices. lack of effective supervision of chws is one of the notable problems chws face in ghana. our experiences in northern ghana suggest that laxity in the supervision of chws is mainly due to the already overstretched nature of the health system, which is attributable in part to the human resources for health crises. given that chws are now taking up more curative care activities in addition to the preventive-based care interventions, their activities should be supervised and coordinated closely to potentially optimise their productivity and improve health outcomes as evident in studies from other settings. also, a further step by the ministry of health (moh) to scale up the number of frontline staff to provide healthcare to the rural communities is the current partnership with the one million chw campaign project to introduce a new cadre of chws in ghana. this represents an important health policy direction in improving access and health outcomes of the rural populace in ghana. the one million chw campaign proposed to introduce a world-class cadre of chws to extend essential health services to household levels functioning as an integral component of the community health system. conceptually and based on the literature on chws, this category of chws will be an informal extension of the formal healthcare system with explicitly defined roles, training and remuneration to augment the delivery of healthcare. notably, this new cadre of chws differs substantially from the chws who are the subject of this paper except in their duties. while the policy issues of existing chws still remain to be addressed, the new programme only proposes to recognise the existing chws provided they will be useful in providing voluntary assistance to the formally remunerated new cadre of chws, and their continuous existence will be dependent on the particular health district. a justifiable policy question may therefore be why introduce a new cadre of chws to take up duties which were essentially carried out by a particular workforce but whose contribution has hitherto not been recognised and whose integration into the new programme has not been explicitly addressed. if such concerns are not addressed, there will most likely be challenges such as conflicting roles, tension between chws of the one million chw campaign and existing chws, lack of community participation and a threat to the sustainability of community-based health interventions. the preceding analysis points to a general policy deficit regarding chws in ghana, given the lack of a national framework to guide activities of chws such as recruitment, credentialling, scope of practice, remuneration, career development, performance management, supervisory mechanisms, integration into the formal health system, capacity development and logistical requirement and deployment. despite the active involvement of chws in the health system, they are invisible nationally and subnationally in terms of policies, strategies and budgeting. we therefore recommend the following immediate and long-term measures to forestall anticipated and existing challenges faced by chws: . the establishment or enactment of a national policy on chws which should define and outline the relevant aspects of their recruitment, credentialling, scope of practice, remuneration, career development, performance management, supervisory mechanisms, integration into the formal health system, capacity development and logistical requirement and deployment. . the establishment of a professional and/or regulatory body that will exercise oversight over chws by defining, monitoring or enforcing the standards and practice of chws in ghana including licensing or a form of certification. . the development of a long-term strategy that will see the gradual replacement or absorption of chws into the mainstream or formal health service in ghana. . that the proposed one million chw campaign project should incorporate an integration plan aimed at enlisting existing deserving chws who have a wealth of experience and skill to their credit and to further develop the capacities of those with inadequate skills to enable them to enlist and participate in the programme. . finally, policy steps should be taken to critically review the who position on tbas' roles in promoting maternal health. given the shortage of skilled birth attendants (sbas) in ghana and across sub-saharan africa as indicated by the latest who report on the 'state of the world's midwifery', it is clear that the ideal of ensuring skilled attendance at all births is not feasible or achievable in the short term. therefore, reasonably acceptable equity and efficiency arguments can be made for the building of working partnerships with and incorporation of tbas into the maternal healthcare system in contexts such as ghana where skilled maternal healthcare provision is acutely limited. indeed, widespread collaboration through policy support for the healthcare system to identify, train and enhance the skill sets of tbas is recommended. partnerships between tbas and sbas would also be critical for helping healthcare workers to learn from tbas how best to address the cultural needs and concerns of childbearing women. thus, even if the ghanaian health system were to train and deploy sufficient numbers of sbas to all parts of the country in the future, tbas could still play important roles in helping healthcare workers to provide culturally competent care. conclusion this relatively modest contribution by chws to healthcare delivery in ghana suggests the need for state and non-state actors alike to build better working partnerships with chws, provide financial remuneration, create career opportunities and other means of motivations to boost their productivity and sustain gains associated with their activities. in addition, there is the need for policy definition to harmonise the issues relating to chws in general. this is because chws play an indispensable role in delivering health to their communities and assume and actively play the role of health activists and advocates. the reported challenges faced by chws can be addressed through appropriate national policy articulation, and therefore development partners should work in partnership with the government of ghana to put in place these policies. handling editor douglas noble. contributors lb and ams conceived the study. lb, ams, pnt and jkg searched the literature. lb drafted the manuscript. all authors contributed substantially to the review of the manuscript for critical and intellectual content. all authors have read and approved the final version of the manuscript for publication. competing interests none declared. provenance and peer review not commissioned; externally peer reviewed. data sharing statement no additional data are available. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work noncommercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. see: http:// creativecommons.org/licenses/by-nc/ . / producing effective knowledge agents in a pluralistic environment: what future for community health workers? thirty years after alma-ata: a systematic review of the impact of community health workers delivering curative interventions against malaria, pneumonia and diarrhoea on child mortality and morbidity in sub-saharan africa questioning the solution: the politics of primary health care and child survival can the deployment of community health workers for the delivery of hiv services represent an effective and sustainable response to health workforce shortages? results of a multicountry study community health workers and the response to hiv/aids in south africa: tensions and prospects community health workers for universal health-care coverage: from fragmentation to synergy feldshers and health promotion in the ussr the barefoot doctors of the people's republic of china health by the people global experience of community health workers for delivery of health related millennium development goals: a systematic review, country case studies, and recommendations for integration into national health systems million community health workers in sub-saharan africa by lay health workers in primary and community health care for maternal and child health and the management of infectious diseases achieving child survival goals: potential contribution of community health workers lay health workers in primary and community health care: a systematic review of trials. geneva: world health organization an intervention involving traditional birth attendants and perinatal and maternal mortality in pakistan cardiovascular disease prevention in ghana: feasibility of a faith-based organizational approach effectiveness of community health workers in the care of persons with diabetes effectiveness of community health workers in the care of people with hypertension using lay counsellors to promote community-based voluntary counselling and hiv testing in rural northern ghana: a baseline survey on community acceptance and stigma the amount and value of work time of community medicine distributors in community case management of malaria among children under five years in the ejisu-juaben district of ghana community health workers: what do we know about them? the state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. world health organization community and formal health system support for enhanded community health worker performance. a us government evidence summit. final report assessment of the adherence of community health workers to dosing and referral guidelines for the management of fever in children under years: a study in dangme west district accelerating reproductive and child health programme impact with community-based services: the navrongo experiment in ghana factors influencing sustainability of community-based health volunteers activities in the kassena-nankana east and west districts of northern ghana the ghana community-based health planning and services initiative for scaling up service delivery innovation community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness community-based health workers: head start or false start towards health for all? community health workers: a review of concepts, practice and policy concerns. a review as part of ongoing research of international consortium for research on equitable health systems (crehs) chasing out traditional birth attendants in ghanaimplications for maternal and newborn health interventions to improve motivation and retention of community health workers delivering integrated community case management (iccm): stakeholder perceptions and priorities bridging the gap between evidence-based innovation and national health-sector reform in ghana accelerating reproductive and child health program development: the navrongo initiative in ghana assessing participation in a community-based health planning and services programme in ghana scaling up health system innovations at the community level: a case-study of the ghana experience guinea worm disease outcomes in ghana: determinants of broken worms dracunculiasis eradication: ministerial meeting motivations and challenges of community-based surveillance volunteers in the northern region of ghana pilot study of the use of community volunteers to distribute azithromycin for trachoma control in ghana innovative approaches to infectious disease prevention in women the role of case containment centers in the eradication of dracunculiasis in togo and ghana community participation in the eradication of guinea worm disease the impact of health education to promote cloth filters on dracunculiasis prevalence in the northern region ghana: guinea worm eradication program gets results in country atlanta early treatment of childhood fevers with pre packaged antimalarial drugs in the home reduces severe malaria morbidity in burkina faso community case management of fever due to malaria and pneumonia in children under five in zambia: a cluster randomized controlled trial world health organization/ united nations children's fund joint statement on integrated community case management: an equity-focused strategy to improve access to essential treatment services for children valuing and sustaining (or not) the ability of volunteer community health workers to deliver integrated community case management in northern ghana: a qualitative study two-year evaluation of intermittent preventive treatment for children (iptc) combined with timely home treatment for malaria control in ghana factors related to retention of community health workers in a trial on community-based management of fever in children under years in the dangme west district of ghana improving maternal healthcare in ghana and beyond does tba training increase use of professional antenatal care services: a review of the evidence assessment of the role of traditional birth attendants in maternal health care in oredo local government area traditional birth attendant training for improving health behaviours and pregnancy outcomes why do some women still prefer traditional birth attendants and home delivery?: a qualitative study on delivery care services in west java province are traditional birth attendants good for improving maternal and perinatal health? yes community health workers for art in sub-saharan africa: learning from experiencecapitalizing on new opportunities scaling up access to antiretroviral treatment in southern africa: who will do the job? a systematic review of task-shifting for hiv treatment and care in africa role and outcomes of community health workers in hiv care in sub-saharan africa: a systematic review populism and health policy: the case of community health volunteers in india management of sick children by community health workers. intervention models and programme examples what works for children in south asia: community health workers community health workers: a front line for primary care? population council. community health volunteers training manual lay workers in directly observed treatment (dot) programmes for tuberculosis in high burden settings: should they be paid? a review of behavioural perspectives health worker motivation in africa: the role of non-financial incentives and human resource management tools the female community health volunteer programme in nepal: decision makers' perceptions of volunteerism, payment and other incentives training the health workforce: scaling up, saving lives world health organization, pepfar and unaids. task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines national experience in the use of community health workers. who health workforce attrition in the public sector in kenya: a look at the reasons world health organization. task force for scaling up education and training for health workers. global health workforce alliance scaling up working practices and incomes of health workers: evidence from an evaluation of a delivery fee exemption scheme in ghana are large-scale volunteer community health worker programmes feasible? the case of sri lanka a community health worker intervention to address the social determinants of health through policy change community health workers " " for primary care providers and other stakeholders in health care systems frontline health workers coalition. a commitment to community health workers: improving data for decision making the state of the world's midwifery : delivering health, saving lives key: cord- -nr fu qb authors: wang, yu; tian, huaiyu; zhang, li; zhang, man; guo, dandan; wu, wenting; zhang, xingxing; kan, ge lin; jia, lei; huo, da; liu, baiwei; wang, xiaoli; sun, ying; wang, quanyi; yang, peng; macintyre, c. raina title: reduction of secondary transmission of sars-cov- in households by face mask use, disinfection and social distancing: a cohort study in beijing, china date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: nr fu qb introduction: transmission of covid- within families and close contacts accounts for the majority of epidemic growth. community mask wearing, hand washing and social distancing are thought to be effective but there is little evidence to inform or support community members on covid- risk reduction within families. methods: a retrospective cohort study of people in families and with at least one laboratory confirmed covid- case was conducted from february to march , in beijing, china. the outcome of interest was secondary transmission of severe acute respiratory syndrome coronavirus (sars-cov- ) within the family. characteristics and practices of primary cases, of well family contacts and household hygiene practices were analysed as predictors of secondary transmission. results: the secondary attack rate in families was . % ( / ). face mask use by the primary case and family contacts before the primary case developed symptoms was % effective in reducing transmission (or= . , % ci . to . ). daily use of chlorine or ethanol based disinfectant in households was % effective (or= . , % ci . to . ). wearing a mask after illness onset of the primary case was not significantly protective. the risk of household transmission was times higher with frequent daily close contact with the primary case (or= . , % ci . to . ), and four times higher if the primary case had diarrhoea (or= . , % ci . to . ). household crowding was not significant. conclusion: the study confirms the highest risk of transmission prior to symptom onset, and provides the first evidence of the effectiveness of mask use, disinfection and social distancing in preventing covid- . we also found evidence of faecal transmission. this can inform guidelines for community prevention in settings of intense covid- epidemics. introduction transmission of covid- within families and close contacts accounts for the majority of epidemic growth. community mask wearing, hand washing and social distancing are thought to be effective but there is little evidence to inform or support community members on covid- risk reduction within families. methods a retrospective cohort study of people in families and with at least one laboratory confirmed covid- case was conducted from february to march , in beijing, china. the outcome of interest was secondary transmission of severe acute respiratory syndrome coronavirus (sars-cov- ) within the family. characteristics and practices of primary cases, of well family contacts and household hygiene practices were analysed as predictors of secondary transmission. results the secondary attack rate in families was . % ( / ). face mask use by the primary case and family contacts before the primary case developed symptoms was % effective in reducing transmission (or= . , % ci . to . ). daily use of chlorine or ethanol based disinfectant in households was % effective (or= . , % ci . to . ). wearing a mask after illness onset of the primary case was not significantly protective. the risk of household transmission was times higher with frequent daily close contact with the primary case (or= . , % ci . to . ), and four times higher if the primary case had diarrhoea (or= . , % ci . to . ). household crowding was not significant. conclusion the study confirms the highest risk of transmission prior to symptom onset, and provides the first evidence of the effectiveness of mask use, disinfection and social distancing in preventing covid- . we also found evidence of faecal transmission. this can inform guidelines for community prevention in settings of intense covid- epidemics. in the absence of a vaccine for covid- , non-pharmaceutical interventions (npis) are the only available disease control measures. we have shown that population level npis, including travel bans and the national emergency response, were effective in flattening summary box what is already known? ► mitigation of the covid- pandemic depends solely on non-pharmaceutical interventions until drugs or vaccines are available. transmission of covid- within families and close contacts accounts for the majority of epidemic growth. community mask wearing, hand washing and social distancing are thought to be effective but the evidence is not clear. what are the new findings? ► the overall secondary attack rate in households was . %. face masks were % effective and disinfection was % effective in preventing transmission, while close frequent contact in the household increased the risk of transmission times, and diarrhoea in the index patient increased the risk by four times. the results demonstrate the importance of the pre-symptomatic infectiousness of covid- patients and shows that wearing masks after illness onset does not protect. what do the new findings imply? ► the findings inform universal face mask use and social distancing, not just in public spaces, but inside the household with members at risk of getting infected. this further supports universal face mask use, and also provides guidance on risk reduction for families living with someone in quarantine or isolation, and families of health workers, who may face ongoing risk. the covid- epidemic curve in china. however, the effect of other npis, such as mask use and hygiene practices, have not been well studied in the covid- pandemic. in the usa, the use of face masks in the community has been recommended. it is thought that universal face mask use (ufmu) may reduce outward transmission from asymptomatically infected people and protect well people from becoming infected. however, the world health organization and public health england recommend against ufmu on the grounds that there is little evidence from randomised controlled trials to support this. some experts suggest that in a pandemic, the precautionary principle should be used and ufmu encouraged as it is unlikely to cause harm and may result in public health gain. in countries where personal protective equipment is scarce, people are making their own masks. in china, over % of human-to-human transmission of severe acute respiratory syndrome coronavirus (sars-cov- ) occurred in families. however, data to inform covid- risk reduction in households are unavailable. given epidemic growth is dominated by household transmission, studying the use of npis, such as face masks, social distancing and disinfection in the household setting, may inform community epidemic control and prevent transmission of covid- in households. we conducted a retrospective cohort study involving families of laboratory confirmed covid- cases in beijing, china. we defined family members as those who had lived with primary cases in a house for days before and for more than hours after the primary cases developed illness related to covid- . as of february , all laboratory confirmed covid- cases reported in beijing were enrolled in our study and followed-up. the outcome of interest was secondary transmission in the household. families with secondary transmission were defined as those where some or all of the family members become infected within one incubation period ( weeks) of symptom onset of the primary case. to analyse the predictors of household transmission, we compared families with and without secondary transmission for various measured risk factors, preventive interventions and exposures. definition of confirmed case according to national prevention and control guideline (fifth edition), confirmed cases were those who met the clinical, epidemiological and laboratory testing criteria for covid- simultaneously. . clinical criteria included: (a) fever and/or one or more respiratory symptoms; (b) radiological evidence of pneumonia; (c) white blood cell count normal or decreased, and lymphocyte count decreased at the early stage of illness. . epidemiological criteria included: (a) visits to/living in wuhan or cities around wuhan or other communities which had already reported covid- cases in the days prior to the onset of symptoms; (b) having contact with a person known to have infection with sars-cov- in the days prior to onset of symptoms; (c) having contact with a person who had fever or respiratory symptoms and came from wuhan or adjacent cities or other communities which had already reported covid- cases in the days prior to onset of symptoms; (d) being one of the cluster cases. suspected cases met one of the epidemiological criteria and any two of the clinical criteria, or met all of the clinical criteria. confirmed cases were those suspected cases who met one of the following criteria: (a) respiratory or blood specimen tested positive for sars-cov- by real time reverse transcriptase-polymerase chain reaction; (b) virus in respiratory or blood specimen was highly homologous with known sars-cov- through gene sequencing. data collection a three part structured questionnaire was developed. the first part included demographic and clinical information of the primary case. the second part was mainly focused on the primary case's knowledge about and attitudes toward covid- , and their self-reported practices (mask wearing, social distancing, living arrangements) and activities in the home. the third part was about self-reported behaviours of all family members, as well as the family's accommodation and household hygiene practices from days before the illness onset to the day the primary case was isolated, including room ventilation, room cleaning and disinfection. close contact was defined as being within m or feet of the primary case, such as eating around a table or sitting together watching tv. the frequency of contact, disinfection and ventilation was measured. after diagnosis, the primary case was hospitalised as per standard practice in beijing. eligible primary cases and their family members were interviewed between february and march. data on the primary case were extracted from epidemiological investigating reports from beijing centre for disease prevention and control and supplemented by interview. the clinical severity of the covid- case was categorised as mild, severe or critical. mild disease included nonpneumonia and mild pneumonia cases. severe disease was characterised by dyspnoea, respiratory frequency ≥ /min, blood oxygen saturation ≤ %, pao /fio ratio < and/or lung infiltrates > % within - hours. critical cases were those who exhibited respiratory failure, septic shock and/or multiple organ dysfunction/ failure. statistical analysis risk factors for secondary transmission were analysed by characteristics of the primary case, characteristics of well family members and household hygiene practices. categorical variables are presented as counts and percentages, and continuous variables as medians (iqr). the χ test and fisher exact test were applied to compare difference between groups when necessary. a composite covid- knowledge score and hand hygiene score were created with multiple sub-questions. a multivariable logistic regression model was used to identify risk factors associated with sars-cov- household transmission. univariable analysis was first performed with all measures and only those variables significant at p< . could be selected in the following multivariable logistic regression analysis. backward elimination was performed to establish a final model retaining those with p< . in the model. statistical analyses were performed using sas software (v. . ). as our study was embedded within the covid- prevention and control practice within public health units, and the telephone interview was a supplementary survey of the epidemiological field investigation, ethics approval was not required. we obtained subjects' verbal informed consent before the start of the interviews. no patients or the public were involved in the study design, setting the research questions, interpretation or writing up of results, or reporting of the research. as of february , confirmed covid- cases in families were reported in beijing. four family clusters were excluded because we were unable to determine whether there was secondary transmission or co-exposure, leaving families. after reviewing information in the epidemiological investigation reports and survey calls, families were excluded as they did not meet the study inclusion criteria. a further families declined to be interviewed and were also excluded, leaving families for study (figure ). over the weeks of follow-up from onset of the primary case, secondary transmission occurred in / families ( secondary cases), and / families had no secondary transmission. the overall secondary attack rate in families was . % ( / ). in the secondary transmission group, primary cases caused secondary cases, with a median secondary case number in families of (iqr - ). in the secondary transmission group, the secondary attack rate in children < years of age was . % ( / ), compared with . % ( / ) in adults, and the difference between these two age groups was significant (χ²= . , p< . ). the median age of the secondary child cases was years (iqr - ), / were bmj global health in multivariable logistic regression model, four factors remained significantly associated with secondary transmission. the primary case having diarrhoea in the home and daily close contact with the primary case in the home increased the risk. transmission was significantly reduced bmj global health by frequent use of chlorine or ethanol based disinfectant in households and family members (including the primary case) wearing a mask at home before the primary case developed the illness (table ) . this study confirms that the highest risk of household transmission is prior to symptom onset, but that precautionary npis, such as mask use, disinfection and social distancing in households can prevent covid- transmission during the pandemic. this study is the first to confirm the effectiveness of mask use prior to symptom onset by family members, daily household disinfection and social distancing in the home. this could inform precautionary guidelines for families to reduce intrafamilial transmission in areas where there is high community transmission or other risk factors for covid- . household transmission is a major driver of epidemic growth. further, in countries where health system capacity is exhausted, many people with infection are required to self-isolate at home, where their household contacts will be at risk of infection. in our study, the median family size of the families was (range - ), usually with children, parents and grandparents, which is similar to the social structure of most chinese families. therefore, the risk of sars-cov- household transmission is high if a primary case was introduced and no measure was adopted. we showed that npis are effective at preventing transmission, even in homes that are crowded and small. ufmu is a low risk intervention with potential public health benefits. the results suggest that community face mask use is likely to be the most effective inside the household during severe epidemics. almost a quarter of family members became infected, and the findings suggest that the risk was highest either before symptom onset or early in the clinical illness, as most primary cases were hospitalised after diagnosis, and interventions were not effective if applied after symptom onset. in the univariate analysis, wearing a mask after illness onset was significant, but in multivariate analysis, only wearing it before symptom onset was effective. viral load is highest in the days before symptom onset and on the first day of symptoms, and up to % of transmission is during the pre-symptomatic period in settings with substantial household clustering. this supports ufmu, probably by reducing onward transmission from people in the pre-symptomatic phase of the illness as well as protecting well mask users. randomised clinical trials of face masks in the household have confirmed protection against other respiratory viruses if compliant, if used within hours of the primary case symptom onset, and alone or in combination with hand hygiene. this study now provides specific evidence for ufmu in settings of high epidemic growth to protect against covid- . in our study, . % ( / ) of primary cases had a high score on hand hygiene, but it was not effective, confirming the results of previous randomised clinical trials which showed hand bmj global health hygiene alone did not protect against respiratory transmissible viruses, but masks combined with hand hygiene did have effect. as the compliance of ufmu would be poor in the home, there was difficulty and also no necessity for everyone to wear masks at home. we recommended that those families with members who were at risk of getting infected with sars-cov- (such as ever having contact with a covid- patient, medical workers caring for a covid- patient or having a history of travelling to high risk areas) should apply ufmu to reduce the risk of household transmission. this study showed that social distancing within the home is effective and having close contact (within m or feet, such as eating around a table or sitting together watching tv) is a risk factor for transmission. the study also provides evidence of effectiveness of chlorine or ethanol based household disinfection in areas with high community transmission, or where one family member is a health worker, or where there is a risk of covid- , such as during home quarantine, consistent with advice provided by local health authorities or organisations. diarrhoea as a symptom in the primary case is also a risk factor for sars-cov- transmission within families, which highlights the importance of disinfection of the bathroom and toilet, as well as closing the toilet lid when flushing to prevent aerosolisation of the virus. our study has limitations. telephone interview has inherent limitations, including recall bias. it would take about min to complete an interview, and % ( / ) of interviews were rated as informative by the interviewers. the evaluation results of mask wearing were reliable, but we did not collect data on the concentration of disinfectant used by families. the strengths of the study were that we had complete follow-up data and were able to accurately ascertain the incidence of secondary transmission in the cohort. household transmission in the pre-symptomatic or early symptomatic period of covid- is a driver of epidemic growth and any measure aimed at reducing this can flatten the curve. this study reinforces the high risk of transmission in households but importantly shows that ufmu and hygiene measures can significantly reduce the risk of household transmission of covid- , independent of household size or crowding. this is the first study to show the effectiveness of precautionary mask use, social distancing and regular disinfection in the household, and can inform guidelines for prevention of household transmission. the results may also be informative for families of high risk groups, such as health workers, quarantined individuals or situations where cases of covid- have to be managed at home. an investigation of transmission control measures during the first days of the covid- epidemic in china recommendation regarding the use of cloth face coverings, especially in areas of significant community-based transmission face masks for the public during the covid- crisis covid- : should the public wear face masks? yes-population benefits are plausible and harms unlikely report of the who-china joint mission on coronavirus disease (covid- ) new coronavirus pneumonia prevention and control program the novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) -china china statistical yearbook- virological assessment of hospitalized patients with covid- temporal dynamics in viral shedding and transmissibility of covid- potential presymptomatic transmission of sars-cov- presumed asymptomatic carrier transmission of covid- face mask use and control of respiratory virus transmission in households facemasks and hand hygiene to prevent influenza transmission in households: a cluster randomized trial hand hygiene and risk of influenza virus infections in the community: a systematic review and meta-analysis centers for disease control and prevention. cleaning and disinfection for households: interim recommendations for u.s. households with suspected or confirmed coronavirus disease (covid- acknowledgements we thank the staff members in the district and municipal centres for disease prevention and control, and medical settings in beijing for conducting field investigation, specimen collection, laboratory detection and case reporting. we also thank all patients and families involved in the study.contributors all authors approved the final draft of the manuscript. the corresponding authors attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.funding this work was supported by beijing science and technology planning project (z ). competing interests none declared.patient and public involvement patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. provenance and peer review not commissioned; externally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. key: cord- - ua ohkq authors: druetz, thomas; browne, lalique; bicaba, frank; mitchell, matthew ian; bicaba, abel title: effects of terrorist attacks on access to maternal healthcare services: a national longitudinal study in burkina faso date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: ua ohkq introduction: most of the literature on terrorist attacks’ health impacts has focused on direct victims rather than on distal consequences in the overall population. there is limited knowledge on how terrorist attacks can be detrimental to access to healthcare services. the objective of this study is to assess the impact of terrorist attacks on the utilisation of maternal healthcare services by examining the case of burkina faso. methods: this longitudinal quasi-experimental study uses multiple interrupted time series analysis. utilisation of healthcare services data was extracted from the national health information system in burkina faso. data span the period of january –december and include all public primary healthcare centres and district hospitals. terrorist attack data were extracted from the armed conflict location and event data project. negative binomial regression models were fitted with fixed effects to isolate the immediate and long-term effects of terrorist attacks on three outcomes (antenatal care visits, of facility deliveries and of cesarean sections). results: during the next month of an attack, the incidence of assisted deliveries in healthcare facilities is significantly reduced by . % ( % ci . to . ). multiple attacks have immediate effects more pronounced than single attacks. longitudinal analysis show that the incremental number of terrorist attacks is associated with a decrease of the three outcomes. for every additional attack in a commune, the incidence of cesarean sections is reduced by . % ( % ci . to . ) while, for assisted deliveries, it is reduced by . % ( % ci . to . ) and, for antenatal care visits, by . % ( % ci . to . ). conclusion: terrorist attacks constitute a new barrier to access of maternal healthcare in burkina faso. the exponential increase in terrorist activities in west africa is expected to have negative effects on maternal health in the entire region. abstract introduction most of the literature on terrorist attacks' health impacts has focused on direct victims rather than on distal consequences in the overall population. there is limited knowledge on how terrorist attacks can be detrimental to access to healthcare services. the objective of this study is to assess the impact of terrorist attacks on the utilisation of maternal healthcare services by examining the case of burkina faso. methods this longitudinal quasi-experimental study uses multiple interrupted time series analysis. utilisation of healthcare services data was extracted from the national health information system in burkina faso. data span the period of january -december and include all public primary healthcare centres and district hospitals. terrorist attack data were extracted from the armed conflict location and event data project. negative binomial regression models were fitted with fixed effects to isolate the immediate and long-term effects of terrorist attacks on three outcomes (antenatal care visits, of facility deliveries and of cesarean sections). results during the next month of an attack, the incidence of assisted deliveries in healthcare facilities is significantly reduced by . % ( % ci . to . ). multiple attacks have immediate effects more pronounced than single attacks. longitudinal analysis show that the incremental number of terrorist attacks is associated with a decrease of the three outcomes. for every additional attack in a commune, the incidence of cesarean sections is reduced by . % ( % ci . to . ) while, for assisted deliveries, it is reduced by . % ( % ci . to . ) and, for antenatal care visits, by . % ( % ci . to . ). conclusion terrorist attacks constitute a new barrier to access of maternal healthcare in burkina faso. the exponential increase in terrorist activities in west africa is expected to have negative effects on maternal health in the entire region. in the past few years, several countries of the sahelian region have been afflicted by a rise in insecurity related to terrorist attacks. the list of affected countries includes nigeria, mali, sudan, niger, chad and most recently burkina faso. initially spared such attacks, since burkina faso has been afflicted by an increased number of violent events related to terrorism. a recent report notes that burkina faso suffered more jihadist attacks than any other country in the sahelian region in . these attacks are mostly (but not exclusively) located in the northern and eastern border areas of the country. ouagadougou, the capital, is located in the centre of the country and has also been hit by attacks, particularly on military bases and places sought after by tourists or foreign workers. as a landlocked country where poverty is endemic (it ranked out of countries on the human development index (hdi), what do the new findings imply? ► regional insecurity needs to be recognised and investigated by the global health research community as a barrier to maternal healthcare and universal health coverage. political, economic, social, health and humanitarian consequences of these intensifying attacks. the potential impact of terrorist attacks on population health goes beyond direct consequences (ie, people killed, injured, displaced or traumatised). like armed conflicts, these attacks can damage public health infrastructure and services; undermine water, electricity and food supply; increase poverty; impede vaccination campaigns; and deteriorate sanitation and transportation. [ ] [ ] [ ] [ ] [ ] [ ] in addition, terrorist attacks aim to generate a feeling of insecurity in the general population, whose negative impact on numerous health indicators has been demonstrated in the context of armed conflicts. for example, studies reveal that the availability and access to maternal healthcare services, including family planning and contraception, are likely reduced under highintensity conflict conditions, possibly contributing to increased maternal mortality. [ ] [ ] [ ] [ ] [ ] this is particularly troubling in burkina faso, where despite noticeable progress over the last two decades maternal health remains one of the biggest public health issues. in , a nationally representative survey estimated the maternal mortality rate to be deaths per live births, compared with per on average in the richest countries. a major cause of this burden is the limited and unequal access to quality healthcare, especially in rural areas. in order to improve coverage, the government of burkina faso has gradually mitigated the cost of healthcare services, first in by reducing fees associated to assisted deliveries by %, then in by abolishing all user fees for maternal healthcare services. studies have demonstrated the positive impact of these initiatives on many indicators of maternal health, including the volume of antenatal care (anc) visits and assisted deliveries, as well as on health inequalities. however, as suggested by a recent study, the improvements in access to healthcare are fragile in burkina faso, and are likely to disappear rapidly if a new barrier is introduced, or if a former barrier is reinstituted. studies have shown that the primary factors that continue to limit women's access to healthcare after user fee abolition are distance to the health facility, low quality of care and informal costs. [ ] [ ] [ ] however, it is plausible that the insecurity generated by terrorist attacks in burkina faso acts as a new type of barrier to maternal healthcare access. this could undermine the government's longstanding efforts to improve maternal and neonatal health. to our knowledge, the presence of such an 'insecurity barrier' to maternal healthcare access has never been examined in burkina faso. studies conducted in other sahelian countries afflicted by terrorist attacks are scarce and provide only limited evidence on the topic. [ ] [ ] [ ] in particular, no studies have used longitudinal evaluation designs to measure the immediate effects of attacks. rather, they typically use data from cross-sectional surveys that are not time specific to such events and are therefore subject to historical bias in interpretation, due to time lag and a small number of time points. the objective of this study is to assess the effects of terrorist attacks on maternal healthcare access by using a more granular, precise spatiotemporal framework. a quasi-experimental study was therefore designed to ( ) assess the immediate effects of terrorist attacks on access to maternal healthcare in burkina faso and ( ) evaluate the longitudinal effects in communes affected by incremental levels of insecurity, defined here by the cumulative frequency of attacks. three key outcomes are investigated, namely anc visits, facility deliveries and cesarean sections. burkina faso is a landlocked country of ~ million inhabitants located in west africa, and surrounded by mali, niger, benin, togo, ghana and côte d'ivoire. between and , the republic was governed by blaise compaoré, a former military man who seized power in a coup d'état. throughout this period, burkina faso was considered to be a relatively secure country despite human rights violations and sporadic tensions and clashes between ethnic or religious groups. however, the security situation changed rapidly in the mid- s. after mounting pressure against his attempt to modify the constitution in order to remain in power, compaoré was forced to resign and flee the country. presidential elections were organised in , but not before the failure of a -week-long contre-coup. during this short period of unrest, approximately people were killed and over were wounded according to press releases. meanwhile, the security situation had dramatically deteriorated in the neighbouring countries of mali, niger and (northern) nigeria, where jihadist groupssometimes allied with rebel movements with territorial claims-carried out regular attacks against both the population and military forces. with these groups moving across borders and pursuing regional ambitions, the exact reasons that burkina faso remained relatively free of terrorist attacks remain unclear. nevertheless, its government agreed in to enter the g sahel joint force, along with mauritania, mali, niger and chad, to coordinate a regional response to the terrorist threat. since then, several jihadist groups have escalated their attacks throughout the country, most notably ansarul islam, islamic state in the greater sahara, and the group to support islam and muslims (known by its arabic acronym jnim). as a member of the g sahel joint force, burkina faso's military and police are supported in the field by operation barkhane, a french-led military force of approximately soldiers. this is a longitudinal quasi-experimental study that used multiple (pooled) interrupted time-series analysis bmj global health to evaluate the effects of terrorist attacks on access to maternal healthcare services at the level of the lowest administrative unit (ie, the commune). immediate effects were defined as level changes in the month of or the month following an attack. longitudinal effects of repeated attacks were examined by defining segments based on the incremental number of attacks in a commune over time and by measuring level change between segments. all communes of the national database were included in the analysis. the study period spanned from january to december , totalling time points of observation. this study has three outcome indicators: ( ) the total number of anc visits per commune per month; ( ) the number of facility-based deliveries per commune per month; ( ) the number of cesarean sections per commune per month. these outcomes were selected because they are key indicators of accessibility to maternal healthcare in low-income and middle-income countries and they are routinely collected in the facilities at the primary care level, including cesarean sections performed in district hospitals. in communes with several health facilities, the outcomes refer to the total number per commune per month. models were adjusted for the proportion of missing data. exposure was operationalised differently according to the objective. to evaluate the average immediate effects of a terrorist attack, communes that recorded at least one attack were defined as being exposed for that particular month and the following one, in order to cover a -day period after the attack. therefore, the first exposure variable is categorical (no attack, single attack, multiple attacks) and reflects immediate exposure to an attack. three categories were defined (rather than two, that is, absence/presence) to verify the presence of a dose-response relationship since it is hypothesised that more attacks will generate more insecurity and further reduce visits to health facilities. to evaluate the longitudinal effects of the incremental levels of insecurity, exposure was defined based on the cumulative number of attacks in a given commune over time. exposure variable is therefore numeric and reflects the shift into a new 'phase' characterised by one additional attack. the duration of these phases (segments) vary since they last until a new attack occurs. for both objectives, a terrorist attack was defined as an act involving a jihadist group in which one of the protagonists used violence (ie, battle, explosion/remote violence, looting/property destruction and violence against civilians). attacks involving 'unidentified armed groups' were included in terrorist attacks. two secondary sources of data were used. first, the utilisation of healthcare services data was extracted from the national health information system in burkina faso. data were available from january to december , which constitutes a reliable time series of points of observation. all public facilities at the primary care level were considered in the analysis, that is, primary healthcare centres ('centres de santé et de promotion sociale') and district hospitals ('centres médicaux avec antenne chirurgicale'). every month, facilities review their record books and complete a form that is sent to the health district, which compiles data from all the facilities in its catchment area. data quality is assessed in each district before being transmitted to the director of health statistics at the ministry of health, where data from all health districts are compiled. the ministry of health performs regular supervision visits and audits in the field. the data collection instruments (record books, monthly reports, national database structure) remained constant during - . data from the passive surveillance system in burkina faso have been proven reliable in previous studies. second, terrorist attack data were extracted from the armed conflict location and event data (acled) project. the acled project collects data on violent events within states, which includes armed conflicts and terrorist activities with or without fatalities. data are disaggregated by date, location and actors. this spatial scale is relevant for the purpose of the present study since its hypothesis is that terrorist attacks reduce access to the surrounding primary care facilities, rather than at the national level. for those violent events with fatalities, acled data were cross-checked and completed by using the uppsala conflict data program georeferenced event dataset (ucdp-gep). based on the gps coordinates of the events, communes were identified by using the database of global administrative areas (gadm). finally, the acled and passive surveillance datasets were merged at the commune-month level of aggregation. the unit of all analyses was the commune-month. to explore the attacks' effects, three separate regression models (corresponding to the three outcomes) were fitted using the exact same set of variables and parameters. even if the outcomes were all count variables, negative binomial regression was preferred over poisson because of overdispersion. in order to best isolate the effect of attacks, the commune unit was entered as fixed effects while using unconditional maximum-likelihood estimation. this allows for control for any stable characteristic of the communes, whether observed or not. the underlying equation of the basic fixed effect level can be expressed as y it =μ t + βx it + α i + ε it with i= , … n (communes) and t= , … t (time) where μ is a constant term, y it is the response value for the commune i at time t, x is a vector of time-variant variables, α i are communespecific intercepts that capture heterogeneity between communes and ε are residual errors. four time-varying variables were entered in the models: the monthly variation (calendar month), the baseline trend (time units since january ), the trend since bmj global health occurrence of the first attack (time units since the month of the first attack in a commune) and the percentage of missing observations. the linearity of the relationship between the outcome and continuous covariate was assessed by adding quadratic terms. multicollinearity was ruled out by using the collin package (statacorp, college station, texas) and verifying that variance inflation factors did not exceed . robust variance estimators (huber/white estimator) were used throughout the analyses. coefficients were expressed as incidence rate ratios. the threshold for statistical significance was set at . (bilateral tests). all analyses were performed in stata v. . (statacorp). maps were created using qgis v. . (open-source gis software). this study only uses secondary, administrative data. gadm, acled and ucdp-gep data are publicly available online (https:// gadm. org/, https:// acleddata. com/ and https:// ucdp. uu. se/). access to the national health information system data was granted by the ministry of health of burkina faso (notice # - ). patients and members of the public were not used in the design, conduct, reporting and dissemination of this research. utilisation of healthcare services by patients were routinely collected by health facilities providers and analysed; however, data were aggregated and individual patients cannot be identified from the reported data. the spatiotemporal structure of the national health information system database is described in table . it totalises commune-months (the level of analysis), representing data from communes (this includes some communal sub-sections of the two largest cities, ouagadougou and bobo-dioulasso) in burkina faso over a -year period. nearly all communes in burkina faso had at least one primary care facility in , which makes the database nationally representative. during that period, there were a total of violent events, of which ( %) involved a jihadist group (see table affected by terrorist attacks increased from in to in , which represents ~ % of the total number of communes in the country (see figure ) . the immediate effects of terrorist attacks on the three study outcomes are presented in table . two different gradients in the effects estimates were observed. first, the effects of multiple attacks (per commune per month) were more severe than the effects of a single attack, regardless of the outcome. second, the effects' magnitude of attacks (single or multiple) was more important for cesarean sections than for assisted deliveries, which in turn was more important than for anc visits. for example, the incidence of cesarean sections following a single attack was immediately reduced by . % (incidence rate ratio (irr) . , % ci . to . ), while multiple attacks reduced it by . % (irr . , % ci . to . ). for the assisted deliveries, irrs were . ( % ci . to . ) and . ( % ci . to . ), respectively, while they were . ( % ci . to . ) and . ( % ci . to . ) for the anc visits. since the number of district hospitals that perform cesarean sections is more limited than the number of primary healthcare centres, it is not surprising that statistical tests reached significance only for the latter, even if effects are more pronounced for the former. for each of the three outcomes, the monthly trend in the phase following the first attack was statistically significantly < . this suggests that trends in the number of cesarean sections, assisted deliveries and anc visits are negatively affected once a commune experiences a terrorist attack. the segmented regression analyses further investigate the longitudinal effects of repeated attacks. they reveal that the incremental number of terrorist attacks, a longitudinal indicator of the cumulative insecurity in a commune, is negatively associated with the three outcomes (see table ). for every additional attack in a commune, the incidence of cesarean sections is reduced by . % in the next segment ( % ci . to . ). for assisted deliveries, incidence is reduced by . % ( % ci . to . ), and for anc visits, by . % ( % ci . to . ). however, as suggested by the modest but statistically significant quadratic terms, the reduction is not constant and tends to lessen as the number of attacks increases. models can therefore predict trends for each of the outcomes based on the number of terrorist attacks in a commune and their timing. figure displays the predicted trends of a commune that recorded terrorist attacks over months (which was the observed situation no of events involving a terrorist group and the armed forces no of events involving the armed forces and civilians no of events involving at least militia or ethnic group in tongomayel, a commune located in northern burkina faso), as well as the natural trend that would have been observed in the absence of terrorist attacks. burkina faso has implemented several measures over the past years to increase its population's access to healthcare services. it has been one of the first countries in sub-saharan africa to remove healthcare user fees for children under years of age and for pregnant women. however, rising insecurity since , mainly caused by terrorist attacks, is a major challenge to the achievement of universal health coverage. these findings have wider repercussions for other countries in the sahel, given their endemic levels of poverty ( of the lowest ranked countries in the hdi are in the sahel ) and their political instability and vulnerability to terrorist attacks. moreover, the risk of jihadist contagion in west africa could also undermine efforts in that region to improve healthcare services. to the best of our knowledge, this study is the first to document the presence (and assess the effects) of an 'insecurity barrier' to healthcare access. it shows that terrorist attacks have immediate repercussions on different indicators of maternal care, notably the number of anc visits, assisted deliveries and cesarean sections. it also reveals that repeated attacks aggravate this insecurity and are further detrimental to healthcare access. †results are derived from three separate models (one per outcome) that were fitted using negative binomial regression with robust variance estimators and fixed effects at the commune level. the exposure variable is categorical and expressed by the number of attacks per month per commune (with three categories). the same set of covariates was used in each model, two of which (the month and the percentage of missing observations) are not displayed here. the number of observations for cesareans is smaller because they are only performed in reference health facilities. irr, incidence rate ratio. all associations were in the anticipated direction and two gradients in the effects were observed. the first gradient that was observed concerns the effects' magnitude and bears serious clinical significance. indeed, the reduction in healthcare services was moderate for anc visits, which is likely due to the fact that these visits happen during daytime hours and can easily be rescheduled. on the other hand, the reduction was more pronounced for assisted deliveries and for cesarean sections, which are critical care seeking and treatment practices to reduce maternal and neonatal mortality. this larger effect for the most proximal indicators of maternal health could partly be explained by the fact that deliveries and obstetric emergencies can take place at night, when insecurity is maximal. women may decide to remain and deliver in their village, especially if the nearest primary care facility no longer operates during night-time hours. other explanations might include disruptions of the healthcare system engendered by the attacks, such as material stock-outs, staff absenteeism or lack of medical transportation to district hospitals. indeed, terrorist attacks can affect both demand for and provision of healthcare services. insecurity may likely encourage health staff to leave the affected areas or to reduce their activities, as suggested by reports of an increasing number of non-functioning health facilities in the country. the second gradient that was observed is similar to a dose-response relationship. regardless of the outcome, the immediate effects of a single attack in a particular month were smaller than the immediate effects of multiple attacks. indicative of a severely insecure environment, the occurrence of multiple attacks in a single commune in month was significantly associated with a reduction in the number of anc visits and of assisted deliveries. the reduction in cesarean sections was even larger, but not statistically significant due to the small number of communes that have district hospitals and were subject to terrorist attacks. the number of attacks per month was preferred over the number of victims per month as an indicator of more intense exposure because data about the latter are harder to validate and likely in collinearity with population density. finally, the longitudinal analysis shows that the insecurity level in a commune is negatively associated with the use of maternal healthcare services. successive terrorist attacks have an incremental effect; for every additional attack, a new segment can be defined where the average number of anc visits, assisted deliveries and cesarean sections is significantly lowered. this reduction is not constant; rather, as the number of attacks increases, the effects tend to be of reduced magnitude, but levels remain significantly lower than those of the counterfactual (the hypothetical situation that communes would have known in the absence of terrorist attacks). this study is a natural experiment that relies on secondary data and, as such, is subject to some limitations. data about the occurrence of attacks in remote areas can be difficult to validate and of inconsistent quality. in particular, errors of misclassification are likely. for example, violent events that concerned armed forces and civilians were excluded from the analysis, while it is possible that the armed forces engaged with individuals who were presumed (but not confirmed) terrorists. also, spatiotemporal information about the events may be inaccurate. several measures were taken to reduce such information bias. first, where possible, terrorist attacks data were corroborated between two databases. second, data were aggregated at the higher spatiotemporal levels (ie, the commune-month) and the analysis was ecological. data from the health surveillance system are subject to non-random missingness since facilities located in areas with higher insecurity could be more prone to cease data entry in record books or cease transmission of information to the health district. even if analyses were adjusted for missing data at the commune level, some information bias is still plausible. bilateral tests suggest no difference in missingness according to the occurrence of a terrorist attack or not. another limitation is the absence of measures at the individual level. in particular, the exposure variable in the longitudinal analysis relates to levels of insecurity that were defined independently from their perception by the community members. however, this was also the case for the outcome variables, all measured at the health facility level. therefore, as stated previously, it is important to acknowledge that this is an ecological study that precludes drawing conclusions at the individual level. the impact of terrorist attacks and growing insecurity levels on the behaviour of pregnant women remains to be investigated. also, it was not possible to adjust the estimates for variations in populations at the commune level. terrorist attacks likely urged some households to leave the affected areas-the number of internally displaced persons has been growing exponentially in burkina faso over the last few years. arguably, these population changes could partly explain the negative long-term trends that were observed for each of the three outcomes in post-attack phases. several measures were taken to increase the internal validity of the effects evaluation in this quasi-experimental study. first, a robust design was used (pre-post with control group) and the conclusions were fuelled by three outcome indicators, following recommendations to use theoretical replication in evaluation studies. second, analyses used multiple segmented regression with fixed effects that controls for time-invariant observables and unobservables at the commune level. with robust variance estimators, this longitudinal analysis is an evaluation design particularly appropriate to adjust for serial autocorrelation and selection bias. finally, this study used a national dataset with a long observation period. these characteristics allow for a robust estimation of secular trends and considerably reduce the risk of historical bias, while the consistency of data collection instruments and aggregation methods throughout the observation period decreases the risk of instrumental bias. conclusion terrorist attacks constitute a new barrier to access of maternal healthcare services in burkina faso. they contribute to changes in delivery practices by reducing the number of anc visits, assisted deliveries and cesarean sections in primary healthcare centres and district hospitals. the exponential increase in the number of terrorist activities in west africa is therefore expected to have deleterious effects on maternal health in multiple countries and through different mechanisms. this problem could be compounded by the covid- pandemic, which threatens to further strain the region's already weakened health infrastructure, to increase inequalities and to reduce coordinated counterterrorist efforts. this, ultimately, could contribute to an upsurge of terrorist activity and increased insecurity across the sahel. perhaps more than ever, regional insecurity needs to be recognised and investigated by the global health research community as a barrier to universal health coverage. as for the wider crisis in the sahel, the international community must remain steadfast in working to resolve the multidimensional problems that threaten the region. international crisis group. burkina faso: stopping the spiral of violence united nations development programme vers une réforme du système de sécurité burkinabè? observatoire du monde arabo-musulman et du sahel terrorism, civil war, onesided violence and global burden of disease documenting the effects of armed conflict on population health insecurity, polio vaccination rates, and polio incidence in northwest pakistan diphtheria outbreak in yemen: the impact of conflict on a fragile health system was there a disparity in age appropriate infant immunization uptake in the theatre of war in the north of sri lanka at the height of the hostilities?: a cross-sectional study in resettled areas in the kilinochchi district the impact of the boko haram insurgency in northeast nigeria on childhood wasting: a double-difference study effects of armed conflict on child health and development: a systematic review adverse effects of exposure to armed conflict on pregnancy: a systematic review maternal health care amid political unrest: the effect of armed conflict on antenatal care utilization in nepal conflict and contraception in colombia organized violence and institutional child delivery: micro-level evidence from sub-saharan africa armed conflict and maternal mortality: a micro-level analysis of sub-saharan africa perceptions of the effects of armed conflict on maternal and reproductive health services and outcomes in burundi and northern uganda: a qualitative study enquête modulaire démographie et santé (emds) du burkina faso trends in maternal mortality: to . geneva: world health organization inequities and their determinants in coverage of maternal health services in burkina faso national user fee abolition and health insurance scheme in burkina faso: how can they be integrated on the road to universal health coverage without increasing health inequities? the impact of user fee removal policies on household out-of-pocket spending: evidence against the inverse equity hypothesis from a population based study in burkina faso the impact of targeted subsidies for facility-based delivery on access to care and equity -evidence from a population-based study in rural burkina faso effect of interrupting free healthcare for children: drawing lessons at the critical moment of national scale-up in burkina faso understanding home delivery in a context of user fee reduction: a cross-sectional mixed methods study in rural burkina faso assessing the impact of geographical access to health facilities on maternal healthcare utilization: evidence from the burkina faso demographic and health survey the role of transportation to access maternal care services for women in rural bangladesh and burkina faso: a mixed methods study women's experiences in accessing reproductive, maternal, and child healthcare services in the mopti regions of mali the local impact of armed conflict on children's nutrition and health outcomes: evidence from chad armed conflict and maternal health care utilization: evidence from the boko haram insurgency in nigeria experimental and quasiexperimental designs for generalized causal inferences burkina faso: a history of power, protest and revolution burkina faso convicts two generals over deadly the sahel: regional politics and dynamics. oxford research encyclopedia of politics the value of interrupted timeseries experiments for community intervention research access to maternal health services: geographical inequalities, united republic of tanzania unraveling the contextual effects on student suspension and juvenile arrest: the independent and interdependent influences of school, neighborhood, and family social controls reconciling methodologically different biodiversity assessments immediate and sustained effects of user fee exemption on healthcare utilization among children under five in burkina faso: a controlled interrupted time-series analysis abolishing fees at health centers in the context of community case management of malaria: what effects on treatment-seeking practices for febrile children in rural burkina faso introducing acled: an armed conflict location and event dataset introducing the ucdp georeferenced event dataset methods in social epidemiology ouagadougou: ministère de l'administration publique et de la décentralisation effect of interrupting free healthcare for children: drawing lessons at the critical moment of national scale-up in burkina faso fragile states index annual report . washington: the fund for peace international crisis group. the risk of jihadist contagion in west africa. brussels: international crisis group counterfactuals and causal inference: methods and principles for social research in data we trust? a comparison of ucdp ged and acled conflict events datasets case study research: design and methods the practice of health program evaluation. thousand oaks: sage fixed effects analysis of repeated measures data use of interrupted time series analysis in evaluating health care quality improvements segmented regression analysis of interrupted time series studies in medication use research research designs for intervention research with small samples ii: stepped wedge and interrupted timeseries designs strengthening prevention with better anticipation: covid- and beyond. geneva: geneva centre for security policy violent extremism, organised crime and local conflicts in liptako-gourma. dakar: institute for security studies the sahel crisis and the need for international support acknowledgements this article is dedicated to all the victims of the terrorist attacks in burkina faso. we would like to acknowledge the support from the ministry of health in burkina faso to get access to the surveillance data. we would like to thank ms loula burton for revising and proofreading the manuscript, as well as the anonymous reviewers for their precious comments.contributors td and ab conceived the study. td, lb and fb were involved in data collection. td and lb analysed the data. td, lb and mim interpreted the results. td, lb and mim drafted the manuscript. all authors read and approved the final manuscript. disclaimer the funding agency had no role in the study design, data collection, analysis, interpretation, writing or decision to submit the manuscript for publication. competing interests none declared.patient and public involvement patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. ethics approval the study only used anonymised secondary and publicly available data. it was approved by the comité d'éthique pour la recherche en santé (deliberation # - - ) and access to surveillance data was granted by the ministry of health in burkina faso (notice # - ).provenance and peer review not commissioned; externally peer reviewed.data availability statement data are available in a public, open access repository. data may be obtained from a third party and are not publicly available. data from the global administrative areas, from the armed conflict location and event data and from the uppsala conflict data program georeferenced event dataset are publicly available online (https:// gadm. org/, https:// acleddata. com/ and https:// ucdp. uu. se/). data from the national health information system can be obtained by contacting the ministry of health of burkina faso.open access this is an open access article distributed in accordance with the creative commons attribution . unported (cc by . ) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. see: https:// creativecommons. org/ licenses/ by/ . /. thomas druetz http:// orcid. org/ - - - key: cord- - ciukd authors: jalloh, mohamed f; li, wenshu; bunnell, rebecca e; ethier, kathleen a; o’leary, ann; hageman, kathy m; sengeh, paul; jalloh, mohammad b; morgan, oliver; hersey, sara; marston, barbara j; dafae, foday; redd, john t title: impact of ebola experiences and risk perceptions on mental health in sierra leone, july date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: ciukd background: the mental health impact of the – ebola epidemic has been described among survivors, family members and healthcare workers, but little is known about its impact on the general population of affected countries. we assessed symptoms of anxiety, depression and post-traumatic stress disorder (ptsd) in the general population in sierra leone after over a year of outbreak response. methods: we administered a cross-sectional survey in july to a national sample of consenting participants selected through multistaged cluster sampling. symptoms of anxiety and depression were measured by patient health questionnaire- . ptsd symptoms were measured by six items from the impact of events scale-revised. relationships among ebola experience, perceived ebola threat and mental health symptoms were examined through binary logistic regression. results: prevalence of any anxiety-depression symptom was % ( % ci . % to . %), and of any ptsd symptom % ( % ci . % to . %). in addition, % ( % ci . % to . %) met the clinical cut-off for anxiety-depression, % ( % ci . % to . %) met levels of clinical concern for ptsd and % ( % ci . % to . %) met levels of probable ptsd diagnosis. factors associated with higher reporting of any symptoms in bivariate analysis included region of residence, experiences with ebola and perceived ebola threat. knowing someone quarantined for ebola was independently associated with anxiety-depression (adjusted or (aor) . , % ci . to . ) and ptsd (aor . % ci . to . ) symptoms. perceiving ebola as a threat was independently associated with anxiety-depression (aor . % ci . to . ) and ptsd (aor . % ci . to . ) symptoms. conclusion: symptoms of ptsd and anxiety-depression were common after one year of ebola response; psychosocial support may be needed for people with ebola-related experiences. preventing, detecting, and responding to mental health conditions should be an important component of global health security efforts. what are the new findings? ► to the best of our knowledge, the assessment was the first national survey that examined the impact of the devastating ebola epidemic on populationlevel mental health using globally validated scales, and conducted after more than a year of ongoing transmission of ebola in the country. ► we found that symptoms of ptsd and anxietydepression were common after one year of the outbreak, especially among those with ebolarelated experiences. ► furthermore, we have demonstrated the ability to rapidly administer brief mental health screeners at the population level to identify factors associated with mental health symptomology towards the end of an unprecedented infectious disease epidemic. recommendations for policy ► preventing, detecting and responding to mental health conditions should be an important component of global health security efforts. ► use of brief mental health screeners during outbreak response could increase the ability to identify and address the needs of at-risk groups. ► so doing could help avert the substantial short-term and long-term effects of mental health disorders on individual health and on national health systems, societies and economies. primarily in sierra leone, liberia and guinea. in sierra leone alone, there were reports of more than ebola cases, resulting in over deaths, and more than individuals were quarantined due to possible ebola exposure. little is known about the epidemic's effects on the mental health of the general population in the affected countries. numerous studies have examined the mental health effects associated with other infectious disease outbreaks including the severe acute respiratory syndrome (sars) epidemic [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and novel influenza a (h n ) pandemic. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the mental health impact of other emergencies, such as bioterrorism, have also been documented among survivors. psychological distress, anxiety, depression and post-traumatic stress disorder (ptsd) have been recorded among populations exposed to mass conflict and displacement including those affected by the civil conflict in sierra leone between and . known risk factors for anxiety, depression and ptsdincluding experience with ill individuals, perceptions of threat, high levels of mortality, food and resource insecurity, stigma and discrimination, and intolerance of uncertainty-may have been experienced by people in sierra leone during the ebola epidemic. adverse mental health outcomes could be expected in the general population given the magnitude of the epidemic. high levels of distress have been documented among ebola survivors in guinea and sierra leone and healthcare workers (hcws) in all three affected countries. there are few mental health resources in sierra leone; for example, when the ebola outbreak began, there was only one trained psychiatrist for the population of over million. assessments of mental health and of risk factors for mental illness can support policy efforts to improve resources to address mental health and inform how resources can be targeted most efficiently-especially in the aftermath of a devastating ebola epidemic. the sierra leone ministry of health and sanitation and the us centers for disease control and prevention collaborated with focus and other stakeholders to implement a national, household-based ebola knowledge, attitudes and practices (kap) survey in july . the survey assessed respondents' ebola-related kap, perceptions of ongoing ebola threat, ebola-related experiences, and anxiety-depression and ptsd symptoms. the present analysis aimed to estimate prevalence of mental health symptoms and factors associated with having symptoms in the general population. the national survey employed a multistage cluster sampling procedure with primary sampling units selected with probability relative to their size. in order to attain % confidence levels and cis of ± % estimates of the national population, individuals were approached across the regions and districts of sierra leone. using sierra leone's most recent census list ( ) of enumeration areas as the sampling frame, enumeration areas were randomly selected across all districts. within each cluster, households were selected using systematic random sampling. to generate reliable district-level estimates for key districts, we oversampled in the three districts still experiencing active ebola transmission. a weighting factor was applied to each record to adjust for the different sample sizes taken in different districts. within each household, the household head and another individual (aged between years and years) or a woman were approached for consent and interviewed. survey questions included sociodemographic characteristics, ebola experience, perceived ebola threat, anxiety-depression symptomology and ptsd symptomology (supplementary file ). ebola experience variables included whether participants knew someone who had died from ebola and whether they knew someone who had been quarantined due to ebola exposure. participants whose only reported experience with ebola-related death ( . %, n= ) or quarantine was related to public figures ( . % of sample, n= ), such as well-known medical doctors who died from ebola, were excluded from this analysis. these two variables were also combined into a two-level composite item which included: ( ) no experience with ebola-related death or quarantine; ( ) knowing others who had been quarantined or had died from ebola. participants' perceptions of ebola as a threat were measured by four items that asked whether they perceived that ebola was no longer a threat to ( ) sierra leone; ( ) their district; ( ) their community; and ( ) their household. participants responded using -point likert scale items ranging from (strongly agree) to (strongly disagree). responses were further dichotomised into 'agree' and 'disagree,' and the scores reversed so that higher scores represented more perceived risk. we also created a composite score across all four domains with representing 'any perceived ebola threat' and representing 'no perceived ebola threat. ' symptoms of anxiety and depression were measured by patient health questionnaire- (phq- ). phq- was developed by combining two ultrabrief screeners, the phq- and the generalised anxiety disorder scale, that have been demonstrated to reliably measure depression and anxiety symptoms. participants were asked to report their symptoms of depression and anxiety in the past weeks on a likert scale from (not at all) to (nearly every day) for a maximum score of . the sample was further dichotomised into those who expressed any symptoms compared with those who did not by creating a new composite variable. we also examined the prevalence of anxiety and depression using the established clinical cut-off total score of , which represents the proportion of people who would be considered as having clinical bmj global health levels of depression or anxiety if the screener were used for diagnostic purposes. symptoms of ptsd were measured by the impact of event scale- (ies- ), which is a validated, shortened version of the full ies-revised (ies-r). the full scale contains items (scored from to ) with demonstrated reliability and validity to measure ptsd symptoms across different cultures and settings. while ies-r is generally not used to diagnose ptsd in clinical settings, it is widely used for screening at-risk patients with ptsd. the ies- includes a total of six items-two items from each of the three subscales of the measure, namely intrusion, hyperarousal and avoidance. participants were asked to report their ptsd symptoms in the past days on a likert scale ranging from (not at all) to (extremely). we dichotomised the sample into those who expressed any symptoms versus those who did not by creating a new composite variable. we evaluated respondents for whom ptsd may be a 'clinical concern' using an inputted . mean item cut-off score (equivalent to / on ies-r). in addition, we assessed respondents who met 'probable diagnosis' of ptsd using an inputted . mean item cut-off score (equivalent to / total score in ies-r). data collection in june , focus recruited experienced data collectors, team supervisors and regional supervisors. they were trained for a week on overall assessment protocols and guidelines, informed consent, safety and security precautions, administration of questionnaire, and quality control and assurance. the training included oral translation of each item into local languages (krio, mende, temne and limba), back translations (orally), group discussions of the translations for accuracy in meaning, role plays to reflect possible range of responses, and group consensus on the final translations to ensure consistent and accurate use of each item. in july , the trained data collectors used open data kit for digital data collection at the household level. nearly all interviews (> %) were conducted in krio. in july , when the ebola kap was administered, % of the cumulative confirmed ebola cases in the country had been reported. control activities continued, including provision of prevention messages, case detection, contact identification, quarantine and monitoring, and management of cases and deaths. quarantine involved days of home-based isolation with armed uniformed police dispatched to enforce restriction of movement in and out of the household. quarantined individuals were clinically monitored, and if ebola was suspected, they were transferred to a holding centre for testing. the data were analysed using spss v. . statistical significance was defined as a two-tailed p-value less than . . for reliability, internal consistency was assessed by calculating cronbach's α values. for factorial validity, the factor structures of the phq- and ies- scales were examined with confirmatory factor analysis (cfa). the relationships between demographic variables (gender, age, education and region of residence), ebola experience, perceived ebola threat and mental health symptoms were examined. frequencies, proportions, % ci of proportions, as well as χ tests were generated to examine the relationships between sample characteristics and mental health symptoms. univariate and multivariate binary logistic regression analyses were conducted to examine the relationship between ebola experience, perceived ebola threat and mental health symptoms. we further examined the effect of ebola experience, perceived ebola threat and interaction between those two variables on mental health status by conducting a multivariable logistic regression controlling for potential confounders. to avoid multicollinearity, only composite scores were entered as predictors into the model. sex, age, education and region were included because they have been associated with mental health symptoms in other studies. goodness of fit index (gfi), comparative fit index (cfi) and root mean square error of approximation (rmsea) were calculated to measure the cfa model. weighted cell count, percentages and ors with % cis are presented in the logistic regression tables. of individuals approached, ( %) consented to participate in the assessment. sample characteristics by mental health symptoms are presented in table . the median age of respondents was years (sd= ); ( %) were male. the sample comprised respondents from all four geographical regions in sierra leone: ( %) from the west, north ( %), east ( %) and south ( %). boosted district samples in kambia and port loko, where cases were still being identified, resulted in a larger sample from the north. of all respondents, % had no formal education, % had some primary school education and % had secondary or higher education. nearly a third ( %) of respondents knew at least one person who died from ebola. similarly, participants ( %) knew at least one person who was quarantined. about a quarter ( %) of respondents knew someone who died from ebola and someone who was quarantined. nearly three quarters ( %) of respondents perceived an ebola threat at one or more levels: in sierra leone ( %), their district ( %), their community ( %) or their household ( %). prevalence of symptoms figure shows % ( % ci . % to . %) of respondents reported at least one symptom of anxiety or depression, with % ( % ci . % to . %) meeting the clinical cut-off definition. of all respondents, % ( % ci . % to . %) reported one or more ptsd bmj global health table a ,b describes respondents' experiences with ebola and the association with anxiety and depression and ptsd symptoms, controlling for age, gender, region and education level. the experience of knowing someone who died from ebola alone was not independently associated with anxiety and depression symptoms (adjusted or (aor) . % ci . to . , p= . ) but was independently associated with ptsd symptoms (aor . % ci . to . , p= . ). those participants who knew someone quarantined due to ebola exposure alone were more likely to report symptoms of anxiety and depression (aor . % ci . to . , p< . ) and ptsd (aor . % ci . to . , p< . ) than those who did not. respondents who had both experiences (that is, they knew at least one person who died from ebola and someone quarantined) were also more likely to report symptoms of anxiety and depression (aor . % ci . to . , p< . ) and ptsd (aor . % ci . to . , p< . ) compared with those who did not report both. those with any ebola experience were more likely to report anxiety and depression symptoms than those who had no ebola experience (aor . % ci . to . , p< . ) and were more likely to report ptsd symptoms than those with no ebola experience (aor . % ci . to . , p< . ). table presents the relationship between perceived ebola threat and reported symptoms of anxiety and depression and ptsd. respondents who perceived some ongoing threat of ebola were more likely to report symptoms of anxiety-depression (aor . % ci . to . , p< . ) and ptsd (aor . % ci . to . , p< . ) compared with those who did not. table presents multivariate analyses of the associations between ebola experience and perceived ebola threat and symptoms of anxiety and depression and ptsd, adjusting for gender, age, region and education levels. ebola experience and perceived ebola threat were independently associated with anxiety and depression symptoms as well as ptsd symptoms. in addition, the interaction between ebola related experience and risk perception was independently associated with both anxiety-depression and ptsd symptoms: participants who had ebola experience and also perceived ongoing ebola threat were more likely to report symptoms of anxiety-depression (aor · % ci · to · , p= . ) and ptsd symptoms (aor · % ci · to · , p= . ). in a national sample of sierra leoneans after more than a year of the unprecedented ebola epidemic, nearly half of all respondents reported at least one symptom of anxiety or depression and three quarters expressed ptsd symptoms. most respondents reported between one and four symptoms. after adjusting for sociodemographic variables, we found that persons with any level of ebola experience were more likely to report symptoms of anxiety-depression and ptsd. even though expression of one or more symptoms was widespread among our sample, a lower proportion of respondents met the clinical cut-off scores for anxiety-depression ( %- %) and probable diagnosis for ptsd ( %- %). the proportion of respondents who exhibited clinical level symptoms of anxiety-depression may be considered 'lower than expected' given the magnitude and duration of the epidemic, but may also point to a culture of resiliency among sierra leoneans. on the other hand, we documented substantial ptsd, which is a public health concern that may require targeted mental health interventions at the individual level and community level for those with some personal ebola experience. a national assessment of the mental health impact of the sars epidemic in taiwan, using a different scale than in our current study, found % prevalence of depression after the epidemic ended. another population-based survey in taiwan revealed % prevalence of psychiatric morbidity following sars. in singapore, a community-based sample detected that a quarter of all respondents had clinical levels of ptsd symptoms. other mental health assessments with sars survivors and hcws documented similar or higher clinical ptsd levels compared with our current assessment. one study found that hcws with a history of mental illness before sars were more likely to report new onset following the epidemic. in our assessment, we cannot determine how past mental health history of ptsd in sierra leone, especially due to the prolonged civil war from to , may have influenced the levels of clinical ptsd concern we detected. similar to sars, the h n pandemic was associated with psychological distress among the general population, family members of hospitalised patients with h n and hcws. in some instances, prevalence of h n -related anxiety was higher among those who had greater intolerance of uncertainty. additional research is required to better understand the relationship between intolerance of uncertainty and quarantine experience during large-scale infectious disease outbreaks. an assessment with hcws in china found that being quarantined and having perceived threat of sars were associated with high depressive symptoms several years after bmj global health the epidemic ended. in a separate study, h n quarantine experience did not predict elevated ptsd levels while dissatisfaction with control measures was a better predictor. to the best of our knowledge, no prior study has assessed the mental health impact of the protracted ebola epidemic at population levels in sierra leone, liberia or guinea. a limited number of studies have examined population-level mental health in other african countries. one such study in a predominantly rural community in ethiopia found that % of the population expressed clinical levels of mild depressive, anxiety and somatic symptoms. on the other hand, a wide variety of studies have examined anxiety and depression in highrisk populations in africa, including patients with tuberculosis in ethiopia and angola, rwandans who had experienced genocide, and nigerian prison inmates. findings of varying levels of mental health symptomology from these studies suggest that further investigations may be required to better understand specific mental health impact of the ebola epidemic on directly affected persons such as ebola survivors. in a systematic review, adverse mental health impact has been documented among conflict-affected persons. in sierra leone, during protracted civil conflict, exposure to traumatic events was associated with non-specific physical ailments. high prevalence of traumatic experiences and psychiatric sequelae has also been documented among sierra leonean refugees. among war affected youth in sierra leone, social disorder and perceived stigma contributed to both externalising and internalising problems. former child soldiers in sierra leone saw reliable improvement in ptsd symptoms over time, suggesting that a supportive environment may encourage resilience. a key recommendation in previous studies and who guidance is to integrate mental health into primary healthcare services. one study found global return on investments for scaling up treatment for depression and anxiety. an example of such effort is in progress in sierra leone wherein public health nurses are trained to screen patients for possible mental health needs. the who mental health gap action programme emphasises that scaling up mental health services is a joint responsibility that requires collaboration from governments, health professionals, donors, civil society, communities and families. limitations although a random national sample was obtained, our sample is not necessarily nationally representative. the sample had a higher proportion of respondents with any education compared with the general population. however, we did not find any association between education level and mental health symptoms, suggesting that this may not have influenced our findings. we acknowledge the necessity of validating survey instruments before using them in a new cultural context. although phq- and ies-r have been widely used globally, - neither has been validated nor used in sierra leone prior to this study. we therefore do not know the validity of clinical cut-off scores for our sample. to the best of our knowledge, phq- and ies-r (or the shortened form in this assessment) have not been used to measure population-level symptoms of mental health in any similar setting; making it impossible to compare our results to similar populations elsewhere. however, we found both had acceptable internal reliability and factorial validity. in the current survey, the phq- instrument demonstrated acceptable internal reliability (cronbach's α= . ) and good factorial validity (gfi= . , cfi= . , rmsea= · ). the shortened ies- scale used in the present study demonstrated acceptable internal reliability (cronbach's α= . ) and good factorial validity (gfi= · , cfi= · , rmsea= . ). in addition, the national sample was not designed to produce specific estimates for directly affected persons such as ebola survivors, families of ebola victims and quarantined persons. moreover, there are no baseline/historical data available for comparisons. we also did not measure the effects of exposure to sierra leone's civil conflict on long-term ptsd outcomes on the population prior to ebola. overall, our findings underscore the feasibility and importance of monitoring and addressing mental health during public health outbreaks as well as building capacity to do so as part of preparedness efforts. use of brief mental health screeners during outbreak response could increase the ability to identify and address the needs of high-risk groups. we have demonstrated the ability to rapidly administer phq- and ies- at a population-level to identify factors associated with mental health symptomology towards the end of an unprecedented infectious disease epidemic. preventing, detecting and responding to mental health conditions should be an important component of global health security efforts. ebola situation reports ebola outbreak in west africa -case counts psychosocial impact among the public of the severe acute respiratory syndrome epidemic in taiwan long-term psychiatric morbidities among sars survivors mental symptoms in different health professionals during the sars attack: a follow-up study predictive factors of psychological disorder development during recovery following sars outbreak prevalence of psychiatric disorders among toronto hospital workers one to two years after the sars outbreak stress and psychological distress among sars survivors year after the outbreak population-based post-crisis psychological distress: an example from the sars outbreak in taiwan depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic psychosocial and coping responses within the community health care setting towards a national outbreak of an infectious disease psychosocial effects of sars on hospital staff: survey of a large tertiary care institution population responses during the pandemic phase of the influenza a(h n )pdm epidemic anxiety, worry and cognitive risk estimate in relation to protective behaviors during the influenza a/h n pandemic in hong kong: ten cross-sectional surveys intolerance of uncertainty, appraisals, coping, and anxiety: the case of the h n pandemic is quarantine related to immediate negative psychological consequences during the h n epidemic? h n was not all that scary: uncertainty and stressor appraisals predict anxiety related to a coming viral threat psychological impact of the pandemic (h n ) on general hospital workers in kobe predicting psychological responses to influenza a, h n ("swine flu"): the role of illness perceptions community psychological and behavioral responses through the first wave of the influenza a(h n ) pandemic in hong kong psychological response of family members of patients hospitalised for influenza a/h n in oaxaca initial psychological responses to influenza a, h n posttraumatic stress among survivors of bioterrorism association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis the sierra leonean refugee experience: traumatic events and psychiatric sequelae the trauma of war in sierra leone the ebola outbreak and mental health: current status and recommended response depressive symptoms among survivors of ebola virus disease in conakry (guinea): preliminary results of the postebogui cohort prevalence of psychological symptoms among ebola survivors and healthcare workers during the - ebola outbreak in sierra leone: a cross-sectional study experiences and psychosocial impact of west africa ebola deployment on us health care volunteers an ultra-brief screening scale for anxiety and depression: the phq- a -item measure of depression and anxiety: validation and standardization of the patient health questionnaire- (phq- ) in the general population psychometric properties of the impact of event scale- in a sample of victims of bank robbery the impact of event scale revised impact of event scale-revised reliability and validity of the japanese-language version of the impact of event scale-revised (ies-r-j): four studies of different traumatic events psychometric properties of the impact of event scale -revised ebola situation report sierra leone emergency management program standard operating procedure for management of quarantine the mental health of children affected by armed conflict: protective processes and pathways to resilience population level mental distress in rural ethiopia prevalence and correlates of depression and anxiety among patients with tuberculosis at wolaitasodo university hospital and sodo health center, wolaitasodo, south ethiopia, cross sectional study emotional distress in angolan patients with several types of tuberculosis traumatic episodes and mental health effects in young men and women in rwanda, years after the genocide prevalence and correlates of depression and anxiety disorder in a sample of inmates in a nigerian prison the trauma of war in sierra leone context matters: community characteristics and mental health among war-affected youth in sierra leone post-traumatic stress symptoms among former child soldiers in sierra leone: follow-up study out of the shadows: making mental health a global development priority scaling-up treatment of depression and anxiety: a global return on investment analysis psychiatric nurses receive mhgap intervention guide world health organization. mhgap mental health gap action programme: scaling up care for mental, neurological, and substance use disorders demographic and health survey psychometric evaluation of the indonesian version of the impact of event scale-revised the global burden of mental disorders: an update from the who world mental health (wmh) surveys global health security: the wider lessons from the west african ebola virus disease epidemic acknowledgements the authors thank the sierra leoneans who participated in this assessment and provided responses in the midst of an unprecedented epidemic. the authors also thank the data collection team from focus for their diligent efforts in ensuring data quality and the government of sierra leone and their national and international partners in the response. finally, we dedicate this article to the memory of our co-author, dr. foday dafae, the late director of disease prevention and control in sierra leone ministry of health and sanitation, in honor of his years of service to the people of sierra leone. contributors mfj, rb, aol and ps led the overall study design with substantial contributions made by the other coauthors. ps, mfj and mbj were responsible for training the data collectors and supervised all data collection and data management efforts. wl led all data analyses. all authors contributed equally to the iterative interpretation of the results and the writing and preparation of the manuscript.funding this study was funded by the centers for disease control and prevention ( . / ).disclaimer the findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the us centers for disease control and prevention or the sierra leone ministry of health and sanitation.competing interests none declared. key: cord- -r td i authors: meessen, bruno title: health system governance: welcoming the reboot date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: r td i nan though a rather recent concept, governance is as old as humanity. over the last two decades, governance has received a lot of attention from the global health community. the governance lens has been applied to, among others, health, health systems, health system strengthening, health system resilience, primary healthcare and hospitals. substantial knowledge and understanding have been accumulated in the process. yet, recent reviews of frameworks have also reported a certain conceptual confusion and lack of progress with the empirical agenda. no framework has managed to impose itself so far. is the health system governance research programme experiencing a stalemate? we don't think so. recent contributions indicate that a conceptual reboot is on its way. a number of researchers are moving away from the government-centred perspective to an understanding of governance as the organisation by human beings of their collective action. the main goal of this paper is to make the case for this extended approach to governance and to explore its implications, both for research and action. the first section consists in a quick summary on the emergence and development of the concept of health system governance. in the second section, a formalised expression of the new approach to governance is sketched; at its centre is the choice set of actions available to groups of individuals. we use the covid- pandemic, one of the biggest collective action problems faced in the history of humanity, to illustrate our point. in the third section, we explore some key benefits attached to the collective agency approach. the paper ends with some suggestions of ways to move forward. in the field of international development, the mainstream view that governance is a determinant of development outcomes follows decades of work developed by the world bank. two who reports have been pivotal in establishing a similar view for health systems: the world health report and, years later, the report entitled 'everybody's business: strengthening health systems to improve health outcomes'. the core contribution of the world health report was to put forward a proposition on how performance of health systems should be conceptualised and measured. its definition of health system performance focused on outcomes which can be attributed to health interventions. the report also looked at determinants of performance. a whole chapter was dedicated to the concept of stewardship, understood as the central responsibility of the government for the overall performance of a country's health system. ► the literature on health system governance is growing. alternative frameworks have been proposed, but none has really imposed itself so far. the empirical agenda is progressing slowly. ► there is a turning point among recent publications: a move away from a government-centred perspective of governance to a broader understanding of governance as the people's organisation of their collective action. ► in this paper, we argue that what matters is the choice set of actions that groups of individuals can undertake, that is, their collective agency. ► the focus on collective agency broadens the perspective for action: the governance of the health system is not only about the ministry of health doing well certain things, it is about groups of individuals being able to organise their collective action, through the state, but also through other mechanisms. ► the collective agency approach opens avenues for research. for example, governance is both an explanatory and an outcome variable. a governance intervention (explanatory variable) may be effective to improve some health outcomes, but also disempower collective action for some groups of the population (outcome variable). by the publication of the report, the concept of stewardship had evolved to 'governance and leadership'. the term 'governance' better captures the fact that health systems are increasingly complex and that in its steering of the health system, a ministry of health has to coordinate with a large set of actors and also to be accountable. the very title of the report acknowledges that health systems are fundamentally collective action problems. however, in subsequent who documents, the distinction between governance and leadership was dropped and many contributors to the field fell back on a ministry of health-centred understanding of governance (see reference ) . the biggest challenge with governance as a concept is probably that it seems to elude measurement. the dominant approach to solve this problem has been to mimic the world bank's approach of state governance and define dimensions. this has led to a proliferation of frameworks. in a report for the european health system observatory in which they compared existing 'frameworks', greer et al concluded that such frameworks were long, normative and arbitrary lists of dimensions or items, and noted that the power of these frameworks to help improve policies still had to be demonstrated. indeed, most have limited empirical validation. this highlights the main limitation with the 'good governance' approach: normative choices (defining how things should be) take a central role in determining both the empirical and the policy agenda. normative orientations are probably inevitable in this field, the problem is that they are rarely cast with sufficient exposure of the values and interests underlying them. this exposes formalisation and subsequent empirical research to arbitrariness or even bias, as authors may be promoting their view of the world or the one that legitimates the theory of change implemented by their agency. because of their constituencies, agencies may be tempted to promote specific governance mechanisms or downplay dimensions that may arouse hostility from some policy actors. recently, several authors have tried to lay down firmer foundations to the governance agenda. for siddiqi et al, 'governance comprises the complex mechanisms, processes and institutions through which citizens and groups articulate their interests, mediate their differences and exercise their legal rights and obligations'. in , abimbola et al explored the lessons from the common-pool resources literature to enlighten collective action for primary healthcare. to our knowledge, this was the first time that the health system governance literature was connecting with the pioneering work of elinor ostrom. if anyone has studied collective action and reflected on how to move from a positivist programme to more prescriptive messages, it is ostrom. in , in a review of the literature, abimbola et al pointed to the shortcomings of the government-centred approach and made the point for a more comprehensive approach to governance and its underlying institutional arrangements. the same year, fryatt et al also came with a more comprehensive approach of governance -it is also marked by their adoption of a non-normative definition of governance-'how societies make and implement collective decisions'. the same year, pyone et al took a similar approach: 'governance is defined as the rules (both formal and informal) for collective action and decision making in a system with diverse players and organisations while no formal control mechanism can dictate the relationship among those players and organisations. adopting such broad and less normative definitions reduces the risk of excluding certain variables from the scope of analysis. with this new view, governance can be summarised as the organisation by human beings of their collective action. we characterise it as a 'reboot' because the focus of the health system governance agenda shifts from the government to the people. governance of the health system is not just about the ministry of health doing certain things well, it is not even about the ministry of health collaborating with other actors, it is about groups of individuals being able to organise their collective action, also through the state, but not exclusively. in the next section, we propose a formalisation of this new perspective. by adopting the extended formulation of governance, we de facto lose our analytical 'anchor': the organisation. as far as health systems are concerned, no longer can our thinking and analysis be organised around the coordination functions played by the ministry of health. what would then be the new variables of interest? our proposition is to organise the analysis around four main sets of variables: ( ) the set of collective action problems to solve (let us call it p) ( ) the group of individuals facing this p (g),( ) the set of possible actions (a) that members of g can take at a time t in order to handle p and ( ) the conditions (c) determining the choice set a. a collective action problem can be defined as any problem whose solution requires some coordination between potentially benefiting individuals. it can be of various natures: a pandemic to contain, child mortality and the need to reduce it, the performance of a specific hospital. g can be any grouping of persons of relevance: investors, local community, the medical profession, a nation, the world population. for sure, it is not limited to civil servants working for the ministry of health. p and g are closely linked. the staff of a hospital (g) will be busy with solving a large set of problems: availability of services, organisation of work, quality of care, management of interpersonal conflicts. many collective action problems require coordination at the level of different gs. as a pandemic, covid- requires action at the global level (eg, under the leadership of who, the international monetary fund, etc), bmj global health but also at the national and community levels. obviously, a multitude of gs creates coordination issues: different groups have diverse interests and sometimes conflicting interests (cf. siddiqi et al's definition). governance is a lot about overcoming such tensions, including, but not exclusively, through mechanisms such as governments. we propose to put the collective agency held by the group, the choice set a, at the centre of the analysis. it can include actions of very different natures. some actions are generic (eg, stating the problem, agreeing on common goals, adopting rules), others are specific to the problem. covid- can be addressed by closing borders, testing, restricting movement, forbidding social gatherings, treatment. an action belongs to a if it is really feasible by g. the set of possible actions a is itself determined by a set of conditions (c): the size and composition of g, the nature, quantity and distribution of resources (including information and trust) endowed by its members, their preferences, organisations (eg, the ministry of health) and other institutional arrangements in place, as well as external factors such as available technology or security. we do not doubt that future work will generate a more granular view of these conditions and their inter-relationships. adopting a collective agency approach to governance has benefits on at least three levels. it creates space for theoretical and empirical research independent from normative preferences. it allows ( ) description of the different sets of interest (p, g, c, a) at different periods of time; ( ) the study of how sets and variables related to each other; ( ) the study of how sets and variables are determined across time (historical studies, path dependency); ( ) the linking of all these variables to other variables of interest. all these aspects can be investigated, in a neutral manner, without some prejudices on some standards of 'good governance'. this opens new territories for health system governance researchers. for example, some researchers may want to study how the actual collective agency of a group is also a result of history. indeed, the capacity of a group to develop health interventions may be partly determined by earlier collective events. good examples of such phenomena are provided by the recent stream of work establishing a link between slave trade or colonial history with trust and capacity to implement collective action in some regions of africa. covid- reveals that this can also play the other way round. in south korea, the painful experience with the middle east respiratory syndromerelated coronavirus outbreak in generated a lot of learning which expanded the set of actions available for the national response to covid- . other analysts may want to reorganise the 'order' of the variables. for the last years, we have looked at governance as a 'building block' contributing to health system performance, the latter being measured in terms of health, responsiveness, financial protection outcomes. by equating governance with collective agency, we can, at last, conceptually handle the fact that our collective agency may also be impacted by health policies-that is, be an outcome variable. with covid- , we have seen how health policies may affect our individual and collective rights. some watchdogs are even worried about long-lasting regressions in terms of civic rights. this new perspective could lead to a better recognition of the contribution of health systems to broader political goals (eg, consolidation of the social contract). by moving the centre of gravity of the analysis (from the ministry of health to our collective agency), the research programme undergoes a double shift which will generate new insights. the first shift is that we now take a neutral approach toward coordination mechanisms. ministries of health, rightly, receive a lot of attention. but let us keep in mind that they are quite modern institutions. our proposition is compatible with the study of institutions organising the practice of medicine in ancient greece or during the islamic golden age, for instance. this is also a reminder that even in our societies, a ministry of health is just one coordination mechanism among others. as stressed by pyone et al's definition, it is the whole nexus of institutions that matters. again, covid- has shown the need to broaden the scope of attention. we have seen how some resources critical for a performing health system (eg, personal protective equipment, test reagents or medicines) are nowadays more governed by global markets than by ministries of health. we have witnessed the spread of conspiracy theories on social media and the subsequent erosion of trust in health authorities. understanding better other coordination mechanisms (eg, social norms, judicial system, the market, social media) seems a prerequisite before calling to an authority for implementing any corrective measure. the second shift is a repositioning of institutional arrangements in the analysis. we do not deny that there is great convenience in anchoring governance analyses on organisations. institutions are key for collective actionthey assign rights and thus reduce uncertainty and coordination costs. as an organisation, a ministry of health constitutes a stable platform. it can issue policies, which are themselves malleable institutions. still, organisations and institutions are just instruments. what ultimately matters to people is the set of actions at their disposal to solve their problems. as analysts we should not forget that this set is determined by more conditions than just institutions. a crucial condition is power. integrating it into the analysis requires going beyond the mere observation that institutions are in place. the right to strike has bmj global health its intrinsic value, but the impact of a strike will depend on how it disrupts the economy and thus empowers the unions in the negotiation. another key factor is trust. low trust in organisations limits options. the covid- crisis has provided examples of nations whose response has been constrained by the growing distrust in the leadership. the collective agency proposition also allows a more opened discussion about what 'good governance' might be. it provides a ranking approach which does not bring straight on the preferences of the authors for, for example, a too specific governance modality. indeed, it gives us probably the least normative ranking criterion possible: for given g and p, it is correct to say that conditions c are superior to conditions c , if a is larger than a . this is not trivial. for instance, from the perspective of a local community (g), a legal system (c ) allowing to set up a community health association is superior to a system (c ) which does not permits that. from the perspective of investors, entrepreneurs or consumers, a social system guaranteeing the rule of law and respect of contracts is also superior to one which does not guarantee such conditions. of course, a choice set a will rarely dominate all the others and more elaborate criteria will be needed to decide on the inescapable trade-offs. this approach will meet its own limitations, but at least, it will lay bare the normative issues encompassed by the health system governance agenda. such an approach valuing 'real rights for collective action' is not without firm moral foundations. it is aligned with the concept of primary goods put forward by rawls or the concept of capabilities developed by nussbaum nd sen. obviously, operationalisation will require to list collective capabilities of importance and establish rules for fair treatment of different groups. we believe this could be done in generic terms (eg, capability for members to appoint a representative to the governing body of the group), but also be tailored to the g, a and p of interest. over these last years, a new view on health system governance has been emerging. a growing number of authors proposed to take collective action as the central issue. we think it is a healthy development, as it will allow to better disentangle the empirical, normative and prescriptive agendas. frameworks and concepts are themselves a source of power and influence; the conceptualisation of governance is, by essence, an area where contributors should be vigilant about their positionality. our message is not that past research and policy guidance should be wiped out. conceptual and empirical efforts dedicated to identifying dimensions of interest (transparency, accountability, etc) and supportive institutional mechanisms remain very valuable. in the end, governments formally take on much of the responsibility for governance; reminding them their duties towards their citizens, especially for 'common goods for health', should remain a central task of multilateral agencies. our point is that this must be embedded in a broader perspective. today, we are far from being conceptually and methodologically equipped to capture the actual rights of the groups of individuals having a stake in health systems. collective agency should be our new conceptual, empirical and prescriptive horizon. we hope that this paper is a useful step in this direction. the collective agency approach to health system governance surely raises its own challenges. its value will depend on how useful it proves when employed in empirical research, reflection and action. it encompasses a risk of misuse, for instance, to legitimate more privatisation, ill-conceived decentralisation, societal fragmentation or the unchecked growth of digital giants. time will tell whether it leads to real progress for people, especially the most vulnerable. at short term, we must be ready to address heads-on some possible tensions, for instance, when a policy is effective to improve some health outcomes but also disempower groups of the population. governance is both an explanatory and an outcome variable for health systems. some of the collective capabilities to protect or to expand may include some sensitive issues (eg, capability to associate or to access reliable information, including through whistle blowers), but there is no escape: excluding them is analytically wrong. we hope that with the collective agency approach, the global health community will manage to get the issue of governance taking off, both as a field of study and an area of intervention. the covid- crisis indicates that it should happen now. governance for health in the st century frameworks to assess health systems governance: a systematic review health governance: principal-agent linkages and health system strengthening governance and capacity to manage resilience of health systems: towards a new conceptual framework towards people-centred health systems: a multi-level framework for analysing primary health care governance in low-and middle-income countries a framework for assessing hospital governance world development report : the state in a changing world health systems: improving performance everybody's business: strengthening health systems to improve health outcomes: who's framework for action monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies a review of health governance: definitions, dimensions and tools to govern framework for assessing governance of the health system in developing countries: gateway to good governance governance: a framework an approach to addressing governance from a health system framework perspective beyond markets and states: polycentric governance of complex economic systems institutional analysis of health system governance health sector governance: should we be investing more? the slave trade and the origins of mistrust in africa violence and indirect rule: evidence from the congo free state national response to covid- in the republic of korea and lessons learned for other countries institutions, institutional change and economic performance economics, organization and management a theory of justice the quality of life measuring governance: accountability, management and research strategies for policy success: achieving 'good' governance financing common goods for health: fundamental for health, the foundation for uhc acknowledgements the paper benefited a lot from the critical comments key: cord- -wfvc l authors: perrin, christophe; cloez, sandrine; dujardin, catherine; ravinetto, raffaella title: europe should lead in coordinated procurement of quality-assured medicines for programmes in low-income and middle-income countries date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: wfvc l nan a secured supply of quality-assured medicines and other medical products is an essential prerequisite for universal health coverage. unfortunately, on average one in medicines do not meet acceptable quality standards in low-income and middle-income countries (lmics). the high prevalence of poor-quality medicines in lmics greatly depends on the globalisation of pharmaceutical production and distribution, combined with the weakness of many national medicines regulatory authorities (nmras). the use of non-quality-assured medicines, often undetected, causes poor case management and unfavourable medical outcomes in individual patients, while at population level, it is translated in poor control of communicable diseases, emergence of resistance to medicines and loss of trust in health systems. - risks are magnified by the covid- pandemic, which triggered disruption of supply chains, stockouts, substandard production, falsification of repurposed medicines and irrational use of medicines. european taxpayers' money is used to fund medical programmes in lmics in the context of humanitarian aid and development. medicines for these programmes are purchased either at international suppliers specialised in the humanitarian sector, or locally in the countries or regions of intervention. these purchases are not exempted from the quality risks that exist in the local and international market. hence, adequate pharmaceutical procurement and quality assurance (qa) policies are needed for three reasons. first, to mitigate the risk of purchasing products of poor quality. second, to assure the same quality standards that would be required for medicines marketed in the donor country. third, these policies are needed to address fundamental moral obligations in terms of equity, transparency and accountability. various european donors play distinct and complementary roles here: the european commission (ec), the national ministries of foreign affairs and the national development cooperation agencies with their aid implementers. the role of donor agencies is particularly crucial. if a donor does not prioritise qa requirements in pharmaceutical procurement policies, and does not foresee a dedicated budget line to secure quality, its aid implementers might choose supply channels that are not fully reliable, or they might purchase medicines that are not subject to stringent regulation even if they are authorised in the recipient country. summary box ► thoughtful procurement policies in humanitarian and development medical programmes can mitigate the risk of purchasing poor-quality medicines, allowing to address fundamental moral obligation to equity, transparency and accountability. ► european donors are aware of the quality problems in the global pharmaceutical market, and some are already translating awareness into explicit procurement and quality assurance policies. however, a joint position and coordinated action is lacking. ► european donors should share existing knowledge and tools, seek the input of recipient countries, and develop a joint position on how the donor community can help to ensure access to affordable and qualityassured health products-also during public health emergencies such as the covid- pandemic. ► applying stringent and harmonised quality assurance requirements, european donors and their implementing organisations can help shaping the global pharmaceutical market towards affordable, quality assured products. a stakeholder survey carried out at the end of by the institute of tropical medicine in antwerp, belgium, shed some preliminary light on the procurement policies adopted by a sample of european donors and implementing actors of the national cooperation programmes. most european donors in the sample directly or indirectly fund the purchase of medicines for development or humanitarian assistance programmes within their official development assistance (oda) ( %). they are aware of the high prevalence of poor-quality medicines in these contexts ( %) and they acknowledge the need for stringent qa requirements in procurement policies. but awareness is not always translated into formal qa policies and guidelines. only a minority ( %) have developed or implemented internal policy briefs, or procurement policies with clear specifications for pharmaceutical qa. there is a lack of structured mechanisms for the monitoring and evaluation (m&e) of pharmaceutical quality in procurement, and no respondents mentioned any provisions for risk management plans. nonetheless, there are also some positive examples of targeted qa policies. in particular, four european donors set the tone. the directorate-general (dg) european civil protection and humanitarian aid operations (echo) of the ec specifically requires that their aid implementers use positive lists of approved procurement entities. to this aim, dg echo has published since a list of humanitarian procurement centres, assessed according to their quality systems, indicating where to procure medical supplies in priority. among eu member states, belgium explicitly requires since that aid implementers ensure the quality of medicines procured for medical programmes in lmics and avoid double-quality standards between the donor and the recipient country. sweden publicly acknowledges its effort to incorporate guiding principles on qa into its contractual requirements with aid implementing partners ; and in june , the uk implemented an internal qa guidance for procurement and supply of medicines inspiring broader guiding principles for donors. there are various reasons for the apparent delay of other european donors. first, securing safe supply chains meets a variety of hurdles, such as the need of complex contractual arrangements with suppliers, as well as the need of adequate tools for m&e, the institutional lack of specific qa expertise at donors and aid implementers' level and the fear that products that have been rigorously assessed for quality would be more expensive. second, some donors may consider that assuring the quality of medicines remains the sole responsibility of aid implementers and/or recipient countries. third, % of donors in our sample explicitly rely on the qa policies of the international actors they support, such as united nations (un) agencies, the global fund to fight aids, tuberculosis and malaria (gfatm) and the gavi alliance-even if they did not mention any specific policy dialogue with these organisations on pharmaceutical quality in procurement. it is also encouraging that in absence of explicit formal qa policies, awareness is translated into a variety of other initiatives that aim to support recipient countries in pharmaceutical qa, and to mitigate the risk of purchasing poor-quality medicines (table ) . these initiatives are either direct, for example, qa trainings for staff and implementers, and/or capacity building projects for national procurement units or nmras; or indirect, through the support to international mechanisms such as the who prequalification programme and the who global surveillance and monitoring system for substandard and falsified products. many european donors also have internal mechanisms to report quality incidents occurring with medicines purchased with their funds; but it is not clear to what extent findings are shared with peers, and used to adapt and improve existing procurement policies or to orient the policy setting agenda. in an ideal world, each country would count on a stringent nmra, able to ensure the quality of medicines manufactured, distributed or imported into their territory. bilateral and multilateral donors can contribute to reinforcing under-resourced nmras, through targeted capacity building programmes, in the frame of health systems strengthening. however, as long as this longterm aim is not achieved and many recipient lmics cannot secure qa in their own procurement, donors can support them by setting explicit and stringent qa policies for procurement of medicines in the programmes they fund. by doing so, they would be accountable about the optimal and ethical use of oda resources, both to recipient countries, and to tax payers and parliaments in their own countries. pharmaceutical qa should become an integral part of donors' risk management plans and policies. adequate qa policies can be direct or indirect. when funds are directly disbursed by a donor, the donor would require its implementers to purchase medicines according to its own qa policy. when funds are indirectly disbursed through channels such as multilateral or bilateral cooperation, humanitarian programmes, non-governmental organisations, investment funds or development banks, the donors would make use of policy dialogue (eg, via their official representation at board meetings) to monitor whether adequate qa standards are applied and evaluated. monitoring and evaluating a (direct or indirect) qa policy requires donors and aid implementers having easy, ongoing access to disaggregated financial data within oda budgets. this allows them to trace funds spent on pharmaceutical purchases and/or qa capacity building and provides access to up-to-date indicators of availability and quality of essential medicines in medical programmes. presently, the qa policies and the mechanisms for accountability and risk management still vary across european development and humanitarian aid programmes, and only a minority of european donors have explicit qa policies in place. harmonisation of such policies across donors would allow setting adequate standards across aid programmes, and to achieve a better protection of individual and public health in recipient countries. efforts to build a common approach across european donors should be encouraged, but are still in their infancy. the existing models and best practices could serve as a basis for other european donors to develop internal policies adapted to their own cooperation strategies, in the frame of a process of european harmonisation. importantly, the input of aid recipient countries should be requested and taken into due account, so as to codesign policies and procedures which respond to existing needs. but european donors could be more ambitious. in line with the resolution developed for the seventy-third world health assembly on the covid- pandemic, they could develop a joint guiding position to affirm how the european donor community should and can collectively ensure equitable access to and availability of qualityassured health products, including medicines. compared with other approaches that focus on developing market opportunities, or that fail to integrate concerns about pharmaceutical quality, european donors can collectively take leadership in promoting the universal right to safe, quality-assured medicines internationally, in partnership with their counterparts from lmics. european donors could also consider proactively sharing the available information on quality of medicines among themselves, and with recipient countries. they could consider adopting mutual recognition of policies and tools that help securing pharmaceutical quality for all. for instance, european donors could agree on positive lists of procurement entities, at international level and in aid recipient countries; they could share reports on qualified manufacturers at international level and in aid recipient countries; and they could share price lists for priority essential medicines in contexts where several european donors intervene. these measures would be particularly helpful for emergency preparedness. during disasters and outbreaks of infectious diseases there are increased, urgent pharmaceutical needs. in a crisis, purchases need to be done rapidly, with no time for in-depth prequalification of products and suppliers. the ongoing covid- pandemics shows that not only lmics, but also high-income countries are confronted with quality problems under such circumstances, for example, for personal protective equipment and diagnostic tests. under these complex circumstances, the resources and know-how of european donors and their aid implementers could contribute to securing a supply of quality-assured health products, by addressing the underlying vulnerabilities in regulations, markets and supply chains. a comprehensive assessment of european initiatives to support recipient countries could help designing and refining shared best practices. this could be the basis for a reliable procurement system for health products, in line with the joint programming scheme where various european donors and their implementing partners aim at maximal complementarity when addressing health needs in the same recipient countries. there may be fears that quality-assured products are costly, and that additional costs would not be compatible with the attainment of universal health coverage. however, the prices of health products do not depend on manufacturing and qa costs only, but also on manufacturing volumes and market opportunities. if all european donors and their aid implementers would apply stringent and harmonised qa requirements in their procurement policies, they could contribute to shaping the market of lmics towards affordable and quality assured products. this would require awareness and political will at (higher) institutional level, enhanced coordination across european donors, and consideration for the hidden-yet high-cost of inaction for individual and public health. twitter raffaella ravinetto @rravinetto world health organization. global surveillance and monitoring system for substandard and falsified medical products. geneva: world health organization world health organization. a study on the public health and socioeconomic impact of substandard and falsified products: executive summary. geneva: world health organization essential medicines and health products. substandard and falsified (sf) medical products. definitions of substandard and falsified (sf) medical products. geneva: world health organization oxford statement signatories. global access to quality-assured medical products: the oxford statement and call to action a link between poor quality antimalarials and malaria drug resistance? medicines quality assurance to fight antimicrobial resistance rpq/reg/isf/alert . . falsified medical products, including in vitro diagnostics signatories from countries. covid- and risks to the supply and quality of tests, drugs, and vaccines the belgian commitment to pharmaceutical quality: a model policy to improve quality assurance of medicines available through humanitarian and development programs a survey of nongovernmental organizations on their use of who's prequalification program analysis of the quality assurance and pharmaceutical procurement policies of a sample of european donors annex iii: principles and procedures applicable to procurement assuring medicines quality in medicines procurement who global benchmarking tool (gbt) for evaluation of national regulatory system of medical products. national regulatory system (rs): indicators and fact sheets. revision vi version . geneva: world health organization covid- response. draft resolution proposed by albania thailand, the african group and its member states, the european union and its member states covid suspicious certificates for ppe -updated / / itm researchers wrote a position paper to guide the use of rapid diagnostic tests to test for covid- infection cooperating internationally to programme development aid and, develop a coordinated, strategic response to key global challenges universal health coverage: drug quality and affordability can go together acknowledgements we are grateful to dg devco and dg echo of the european commission; the ministries of foreign affairs in belgium, denmark, france, germany, italy, ireland, luxembourg, netherlands, spain, sweden and switzerland; and the aid implementers of the national cooperation programmes in belgium, france, germany, italy, ireland, netherlands, norway, spain, sweden, switzerland and the united kingdom. we thank roeland scholtalbers for re-reading and editing key: cord- -xit najq authors: van damme, wim; dahake, ritwik; delamou, alexandre; ingelbeen, brecht; wouters, edwin; vanham, guido; van de pas, remco; dossou, jean-paul; ir, por; abimbola, seye; van der borght, stefaan; narayanan, devadasan; bloom, gerald; van engelgem, ian; ag ahmed, mohamed ali; kiendrébéogo, joël arthur; verdonck, kristien; de brouwere, vincent; bello, kéfilath; kloos, helmut; aaby, peter; kalk, andreas; al-awlaqi, sameh; prashanth, ns; muyembe-tamfum, jean-jacques; mbala, placide; ahuka-mundeke, steve; assefa, yibeltal title: the covid- pandemic: diverse contexts; different epidemics—how and why? date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: xit najq it is very exceptional that a new disease becomes a true pandemic. since its emergence in wuhan, china, in late , severe acute respiratory syndrome coronavirus (sars-cov- ), the virus that causes covid- , has spread to nearly all countries of the world in only a few months. however, in different countries, the covid- epidemic takes variable shapes and forms in how it affects communities. until now, the insights gained on covid- have been largely dominated by the covid- epidemics and the lockdowns in china, europe and the usa. but this variety of global trajectories is little described, analysed or understood. in only a few months, an enormous amount of scientific evidence on sars-cov- and covid- has been uncovered (knowns). but important knowledge gaps remain (unknowns). learning from the variety of ways the covid- epidemic is unfolding across the globe can potentially contribute to solving the covid- puzzle. this paper tries to make sense of this variability—by exploring the important role that context plays in these different covid- epidemics; by comparing covid- epidemics with other respiratory diseases, including other coronaviruses that circulate continuously; and by highlighting the critical unknowns and uncertainties that remain. these unknowns and uncertainties require a deeper understanding of the variable trajectories of covid- . unravelling them will be important for discerning potential future scenarios, such as the first wave in virgin territories still untouched by covid- and for future waves elsewhere. late in , a cluster of acute respiratory disease in wuhan, china, was attributed to a new coronavirus, - later named severe acute respiratory syndrome coronavirus (sars-cov- ). it was soon discovered that the virus is easily transmitted, can cause summary box ► severe acute respiratory syndrome coronavirus (sars-cov- ), the virus that causes covid- , has spread to nearly all countries of the world in only a few months. it is unique that an emerging respiratory virus becomes a pandemic, and can continue human-to-human transmission unabated, probably permanently. ► depending on the context, the trajectory and the impact of the covid- epidemic vary widely across affected countries. this is in fact the case with most infectious diseases. ► despite limited initial knowledge on covid- , most societies have deployed draconian measures, including lockdowns, to contain the virus and mitigate its impact. this had variable success, but invariably with profound socioeconomic collateral effects. ► through research and rapid sharing of its findings, progressively more insights on sars-cov- and covid- have been uncovered (knowns), mainly based on evidence from china, europe and the usa; however, important knowledge gaps remain (unknowns). ► the different covid- epidemics and the responses unfolding in the global south are little described, analysed or understood. insights from these less researched contexts are important for discerning potential future scenarios, not only for the first wave in virgin territories still untouched by covid- , but also for future waves. ► more understanding of lived experiences of people in a variety of contexts is necessary to get a full global picture and allow learning from this variety. ► bmj global health and emerging voices for global health have launched a call for such on-the-ground narratives and analyses on the epidemics of, and responses to, covid- . severe disease and can be quite lethal especially in the elderly and those with comorbidities. [ ] [ ] [ ] [ ] the new human disease is called covid- . soon it became clear that its global spread was unstoppable. even with draconian containment measures, such as strict movement restrictions, the so-called lockdown, it spread, and within a few months reached almost all countries and was declared a pandemic by the who. table summarises key events in the unfolding of the covid- pandemic, from december to may . this progression is quite unique. new human pathogens emerge frequently from an animal host, but most cause only a local outbreak. human-to-human transmission stops at some point, and the virus can only re-emerge as a human pathogen from its animal host. only very rarely does an emerging pathogen become a pandemic. over the past decades, a totally new pathogen emerged, caused serious disease, and spread around the globe continuously only once before: the hiv. it seems increasingly likely that sars-cov- transmission will be continuing. all countries are now facing their own 'covid- epidemic'. in only a few months, the scientific community has started to learn the virus's characteristics and its manifestations in different contexts. but we fail to understand fully why the virus spreads at different speeds and affects populations differently. our main objective is to make sense of those different expressions of the covid- pandemic, to understand why covid- follows variable trajectories in ways that are often quite different from the collective image created by the mediatisation of the dramatic covid- epidemics in densely populated areas. we start by exploring the role of context, followed by a brief summary of what is already known at the time of writing about sars-cov- and covid- . we then bmj global health compare these knowns with what is known of some other viral respiratory pathogens and identify the critical unknowns. we also discuss the coping strategies and collective strategies implemented to contain and mitigate the effect of the epidemic. we finally look ahead to potential future scenarios. the unfolding covid- pandemic: importance of context initially, human-to-human transmission was documented in family/friends clusters. [ ] [ ] [ ] [ ] [ ] [ ] progressively, it became clear that superspreading events, typically during social gatherings such as parties, religious services, weddings, sports events and carnival celebrations, have played an important role. [ ] [ ] [ ] [ ] dense transmission has also been documented in hospitals and nursing homes possibly through aerosols. sars-cov- has spread around the world through international travellers. the timing of the introduction of sars-cov- has largely depended on the intensity of connections with locations with ongoing covid- epidemics; thus, it reached big urban centres first and, within these, often the most affluent groups. from there, the virus has spread at variable speeds to other population groups. as of may , the most explosive covid- epidemics observed have been in densely populated areas in temperate climates in relatively affluent countries. the covid- pandemic and the lockdowns have been covered intensively in the media and have shaped our collective image of the covid- epidemic, both in the general public and in the scientific community. the covid- epidemic has spread more slowly and less intensively in rural areas, in africa and the indian subcontinent, and the rural areas of low and lower-middle income countries (lics/lmics). not only the media but also the scientific community has paid much less attention to these realities, emerging later and spreading more slowly. the dominant thinking has been that it is only a question of time before dramatic epidemics occur everywhere. this thinking, spread globally by international public health networks, has been substantiated by predictive mathematical models based largely on data from the epidemics of the global north. however, what has been observed elsewhere is quite different although not necessarily less consequential. the effects of the covid- epidemic manifest in peculiar ways in each context. in the early stages of the covid- epidemic in sub-saharan africa, the virus first affected the urban elites with international connections. from there, it was seeded to other sections of the society more slowly. in contrast, the collateral effects of a lockdown, even partial in many cases, are mostly felt by the urban poor, as 'stay home' orders abruptly intensify hardship for those earning their daily living in the informal urban economy. governments of lics/lmics lack the budgetary space to grant generous benefit packages to counter the socioeconomic consequences. international agencies are very thinly spread, as the pandemic has been concurrent everywhere. donor countries have focused mainly on their own covid- epidemics. the epidemic is thus playing out differently in different contexts. many factors might explain sars-cov- transmission dynamics. climate, population structure, social practices, pre-existing immunity and many other variables that have been explored are summarised in table . although all these variables probably play some role, many uncertainties remain. it is difficult to assess how much these variables influence transmission in different contexts. it is even more difficult to assess how they interact and change over time and influence transmission among different social groups, resulting in the peculiar covid- epidemic in any particular context. we do not attempt to give a complete overview of viruses but select only those viruses that emerged recently and caused epidemics such as ebola, that have obvious similarities in transmission patterns such as influenza and measles, or that are closely related such as other coronaviruses. respiratory viruses such as severe acute respiratory syndrome coronavirus (sars-cov), middle east respiratory syndrome coronavirus (mers-cov) and avian influenza a and also ebola have originated from animal hosts and caused human diseases (table ) . these viruses do not continuously circulate from human to human. they create an outbreak only when there is interspecies cross-over transmission, most frequently from bats to another animal host. the first human case of a disease from an emerging viral pathogen, the 'index case' or 'patient zero', is invariably someone in close contact with the originating animal host or an intermediary animal host. if this contact occurs in a remote rural community, the spread is usually slow, at low intensity, and could fade out before the pathogen gets a chance to spread to another community. the spread can suddenly intensify if seeded in a densely populated community, frequently in a particular context such as a hospital or during a social event, often referred to as a superspreading event. when the spread reaches a city, it can become a major outbreak, from where it can spread further; this happened with sars-cov in hong kong in and with ebola in conakry, freetown and monrovia in - . but at some stage human-to-human transmission is interrupted and the outbreak stops. only very exceptionally can a new viral pathogen sustain continuous human-to-human transmission. other viral diseases such as measles and influenza are 'old' diseases; they have been studied in great depth. what can we learn from them? measles and influenza: the importance of context it is thought that measles emerged thousands of years ago in the middle east. it is assumed that a cross-over occurred from the rinderpest virus, to become the human measles virus. measles has since spread around the globe in continuous human-to-human transmission. when measles, along with other viruses such as smallpox and influenza, was introduced in the americas by european conquerors, it contributed to a massive die-off of up to % of the original population. the transmission dynamics of sars-cov- can be compared with influenza. influenza typically causes yearly epidemics in temperate climates during winter with less seasonal patterns in tropical or subtropical regions. in hotter climates, such as in sub-saharan africa or south and southeast asia, it is transmitted year round, often not identified as influenza. such different epidemic patterns of influenza are still incompletely understood but thought to be associated with temperature and humidity and human behavioural factors such as indoor crowding. but, in contrast to sars-cov- , the influenza virus is not new. influenza is a very old disease, certainly circulating for several centuries. it has infected most human beings living on the planet already, many of them several times, leaving some immunity but no durable protection. the virus also mutates, giving rise to a new dominant strain every influenza season. influenza is every year a slightly different virus (due to antigenic drift as a result of progressive mutations) with major differences every few decades (antigenic shift as a result of recombination with novel strains). one such antigenic shift resulted in the h n 'spanish' influenza pandemic, which had an estimated case fatality rate (cfr) of %- %, killing millions. box summarises some key facts about h n , including factors thought to be associated with its high cfr. a major difference between covid- and influenza is that sars-cov- is a new pathogen and influenza is not. at the time of writing (may ), sars-cov- has triggered an immune response in over million confirmed infections (and probably in many more), definitely too few to create anything close to herd immunity. calculations using an estimated reproductive number (r ) for sars-cov- suggest that herd immunity would require at least % of the population to have protective immunity (see box ). like covid- , measles and influenza have different epidemic patterns in different contexts. this also is the case for cholera, tuberculosis, hiv/aids and most infectious diseases. the difference in patterns is most pronounced and so is easily understood with vectorborne and water-borne diseases. epidemic patterns are also different for air-borne infections, although they are less easily understood. transmission of respiratory viruses is influenced by factors related to the virus and box pandemic h n influenza, - ► the h n virus probably infected one-third of the world's population at that time (or ~ million people). ► the pandemic had three waves in quick succession; the second wave, in , was worse than the first wave. ► high mortality, especially in younger persons ( - years; ~ % of total deaths) in the pandemic, may have been due to antibody-dependent enhancement and 'cytokine storms'. another possible explanation is that older persons had some protective cross-immunity from previous influenza outbreaks while younger persons did not. ► h n continued to circulate along with seasonal influenza viruses, often recombining to produce more severe local outbreaks, including other pandemics between and , giving it the nickname 'mother of all pandemics'. ► the original h n strain was replaced by a(h n )pdm virus that resulted from an antigenic shift and caused the h n influenza pandemic. ► the h n virus originated in pigs in central mexico in march and was responsible for an estimated deaths worldwide with an estimated cfr< . %. ► during the pandemic, mortality was much lower than in the pandemic. higher mortality in persons younger than years was related to cytokine storms. a role of protective crossimmunity from previous influenza strains in older persons has been suggested. ► after august , the a(h n )pdm virus appeared to have integrated with circulating strains of influenza and continues to cause localised seasonal influenza outbreaks worldwide. box on the use of mathematical models during epidemics a dominant way of studying the transmission dynamics of an infectious disease such as covid- , and predicting the amplitude and peak of the epidemic in a population (city, province, country) and analysing the effect of control measures is using mathematical models. based on available data and several assumptions, a model attempts to predict the course of the epidemic, the expected number of infections, clinical cases and deaths over time. critical is the effective reproductive number (rt). when rt > , the number of cases in a population increases; when rt < , the number of cases decreases. a relatively simple and widely used model is the susceptible-exposed-infectious-recovered model, as used in the two papers recently published in bmj global health on covid- in africa. there are many more types of models, with varying degrees of complexity. the use of such models has strengths and limitations. building a mathematical model implies trade-offs between accuracy, transparency, flexibility and timeliness. a difficulty, in general, is that the parameters on which the model is based, the so-called assumptions are frequently uncertain (table ) and predictions can vary widely if any of the parameters are modestly different. this uncertainty is captured in a sensitivity analysis, leading to various possible quantitative outcomes, usually expressed as a range of plausible possibilities, between 'worst-case' and 'best-case' scenarios. with a new disease such as covid- , certainly at the start of the outbreak, the parameters had to be based on very limited data from a particular context. however, many variables can widely differ across communities as they critically depend on contextual factors (table ) . in mathematical models, all such uncertainties and unknowns are somehow hidden in the complex formulae of the model, as a quasi 'black box'. few people have the knowledge and skill to 'open up the black box'. as uncertainties in covid- are large, the range of possibilities produced by a model is wide, with the worst-case scenario typically predicting catastrophic numbers of cases and deaths. such predictions are often misunderstood by journalists, practitioners and policy-makers, with worst-case estimates getting the most attention, not specifying the huge uncertainties. bmj global health the human host but also by factors related to the natural and human environment (table ) . however, we are quite unable to explain fully which factor has which influence, how these factors vary among different social groups and how interdependent or isolated they are. we are certainly unable to fully model all these variables mathematically to explain the epidemic pattern across a variety of different contexts. too many variables and their interrelations are difficult to quantify, and when all these factors change over time while the pathogen continues to spread in diverse societies, the complexity becomes daunting. understanding transmission dynamics is a bit less daunting for measles, as several variables are well known and rather constant across individuals and contexts. the natural transmission pattern of measles, before the introduction of vaccines, has been well described. measles is mostly a childhood disease, but this is not the case in very remote communities, where measles transmission had been interrupted for extended periods (such as the faroe islands). measles affected all age groups when reaching new territories, causing dramatic first-wave epidemics, a phenomenon called 'virgin soil epidemic'. the latest stages of the global dissemination of measles have been well documented, including in australia, the fiji islands and the arctic countries, where such virgin soil epidemics occurred in the th and the mid- th centuries. fortunately, measles infection creates robust protective immunity and after a first wave becomes a typical childhood disease, affecting only those without any prior immunity. human-to-human transmission of measles virus in a community stops when the virus cannot find new susceptible human hosts and the so-called herd immunity is reached. but transmission of measles continues elsewhere on the planet from where it can be reintroduced a few years later when the population without protective immunity has grown large enough to allow human-to-human transmission again. the epidemic patterns of measles are easily understood as measles is highly infectious, creates disease in almost every infected person and leaves lifelong natural immunity. measles circulation, prior to vaccination, was continuous only in large urban areas with high birth rates. everywhere else reintroduction occurred typically every - ► genetic stability or variability (affecting the potential of long-lasting immunity). ► viral load determines the incubation period with the formula high load ->short incubation period ->high severity. human host ► human susceptibility to the virus; transfer of parental immunity to newborns. ► route and efficiency of human-to-human transmission. ► presence and capacity of asymptomatic carriers to transmit the virus. ► immunity created after infection, its robustness and how long-lasting it is. ► severity and duration of the disease: proportion symptomatic, lethality (cfr). ► pathogenicity and disease spectrum; disease pattern according to age and comorbidities, and related potential to spread. natural environment ► temperature, humidity and seasonal changes in climate affecting the stability and transmission potential of the virus and human susceptibility. ► increasing extreme weather conditions such as droughts and severe storms, as well as global climate change may also affect transmission patterns. ► air pollution may also play a role in the transmission and stability of the virus. human environment/social geography ► demographic variables such as population density, age structure and household composition. ► mixing patterns within households, including bed sleeping patterns, related to housing conditions and hygiene practices. ► house construction with solid walls or permeable walls (thatched walls, straw mats). ► mixing patterns among households related to settlement patterns: social networks, urban-rural differences, working conditions, religious practices and commuting patterns. ► variables related to built environments, road infrastructure and socioeconomic conditions. ► mobility between communities, including international travel. ► crowding institutions: for example, elderly homes, extended families, boarding schools, child institutions, seclusion during tribal ceremonies, hospitals, nursing homes, military barracks and prisons. cfr, case fatality rate. years but sometimes only after or years in isolated rural communities (such as among nomadic groups in the sahel), causing epidemics among all those without acquired immunity and having lost maternal antibodies. these diverse patterns of measles epidemics have been fundamentally changed by variable coverage of measles vaccination. they can still help us make sense of the diversity of covid- epidemics being observed in . measles illustrates convincingly that the transmission pattern of a respiratory virus is strongly influenced by the demographic composition, density and mixing pattern of the population and the connectedness to big urban centres. measles transmission is continuous only in some large urban areas. it presents in short epidemics everywhere else with variable periodicity. this transmission pattern may well be a bit similar for covid- . but it took thousands of years for measles to reach all human communities while sars-cov- spread to all countries in only a few months, despite measles being much more transmissible than sars-cov- . factors such as increased air travel and more dense community structures play bigger roles for sars-cov- than they did for measles. comparison with other pathogenic coronaviruses sars-cov- has many close relatives. six other human coronaviruses (hcovs) are known to infect humans. sars-cov and mers-cov (causing sars and mers, respectively) are very rare and do not continuously circulate among humans. the other four (hcov- e, hcov-oc , hcov-hku and hcov-nl ) cause the common cold or diarrhoea and continuously circulate and mutate frequently. they can cause disease in the same person repeatedly. the typical coronavirus remains localised to the epithelium of the upper respiratory tract, causes mild disease and elicits a poor immune response, hence the high rate of reinfection (in contrast to sars-cov and mers-cov, which go deeper into the lungs and hence are relatively less contagious). there is no cross-immunity between hcov- e and hcov-oc , and new strains arise continually by mutation selection. coping strategies and collective strategies how a virus spreads and its disease progresses depend not only on the variables described above (table ) but also on the human reactions deployed when people are confronted with a disease outbreak or the threat of an outbreak. all these variables combined result in what unfolds as 'the epidemic' and the diverse ways it affects communities. what a population experiences during an epidemic is not fully characterised by the numbers of known infections and deaths at the scale of a country. such numbers hide regional and local differences, especially in large and diverse countries. the epidemic reaches the different geographical areas of a country at different moments and with different intensities. it affects different communities in variable ways, influencing how these communities perceive it and react to it. what constitutes a local covid- epidemic is thus also characterised by the perceptions and the reactions it triggers in the different sections of the society. even before the virus reaches a community, the threat of an epidemic already causes fear, stress and anxiety. consequently, the threat or arrival of the epidemic also triggers responses, early or late, with various degrees of intensity and effectiveness. the response to an epidemic can be divided into individual and household actions (coping strategies), and collectively organised strategies (collective strategies). coping strategies are the actions people and families take when disease threatens and sickness occurs, including the ways they try to protect themselves from contagion. collective strategies are voluntary or mandated measures deployed by organised communities and public authorities in response to an epidemic. these include, among others, isolation of the sick or the healthy, implementation of hygiene practices and physical distancing measures. they can also include mobility restrictions such as quarantine and cordon sanitaire. coping strategies and collective strategies also include treatment of the sick, which critically depends on the availability and effectiveness of diagnostic and therapeutic tools, and performance of the health system. collective strategies also include research being deployed to further scientific insight and the development of diagnostic and therapeutic tools, potentially including a vaccine. implementation of these measures depends not only on resources available but also on the understanding and interpretation of the disease by both the scientific community and the community at large, influenced by the information people receive from scientists, public authorities and the media. this information is interpreted within belief systems and influenced by rumours, increasingly so over social media, including waves of fake news, recently labelled 'infodemics'. coping strategies and collective strategies start immediately, while there are still many unknowns and uncertainties. progressively, as the pandemic unfolds and scientists interpret observations in the laboratory, in the clinic, and in society, more insights are gained and inform the response. table lists measures recommended by the who for preventing transmission and slowing down the covid- epidemic. - 'lockdown' first employed in early in wuhan, china, is the label often given to the bundle of containment and mitigation measures promoted or imposed by public authorities, although the specific measures may vary greatly between countries. in china, lockdown was very strictly applied and enforced. it clearly had an impact, resulting in total interruption of transmission locally. this list or catalogue of measures is quite comprehensive; it includes all measures that at first sight seem to reduce transmission opportunities for a respiratory virus. however, knowledge is lacking about the effectiveness of each measure in different contexts. as a global health bmj global health agency, the who recommends a 'generic catalogue' of measures from which all countries can select an appropriate mix at any one time depending on the phase of the epidemic, categorised in four transmission scenarios (no cases, first cases, first clusters, and community transmission). however, under pressure to act and with little time to consider variable options, public authorities often adopted as 'blueprint' with limited consideration for the socioeconomic context. the initial lockdown in china thus much inspired the collective strategies elsewhere. this has been referred to as 'global mimicry', : the response is somehow partly 'copy/paste' from measures observed previously (strong path dependency). some epidemiologists in northern europe (including the uk, sweden and the netherlands ) pleaded against strict containment measures and proposed that building up herd immunity against sars-cov- might be wiser. towards early april , it became increasingly clear that reaching herd immunity in the short term was illusive. most countries thus backed off from the herd immunity approach to combating covid- and implemented lockdowns. the intensity of the lockdowns has been variable, ranging from very strict ('chinese, wuhan style'), over intermediary ('french/italian/new york city style' and 'hong kong style'), to relaxed ('swedish style'), or piecemeal. the effectiveness of lockdowns largely depends on at what stage of the epidemic they are started, and how intensively they are applied. this is quite variable across countries, depending on the understanding and motivation of the population and their perceived risk ('willingness to adhere'), on the trust they have in government advice ('willingness to comply'), and on the degree of enforcement by public authorities. the feasibility for different population groups to follow these measures depends largely on their socioeconomic and living conditions. it is obviously more difficult for people living in crowded shacks in urban slums to practise physical distancing measures and strict hand hygiene when water is scarce than for people living in wealthier parts of a city. collateral effects of the response every intervention against the covid- epidemic has a certain degree of effect and comes at a cost with collateral effects. each collective strategy ( ) has intended and unintended consequences (some are more or less desirable); ( ) is more or less feasible and/or acceptable in a given context and for certain subgroups in that society; ( ) has a cost, not only in financial terms but in many other ways, such as restrictions on movement and behaviour, stress, uncertainty and others. these costs are more or less acceptable, depending on the perception of the risk and many societal factors; ( ) can be implemented with more or less intensity; and ( ) can be enforced more or less vigorously. the balance between benefit and cost is crucial in judging whether measures are appropriate, which is very context specific. furthermore, benefits and costs are also related to the positionality from which they are analysed: benefits for whom and costs borne by whom? more wealthy societies with strong social safety nets can afford increased temporary unemployment. this is much more consequential in poorer countries, where large proportions of the population live precarious lives and where public authorities cannot implement generous mitigation measures at scale. the adherence to hygiene and distancing measures depends not only on living conditions but also on risk perception and cultural norms. mass masking has been readily accepted in some asian countries, where it was already broadly practised even before the covid- bmj global health epidemic. it remains more controversial in western societies, some of which even have legal bans on veiling in public places. lockdowns are unprecedented and have triggered intensive public debate. not surprisingly, the impact of lighter lockdowns on the transmission is much less impressive; they decrease transmission but do not stop it. quite rapidly, the justification for lockdowns shifted from stopping transmission to 'flattening the curve'. also, once a lockdown is started, rationalised, explained and enforced, it is difficult to decide when to stop it. exit scenarios, usually some form of progressive relaxation, are implemented with the knowledge that transmission will be facilitated again. what we already know the available information on sars-cov- and the spectrum of covid- disease is summarised in tables and . it is increasingly becoming clear that most transmission happens indoors and that superspreading events trigger intensive dissemination. the virology and immunology of sars-cov- / covid- are being studied intensively. this is critical not only to understand what will potentially happen in future waves but also for the development of a vaccine. some scientists and companies are very upbeat about the possibility of producing a vaccine in record time. having a vaccine is one thing, but how effective it is, is quite another. as acquired immunity after a natural infection is probably not very robust (table ), it will also be challenging to trigger robust immunity with a vaccine, but perhaps it is not impossible. many questions remain, some of which are summarised in table . regarding the severity of covid- , initial fears of very high mortality have also lessened. it has progressively become clear that many infections remain asymptomatic, that severe disease is rare in children and young adults, and that mortality is heavily concentrated in the very old and those with comorbidities. table summarises a fuller overview of the present state of knowledge regarding covid- . with covid- epidemics unfolding rapidly, several of the variables in the transmission of sars-cov- and the disease spectrum of covid- could be quantified. this allows for mathematical modelling. several models have been quickly developed, leading to predictions of the speed of transmission and the burden of covid- (box ). predictive models developed by the imperial college ; the center for disease dynamics, economics & policy and johns hopkins university ; the institute for health metrics and evaluation ; harvard university ; and the who, including an 'african model', are a few that are influencing containment strategies around the world. although the covid- pandemic triggered unprecedented research efforts globally, with over scientific papers published between january and april , there are still critical unknowns and many uncertainties. tables and summarise many of the knowns, but their relative importance or weight is not clear. for instance, the virus can spread via droplets, hands, aerosols, fomites and possibly through the environment. however, the relative importance of these in various contexts is much less clear. these factors undoubtedly vary between settings, whether in hospitals, in elderly homes, or at mass events. the weight of the variables also probably differs between the seeding and initial spread in a community and the spread when it suddenly amplifies and intensifies. the importance of each variable probably also depends on climatic conditions, not only outdoors, but also on microclimates indoors, influenced by ventilation and air conditioning and built environments. we summarise the critical unknowns in table along some elements to consider in addressing the unknowns and thoughts on their importance. uncertainty remains, leading to controversy and directly influencing the choice of containment measures. controversy continues regarding when and where lockdown or more selective measures are equally effective with lower societal effects. relationship between the dose of the initial infectious inoculum, transmission dynamics and severity of the covid- disease new evidence is being discovered rapidly. some evidence comes from field observations and ecological studies; other evidence results from scientific experiments or observations in the laboratory and the clinic. sense-making by combining insights from different observations and through the lens of various disciplines can lead to hypotheses that can be tested and verified or refuted. one such hypothesis is that there is a relationship between the dose of virus in the infectious inoculum and the severity of covid- disease. several intriguing observations in the current pandemic could be (partially) explained by such a relationship. we develop this hypothesis in box , as an example of possible further research, to create new insight which may influence control strategies. this viral inoculum theory is consistent with many observations from the early stages of the covid- pandemic, but it is not easy to test scientifically. as covid- is a new disease, we should make a distinction between ( ) the current - 'virgin soil pandemic' caused by sars-cov- , specifically in how it will further spread around the globe in the first wave, and ( ) the potential future transmission in subsequent waves. in some countries, transmission will continue at lower levels. in other countries, such as china, the virus bmj global health may have been eliminated but can be reintroduced in identical or mutated form. for the current first wave, using influenza and the common cold as reasonable comparisons, it is possible that the major epidemics, as witnessed in wuhan, northern italy, or new york, will typically occur in temperate climates in the winter season. some predict that such epidemics will last between and weeks (but this is just a plausible and reasonable comparison in analogy with seasonal influenza). it is possible that in hotter climates the transmission may become continuous, year round at lower levels. it is increasingly clear that hot climate does not exclude superspreading events as observed in guayaquil, ecuador and in various cities in brazil. ventilation, air-conditioning and crowded places may still create favourable environments for intensive transmission. it is also quite possible that the more difficult spread of sars-cov- in such climates may, in certain table knowns, uncertainties and unknowns about severe acute respiratory syndrome coronavirus (sars-cov- ), as of may origin of sars-cov- ► most probably from bats via intermediate animal hosts to index case. all subsequent cases resulted from human-to-human transmission. transmission ► mainly through respiratory droplets from infected persons ; by hands, after contamination at nose, mouth or eyes; also through air on exposure to sneezing or coughing from an infected person at close distance. ► through aerosols, while singing/talking loudly in congregations, groups, parties, karaoke, and so on, especially in poorly ventilated spaces. ► through fomites. ► possibly via faecal-oral route ; detection in sewage. [ ] [ ] [ ] ► related to peak in upper respiratory tract viral load prior to symptom onset in presymptomatic (paucisymptomatic) persons. ► transmission dynamics in asymptomatic persons not fully elucidated although viral shedding occurs. influence of climate and/or air pollution on transmission ► influence of climate on the capacity of the virus to survive outside human body (in air, in droplets, on surfaces, etc.) and to spread has been speculative. ► may spread more readily in milder/colder climate ; although variability of the reproductive number could not be explained by temperature or humidity. ► existing levels of air pollution may play a role; air pollutants, such as particulate matter, nitrogen dioxide and carbon monoxide, are likely a factor facilitating longevity of virus particles. ► elevated exposure to common particulate matter can alter host immunity to respiratory viral infections. immunity-protective antibodies ► igm and iga antibody response - days after onset of symptoms, does not depend on clinical severity, correlates with virus neutralisation; igg is observed ~ days after onset of symptoms, may or may not correspond to protective immunity. whether antibody response is long lasting has remained unclear. ► rechallenge in rhesus macaques showed immunity post primary infection. how protective immunity after first infection is against subsequent infection with an identical or mutated strain has been uncertain. ► incidental reports showed recovered persons positive by real-time pcr, later attributed to testing errors. seroprevalence to sars-cov- ► reported estimates for seroprevalence range between . % and . % ; differences in timing of the serosurvey, the use of assay kits with varying sensitivity/specificity, and different methods for detection may contribute to this large variation. ► seemingly high seroprevalence may be due to cross-reactive epitopes between sars-cov- and other hcovs. ► whether seroprevalence implies immune protection is unclear, yet, some countries have considered use of 'immunity passports'. ► for herd immunity to be effectively achieved, an estimated seroprevalence of % of the population will be required. other studies estimate between . % and % seroprevalence in different countries. communities, be compensated for by human factors such as higher population density, closer human contacts and lesser hygiene (as, for instance, exist in urban slums in mega cities in low income countries). how all this plays out in sub-saharan africa, in its slums and remote areas, is still largely unknown. with sars-cov- , transmission scenarios are mainly based on mathematical models despite their serious limitations (box ). as the virus continues to circulate, it will progressively be less of a 'new disease' during subsequent waves. the immunity caused by the first epidemic will influence how the virus spreads and causes disease. whether later waves will become progressively milder or worse, as observed in the - spanish influenza, is a matter of intense speculation. both views seem plausible and the two are not necessarily mutually exclusive. indeed, immunity should be defined on two levels: individual immunity and herd immunity. individual immunity will dictate how mild or severe the disease will be in subsequent infections. herd immunity could be defined in different communities/regions/ disease spectrum ► many different estimates: ► initially, it was estimated that among infected, % remained asymptomatic, %- % had mild/moderate disease, %- % had severe disease, and %- % became critically ill. - ► very variable estimates for remaining totally asymptomatic (estimated %- % [ ] [ ] [ ] [ ] ). ► what determines that an infection remains asymptomatic? ► quasi-absence of disease in children: why? case fatality rate (cfr) ► initial estimates cfr: %- %; comparisons: influenza . %; common cold: %; sars: %- %; mers: %. ► calculated infection fatality rates (cifr) and calculated cfr (ccfr) on the princess diamond were . % and . %, respectively (for all ages combined), and projected cifr and ccfr for china were between . %- . % and . %- . %, respectively. in gangelt, germany: ccfr of . %. ► cfr is influenced significantly by age; male sex; comorbidities; body mass index and/or fitness; and adequacy of supportive treatment, mainly oxygen therapy. if a vaccine is developed? ► what type of vaccine will it be (live/non-live, classic killed, dna, or recombinant)? ► will it need special manufacture and transport conditions (such as cold chain)? ► how robust will be vaccine-acquired immunity? after how many doses? ► how protective will it be against infection? ► for how long will vaccine-acquired immunity last? and hence: how often will the vaccine have to be administered? only once? or yearly? ► will there be any adverse effects? acquired immunity is not very strong; hence, what is the consequence regarding herd immunity? ► to achieve herd immunity, how efficient will the vaccine need to be? ► what proportion of the population (critical population) will need to be vaccinated? ► how long will it take to effectively vaccinate the critical population? ► will vaccination be acceptable in the population? or will vaccine hesitancy reduce uptake? what are the socioeconomic implications? ► which countries will get the vaccine first (implications for lics/lmics)? ► how expensive will the vaccine be? ► will vaccination be made mandatory, especially for international travel? the various degrees of societal disruption and the collateral effects on other essential health services (eg, reluctance to use health services for other health problems, because of 'corona fear'). our growing knowledge may enable us to progressively improve our response. learning from the variety of ways the covid- epidemic is unfolding across the globe provides important 'ecological evidence' and creates insights into its epidemiology and impacts. until now, the insights gained on covid- have been largely dominated by the covid- epidemics in the global north. more understanding of lived experiences of people in a variety of contexts, where the epidemic is spreading more slowly and with different impacts, is necessary to get a full global picture and allow learning from this variety. this is an important missing piece of the covid- puzzle. bmj global health and emerging voices for global health have launched a call (https:// blogs. bmj. com/ bmjgh/ / / / from-models-to-narratives-andback-a-call-for-on-the-ground-analyses-of-covid- spread-and-response-in-africa/) for such on-the-ground narratives and analyses of the spread of and response to covid- , local narratives and analyses that will hopefully help to further enrich our understanding of how and why the covid- pandemic continues to unfold in multiple local epidemics along diverse trajectories around the globe. table some critical unknowns in sars-cov- transmission which transmission patterns will occur and will human-to-human transmission continue permanently? ► seasonal transmission in temperate climate? ► continuous tides, with ups and downs? ► the experience from china and some other countries showed that 'local elimination' is possible but risk of reintroduction remains. ► increasingly unlikely that elimination everywhere is possible. this will strongly depend on: how strong will the acquired immunity after a first infection with sars-cov- be and how long will it last? ► evidence of acquired immunity against subsequent infections has been limited. ► measurable antibodies have been observed in most persons who have recovered from covid- , and research in animal models has suggested limited possibility of reinfection. ► it is still unclear as to how robust the immunity is and how long it will last. ► debate on use, practicality and ethics of 'immunity passports' for those recovered from covid- has been ongoing. how stable is the virus (mutation) and do the different clades seen worldwide have any effect on the transmission potential/severity of the disease? ► if the virus mutates quickly and different strains develop, then antibodydependent enhancement might be an important risk, as in dengue with its four different strains. if so, then in subsequent waves progressively more severe cases could occur. ► this has been reported for the spanish influenza, where the second and third waves were characterised by a more severe disease pattern. what is the role of children in transmission? ► children have quasi-universally presented less severe disease. however, their susceptibility to infection remains unclear, with large heterogeneity reported between studies. ► their role in transmission has remained unclear, but evidence points to a more modest role in transmission than adults. how significant are asymptomatic carriers in transmission? ► there have been several reports of asymptomatic transmission and estimates based on modelling. ► increasing consensus that asymptomatic carriers play an important role in transmission. box relationship between the dose of the initial infectious inoculum, transmission dynamics and severity of the covid- disease hypothesis: the dose of the virus in the initial inoculum may be a missing link between the variation observed in the transmission dynamics and the spectrum of the covid- disease. it is plausible that: ► viral dose in inoculum is related to severity of disease. ► severity of disease is related to viral shedding and transmission potential. this hypothesis plays out potentially at three levels: ► at individual level: a person infected with a small dose of viral inoculum will on average develop milder disease than a person infected with a high viral inoculum and vice versa. ► at cluster level: a person with asymptomatic infection or mild disease will on average spread lower doses of virus in droplets and aerosols and is less likely to transmit disease; when the person transmits, the newly infected person is more likely to have milder disease than if infected by a severely ill person, who spreads on an average higher doses of virus. this causes clusters and chains of milder cases or of more severe cases. ► at community level: in certain contexts, such as dense urban centres in moderate climates during the season when people live mostly indoors, the potential for intensive transmission and explosive outbreaks is high, especially during indoor superspreading events. in other contexts, such as in rural areas or in regions with hot and humid climate where people live mostly outdoors, intensive transmission and explosive outbreaks are less likely. outbreak of pneumonia of unknown etiology in wuhan, china: the mystery and the miracle new-type coronavirus causes pneumonia in wuhan: expert a novel coronavirus from patients with pneumonia in china coronaviridae study group of the international committee on taxonomy of viruses. the species severe acute respiratory syndrome-related coronavirus: classifying -ncov and naming it sars-cov- pathological findings of covid- associated with acute respiratory distress syndrome the clinical characteristics of pneumonia patients coinfected with novel coronavirus and influenza virus in wuhan clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia naming the coronavirus disease (covid- ) and the virus that causes it world health organization. who director-general's opening remarks at the media briefing on covid- - severe acute respiratory syndrome coronavirus (sars-cov- ) and coronavirus disease- (covid- ): the epidemic and the challenges clinical features of pediatric patients with covid- : a report of two family cluster cases a covid- transmission within a family cluster by presymptomatic infectors in china report of the who-china joint mission on coronavirus disease (covid- ) cluster of coronavirus disease (covid- ) in the french alps investigation of a covid- outbreak in germany resulting from a single travelassociated primary case: a case series a familial cluster of pneumonia associated with the novel coronavirus indicating personto-person transmission: a study of a family cluster high sars-cov- attack rate following exposure at a choir practice estimating the overdispersion in covid- transmission using outbreak sizes outside china why do some covid- patients infect many others, whereas most don't spread the virus at all? science the cluster effect: how social gatherings were rocket fuel for coronavirus identification of a super-spreading chain of transmission associated with covid- possible role of aerosol transmission in a hospital outbreak of influenza aerodynamic analysis of sars-cov- in two wuhan hospitals covid- : the rude awakening for the political elite in low-and middle-income countries travellers give wings to novel coronavirus ( -ncov) total confirmed covid- cases per million vs gdp per capita the center for disease dynamics economics & policy. modeling the spread and prevention of covid- the ebola outbreak, - : old lessons for new epidemics overview on sars in asia and the world origin of measles virus: divergence from rinderpest virus between the th and th centuries plagues and people influenza seasonality in the tropics and subtropics -when to vaccinate? influenza in temperate and tropical asia: a review of epidemiology and vaccinology what settings have been linked to sars-cov- transmission clusters? the origin and virulence of the "spanish" influenza virus what policy makers need to know about covid- protective immunity observations made during the epidemic of measles on the faroe islands in the year a scaling analysis of measles epidemics in a small population measles in australasian indigenes epidemics among amerindians and inuits. a preliminary interpretation chapter : lethal gift of livestock. guns, germs, and steel: the fates of human societies studies on immunity to measles reproduction numbers and sub-threshold endemic equilibria for compartmental models of disease transmission herd immunity": a rough guide measles in a west african nomadic community zoonotic origins of human coronaviruses epidemiology, genetic recombination, and pathogenesis of coronaviruses chapter : coronaviruses. in: fenner and white's medical virology. . th edition how to fight an infodemic responding to community spread of covid- : interim guidance world health organization. critical preparedness, readiness and response actions for covid- : interim guidance novel corornavirus ( -ncov): strategic preparedness and response plan effect of nonpharmaceutical interventions to contain covid- in china early dynamics of transmission and control of covid- : a mathematical modelling study covid- : towards controlling of a pandemic the devastating consequences of coronavirus lockdowns in poor countries sir patrick vallance, the govt chief scientific adviser, says the thinking behind current approach to #coronavirus is to try and "reduce the peak" and to build up a "degree of herd immunity so that more people are immune to the disease inside sweden's radically different approach to the coronavirus -no lockdown, no quarantines, just voluntary advice and a big dose of hope coronavirus: full text of prime minister rutte's national address in english to beat covid- , we'll ultimately need it revealed: data shows countries risking coronavirus second wave as lockdown relaxed report : impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand available: https:// covid . healthdata. org/ united-states-ofamerica projecting the transmission dynamics of sars-cov- through the postpandemic period novel coronavirus (covid- ) the potential effects of widespread community transmission of sars-cov- infection in the world health organization african region: a predictive model epidemics and fear virus mutations reveal how covid- really spread sars-cov- was already spreading in france in late covid- ) -situation report - a historic quarantine: china's attempt to curb a viral outbreak is a radical experiment in authoritarian medicine world health organization day : world's largest coronavirus lockdown begins update -sars: chronology of a serial killer summary table of sars cases by country pandemic influenza risk management who risk assessment of human infections with avian influenza a(h n ) virus human infection with avian influenza a(h n ) virus -update fact sheet: ebola virus disease influenza: the mother of all pandemics geographic dependence, surveillance, and origins of the influenza a (h n ) virus estimated global mortality associated with the first months of pandemic influenza a h n virus circulation: a modelling study writing committee of the who consultation on clinical aspects of pandemic (h n ) influenza world health organization. h n in post-pandemic period: director-general's opening statement at virtual press conference the relatively young and rural population may limit the spread and severity of covid- in africa: a modelling study estimates of the severity of coronavirus disease : a model-based analysis epidemiology working group for ncip epidemic response -chinese center for disease control and prevention. epidemiological analysis of new coronavirus pneumonia characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship field briefing: diamond princess covid- cases estimation of the asymptomatic ratio of novel coronavirus infections (covid- ) covid- : what proportion are asymptomatic? : oxford covid- evidence service team covid- -navigating the uncharted estimating the infection and case fatality ratio for coronavirus disease (covid- ) using ageadjusted data from the outbreak on the diamond princess cruise ship preliminary result and conclusions of the covid- case cluster study (gangelt municipality);. land. nrw features of uk patients in hospital with covid- using the isaric who clinical characterisation protocol: prospective observational cohort study estimating excess -year mortality associated with the covid- pandemic according to underlying conditions and age: a population-based cohort study covid- and italy's case fatality rate: what's the catch? ispi (italian institute for international political studies) cross-country comparison of case fatality rates of covid- /sars-cov- mystery deepens over animal source of coronavirus aerosol emission and superemission during human speech increase with voice loudness presymptomatic transmission of sars-cov- -singapore aerosol and surface stability of sars-cov- as compared with sars-cov- covid- : gastrointestinal manifestations and potential fecal-oral transmission characteristics of pediatric sars-cov- infection and potential evidence for persistent fecal viral shedding presence of sars-coronavirus- in sewage first confirmed detection of sars-cov- in untreated wastewater in australia: a proof of concept for the wastewater surveillance of covid- in the community sars-cov- in wastewater: potential health risk, but also data source high transmissibility of covid- near symptom onset quantifying sars-cov- transmission suggests epidemic control with digital contact tracing temporal dynamics in viral shedding and transmissibility of covid- spread of sars-cov- coronavirus likely to be constrained by climate temperature, humidity and latitude analysis to predict potential spread and seasonality for covid- the role of absolute humidity on transmission rates of the covid- outbreak air pollution and the novel covid- disease: a putative disease risk factor profiling early humoral response to diagnose novel coronavirus disease (covid- ) reinfection could not occur in sars-cov- infected rhesus macaques pcr assays turned positive in discharged covid- patients positive rt-pcr test results in patients recovered from covid- lessons from a rapid systematic review of early sars-cov- serosurveys severe acute respiratory syndrome coronavirus -specific antibody responses in coronavirus disease patients prevalence of antibodies to four human coronaviruses is lower in nasal secretions than in serum the role of antibody testing for sars-cov- : is there one? world health organization the disease-induced herd immunity level for covid- is substantially lower than the classical herd immunity level individual variation in susceptibility or exposure to sars-cov- lowers the herd immunity threshold herd immunity -estimating the level required to halt the covid- epidemics in affected countries phylogenetic analysis of ncov- genomes sars-cov- (covid- ) by the numbers the establishment of reference sequence for sars-cov- and variation analysis the coronavirus isn't mutating quickly, suggesting a vaccine would offer lasting protection. the washington post genomic epidemiology of novel coronavirus implications of test characteristics and population seroprevalence on 'immune passport' strategies systematic review of covid- in children shows milder cases and a better prognosis than adults susceptibility to and transmission of covid- amongst children and adolescents compared with adults: a systematic review and meta-analysis presumed asymptomatic carrier transmission of covid- transmission of -ncov infection from an asymptomatic contact in germany acknowledgements we would like to thank johan leeuwenburg, piet kager, and luc bonneux for useful comments on a previous draft, the teams of the riposte corona, inrb, kinshasa and the belgian embassy in kinshasa for welcoming and hosting wvd during his unscheduled extended stay in kinshasa during the lockdown, march-june . we are thankful to mrs. ann byers for editing the manuscript at short notice. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.competing interests none declared. provenance and peer review not commissioned; externally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. key: cord- -ca ll tt authors: jia, peng; yang, shujuan title: early warning of epidemics: towards a national intelligent syndromic surveillance system (nisss) in china date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: ca ll tt nan after the sars pandemic in , an urgent demand for an effective national disease reporting and surveillance system could not be clearer in china. the national notifiable disease reporting system (nndrs) operated by the chinese center for disease control and prevention (cdc), also known as the china information system for disease control and prevention, was established in to facilitate the complete and timely reporting of cases during the outbreak. the outbreak of the covid- has further advanced the demand for an intelligent disease reporting system, also known as the national intelligent syndromic surveillance system (nisss), which would be able to analyse these suspected cases on the basis of prior knowledge and real-time information before a disease is confirmed clinically and in the laboratory. by doing so would tackle the epidemic quickly during the outbreak and even forecast the outbreak accurately and robustly at early stages. however, it remains difficult to forecast early risks for epidemics in the nisss with only disease cases reported from hospitals. more novel information input from end users and other external sources is required. the current technology enables the end user reporting or input modules in at least seven manners (figure ). first, the lowest level reporting parties in the current system (ie, hospitals and primary healthcare clinics) should go further down to doctors, who should be able to post and gather the suspected cases they have seen or treated. doctors see patients directly and are generally more sensitive to suspected cases, which could further reduce the delay under the current nndrs structure which only allows reporting the potential epidemic from the hospital administration after confirmation by expert panel. this is increasingly important because not only the covid- outbreak added this urgent demand to this system, but the current healthcare reform is shifting more gatekeeper roles down to the primary healthcare clinics. many western countries are more efficient on this because suspected cases are usually reported first by doctors in private clinics who are the first contact with patients and, under such a structure, are more encouraged to report the suspected cases. with that said, a hierarchical healthcare system is crucial to the successful early detection of infectious diseases. therefore, efforts on improving the nndrs should be aligned with the healthcare reform efforts. second, citizens should be enabled to report their surrounding risk through this novel crowdsourcing system. crowdsourcing is a sourcing model in which summary box ► a national intelligent syndromic surveillance system (nisss) is necessary in order to tackle the epidemic quickly during the outbreak, and forecast the outbreak accurately and robustly at early stages. ► doctors who see patients directly and citizens who are active on the ground are generally more sensitive to and should be enabled to report suspected cases and risk in the nisss. ► hospital and other types of information systems (eg, environmental, ecological, agricultural, wildlife and animal) should be tightly linked with the nisss to enable more timely information sharing and make syndromic surveillance. ► literature databases containing valuable research findings and knowledge and internet activity data reflecting cyber user awareness should be incorporated into the nisss in a real-time way for warning or fighting the epidemic. ► incorporating real-time data into the nisss could greatly facilitate the real-time tracking and consequently guide the epidemic control and prevention work on the ground for curbing the epidemic efficiently. ► the international institute of spatial lifecourse epidemiology (isle), a global health collaborative research network, has committed to working with multiple stakeholders to codevelop the nisss in china. information can be obtained from a large, relatively open and often rapidly-evolving group of internet users. such passive surveillance, if well used, could be even more sensitive to the potential risk than reporting by doctors. for example, the crowdsourcing platform muggenradar has been used by the dutch citizens to report the nuisance level of mosquito in order to indicate the potential risk of malaria. moreover, smartphone-based applications have been popular in china in almost every corner of the daily life, except the disease control and prevention, so crowdsourcing systems should be developed and integrated with the nisss with high priority. the individuals' communication tools could be even more advanced than the level of information technology infrastructure in some less developed remote areas, where smartphone-based user ends should also be made available for hospitals and doctors to report disease case information, in order to cancel off the low level of information technology infrastructure. therefore, a crowdsourcing system may work even better in china and other large countries with great variation in economic development. however, citizens should be better educated to be aware of their surrounding risk, which requires incorporating the public health education into the current education system at all stages. third, hospital information systems should be tightly linked with the nisss to enable more timely information sharing and make syndromic surveillance possible. currently, hospital information systems are not directly linked to the diagnosis-based (or diseasebased) nndrs in china, which could also cause reporting delay and errors (eg, manual typing errors) and should be improved. in the nisss, information about health events that precede a firm clinical diagnosis should be captured early and rapidly from electronic health records (ehrs), and analysed frequently to detect signals that might indicate an outbreak requiring investigation. this has been unprecedentedly possible since artificial intelligence (ai) is nowadays used to predict the future disease risk on the basis of ehrs. ai support is also required to link new symptoms with prior knowledge. in addition, information about hospital resources could be incorporated and updated in the nisss, which will enable the quick reallocation of the limited healthcare resources among hospitals and even among cities and provinces during the outbreak. fourth, information systems in other sections should also be linked with the nisss, so multisource information could be synthesised to maximise clues for the potential risk for epidemics. for example, linking environmental, ecological, agricultural and wildlife and animal information systems that have been continuously monitoring the nature and humannature interfaces would help to better early detect the appearance of disease cases with a natural origin, such as covid- . such linkage can also alarm other sectors how they could be affected by the epidemic, so they all could make their own strategies to reduce their loss while effectively avoiding the epidemic, and to alleviate other common issues, such as inadequate staffing and funding in those sectors. fifth, literature databases, especially in biomedical fields, normally contain valuable research findings and knowledge and should be incorporated into the nisss in a real-time way for warning or fighting the epidemic. for example, one article published months ahead of the covid- outbreak revealed several first-time detection of parasites in farmed and wild snakes in wuhan huanan seafood wholesale market, which could have been an early warning for that region requiring in-depth investigation. identifying and integrating scientific publications have been realised on several commercial social networking sites for scientists and researchers to share papers. ai support is also needed to conduct semantic analyses and identifies potential risk from a sea of knowledge, which can further be automatically positioned by spatial technologies and analysed as a whole. sixth, data of internet activities can be leveraged as a complementary source to reflect cyber user awareness, understand the epidemiological factors of diseases and imply the disease risk in users' surroundings. for example, internet-based search engine (volume of search keywords) and social media activity data (eg, twitter messages, wechat posts) have been associated with the daily numbers of reported human h n cases ; google flu trends was a web service that provided estimates of influenza activity by aggregating google search queries. hence, as the internet and social media are increasingly becoming major sources of health information, such internet surveillance is also more important than ever before in public health emergency control and prevention. such even more passive surveillance should be an additional module in the nisss for disease surveillance where the frequently searched disease-related keywords may deserve special attention by cdc. last but not least, incorporating real-time data into the nisss, if set up properly ahead of time, could greatly facilitate the real-time tracking and consequently guide the epidemic control and prevention work on the ground for curbing the epidemic efficiently. such data-sharing mechanisms and infrastructures would also facilitate timely spatial epidemiological research on the basis of individual-level infected cases linked with respective location data from mobile service providers and/or smartphone-based apps without violating confidentiality requirements. as spatial lifecourse epidemiology is capable of capturing the real-time interaction of three dynamic components (hosts, agents and environments), nisss running on the basis of real-time data would maximise the strengths of spatial lifecourse epidemiology in the real world, enabling it to outpace the epidemics and realise 'precision epidemic prevention and control'. in addition, by setting up such infrastructure ahead of time, the safety of individual confidentiality and information exchange will never be compromised in this powerful system. some practical aspects of implementation include the integration of disparate data sources in the nisss and the governance and privacy concerns of the nisss. the integration of data sharing between agencies can be realised by creating and using an application programming interface (api) for each service, which usually defines many items including the types of calls or requests that can be made and how to make them by data users, and the data formats to use and the conventions to follow by data owners. data users can request raw data to make forecasts on local machines or servers, which will need data-masking methods (eg, k-anonymity, l-diversity, t-closeness) for better privacy protection. some non-technical factors may hinder the realisation of raw data sharing, which may require the identification of a third-party governmental agency and legislation to facilitate data-sharing among sectors; for example, the ongoing beijing big data action plan, by beijing municipal bureau of economy and information technology and beijing municipal bureau of big data management, has linked data from government information systems in more than municipal departments in beijing. with sufficient prior knowledge (eg, knowing which variables are necessary to be used), data users can also request a subset of raw data or processed data to make forecasts, which would decrease the demand for local machine or server configuration and help overcome those non-technical barriers to some extent. however, extra costs will be incurred by creating apis for (multiple) services, which may require higher-level coordination for cost sharing and/or a data-sharing subsidy among sectors. lessons could be drawn from some examples of data sharing in other areas but adopting similar approaches. for example, medical big data sharing is gradually being allowed in south korea; the four main health maintenance organisations in israel and their affiliated hospitals have used the same electronic medical record (emr) platform for the past two decades, with access to patient records available to each point of care as needed, and % of the population has been using the same linked emr system for decades. in addition, multiple stakeholders at different levels of context should sit together, adopting participatory survey and discussion methods to identify more context-specific difficulties and solutions related to the practicality of the nisss, such as ( ) a hierarchy of data sources with the levels of confidentiality and necessity evaluated for each source, ( ) more approaches of organising and integrating disparate data sources and conducting analyses, ( ) more conceptual, architectural and analytical challenges that would arise and ( ) the corresponding solutions that would function best among multiple stakeholders nationally and internationally, including applicability and adaptability of the solutions to similar problems in other countries. the international institute of spatial lifecourse epidemiology (isle), established as a global health collaborative research network, has committed to identifying the key research issues and priorities for spatial lifecourse epidemiology, advancing the use of state-of-the-art technologies in lifecourse epidemiological research and emerging infectious disease research, and facilitating the quality of reporting of transdisciplinary health research. establishing the nisss will be one of the top public health priorities in the next decade, and also on top of isle's agenda. owing to a diverse variety of scholars' backgrounds, isle communicates crossinterdisciplinary knowledge and research findings in a plain language with scholars from various disciplines and multiple stakeholders including policy-makers. isle has committed to working with multiple stakeholders, from different levels of cdcs to industrial partners, doctors and citizens, to codevelop the nisss in china. this effort will exemplify the nextgeneration infectious disease reporting and surveillance system in the st century and serve as a model for many other countries in the world. china needs a national intelligent syndromic surveillance system citizens as sensors: the world of volunteered geography what is syndromic surveillance? mmwr deep patient: an unsupervised representation to predict the future of patients from the electronic health records what next for the coronavirus response? the tsinghua-lancet commission on healthy cities in china: unlocking the power of cities for a healthy china molecular identification and phylogenetic analysis of cryptosporidium, hepatozoon and spirometra in snakes from central china importance of internet surveillance in public health emergency control and prevention: evidence from a digital epidemiologic study during avian influenza a h n outbreaks influenza forecasting with google flu trends spatial lifecourse epidemiology and infectious disease research are we ready for a new era of high-impact and highfrequency epidemics? integrating kindergartener-specific questionnaires with citizen science to improve child health top research priorities in spatial lifecourse epidemiology spatial lifecourse epidemiology spatial lifecourse epidemiology reporting standards (isle-rest) statement contributors both authors have equally contributed to the planning, conduct and reporting of the work described in the article.funding we thank the national natural science foundation of china ( ), the special funds for prevention and control of covid- of sichuan university ( scuncov ), and the international institute of spatial lifecourse epidemiology (isle) for the research support.competing interests none declared. provenance and peer review not commissioned; externally peer reviewed.data availability statement all data relevant to the study are included in the article.open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /.orcid id peng jia http:// orcid. org/ - - - key: cord- -c xypzdx authors: alahmad, barrak; kurdi, hussam; colonna, kyle; gasana, janvier; agnew, jacqueline; fox, mary a title: covid- stressors on migrant workers in kuwait: cumulative risk considerations date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: c xypzdx as a marginalised subpopulation, migrant workers often fall short from protection by public policies, they take precarious jobs with unsafe working and living conditions and they grapple with cultural and linguistic barriers. in light of the current covid- pandemic, migrant workers are now exposed to additional stressors of the virus and related responses. we applied a comprehensive qualitative cumulative risk assessment framework for migrant workers living in kuwait. this pandemic could be one of the few examples where the stressors overlap all domains of migrant workers’ lives. no single intervention can solve all the problems; there must be a set of interventions to address all domains. local authorities and employers must act quickly to stop the spread, ensure easy access to testing and treatment, provide adequate housing and clear communication, encourage wide social support, safeguard financial protection and mental well-being and continuously re-evaluate the situation as more data are collected. background nearly . % of the world's population lives outside their home country, and half of them are estimated to be migrant workers. in many countries, migrant workers are recognised as one of the most vulnerable subpopulations, as they: ( ) often are excluded from protections provided by public policies; ( ) frequently take precarious jobs with less pay and longer hours; ( ) often work in unsafe working conditions with little occupational safety and health (osh) training; and ( ) grapple with major cultural and language barriers. on march , the who declared that the infectious covid- outbreak caused by the severe acute respiratory syndrome coronavirus , is a pandemic. since its initial cluster of pneumonia cases in wuhan, china, the virus has infected millions and caused hundreds of thousands of deaths globally. migrant workers are particularly susceptible to this infection-an additional stressor combined with those identified above. understanding the detrimental effects of covid- alone on workers' health may not be sufficient. recent osh risk assessment frameworks and methods have advanced towards cumulative risk assessment (cra). these cumulative frameworks recognise that an occupational exposure to a contagion like covid- does not occur in isolation from other stressors. in light of the current pandemic, we anticipate that employers and authorities must now address the variable job health and safety needs of migrant workers. in kuwait, there is a considerable heterogeneity with regards to vulnerable employment and extreme working poverty. non-kuwaiti migrant workers make up more than % of the total population and are mostly employed in low-skilled sectors and domestic work. about % of non-kuwaitis are males, and only % of non-kuwaitis have educational attainment of high-school or higher. the majority of the migrant non-kuwaiti subpopulation come to the country unaccompanied by their families. striking differences in health outcomes attributable to bmj global health environmental exposures such as heat and air pollution between the kuwaiti and the non-kuwaiti subpopulations have been recently documented. this work investigates the multiple stressors associated with the covid- pandemic on migrant workers by applying a holistic cra framework, using kuwait as an example. furthermore, we use the framework to suggest potential interventions for individuals, employers and authorities to improve the health of migrant workers in the country. the conventional risk assessment process is typically applied to address one hazard at a time. in reality, workers are often exposed to multiple hazards at any given time. the us environmental protection agency defines cumulative risk as 'the combined risks from aggregate exposures to multiple agents or stressors'. in this paper, we will apply a workplace cra framework that was presented by fox et al. in brief, the framework acknowledges that multiple stressors in different domains can interact with each other resulting in cumulative risk that can then be used to inform new risk management approaches, exposure reduction and prevention strategies. the model assumes that stressors arise from four dynamic interactive domains: the workplace (occupational); ambient environment; individual (behaviour and genetic); and community (family and other social interactions) ( figure ). this cra framework will provide a qualitative evaluation of multiple stressors affecting migrant workers in kuwait (table ) . we apply the framework in a stepwise process starting with identifying the importance and scope of the problem, that is, why it should matter and who should care (step ). steps - assess the target population, the stressors/hazards, the overall pattern of health among the target population and consider the interactions between stressors and the domains. finally, we propose potential interventions in light of the findings from the previous steps (step ) . the first confirmed cases in kuwait occurred on february , among four kuwaiti passengers who arrived on an evacuation flight from iran. since then, more than % of the total cases have been non-kuwaiti nationals (https:// corona. e. gov. kw/). the situation is not much different in other gulf states. uncontrolled outbreaks within clusters of migrant workers can result in catastrophic outcomes including the loss of many lives, an overwhelmed healthcare system and other deleterious economic losses. however, even if the spread of the infection is controlled, enforced lockdowns and business closures can have dire consequences for migrant workers. most migrant workers in kuwait are men from south and southeast asia. examples of essential non-healthcare migrant work in kuwait include staffing in the retail and food, transportation, security and construction industries. these workers are continuously interacting with the rest of their community and may potentially contract the disease from infectious individuals. migrant workers who are in non-essential businesses that remain closed could figure a cumulative risk assessment framework for occupational health and safety with four overlapping domains described by fox et al. the occupational domain (highlighted) cannot be viewed in isolation from other domains. bmj global health be living in labour camps outside the city or in other cramped dormitories. the workplace several dangerous trades occupied by migrant workers present health threats from chemical and physical exposures, often existing as mixtures or in combinations. issues associated with these hazards can be significantly amplified among migrant workers due to language and cultural barriers. as a consequence, the effectiveness of any occupational prevention measure (eg, work practices and wearing personal protective equipment) can be compromised. language barriers also make it difficult for migrant workers to report symptoms or raise concerns with their managers. training on measures such as social distancing and/or hygiene instructions may not be supported for the typical wide range of languages among worker populations. a large proportion of migrant workers in kuwait live in cramped dormitories with poor housing conditions: small rooms with tens of men living together; unmaintained and shared toilets; poor or no ventilation; and high risk of bed bugs and other pests. such environments with consistent close proximity among occupants have the potential to increase covid- outbreaks among migrant workers. in addition, there are environmental exposures like heatwaves and air pollution that can independently increase vulnerability and promote comorbidities; migrant workers in kuwait have been shown to be especially vulnerable to air pollution. the community nearly % of the non-kuwaiti subpopulation are males. the majority are not accompanied by their families. their distant families rely on them for financial support (eg, transferring money and shipping goods) to meet basic needs such as paying school fees and getting food. for many households in the receiving countries, money from migrant workers is likely the sole source of cash. however, migrants are often employed in less secure or precarious jobs with no permanent employment contract. this imposes significant job uncertainty. the current pandemic undoubtedly has compounded severe financial hardship and interpersonal difficulties within families who may not be able to survive job loss or delayed payments. returning home is rarely an option. during the covid- induced lockdowns, migrant workers will likely face mounting debts, unemployment and difficulties in daily living. the lockdowns in workers' home countries have had enormous negative impacts on daily wages of labourers who were unable to earn their daily living and were not able to move. these stressors are difficult to address since the political climate in the host country may also bring about xenophobia, suspicion and unequal rights. the current immigration system in kuwait and other gulf states (the kafala system) requires all migrant workers to have an in-country sponsor for their visa and legal status. this system restricts changing employers and has been associated with trafficking and forced labour. it is unlikely that workers would have an option to transfer to jobs with less risk of exposure to covid- . although a large proportion of migrant workers in kuwait are young and healthy, those living with comorbidities, some of which might be due to work-related illnesses or injuries, may be more vulnerable to the effects of covid- . we do not have data on the prevalence of unhealthy behaviours that can increase the risk of severe covid- illness, such as smoking or diet. furthermore, there might be difficulty accessing healthcare due to documentation status, limited knowledge of health coverage, costs and poverty. without serviceable command of the local language, migrant workers were found to be likely to take more dangerous jobs and incur occupational injuries. additionally, the constantly changing covid- lockdown and curfew messages may not reach migrant workers, putting them in legal jeopardy. violating curfew is a serious offence in kuwait that could lead to deportation for non-nationals. in addition, migrant workers experience difficulty communicating with medical professionals, have little knowledge of the health insurance systems and report lack of access to interpreters. all these factors contribute to low turnout at testing stations and treatment centres for covid- . in addition, such barriers to healthcare utilisation may result in delayed presentation for a number of days before seeking help, likely affecting the severity of outcomes from the infection. there have been numerous reports of person-to-person transmission of covid- within the same household. high air exchange rates, proper use and disinfection of toilets, and open spaces were associated with lower aerosol transmission of covid- . self-isolation is nearly impossible. people living in areas with high outdoor air pollution levels were shown to be at higher risk of dying from covid- . although social lockdowns have substantial positive impact on the overall environment and air pollutants, especially no and particulate matter, it is unclear how this reduction in short-term exposure can translate into public health gains for migrant workers. individuals with low educational attainment and low income are more likely to be exposed to factors contributing to poor health compared with those with more socioeconomic resources. additionally, stress from the uncertainty of precarious jobs and fear of job loss or deportation can have negative mental health outcomes. other mental disorders can also be exacerbated by financial hardship for migrant workers who are no longer able to send money to their families because of the lockdown orders. beyond mental health, stress is also associated with premature death and coronary heart disease. with regard to behavioural factors, there is some evidence that smoking is associated with poor progression and health outcomes from covid- exposures. cra considerations even when we only focus on the health impacts of covid- on workers in the occupational domain, we saw a strong influence from other related stressors originating from sources across all domains. considering figure , covid- adds to the existing serious health risks experienced by migrant workers in kuwait. put another way, this pandemic could be one of the few examples where the risk overlaps all aspects of migrant workers' lives (as seen in shaded area - figure ). no single intervention can solve all the problems outlined; rather, a set of interventions that address all domains is in order. we propose a holistic approach to this multidimensional problem for the migrant workers in kuwait, consistent with the global call to action to protect migrant health from covid- . stop the spread (community/individual) the prevalence and incidence of infection among migrant workers are not known. kuwait has taken many public health control measures to stop and slow down the spread of covid- , including closures of schools and universities, closures of all non-essential businesses, a full border lockdown and a partial curfew. when the disease started spreading in areas populated by migrant workers, the government enforced zonal isolation. outreach to migrant worker communities to educate about the symptoms of illness and its prevention and active public health surveillance efforts are needed to identify cases at an early stage and prevent the progression to severe illness as well as reduce the number of people who could potentially get infected. ideally, health authorities would employ testing to further understand the distribution and the spread of the disease although capacity to test remains limited in many places. absent testing, monitoring hospitalisations and deaths linked with contact investigations help identify and move cases into treatment. healthcare access (community/individual) migrant workers should have free access to testing and treatment for covid- . easy-access facilities should include drive-through and walk-in testing. these are alternative solutions for temporary testing operations that can reduce patient-provider exposure and accelerate test administration. for example, large segments of the migrant workers subpopulation may not have access to cars; therefore, a walk-in testing booth is an appropriate option. similarly, mobile clinics and field hospitals in underserved areas can be very important to protect vulnerable marginalised groups from covid- . free health services including health education, screening and advice can be provided by mobile clinics. workers who do not live near hospitals and do not have access to adequate transportation can benefit the most. in addition, unlawful migrant workers may be reluctant to report symptoms or access testing facilities because they fear detention and deportation. this reluctance can carry a significant risk to the health of these workers and that of the community. in the short term, let public health take precedence over enforcement; immigration authorities should send clear messages to encourage unlawful migrant workers to get covid- tests and report symptoms. temporary housing (workplace/environment/community) many workers may not be able to effectively self-isolate should they test positive for covid- . in cases where housing conditions cannot be adjusted to new social distancing protocols, the government has to work with employers to consider some form of separate temporary housing for migrant workers who test positive. these include hotels and other temporary housing on work sites. moving forward, the authorities need to create a long-term plan to improve the living facilities for all workers. information access (workplace/community) migrant workers may be at risk of being penalised for unknowingly breaking curfew laws. the government must work with the relevant embassies to provide workers with information on covid- in a language they understand. similarly, employers must have training programmes that incorporate methods that transcend linguistic and cultural barriers such as pictograms, illustrations and hands-on exercises. worker protection (workplace/community) many workers are now facing layoffs, furloughs, nonpayment and late payment of wages putting them in significant financial hardship. the government and employers should reach some mutual agreement to continue paying workers living in isolated zonal areas or under health quarantine. any gaps in financial support to workers should be adequately covered. community support (environment/community/individual) many individuals and organisations are putting in enormous time and effort to provide relief for migrant workers in kuwait. community volunteers, charity organisations, donors and non-profit organisations should come together to raise funds to cover basic necessities for migrant workers such as meals, masks and sanitary supplies. community support can go beyond daily essentials towards mental well-being of workers through implementing mental health programmes, provision of internet connectivity and prepaid phones for worker to contact their families. continuous evaluation (all domains) implemented policies must be continuously reassessed in light of the fast-changing situation and new data. it is key that policy evaluation is carried out at a high temporal (daily monitoring) and spatial (household level) resolution. that is, there should be careful monitoring of the number of new confirmed cases, deaths, hospitalisations and admissions to intensive care among migrant workers. furthermore, geospatial mapping of cases through geographic information systems are critical for identifying emerging clusters. migrant workers are a marginalised subpopulation in kuwait. they often fall short of protection by public policies, face language and cultural barriers and take precarious jobs with more hazards, less pay and longer hours. the covid- pandemic has placed multiple extraordinary stressors on migrant workers in kuwait both on and off the job. we applied a cumulative risk assessment framework that enabled us to assess stressors on migrant workers in the workplace, environment, community and individual domains. we used the framework to inform new risk management approaches and exposure reduction strategies that address these multiple stressors. although our assessment lacked quantitative data, we highlighted the type of data that would be needed to ensure continuous re-evaluation. this may be resource intensive (money, people and time), but a coordinated effort aimed at key social supports will have substantial health benefits for the entire community. this cumulative risk assessment framework for migrant workers in kuwait can be applied in other countries and different settings. twitter barrak alahmad @barrak ilo global estimates on migrant workers: results and methodology. geneva: international labour office migrant workers and their occupational health and safety implications of applying cumulative risk assessment to the workplace the public authority for civil information. government of kuwait extreme temperatures and mortality in kuwait: who is vulnerable? acute effects of air pollution on mortality: a -year analysis in kuwait framework for cumulative risk assessment inter nation social lockdown versus medical care against covid- , a mild environmental insight with special reference to india trafficking and contract migrant workers in the middle east do immigrants work in riskier jobs? a familial cluster of pneumonia associated with the novel coronavirus indicating personto-person transmission: a study of a family cluster aerodynamic analysis of sars-cov- in two wuhan hospitals exposure to air pollution and covid- mortality in the united states nurture to nature via covid- , a self-regenerating environmental strategy of environment in global context socioeconomic status and health. the challenge of the gradient effects of social determinants on chinese immigrant food service workers' work performance and injuries: mental health as a mediator the neglected health of international migrant workers in the covid- epidemic stress and cardiovascular disease covid- and smoking: a systematic review of the evidence sex difference and smoking predisposition in patients with covid- global call to action for inclusion of migrants and refugees in the covid- response the impact of language and culture diversity in occupational safety competing interests none declared.patient consent for publication not required.provenance and peer review not commissioned; externally peer reviewed.data availability statement no additional data are available.open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /.orcid id barrak alahmad http:// orcid. org/ - - - key: cord- -vd pftu authors: doherty, tanya; kroon, max; reynolds, louis; fawcus, sue; lake, lori; solanki, geetesh title: building back from the ground up: the vital role of communities date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: vd pftu nan globally the covid- pandemic has destabilised health systems and communities. governments in low-and middle-income countries (lmics) followed the approaches adopted by the global north and advocated by international bodies such as the who, and instituted varying degrees of nationwide stay at home orders (lockdowns) from strict restrictions (such as in south africa, india and zimbabwe) to weakly enforced lockdown as in brazil. many have questioned the appropriateness of these measures in lmic contexts where key preventive behaviours such as social distancing and frequent hand washing are impossible to implement in densely populated informal housing settlements. people rely on crowded public transport to get to work, households are cramped and lack easy access to water and sanitation; loss of income leads to food insecurity and hunger as well as high levels of stress and violence. in such conditions viral spread is impossible to control and economic devastation is inevitable. in this commentary we examine ( ) some of the unintended impacts of this approach for lmics and ( ) the steps that need to be taken in the short-term and longer-term to mitigate these impacts and the vital role of civil society and communities in this recovery process. the response from lmic governments to contain the covid- pandemic aimed primarily to limit virus spread. the unintended consequences of the instituted measures are wide reaching. unicef reports from the early months of the covid- pandemic suggest a % reduction in the coverage of essential nutrition services in lmics and declines of % to % under lockdown contexts. a preliminary assessment by the un food and agricultural organization suggests the pandemic may add between and million people globally to the total number of undernourished in as a result of loss of income and livelihoods. in terms of health service access, a who survey reported that % of essential health services were at least partially disrupted in the african region in response to the pandemic. family planning services were disrupted in % of countries, % of countries reported partial disruptions in antenatal care services and % in facility-based birth services. despite who and country guidance to the contrary, mother-newborn separation has occurred in many lmics. research from nepal has described a . % decline in breast feeding within hour of birth during lockdown, from an already low rate of %. disruption or suspension of outreach immunisation services was reported by % of countries in the african region and disruption of immunisation services at health facilities for % of countries. lockdowns exacerbated the silent pandemic of gender-based and intimate partner violence in countries with already high levels. research undertaken during the lockdown in bangladesh found significantly increased summary box ► the medicalised response to covid- in low-and middle-income countries has had unintended and far-reaching consequences. ► communities, non-governmental organisations and civil society organised themselves from the 'groundup' to alleviate the economic, social and health impacts of covid- . ► urgent intersectoral mitigation strategies required for covid- recovery will not be fulfilled through state services alone. ► investing in community cadres and organisations has the potential to build social solidarity, mitigate the impact of covid- and strengthen intersectoral collaboration and safety nets for future crises. bmj global health levels of emotional, physical and sexual violence among women living with their husbands. in south africa, data collected from the government gender-based violence and femicide command centre revealed more than victims in the first weeks of lockdown. as a result of these unintended impacts, there is a high probability that covid- will deliver us into the next set of crises in the form of increasing inequality, poverty and food insecurity, outbreaks of vaccine preventable diseases, unintended pregnancies and rising child malnutrition which will be felt for generations to come. while lmic governments have focussed almost exclusively on reducing covid- case numbers, many communities organised themselves with 'ground-up' mitigation measures to address the worsening unintended effects. examples have emerged from many lmics of neighbourhood initiatives to support vulnerable families. in india, the health focussed non-governmental organisation (ngo) swasti brought together a group of ngos to found the covid- action collaborative. its member organisations are now coordinating efforts and sharing knowledge to provide integrated health, nutrition, social protection, livelihood and financing support to over million vulnerable people across states. women's empowerment groups in kerala helped to map where older people live to ensure they had access to medicine and food while social distancing. in south africa, a movement of self-organising, neighbourhoodlevel community action networks (cans) has contributed significantly to the community-based response to covid- . without any financial support from the government these cans have initiated community support activities such as establishing community kitchens, developing communication materials, distributing clothing and skills upliftment training. concerted civil mobilisation also led to a court case brought by civil society organisations breast feeding potential for declines due to mother-infant separation and health worker fears of covid- transmission. rapidly disseminate strong messages through community-based organisations and chws about the importance of breast feeding in the context of covid- , and the harmful consequences of separating mothers and newborns. declines in routine immunisation due to health service disruptions, reallocation of staff to covid- and fears of mothers to attend health facilities. visits by chws to all households with children under years of age to check immunisation status. catch up immunisation campaigns in schools and early child development centres. chronic medication disruptions to chronic medication distribution leading to gaps in adherence. establish community distribution points chws supporting medication distribution to households with elderly or ill. weak community platform with too few chws to augment public sector response to crises chws re-assigned to covid- unable to perform their usual household visits and functions. strengthen community delivery platforms with increased numbers of chws. high coverage of households to undertake detailed assessments of covid- recovery needs. civil society actions to support covid- were implemented in parallel to government actions with little/no co-ordination or community consultation on the appropriateness of government solutions. policy mandated forums for community consultation and accountability mechanisms to ensure feedback and progress tracking. prioritisation of domestic spending covid- stimulus packages risk deepening inequity by prioritising large companies and leaving behind small business and community enterprises. embark on a transparent, participatory prioritisation process to inform the allocation of covid- stimulus funding with a focus on growing 'township' economies. chws, community health workers. and school governing bodies to have the national school nutrition programme which provides a daily meal to roughly nine million children, reinstated months after school closures. the intense lockdown periods and burden of covid- -related illness have revealed the inadequacies of strained, under-resourced public health facilities, and in some instances inept lmic governments' responses to crises; and the critical role of resilient, mobilised community structures. the urgent intersectoral mitigation strategies required for covid- recovery will not be fulfilled through state services alone. the efforts already being led by ngos and civil society need to be supported and harnessed, both to develop context-specific solutions and to implement them. several areas will require short-term and long-term mitigation measures implemented through strong primary healthcare systems and community participation. some specific illustrative examples are given in table . an important community cadre that has the potential to play a critical role in mitigation strategies in lmics are community health workers (chws). chws have been at the forefront of efforts to screen and trace individuals as part of the covid- response in many lmics including south africa, india and brazil. however, this additional work has meant neglect of their usual functions of providing health promotion, prevention and care to vulnerable families. long-term covid- mitigation strategies should prioritise increasing the number of chws to ensure an optimal ratio of workers to households to cope with the more intensive covid- recovery period. through home visits chws can assess and identify household needs such as catch up immunisation, family planning, antenatal care, growth monitoring, birth registration, hiv, tuberculosis and chronic disease management and mental health. increasing the numbers of female chws serves not only to improve coverage of care for households and thus a return on investment due to a healthier population, but there are other important societal benefits. modelling based on the south african situation estimated that increasing the number of chws to (from ) and paying the minimum wage would cumulatively, over years, contribute an additional r . billion (south african rand) to the economy (equivalent to . % of gdp (gross domestic product)) given that the employed women would spend this salary primarily on the health, education and nutrition of their children thus also benefitting their local community economies. appropriately funded community cadres and organisations have the potential to build social solidarity that would enable a more rapid intersectoral response for future crises. the recovery process and accompanying investments (domestic or multilateral) are an opportunity to embark on open and transparent prioritisation processes to determine how best to use resources with a pro-equity focus. given the enormous constraints facing lmic governments in the covid- aftermath, it is only through the active participation of communities and civil society in designing and implementing solutions, that lasting sustainable societal improvements will be realised. the challenges highlighted by the covid- epidemic in lmics are in many respects an acute manifestation of long-standing chronic problems and the recovery phase should address them. the resource constraints faced by governments in lmics (sometimes compounded by inappropriate decision-making and undermined by corrupt disbursement of covid- funding) and the generally weak public healthcare systems of these countries means that they cannot be solely relied on to address such crises. the covid- experience has further demonstrated the contributions communities and civil society can make and the critical need to incorporate them into efforts to mitigate the health, social and economic effects of covid- . this is the only way to move towards sustainable positive change that better builds resilience for the inevitable future crises. covid- in brazil an appeal for practical social justice in the covid- global response in low-income and middleincome countries situation tracking for covid- socioeconomic impacts food and agricultural organization of the united nations. the state of food security and nutrition in the world pulse survey on continuity of essential health services during the covid- pandemic effect of the covid- pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in nepal: a prospective observational study immediate impact of stayat-home orders to control covid- transmission on socioeconomic conditions, food insecurity, mental health, and intimate partner violence in bangladeshi women and their families: an interrupted time series shocking stats on gender-based violence during lockdown revealed sowetan live philanthropy's distinct role in india's covid- response.devex covid- care in india: the course to self-reliance what is covid- teaching us about community health systems? a reflection from a rapid community-led mutual aid response in cape town, south africa judgement in the matter between equal education, the school governing body of vhulaudzi secondary school, the school governing body of mashao high school and the minister of basic education. high court of south africa community-based screening and testing for coronavirus in cape town, south africa: short report india's first line of defense against the coronavirus is an army of , women without masks or hand sanitizer buzfeed news community health workers reveal covid- disaster in brazil saving lives, saving costs: investment case for community health workers in south africa. cape town: south african medical research council key: cord- -pgel i y authors: chan, tak kwong title: universal masking for covid- : evidence, ethics and recommendations date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: pgel i y nan ► policy makers must rely on best available evidence rather than awaiting strongest evidence when devising urgent policies that can potentially save human lives. ► there is no shortage of mechanistic evidence and observational studies that affirmed the benefits of wearing a face mask in the community, which should drive urgent public health policy while we await the results of further research. ► there is no valid scientific evidence to support the assertion that the use of a face mask in the community may impose a higher risk of infection on the ground of improper use or false sense of security. ► rationing offers no moral ground to ignore the evidence about the benefits for the users of lower priorities. ► the proper approach to addressing shortage is to formulate stratified recommendations that take full account of the benefits of using face masks in the community and provide viable solutions at different scenarios (see table in the main text). ► i urge the who and policy makers worldwide to consider my stratified recommendations, or adopting measures to a similar effect, particularly as the authorities are contemplating relaxation of other aggressive measures such as border closure, lockdown and social distancing. this commentary echoes the plea from greenhalgh et al to encourage people to wear a disposable surgical mask (face mask) in the community. there is limited clinical evidence that wearing a disposable face mask, enhancing hand hygiene practice or social distancing can reduce transmission of respiratory viral infections in the community, although there is mechanistic basis for these measures to work. for covid- , hand hygiene and social distancing are widely recommended, while universal use of face masks in the community is not widely recommended, especially in some western countries. [ ] [ ] [ ] [ ] some doubted the effectiveness of wearing a face mask in the community. some argued it may foster a false sense of security. some said face masks should be reserved for healthcare workers. inconsistent messages from the experts and policy makers about the rationale for the recommendation has led to confusion in the community. i aim to provide further clarification of the evidence and ethics on this issue (which can provide grounds alternative and/or supplementary to the precautionary principle applied by greenhalgh et al) and make a plea to the world health organisation (who) and policy makers to reformulate current recommendations with a view to enhancing the practice of wearing a face mask in the community. current best available evidence should guide urgent policy while public health decisions should be evidence-based, drawing on randomised controlled trials (rct) as an important source of information, the methodological challenges of evaluating large-scale public health interventions need to be recognised. when there is logistic difficulty in conducting an rct, evidence from other data sources can provide valid support for an urgent public health action. the mechanistic effects of handwashing and wearing a face mask have been demonstrated, thus offering some scientific basis for their benefits in terms of disease control. a recently published article shows turbulent gas cloud can prolong the life of pathogenbearing droplets and allow them to travel a longer distance. the turbulent gas cloud dynamics should offer further scientific basis to recommend the use of face masks for source control and protection of the wearer. healthcare workers are recommended to wear a face mask as part of droplet precautions, which may prevent them from splashes bmj global health of respiratory droplets from sneezing, coughing or talking patients. some experts suggested that while there is a perception that wearing a face mask may help, there is little evidence of any benefit outside the clinical setting. in a recent meta-analysis, six rcts were identified reporting the effect of wearing a face mask with enhanced hand hygiene in reducing laboratory-confirmed influenza in the community. although none of them supported a significant protective effect, all the authors acknowledged that their studies may have underestimated the effect of the intervention (see table for their limitations). [ ] [ ] [ ] [ ] [ ] [ ] their results also may not be generalisable to the universal use of face masks in the community during an actual pandemic which should result in heightened level of public awareness and community efforts. as some authors unequivocally made it clear, due to the inherent limitations, one cannot base on their rcts to conclude that it offers no benefits to wear a face mask in the community during a pandemic. furthermore, an absence of evidence (from rcts in this instance) should be distinguished from evidence of absence. a previous systematic review identified two case controlled observational studies to assess the effectiveness of wearing a face mask in the community. [ ] [ ] [ ] subsequent to that systematic review, one further relevant observational study was published. all these three observational studies concurred with each other, showing a significant protective effect of face masks in the community, although their findings may be limited by misclassification and reporting bias (see table for details). in view of the imperfect data from the rcts, the mechanistic evidence and the observational studies should contribute to the best available evidence guiding the policy. while efforts should be guided for further clinical research, the benefits of wearing a face mask in the community during a pandemic should be affirmed in the interim. put another way, while the strongest evidence from valid rcts is not yet available, and perhaps it will never be available because of the methodology issue, the choice should favour accepting current best available evidence over putting human lives at risk during a pandemic. summing up, i wish to quote greenhalgh et al as saying '… while there are occasions when systematic review (of rcts) is the ideal approach to answering specific forms of questions, the absence of thoughtful, interpretive critical reflection can render such products hollow, misleading and potentially harmful'. face mask wearers are offered added protection rather than put at higher risk of infection the who recommend that in the community only symptomatic patients and caretakers should wear a face mask. but studies have shown that covid- carriers may be asymptomatic and so members of the public may be unaware that they carry the virus. the effective control of disease outbreak relies on the concerted efforts of everyone in the community. as the symptomatic infected are asked to wear a mask to avoid splash onto others, the logic should follow that all healthy individuals should also wear a face mask for two reasons. first, they should avoid a splash from others who may be asymptomatic carriers not wearing a mask. second, they may be an asymptomatic carrier themselves. some experts talked about the downside to wearing a face mask and thereby opposed the idea that the general public should wear a face mask. they said people wearing a face mask may be exposed to a higher risk of getting the infection-if they touch their face more often, if they wear the mask improperly or if they dispose of the mask unsafely. there is a previous study showing that some people may touch their face times a day. it was therefore argued that mask wearers who touch the mask on their face may be exposed to a higher risk of infection. such arguments are flawed in that there is no evidence that people who wear a face mask would touch their face more often than those who do not. indeed, given the splash that one without a face mask may receive on the face during usual contact with other people, people who touch their face often is likely exposed to the similar risk of infection regardless of whether they wear a face mask or not. there were also concerns about the use of a face mask because this may offer a false sense of security. no effective measure would by itself offer % protection. people who wash hands properly and frequently may also have a false sense of security let alone those who do not wash their hands long enough or thoroughly enough. various measures need to be applied in combination to achieve maximal effectiveness. the proper response should be to reinforce the proper way of applying all useful measures in combination through education. a previous study showed that the use of a face mask likely reduces viral exposure and infection risk on a population level in spite of imperfect fit and imperfect adherence. to assert that the use of a face mask in the community may impose a higher risk of infection on the ground of improper use or false sense of security has no support of valid scientific evidence, defies common sense and raises suspicion of an implicit decision not to act or to act on the basis of past practice rather than available evidence. the current available evidence about the benefits of its use should prompt the policy makers to recommend it with no further delay. rationing offers no moral ground to ignore the evidence about the benefits of wearing a face mask in the community it has been suggested that face masks should be reserved for healthcare workers, the sick and caregivers. while this can be a ground for rationing the distribution of face masks to those in greater needs, this by no means offers a reasonable basis to ignore the evidence about its benefits in the community setting. to start with, the authorities bmj global health should have always kept a sufficient amount of protective gears for the healthcare workers and for everyone in the community in preparation of an outbreak. in case of shortage during a pandemic, there is no dispute that those in greater needs such as healthcare workers should be given higher priorities of getting face masks. however, it is also important to protect the public and slow the spread of the infection in the community. the proper approach to addressing shortage is to formulate stratified recommendations that take full account of the benefits of using face masks in the community and provide solutions at different scenarios (see table ). acknowledging the benefits of using face masks in the community does make a big difference. an analogy can be made to patients with end-stage renal disease. even for those who are given lower priorities for renal transplantation, amid severe organ shortage, they deserve to have their needs recognised, to be put on a waiting list and to be given the hope and the chance of receiving the best cure. the rationale is plain. dignity is an essential dimension of human health and even dying patients deserve to have their needs recognised and treated with respect. in a similar vein, during a pandemic, even when the public cannot be allocated sufficient face masks, they deserve to have their needs treated with respect. in case the public are asked to sacrifice their well-being for the overall benefits of the entire community, they need to be told of this and they deserve the credits. those who are given higher priorities for face masks are protected by administrative tools and legal means available to the authorities to ensure adequate supplies to them. on the other hand, manipulating the otherwise legitimate demand from those given lower priorities would unjustly deny the free market a chance to respond to their genuine need with accelerated production of face masks or invention of substitute products. any effort of rationing by means of ignoring the evidence about the benefits for the users of lower priorities does not fit into any current ethical framework and would be counter to maintaining public trust in the public office and the medical profession. herd immunity offers no moral ground to let the infection spread one may even suggest that infection should be allowed to spread to produce herd immunity. herd immunity was recognised when it was observed in the s that the number of new infection subsequently dropped after a significant number of children became immune to measles. nowadays, it can be produced by vaccinating the community. in theory, allowing the infection to spread naturally can also produce herd immunity. given the existing public health tools to slow down the spread of bmj global health infection, however, allowing infection to spread naturally would mean sacrificing human lives with intention. at best, this would be highly controversial and would only be remotely justifiable if and only if there was evidence that sacrificing some human lives at first can save more human lives at the end. there is no such evidence. nor do we have any evidence that people infected with covid- at one time point may develop immunity in the subsequent exposure to the same or slightly mutated virus. we may also remain optimistic that a vaccination may be available in a matter of months or early next year. in the circumstance, the priority should be to protect human lives by all means. when there are measures that potentially can slow down the spread of infection, with wearing a face mask in the community being one of them, they must be actively pursued. we are still in the battle against covid- . while social distancing and hand washing form the main recommendations, there is no shortage of mechanistic evidence and observational studies that affirmed the benefits of wearing a face mask in the community. wearing a face mask is an effective, cheap and easy-to-implement measure. it is more essential when social distancing is less feasible, such as on public transport, when people shop for daily essentials, and for people who cannot work from home. the development of covid- pandemic and the current crisis may in part be attributable to the insufficient protection for the community. while the benefits of the universal use of face masks in the community should have been recognised earlier, it will never be too late to implement what is necessary. there may be a long period that other more aggressive measures such as border closure, lockdown and social distancing need to be relaxed to some extent after the peak of the pandemic but before the pandemic completely subsides. this will be the time the general public will need sufficient protection more than ever. the recommendations can be tailored to different scenarios but the bottom line is that it should remain faithful to the current available evidence. i urge the who and policy makers worldwide to consider my stratified recommendations, or adopting measures to a similar effect (see table ). acknowledgements the author would like to thank ben cowling for helpful comments on an earlier draft. funding the author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests none declared. patient consent for publication not required. provenance and peer review not commissioned; externally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. orcid id tak kwong chan http:// orcid. org/ - - - face masks for the public during the covid- crisis nonpharmaceutical measures for pandemic influenza in nonhealthcare settings-personal protective and environmental measures nonpharmaceutical measures for pandemic influenza in nonhealthcare settings-social distancing measures a quantitative assessment of the efficacy of surgical and n masks to filter influenza virus in patients with acute influenza infection efficacy of soap and water and alcohol-based hand-rub preparations against live h n influenza virus on the hands of human volunteers coronavirus disease (covid- ) advice for the public: when and how to use masks covid- ): steps to prevent illness are face masks useful for preventing coronavirus daily updates on the coronavirus: is wearing a surgical mask, as protection against acute respiratory infections said in a video on bbc reported as saying on bbc evidence-based public health: moving beyond randomized trials evidence for health decision making -beyond randomized, controlled trials turbulent gas clouds and respiratory pathogen emissions: potential implications for reducing transmission of covid- quoted as saying on bbc mask use, hand hygiene, and seasonal influenza-like illness among young adults: a randomized intervention trial facemasks, hand hygiene, and influenza among young adults: a randomized intervention trial facemasks and hand hygiene to prevent influenza transmission in households: a cluster randomized trial impact of nonpharmaceutical interventions on uris and influenza in crowded, urban households findings from a household randomized controlled trial of hand washing and face masks to reduce influenza transmission in the role of facemasks and hand hygiene in the prevention of influenza transmission in households: results from a cluster randomised trial rational use of face masks in the covid- pandemic the use of masks and respirators to prevent transmission of influenza: a systematic review of the scientific evidence sars transmission, risk factors, and prevention in hong kong risk factors for sars among persons without known contact with sars patients effectiveness of vaccination and wearing masks on seasonal influenza in matsumoto city time to challenge the spurious hierarchy of systematic over narrative reviews? the transmission and diagnosis of novel coronavirus infection disease (covid- ): a chinese perspective face touching: a frequent habit that has implications for hand hygiene professional and homemade face masks reduce exposure to respiratory infections among the general population promoting dignity: the ethical dimension of health fair allocation of scarce medical resources in the time of covid- key: cord- - i rfpvd authors: norton, alice; de la horra gozalo, arancha; feune de colombi, nicole; alobo, moses; mutheu asego, juliette; al-rawni, zainab; antonio, emilia; parker, james; mwangi, wayne; adhiambo wesonga, colette; marsh, kevin; tufet, marta; piot, peter; lang, trudie title: the remaining unknowns: a mixed methods study of the current and global health research priorities for covid- date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: i rfpvd introduction: in march , the who released a global research roadmap in an effort to coordinate and accelerate the global research response to combat covid- based on deliberations of experts across the world. three months on, the disease and our understanding have both evolved significantly. as we now tackle a pandemic in very different contexts and with increased knowledge, we sought to build on the work of the who to gain a more current and global perspective on these initial priorities. methods: we undertook a mixed methods study seeking the views of the global research community to ( ) assess which of the early who roadmap priorities are still most pressing; ( ) understand whether they are still valid in different settings, regions or countries; and ( ) identify any new emerging priorities. results: thematic analysis of the significant body of combined data shows the who roadmap is globally relevant; however, new important priorities have emerged, in particular, pertinent to low and lower middle-income countries (less resourced countries), where health systems are under significant competing pressures. we also found a shift from prioritising vaccine and therapeutic development towards a focus on assessing the effectiveness, risks, benefits and trust in the variety of public health interventions and measures. our findings also provide insight into temporal nature of these research priorities, highlighting the urgency of research that can only be undertaken within the period of virus transmission, as well as other important research questions but which can be answered outside the transmission period. both types of studies are key to help combat this pandemic but also importantly to ensure we are better prepared for the future. conclusion: we hope these findings will help guide decision-making across the broad research system including the multilateral partners, research funders, public health practitioners, clinicians and civil society. introduction covid- was declared a public health emergency of international concern on january and then a global pandemic on march . the who published their global research roadmap on march , within the context of the situation and what is already known? ► the who produced a roadmap that sets out the research priorities following a meeting in february, just before covid- was declared a pandemic. now, at this point in the evolution of this novel disease across the world, and almost months later, it is important to assess whether these priorities remain and if research teams in all countries across the globe agree that these are the most important questions that need to be tackled within their healthcare setting and communities, both to mitigate this outbreak and to learn for next time. what are the new findings? ► over healthcare workers and researchers contributed to this research and their data tell us that across the globe there has been a shift in priorities and new questions have emerged, particularly from low-resourced settings. for example, there is a strong call for evidence on the relative effectiveness and optimal implementation of public health interventions in varied global settings, for social science studies to guide how to gain public trust and mitigate myths, to understand the impact on already present diseases within communities and to explore the ethics of research within a pandemic. what do the new findings imply? ► the who roadmap is globally relevant; however, our findings also provide insight into the temporal nature of these research priorities, highlighting the urgency of research that can only be undertaken within the period of virus transmission, as well as other important research questions but which can be answered outside the transmission period. both types of studies are key to help combat this pandemic but also importantly to ensure we are better prepared for the future. bmj global health the epicentre of infection at that time. the roadmap was built on deliberations of the global research forum, whereby over participants from different sectors across the world identified three to four immediate research priorities for the following months across each of nine themes. now, in june , we see the evolution of this pandemic at different points across the globe. we know from our previous experience with ebola and other outbreaks that it is essential to embed research into the response to an outbreak, and that there is a finite and unknown window where these questions can be answered. covid- is an unprecedented situation and therefore we must take every opportunity to undertake all the possible research that funding and capabilities allow; and high-quality studies should happen everywhere there are cases in order to maximise the evidence generated and ensure that the resulting data and findings are globally applicable. therefore, it is important to assess now, what are the most key remaining global health questions that need to be addressed, both to ensure this pandemic can be halted and to learn for future outbreaks of this pathogen or another. this research intentionally builds from the who roadmap, with the aim of strengthening the global health research response effort already aligned to this, rather than generating a completely new set of priorities. using broad consultative workshops, we have identified additional considerations beyond the who roadmap scope in order to broaden the current global research priorities at this point in time to tackle the covid- pandemic and to help learn for any future outbreaks. an online multilanguage survey was developed where ranking questions were coupled with open-ended questions. this was based on a previous survey led by the african academy of science (aas) that was undertaken in march to assess how well the who priorities were applicable to africa. here, we worked from the aas survey so we could now assess whether the findings remained relevant across the globe, and if they had changed over time. seventy-three potential priorities ( from the original who document and generated as part the aas survey and consultations) were arranged under the nine topic headings used in the who research roadmap. participants ranked their top three options for both short-term and long-term priorities ( total ranking questions). free text boxes were provided under each of the broad topics, where participants were asked to list any research priority they felt was not included in the options provided. recognising that this survey inherently focused respondents on the existing who priority framework, we expanded our consultation through workshops to enable broader discussions of research priorities. after the survey closed, a virtual workshop was held on the fifth of june to seek wider global comment and discussion on the survey findings and to discuss current priorities and unmet research areas beyond the scope of the existing who priority framework. we conducted further open access workshops with research teams and health workers across the globe, led by the the global health network (tghn) covid- research implementation and knowledge hub between april and june . these workshop meetings were recorded with permission of participants, and comments and questions captured. a thematic content analysis methodology was developed to report the findings of each. here, we applied this to the cumulative data of all workshops to add to the survey data and better address the question: what are the current global research priorities during the covid- pandemic? quantitative data analysis methods responses from the survey were downloaded in excel format, all data were fully anonymised, password protected and access restricted to the study team. descriptive analyses were undertaken within excel to provide a ranking score for each research priority for immediate and longer term, as per the survey. priorities ranked as first were given a score of , those ranked second were given a score of and those ranked third were given a score of . this analysis was conducted within the category headings from the who roadmap and included both the original who priorities and new priorities suggested in the aas report. therefore, these data show us how responders currently rank the priorities set within the who roadmap and the aas report. the data were split for comparison between the global researcher responses and those originating from less-resourced settings. within the less-resourced setting category, we include low and lower middle-income countries as defined by the world bank. the aim of the open-ended survey was to determine whether there are new priorities that were not included in the original who roadmap or the aas survey findings. these written comments were imported into nvivo qualitative data analysis package and we undertook a pragmatic thematic content analysis. analysing the data from the workshops allowed a further open consideration of current research priorities as this step expanded beyond the limitation that the survey had of asking questions within the framework of the who roadmap. following the methodology established after the first workshop, we compiled a dataset by transcribing the spoken and written comments from each workshop. a coding framework was generated through an inductive and then deductive approach, following the same categories used in the survey. the participants in this study were the global health research and healthcare community and the very aim was to give them a voice in the requirement to assess bmj global health whether the right research questions are being tackled in covid- . we made ongoing open calls through social media for contributions to surveys and the workshops were open access on tghn and also on facebook. the research question was set to address prior lack of engagement with the wider, global community, and the design was based on ongoing engagement with this community and our understanding of how to most effectively engage and gain their involvement. the study was entirely open throughout all the steps and the time taken to complete the survey and taking part in the workshops was made clear to participants. in total, individuals completed the online survey and attended the workshops, from across countries, ensuring representation from all of the who regions (african region= ( %); american region= ( %); eastern mediterranean region= ( %); european region= ( %); south east asia region= ( %); western pacific region= ( %)). participants were most commonly employed in academia ( %), hospitals ( %), research organisations ( %) and nongovernment organisations ( %). the survey results (table ) show how priorities were ranked across the immediate and longer term within the who categories. we present these globally, along with a subgroup analysis of less-resourced countries, to understand whether there are differences in priorities for lessresourced countries. the ranking of these priorities broadly indicates what researchers feel to be the most important research areas from the who roadmap at this point within this pandemic. the qualitative data from the survey and the workshops then provide further insight to guide where emphasis should be placed and where completely new priorities are relevant, particularly in low-resourced nations. the qualitative data analysis from the survey, workshops and working groups supported the existing who roadmap and highlights where greater research emphasis is needed at this later point in the pandemic. however, most importantly new broader priorities have also come through from this study (table ) . these data suggest that that original who covid- research roadmap remains broadly globally applicable. here, we also show which research questions require the most emphasis and also that potential new priorities have emerged that were not within the initial roadmap. some newly suggested priorities reflect the progress of the pandemic and acquisition of knowledge as to where the gaps lie; notably research in children, pregnancy, long-term health impacts of the disease and that there is a strong call for research that assesses the effectiveness of public health measures put into place across the globe to reduce transmission of this virus. these were alongside a demand for greater social science research to determine public perception, and better ways to change behaviours and build trust (including a need for social sciences to cross-cut the other more biomedical priorities). we also identified a range of new priorities relating to addressing covid- in lower resource settings, where multiple pressures including ongoing endemic infectious diseases and other comorbidities are competing within the health and policy systems for limited resources. these pressures have led to emphasis on cheaper and field applicable tools and research and health capacity strengthening. the need for further studies to evaluate public health measures and studies on other potential interventions as they arise were ranked highly by the survey respondents and workshop participants. these studies must be undertaken as quickly as possible, in highly varied social contexts, if we are to gain evidence now on just how effective measures such as lockdown, handwashing and social distancing are on reducing transmission and to understand the relative risks and benefits. the need for social science research and mixed methods came through very strongly, with an emphasis on determining how to gain trust and successfully deliver public health messages. this needs evidence-based community engagement strategies; tested and evaluated everywhere. limitations of our approach include the fact that we built the questions to align with the original who broad priority headings, this would have inherently focused the survey respondents around the largely biomedical focus of these priorities and this meant that some headings (eg, the animal human interface) had relatively few suggested priorities, while others (eg, social sciences in the outbreak response) had much larger numbers. we also retained the original order of priorities from the who research roadmap and the aas survey and this may have influenced the ranking given by respondents. the workshops however were open and purposefully invited researchers to make whatever comments they wanted in regard to where current research priorities lie, beyond the scope of the who research roadmap. therefore, taken together, we suggest that these data support the importance of the who research roadmap approach and highlight where funders and researcher should be placing emphasis as well as identifying potential new areas that should be tackled within this pandemic. consideration of both immediate and long-term priorities is important to address this specific pandemic and to better prepare for the future. there are studies that need ongoing transmission, at a high enough rate to answer the question they set. these might be essential for this pandemic, for example, clinical trials to determine the efficacy of drugs or vaccines, or address questions to guide future outbreaks, such as evaluating the effectiveness of public health interventions. other studies do not need circulating virus and could still guide the effort to bmj global health investigate ways of ensuring transparency of information flow and mitigating false information spread by various mechanisms ensure that knowledge is produced according to local, national and regional needs ensure that knowledge is produced according to local, national and regional needs promote the prioritisation of knowledge needs according to epidemic dynamics examine optimal ways of communicating about potential interventions in high-density low socioeconomic status urban settings ppe, personal protective equipment. table existing priorities now requiring greater research emphasis and new priorities not in the who roadmap or aas list (all data from participants working in less-resourced countries apart from those priorities asterisked which originated from participants working in higher income countries) existing priorities now requiring greater research emphasis social sciences in the outbreak response understanding covid- in the contexts of conflict, civil war and refugee situations. examine the effects of the pandemic on the participation of the public in democratic processes. infection prevention and control how to ensure effective social distancing in public spaces and congregate settings post lockdown** the environmental impact of the response to covid- determine the impact of: public health interventions on the environment (including air pollution and carbon dioxide emissions) ► disinfectants and hand sanitisers on the environment. ► large-scale ppe production and disposal. preparing for the next pandemic ensure effective measures including community surveillance and animal screening techniques are in place to rapidly identify emerging zoonotic diseases. evaluation of governmental policies and lessons learnt in preparation for the next pandemic. cross-cutting the use of technology in various aspects of pandemic response. assess effective ways of conducting cross-disciplinary research. all data from low-income countries apart from the three priorities marked as ** which are only from participants from high-income countries. lmics, low-and-middle-income countries; ppe, personal protective equipment. priorities to enable funders and researchers identify gaps and opportunities, and inform future research investments or coordination needs. finally, we want to highlight both the importance of fully involving the global research community in priority settingand the ongoing need to review priorities where knowledge and practice is advancing rapidly. we recognise that these efforts need to be complemented by further research priority scoping work, beyond the global health focus to further strengthen cross-disciplinary efforts. here, we have shown that the global health research community supports the recommendations of the who research roadmap, but that important new priorities have emerged both due to the transition through the pandemic and consideration of differing global epidemiological, health system, policy and research contexts. twitter wayne mwangi @thogoto patient consent for publication not required. ethics approval this research was limited to seeking the views of healthcare professionals and research staff; patients and the wider community were not involved. therefore, this research would be considered 'minimal risk' and does not come under the definition of research involving human subjects. however, this work does still fall with our research methodology and remit for the protocol that is approved by the university of oxford research ethics committee (oxtrec) protocol number oxtrec - . provenance and peer review not commissioned; externally peer reviewed. data availability statement data are available in a public, open access repository. all the data from this study will be openly available on the global health network. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. author note the results from the survey were shared with the community through the 'research priorities' workshop and the reports from each workshop are being shared on the platform. the wider, cumulative report is being shared online and the release of that will also be widely disseminated. one of our core aims with this research is to make these findings as widely known as possible so that the prioritise that this work highlights translates to studies undertaken by this same community. who director-general's statement on ihr emergency committee on novel coronavirus ( -ncov) who director-general's opening remarks at the media briefing on covid- a coordinated global research roadmap: novel coronavirus geneva figure priority assessment matrix for research within the covid- pandemic. ppe, personal protective equipment ebola: embed research in outbreak response emergent threats: lessons learnt from ebola research and development goals for covid- in africa -the african academy of sciences priority setting exercise malaria and covid- : a rapid determination of unknowns and call for research the uk collaborative on development research. covid- research project tracker by ukcdr & glopid-r, acknowledgements we acknowledge and thank all survey and workshop participants for their contributions.contributors km, ca, wm, jma and ma developed the original survey with input from mt; all the authors then contributed to further developing and delivering this global version with oversight from tl. an and tl guided this analysis along with adlhg, nc, ea with support from za-r and jp. the workshops were delivered by tl and nfdc, with support from za-r and jp. tl led the drafting with an and mt, pp and km were closely involved throughout and contributed to the draft and review. the other authors contributed significantly and equally in conducting the study and analysing the data. the corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. tl is responsible for the overall content as guarantor.funding the global health network is supported by a grant from the bill and melinda gates foundation (https://www. gatesfoundation. org/ grant number: opp ). the covid- knowledge hub is supported by a grant from uk research and innovation (https://www. ukri. org/ grant number: mc_pc_ ). an & mt are employees of ukcdr, which receives funds from beis, dhsc, dfid, ukri and wellcome for its core activities. no other specific funding supported this work. the funders played no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. all researchers are independent from funders, and all authors, external and internal, had full access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.patient and public involvement patients and/or the public were involved in the design, or conduct, or reporting or dissemination plans of this research. refer to the methods section for further details. key: cord- -ot pvexv authors: lönnroth, knut; tessier, lou; hensing, gunnel; behrendt, christina title: income security in times of ill health: the next frontier for the sdgs date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: ot pvexv nan ► universal health coverage (uhc) is at the forefront of the discussions on how to achieve the health-related sustainable development goals (sdg). ► a prominent part of the uhc agenda is to ensure that people are not impoverished due to high healthcare expenditures. while this is crucial, it is not sufficient to protect people from hardship in times of ill health, as illustrated in the ongoing covid- pandemic where lack of income security creates barriers for people to adhere to infection control measures. ► social protection systems ensuring income security when unable to work due to sickness are as important as schemes designed to reduce out-of-pocket healthcare expenditure. yet, this is not part of the uhc framework and not sufficiently visible in the sdg target on social protection. ► this contrasts sharply with the high prioritisation of income security in times of ill health when universal social protection systems were built in the last century in many of today's high-income countries. poor health can trap individuals, families and communities in a vicious disease-poverty cycle. while ensuring universal access to affordable healthcare in times of need is essential to break this cycle, income security in time of sickness or injury for all is equally important. recent evidence indicates that people who cannot work or are not allowed to work due to illness face high indirect costs linked to income loss, which can be compounded by the opportunity cost of time spent seeking and staying in care. for example, the ongoing covid- pandemic illustrates that lack of income security leads to economic hardship for individuals and creates barriers for adhering to infection control measures, and similar challenges have previously been well-documented concerning tuberculosis. both access to healthcare services and income security in case of illness are enshrined in the human rights to health and social security and in international standards on social protection. income security acts on both the social determinants and the adverse consequences of ill health. the provision of sickness benefits is the primary responsibility of the state, usually implemented by social protection institutions under the joint stewardship of the health, social and labour sectors. yet, while access to healthcare services is at the forefront of the agenda through a dedicated target on universal health coverage (uhc), income security in case of ill health has limited visibility within the sustainable development goals (sdgs) and is underresearched, especially in low-income and middle-income countries (lmics). unpacking sdg targets and indicators the sdgs constitute an unprecedented opportunity to accelerate synergistic actions on health and social protection. achieving the health targets under goal will contribute to social well-being. moreover, the uhc target ( . ) has a specific indicator for financial protection ( . . ), which measures occurrence of catastrophic out-of-pocket healthcare expenses. the focus is on direct medical costs while income security in times of ill health is not included. this was a conscious choice as the indicator measures what uhc intends to achieve: access to needed healthcare without financial hardship from paying for these services. sdg target . on social protection aims to implement nationally appropriate social protection systems and measures for all, including floors. in principle, this scope includes income security in case of ill health. still, this dimension is currently missing in the related monitoring indicator . . ('percentage of the population covered by social protection floors/systems') which reports social protection coverage for children, unemployment, old age, disability and work injury benefits, but not for sickness benefits. this exclusion directly correlates to a shortage of comparable data across countries. indicators cannot capture all that is important of course, but they are an opportunity to set an accountability framework fostering the collection and publication of more and better data. in this respect, progress needs to be made. in line with the nine branches of social security defined under the international labour organization (ilo) convention no. , the world social protection database provides information on whether the legal framework includes entitlements to income support in case of sickness and collects national-level data on effective coverage for this contingency. yet, more reporting is necessary to allow for the elaboration of global estimates. these challenges relate to the setup of such guarantees. indeed, many countries chose to cover this contingency through an employer's liability (ie, there is no social protection scheme as such, each employer is responsible to continue to pay the worker's salary during sick leave). this model has two effects. first, this form of protection is often limited to those covered under national labour legislation while those in informal employment remain unprotected. second, it can create a disincentive for employers to hire and retain workers from groups prone to sickness, as the full cost of sick leave falls on them. this is a concern for small and medium enterprises where resources can be limited. the labour force in lmics is still largely informal. more efforts are necessary to extend social protection coverage, including income security in case of sickness, to those in informal employment and facilitate their transition to the formal economy, which also contributes to fostering decent work under goal and the broader sdg agenda. income security in times of ill health has been part of social protection systems in many high-income countries (hic) for over half a century, often longer than universal access to healthcare. after a long period of heterogeneous and small-scale union-based or guild-based mutual funds, the first national legislations on social insurance came into force around the turn from the th to the th century in countries that are today classified as hic, but at the time had fiscal space that was no larger than today's poor countries. the th century saw scale-up in fits and starts towards universalism through periods of devastating wars and economic depression. the bismarck and beveridge models did not only concern health coverage as defined today under the uhc framework. they were models for comprehensive social health protection, including both access to healthcare without hardship and income security in times of sickness. one underpinning argument was that income security coupled with rehabilitation would help prevent permanent incapacity to work due to chronic conditions and hence reduce the burden on disability pension and poverty relief schemes. another was that income security would facilitate implementation of infectious disease control measures. none of the early schemes had only healthcare benefits. in many countries, including germany, uk and sweden, sickness benefits came first, followed by gradual introduction of healthcare benefits. lord beveridge stated upfront in his report that uk had by then already made progress on social insurance, and argued that it was now time to include also healthcare coverage since 'a plan for social security assumes a concerted social policy in many fields'. the human rights framework and international labour standards followed this approach, considering income security in case of sickness an integral part of social health protection. as early as , the ilo adopted the first convention on sickness benefits, which was subsequently included in the social security (minimum standards) convention, (no. ), the medical care and sickness benefits convention, (no. ) and recommendation, (no. ) . those instruments call on member states to set up systems ensuring protection in case of 'incapacity for work resulting from a morbid condition and involving suspension of earnings'. however, their global implementation was hampered by various factors, and the available data suggests effective coverage remains very low. in spite of the inclusion of income security during sickness in the social protection floors recommendation, (no. ), the recent united nations resolutions do not elaborate on it and more needs to be done to better reflect it in the sdg framework. despite the universal declaration of human rights including 'the right to security in the event of sickness' and who's definition of health as including 'social wellbeing', attention to income security in times of sickness remains limited in the global health field. a reason is perhaps that uhc and scientific advances are expected to solve the problem through swift cures for most conditions. medical and allied science have advanced tremendously. healthcare services can cure more diseases and reduce risk of long-term disability. still, uhc will not eliminate the risk of income insecurity in case of sickness. the global tuberculosis and hiv/aids strategies are ahead of the game. they include policy commitments on social protection and monitoring tools. heavily subsidised healthcare services have been scaled up globally for those diseases, which is probably why the limitations of affordable healthcare alone to prevent poverty effects of diseases have become obvious. evidence indicates that patients who pay little out of pocket for quality healthcare still face high indirect costs. the national tuberculosis patients cost surveys coordinated by who show that patients experience variable levels of direct medical costs depending on the country context, but also high direct non-medical costs (mostly transport and nutrition) bmj global health and income loss, creating additional incentives to forgo care. there is good reason to believe that income security is an equally important global challenge for people with both communicable and non-communicable diseases, including diabetes, cancer, cardiovascular diseases and mental health problems. the long-term solution should not be disease-specific social protection schemes but universal systems that provide better ways to extend income security protection in case of sickness for all. let's not wait until to put this issue firmly on the global health agenda and in the discussions on the future of social protection. acknowledgements all authors are members of the health and social protection action research & knowledge sharing network (sparks), an international interdisciplinary research network. sparks' multi-sectoral team characterizes and evaluates the direct and indirect effects of social protection strategies on health, economic, and wider outcomes. contributors all authors conceptualised the paper, wrote it jointly and approved the final version. funding funding was received from the swedish research council ( - ). competing interests none declared. patient consent for publication not required. provenance and peer review not commissioned; externally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. orcid id knut lönnroth http:// orcid. org/ - - - income security during public health emergencies: the novel coronavirus (covid- ) poverty trap in vietnam social protection response to the covid- crisis who. global tuberculosis report general comment no. : the right to social security towards universal health coverage: social health protection principles. social protection spotlight brief income security during periods of ill-health: a scoping review of policies and practice in low-and middle-income countries tracking universal health coverage: global monitoring report jsessionid= ed a e bc a e f a c eb? sequence= [accessed metadata for sustainable development goal universal social protection to achieve the sustainable development goals can productivity in smes be increased by investing in workers' health? the emerging welfare state -swedish social insurance - . lund, arkiv förlag gesundheitspolitik in der nachkriegszeit: grossbritannien und die bundesrepublik deutschland im vergleich universal health coverage" as a goal of international health politics, - health insurance: the influence of the beveridge report paid sick leave: incidence, patterns and expenditure in times of crises transforming our world: the agenda for sustainable development, resolution adopted by the general assembly on global strategy and targets for tuberculosis prevention, care and control after unaids. unaids strategy - -on the fast-track to end aids beyond uhc: monitoring health and social protection coverage in the context of tuberculosis care and prevention centenary declaration for the future of work key: cord- -vw up u authors: mcdiarmid, melissa; crestani, rosa title: duty of care and health worker protections in the age of ebola: lessons from médecins sans frontières date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: vw up u nan ► health workers were differentially infected during the to ebola outbreak with an incidence rate of to / depending on their job duties, compared to the wider population's rate of . / , according to the who. ► médecins sans frontières (msf) health workers had a much lower incidence rate of . / , explained as the result of msf's 'duty of care' toward staff safety. ► duty of care is defined as an obligation to conform to certain standards of conduct for the protection of others against an unreasonable risk of harm. ► the duty of care was operationalised through four actions: performing risk assessments prior to deployment, organising work and work practices to minimise exposure, providing extensive risk communication and training of staff and providing medical follow-up for staff exposures. ► adopting and consistently enforcing these broader, duty of care safety policies in deployed teams augments and fortifies standard infection prevention practices, creating a more protective, comprehensive safety programme. ► prioritising staff safety by taking such actions will help avoid the catastrophic loss of the health work force and assist in building resilient health systems. protecting health workers from preventable illness, disability and death must become a fundamental first step in building resilient health systems capable of planning for and effectively responding to public health emergencies while maintaining core services. the health sector is already known as a 'highhazard' employment zone, even when workers provide routine clinical care under circumstances clearly safer than an emergency response. beyond the anticipated infectious agents such as tuberculosis and hepatitis that a worker might encounter, other hazard categories include chemical, physical and psychological risks which threaten worker health and safety. the sector's poor workforce illness and injury rates reflect these hazards, even in well-resourced settings. in the uk, for example, illness and injury rates are about % higher than the all industry average. these hazards not only endanger the personal safety of skilled health staff, but cripple health systems already burdened by workforce shortages. in the special case of public health emergencies, unique threats arising from the complexity of urgent care delivery add to the heightened health worker occupational risk. this was especially evident in the ebola context, where significant health worker infections and deaths occurred during the initial emergence and in subsequent early hospital-based outbreaks. recent review of the largely who-led ebola response of to examined health worker infections and deaths. though exact numbers were never finalised, two-thirds of the known and presumed health workers infected were reported to have died of the disease. the estimated cumulative ebola virus disease incidence rate for health workers was reported to range from about to per persons depending on job title, compared with the non-health worker rate of . per . compare this to the incidence rate of médecins sans frontières (msf) health workers, at about . per based on infections among about responders. compared with other responding teams, msf-deployed staff had significant experience in ebola response and safety practices leading into . another specific difference, considering their lower staff infection rate, may be the agency's 'duty of care'. the bmj global health concept of duty of care has roots in both ethics and the law and is generally defined as an obligation to conform to certain standards of conduct for the protection of others against an unreasonable risk of harm. the duty of care principle appears in professional codes of ethics for health workers to provide care for their patients, including obligations to populations during pandemics. after the severe acute respiratory syndrome epidemic and the notable loss of life among health workers, several authors raised the ethical need to consider the added risk workers assumed. they suggested that employers have a reciprocal obligation to their employees, which in some settings has become legally binding, to provide the needed training, organisation and protective equipment to make hazardous work as safe as possible. given their mission to respond to humanitarian emergencies, msf is well aware of the out-sized safety and security risks that threaten health workers. thus, duty of care as a policy, having evolved over time, was formalised in . the policy committed the agency to operate under the obligation to protect its staff. as was observed during the ebola outbreak, an imbalance in this reciprocity endured more broadly, where employers in both limited income and well-resourced countries failed to take commensurate protective actions against the risks workers were expected to shoulder. the duty of care commitment is operationalised for all msf missions in safety policies and practices, and is achieved through four actions: . performing detailed analyses of health risks related to the job proposed. . implementing all necessary preventive measures and actions to control risks including the design of safety and emergency procedures. . informing workers of the remaining risks. . providing follow-up for any illness or work-related injury. analyses of health risks related to the job proposed months before the who declared the ebola outbreak an international public health emergency in august , msf teams were already deployed to multiple sites in the affected west africa region, providing patient care, contact tracing, community outreach and logistical support to the ebola response. at the height of the agency's involvement, msf had different ebola treatment projects across guinea, liberia and sierra leone, ultimately caring for about one-third of the total patients affected by the crisis. prior to undertaking any of these new missions, experienced msf staff conduct a health risk analysis (action ). using a checklist to assess context, political background, health risks and population beliefs and behaviours, a general profile is determined for any new mission being considered. for ebola missions, the availability of protective clothing, the circuit or layout of the treatment building and the training level of the staff is assessed. the overall risk is graded with a specific tool to determine if the risk is acceptable to undertake. if the mission is undertaken, monthly biosafety expert visitors from headquarters augment baseline safety assessments by performing monthly monitoring, again using checklists and a colour scale (green, yellow, red) for each performance element. this is shared with the local staff at the site level to encourage improvement over time. the health focal point also addresses ongoing health worker risk management and the 'wash' supervisor (water, sanitation and hygiene) reviews and provides feedback for the wash staff (staff who perform decontamination, laundry and burial duties). health-related preventive actions (action ) include providing worker training to minimise infection risk. pre-deployment, worker health status and vaccine documentation are validated and malaria prophylaxis is provided. the briefings and training for prospective international ebola staff emphasise specific sanitation and infection prevention and control (ipc) work practices, which limit exposure to infectious body fluids or objects. this includes requiring strict adherence to the 'no touch' policy of any other person, except when wearing proper personal protective equipment (ppe). training to wear and safely remove ppe ensembles in hypothetical scenarios is also practiced and reinforced on site, as is safe duration times in treatment units to prevent heat stress. national staff follow a similar training process locally. both national and international msf staff are required to observe health guidelines and ipc practices throughout the mission. logistical and medical coordinators ensure compliance on site by observing daily work performance, re-training staff on an ongoing basis and ensuring the availability of needed ppe. human resource measures also encourage a positive safety climate through scheduled rest and days off, and by use of clear job profiles. risk analyses, including residual risk and safety policies, are extensively communicated through written documents and face-to-face briefings (action ). the special safety aspects of an ebola mission, including modes of ebola transmission, lack of efficient treatment and high risk of mortality are clearly communicated to staff in a safety policy. prospective staff are informed of the right to withdraw from work if they do not feel safe. in some high-risk situations, a written consent is requested of the staff member to ensure their understanding of the remaining risk. providing follow-up for any illness or work-related injury staff illness, including suspected ebola cases, are managed by the team-based health focal point (action ). each site bmj global health has the capacity to isolate and treat potentially infected staff. standard operating procedures are detailed in policy documents. msf operational centre's clinical expertise is also sought. referral for treatment locally, nationally and internationally is based on availability but is preferentially provided in a special treatment facility for responder staff. closely monitored medical and psychosocial follow-up is provided by msf staff present on all ebola mission teams, and at the capital and operational centre level if evacuation is required. after the mission, debriefing of staff occurs at both the country and headquarters level. lessons from the msf ebola experience it is difficult to make direct comparisons between the msf-deployed teams and those organised by the who, though some broad observations are evident. both who and partners, as well as msf, deployed many diverse response teams composed of international and national staff. msf also had comprehensive, agency-wide safety policies in place for health workers that went beyond ipc. who-convened teams were guided primarily by ipc documents, though by the time these were available in august , more than health workers had already been infected. prior to this, existing ipc guidance for filovirus haemorrhagic fever was available. in september who also issued a health and safety handbook for its deployed headquarters and country staff responders (clinical and non-clinical), which focused on personal measures staff could take to prevent exposure. although who-convened teams had essential ipc training, in its report on health worker ebola infections, who found '…serious gaps in ipc standards… in the settings where transmission likely took place or where infected health workers were employed.' the report identified other risk factors for caregiver infections, grouped into several domains. these included deficiencies in administrative controls or work organisation, lack of engineering and environmental controls related to isolation and hygiene and problems with availability and compatibility of ppe. also listed were poor employment conditions (human resource issues). many of these domains are outside the confines of ipc but are addressed in msf policies. they also mirror the classical occupational health exposure prevention approach of hazard anticipation, mitigation and control using engineering and administrative methods, work organisation and ppe. while compliance with safety policies was not formally tracked, the desired safety behaviours were routinely reinforced, as described above. we believe that organisational commitment and robust adherence to both ipc and other safety policies help explain msf's lower staff infection rates and suggest a roadmap for future pandemic planning. specifically, occupational health approaches to identify and control hazards, assure safe work organisation through assigned safety roles and responsibilities and vigilant ppe use augment and fortify standard ipc practices. together, these efforts form a more protective, comprehensive safety programme, as the msf outcome demonstrates. as who has now declared the current ebola outbreak in the democratic republic of congo a 'public health emergency of international concern', the global response must advance beyond efforts to raise staffing numbers and medical competency. indeed, a competent response requires a protected health workforce. building on the msf experience, pandemic planning and emergency response starts with the comprehensive organisation of the care mission from a safety perspective. this requires anticipating hazards and providing linked prevention services, training commensurate to the significant hazards present and appropriate and sufficient protective equipment for caregivers. these duty of care actions form a fortified framework of safety and health protections for the health workforce, which in turn, add resilience to fragile health systems. acknowledgements the authors thanks drs axelle ronsse and rosemary sokas and ms elyse delaittre for thoughtful review of the manuscript and ms marian condon for skillful manuscript preparation. contributors mm and rc participated in the writing, reviewing and editing of the article. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests none declared. patient consent for publication not required. provenance and peer review not commissioned; externally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. advocating for the health worker what is a resilient health system? lessons from ebola cdc/niosh: state of the sector: healthcare and social assistance health and safety authority (has) healthcare illness and injury statistics world health organization. health worker ebola infections in guinea the - ebola outbreak in west africa: hands on duhaime's law dictionary. duty of care definition virulent epidemics and scope of healthcare workers' duty of care the duty to care of healthcare professionals: ethical issues and guidelines for policy development duty of care employer's responsibility duty of care project msf internal document, general directorate health guidelines and procedures for expatriate staff, msf internal document national staff health policies, msf internal document ebola guideline, staff health chapter who interim infection prevention and control guidance for care of patients with suspected or confirmed filovirus haemorrhagic fever in health-care settings, with focus on ebola who interim infection control recommendations for care of patients with suspected or confirmed filovirus (ebola, marburg) haemorrhagic fever who ebola outbreak response handbook for health and safety in the field occupational hygiene: control of exposures through intervention. ilo encyclopedia of occupational health and safety occupational safety and health administration (osha). recommended practices for safety and health programs. hazard prevention and control who: ebola outbreak in the democratic republic of congo declared a public health emergency of international concern key: cord- -w e lw authors: ebuenyi, ikenna d; smith, emma m; holloway, catherine; jensen, rune; d'arino, lucía; maclachlan, malcolm title: covid- as social disability: the opportunity of social empathy for empowerment date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: w e lw nan social empathy is 'the ability to more deeply understand people by perceiving or experiencing their life situations and as a result gain insight into structural inequalities and disparities'. social empathy comprises three elements: individual empathy, contextual understanding and social responsibility. covid- has created a population-wide experience of exclusion that is only usually experienced by subgroups of the general population. notably, persons with disability, in their everyday lives, commonly experience many of the phenomena that have only recently been experienced by members of the general population. although about billion people or approximately % of the world's population, have some form of disability, ignorance and fear about disability and discrimination towards people with disability still persists. public understanding of disability is shaped by a medical model of individual deficit, ignoring societal barriers that transpose the attribute of some type of psychological or bodily impairment into the social experience of disability . this is the core message of the social model of disability that recognises the role of the social environment in the experience of disability. while there are many personal and social aspect of disability that people without a disability may never experience, there is an opportunity for the population-wide experience of covid- to change others' perceptions of people with disability. the reported differential impact of covid- on persons with disabilities highlights systemic barriers and their impact on those left behind by the social system. the conflating of disability with 'comorbidity' or 'frailty' is not due to any biological predilection for the virus but rather to implicit ableist assumptions that the 'elderly' or persons with pre-exiting 'conditions' are similar to people with disability. this also ignores the intersectionality of discrimination (gender, income, ethnicity and education) that compounds and heightens risk for persons with disability. the covid- experience may offer contextual experience of the prepandemic lives of persons with disabilities and in doing so foster greater social responsibility and opportunities for change and a more inclusive society. in the following commentary, we highlight this by drawing parallels between articles of the united nations convention on the rights of persons with disabilities (uncrpd) about the covid- experience and common experiences of people with disabilities. confinement, isolation, lack of connection and interaction with immediate surroundings and family is an aspect of the covid- experience and is highlighted in article summary box ► covid- has conferred new experiential knowledge on society and a rare opportunity to better understand the social model of disability and to improve the lives of persons with disabilities. ► the covid- experience may offer contextual knowledge of the prepandemic lives of persons with disabilities and foster greater social awareness, responsibility and opportunities for change towards a more inclusive society. ► information, family and social relationships, health protection and healthcare, education, transport and employment should be accessible for all groups of the population. the means must be developed and deployed to ensure equity -the deployment of resources so that people with different types of needs have the same opportunities for living good lives in inclusive communities. ► we have learnt from covid- that inclusive healthcare and universal access should be the new normal, that its provision as a social good is both unifying and empowering for society as a whole. (uncrpd): 'living independently and being included in the community'. the covid- experience has given some a sense of what it must be like to live in institutions and not being able to 'get out', or living in a house in the community but still feeling apart from the local community. isolation and loneliness are a common experience for some people with disability. feeling well informed-having access to good information-has, for some, been a struggle in covid- times. uncrpd article concerns 'access to information' ; due to the covid- pandemic, the general population have experienced the challenges of receiving information that is not always clear or understandable. this is similar to the everyday experience of some people with disabilities who have to contend with public health information that is rarely available in accessible formats (sign language, captioning, easy-to-read or braille documents). there have also been reports of some people being made to feel 'different' because of their covid- status. article of the uncrpd relates to 'equality and non-discrimination.' the onset of covid- has shown that people might be discriminated against based on nationality, age or other attributes because of the perceived predilection for covid- . the advent of covid- , may have created anxiety about contamination, and fearful reactions to and stigmatisation of those who are believed to have come in contact with it. this may even extend to the development of prejudice towards whole groups-asian people -the vast majority of whom obviously have no association with covid- . the recent plan by the chilean government to issue 'release certificates' to persons recovered from covid- is another instance of use of illness as a divisive factor. this may be representative of the experience of legitimacy/illegitimacy experienced by some people with disability. access to healthcare for persons with or without covid- has become difficult and is related to the article of the uncrpd that describes 'right to health'. covid- has led to prioritisation of people who receive healthcare services, with the concept of 'worth' attached to individuals, based on pre-existing health status, with cancelled, delayed or suspended services. these challenges typify the barriers to accessing healthcare experienced by persons with disabilities, due to limited accessible services, poor understanding of individual needs, and lack of appropriate equipment. reduced opportunities for or access to education, work and employment are the focus of articles and , respectively. the covid- experience offers insights into the experience of loss of meaning, loss of opportunity to participate, loss of income, living on benefits but not being able to contribute, loss of identity as an independent and valued asset of the community and perhaps an inability to work or study remotely due to lack of accessibility. however, we now have a greater understanding as a society that alternative work and/or education formats are possible and are effective, which may result in increased chances for persons with disabilities and equalise opportunity in the future. these few examples provide the general population an opportunity for social empathy and action to enhance social inclusion for people with disability. we offer the following recommendations to ensure that this moment of collective social insight is not squandered, repressed or simply forgotten as we rush back to 'normal': ► first, it obvious that being forced to stay indoors is not pleasant for anybody, nor is it socially acceptable for others to be lonely or isolated. it is important to promote varied mechanisms for interaction, inclusion and participation within and across our communities for persons with disabilities. ► second, information should be accessible to all groups of the population, and alternative means of communication should be incorporated systematically to inform and enable all persons based on their own needs and abilities. ► third, some population groups are more likely to experience discrimination and to be pushed into the corners of society. social policies that promote equitythe distribution of resources so that people with different attributes have the same opportunities-in society will create a society for all. ► fourth, we have learnt from covid- that inclusive healthcare is desired by all, that it has the potential to weave us together and that no one should be denied access based on personal attributes. universal healthcare should be the new normal not a privilege. ► finally, we now understand the socioeconomic experiences of vulnerable groups in settings where social welfare is absent. social protection and benefits are among the measures recommended by the international labour organization to fight covid- . as we come out of covid- , it is important to recognise the purpose and meaning of engaging in work, for all, across all abilities. alternative means of working and studying should allow for greater accessibility for everyone. covid- has conferred new experiential knowledge on all of us. we have a rare opportunity to understand and better the lives of persons with disabilities for whom some aspects of the covid- experience are enduring. this allows us greater understanding of the importance of implementing in full a social and human rights model of disability, as outlined in the uncrpd. to not learn from history may well doom us to repeat it, but to not learn from our experience of the present, is to wilfully neglect the opportunities of the moment. as a society have we learnt that we are better than that? contributors all authors were involved in the conceptualisation and drafting of the manuscript. competing interests none declared. social empathy: a model built on empathy, contextual understanding, and social responsibility that promotes social justice the covid- response must be disability inclusive world health organization. who global disability action plan - : better health for all people with disability. world health organization routledge handbook of disability studies. routledge disability, urban health equity, and the coronavirus pandemic: promoting cities for all retweeting covid- disability issues: risks, support and outrage convention on the rights of persons with disabilities (crpd) psychiatrists beware! the impact of covid- and pandemics on mental health public responses to the novel coronavirus ( -ncov) in japan: mental health consequences and target populations chile plans controversial covid- certificates covid- : maintaining essential rehabilitation services across the care continuum access to lifesaving medical resources for african countries: covid- testing and response, ethics, and politics this one will delay us": barriers to accessing health care services among persons with disabilities in malawi disability and health: a research agenda covid- : an opportunity for african governments to rethink social welfare benefits and protection covid- : protecting workers in the workplace key: cord- -ljt rn z authors: ghisolfi, selene; almås, ingvild; sandefur, justin c; von carnap, tillman; heitner, jesse; bold, tessa title: predicted covid- fatality rates based on age, sex, comorbidities and health system capacity date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: ljt rn z early reports suggest the fatality rate from covid- varies greatly across countries, but non-random testing and incomplete vital registration systems render it impossible to directly estimate the infection fatality rate (ifr) in many low- and middle-income countries. to fill this gap, we estimate the adjustments required to extrapolate estimates of the ifr from high-income to lower-income regions. accounting for differences in the distribution of age, sex and relevant comorbidities yields substantial differences in the predicted ifr across world regions, ranging from . % in western sub-saharan africa to . % for high-income asia pacific. however, these predictions must be treated as lower bounds in low- and middle-income countries as they are grounded in fatality rates from countries with advanced health systems. to adjust for health system capacity, we incorporate regional differences in the relative odds of infection fatality from childhood respiratory syncytial virus. this adjustment greatly diminishes but does not entirely erase the demography-based advantage predicted in the lowest income settings, with regional estimates of the predicted covid- ifr ranging from . % in western sub-saharan africa to . % for eastern europe. key policy decisions for covid- containment hinge on its infection fatality rate (ifr). data from the hardest-hit countries show that the ifr varies by sex, age and certain comorbidities, suggesting a method to extrapolate estimates to new contexts with limited data infrastructure. [ ] [ ] [ ] [ ] [ ] [ ] [ ] in this article, we combine recent estimates of the sex-specific and agespecific ifr from france with data on comorbidities conditional on death with covid- in italy to calculate the inverse: an ifr conditional on sex, age and comorbidity (cifr). we apply these estimates to the distribution of sex, age and relevant morbidities for countries from the global burden of disease (gbd) data set. results reveal substantial differences across world regions, with demographics-based ifr predictions ranging from . % in western sub-saharan africa to . % for high-income asia pacific. despite the comparatively low ifr estimates our model predicts for the lowest income regions, these ifr estimates are appreciably higher than other recent estimates for the same areas. we understand these predicted ifrs as lower bounds on mortality in low-and middleincome countries, since they are derived implicitly assuming access to advanced healthcare. to account for the likelihood of higher fatality rates in under-resourced health systems, we adjust the predicted ifrs for differences in the relative odds of infection fatality from childhood respiratory syncytial virus (rsv) between world regions as a proxy for local capacity to treat viral respiratory illnesses. this adjustment greatly summary box ► given limited testing and vital statistics data, few measures of the covid- infection fatality rate (ifr) exist for developing countries. ► in europe and north america, measures of covid- ifrs are known to vary by age, gender and comorbidities. ► existing model-based estimates for the developing world have not fully accounted for these factors in predicting ifrs. ► using variation in demographics, comorbidities and health system capacity, we predict covid- ifrs for countries, ranging from . % in western sub-saharan africa to . % in eastern europe. ► despite lower measured health system capacities, predicted ifrs for most of sub-saharan africa nonetheless remain well below ifrs for high-income countries, while eastern europe is predicted to fare particularly poorly. ► policy-makers in low-income countries should be cognizant that any demographic advantages with respect to covid- fatality rates are likely to be partially offset by disadvantages in health system capacity. diminishes, but does not entirely erase, the demographybased advantage predicted in the lowest income settings, with regional estimates of the predicted covid- ifr ranging from . % in western sub-saharan africa to . % for eastern europe. here we outline the calculation of our benchmark: the predicted cifr status, starting from the ifr estimates by age and sex reported in salje et al for france. the latter are, to our knowledge, the most recent peer-reviewed ifr estimates for covid- which report variations for all age brackets and differentiate by sex. they are lower than earlier figures from walker et al , particularly among younger age groups, but are quite similar in the highest age brackets. the core assumption behind our approach is that variation in the ifr within france by age, sex and comorbidity can be used to predict the variation in ifrs across countries based on their age, sex and comorbidity distributions. to date these are the key factors that have well studied, statistically and clinically significant associations with covid- severity and death. importantly, we do not require that the underlying distributions of age, sex or comorbidities are similar between france and other countries in our sample; on the contrary, differences across countries in these distributions will drive the variation in predicted ifrs. we now demonstrate our method to extricate from the french age and sex-specific ifrs that part which we claim is portable across contexts: the probability of dying (d) given infection from covid- (i) and the age (a), sex (s), and comorbidity status (c) of patients, that is, p ( d|c; i, a, s ) . we term this the cifr and use subscripts for notational convenience, so that cifr = p ias ( d|c ) applying bayes' rule, we can recover this cifr by relating it to the ratio of comorbidity prevalence among covid- fatalities relative to covid- infections (conditional on age and sex) and age and sex-specific ifrs: we now discuss how we measure each of these probabilities. ( ) p ias ( c|d ) denotes the probability of comorbidity status given death of covid- , age and sex. we rely on the assumption that this probability is independent of age and sex, p ias ( c|d ) ≈ p ( c|d, i ) , which is supported by data from new york city. (as shown in online supplemental figure , data from new york city indicate that among those who die from covid- , the share that has any comorbidity is stable across age groups and very similar for both.) we calculate p ( c|d, i ) , using the italian istituto superiore della sanità reports on the number of comorbidities conditional on covid- death. the choice to combine data from france and italy was motivated by the fact that the latest published estimates of mortality by age and gender come from france, while reliable data on comorbidities among covid- deaths are available for italy but not france. given our assumption that the cifr is portable across contexts (with the same health system capacity), countries with the same comorbidity and sex distribution at each age should have the same age-specific ifr. we show in theonline supplemental figure that france and italy are similar in terms of comorbidity and sex distributions for a given age, and that the age-specific ifr estimates for the two countries (reported in salje et al and ferraro et al ) are very close. thus by equation ( ), the two countries should also have the same prevalence of comorbidities among their covid- fatalities at each age. ( ) p ias ( c ) denotes the presence of underlying conditions given infection, age and sex. we assume p ias ( c ) ≈ p ( c|a, s ) and take the probability of having any covid- -relevant comorbidity by age and sex in france from the gbd data set. this assumption would be violated if the pool of infected systematically differs from the general population. recent evidence from the usa suggests that comorbidities are as present among the infected as in the general population. furthermore, data from italy show attack rates above % in some provinces. this, together with the absence of widespread immunity further supports this claim. note that for simplicity we rely on an indicator for any covid- relevant comorbidity, although the type, number and combination of different diagnoses are likely to affect the cifr. the comorbidities considered relevant for covid- by clark et al are the following: cardiovascular diseases, chronic kidney diseases, chronic respiratory diseases, chronic liver disease, diabetes mellitus, cancers with direct immunosuppression, cancers with possible immunosuppression, hiv/aids, tuberculosis, chronic neurological disorders, sickle cell disorders. ( ) p ias ( d ) denotes the sex and age-specific ifrs from salje et al which come from france. with these ingredients, we can calculate the cifr assuming healthcare levels similar to high-income countries (hics) in ( ), which we find to be an increasing and non-linear function of both age and comorbidity (figure and table , labelled 'hic'). for those without a comorbidity, the cifr is effectively zero and flat up to the age of , and then increases roughly -fold between - and - years (from . % to . % for women and from . % to . % for men). with a comorbidity, the pattern is similar, but because the cifr is already higher at younger ages, the age gradient is flatter, roughly doubling the cifr for each decade above age . the difference in the cifr between patients with and without comorbidities is large but declines rapidly with age. finally, the female cifr is lower than the male cifr for each age and comorbidity status. we integrate the cifr over each country's sex, age and comorbidity distribution to obtain a country-specific average ifr. figure shows our main results, aggregated bmj global health figure cifrs, adjusted for health system capacity, by country income group (log scale). cifrs, infection fatality rates conditional on age, sex and comorbidity; hics, high-income countries; lics, low-income countries; lmics, lower middleincome countries; umics, upper middle-incomecountries. bmj global health by world regions (we display the unaggregated results in online supplemental figure ). we find substantial variation in predicted ifrs across regions-by a factor of between the highest (high-income asia pacific with an ifr of . %) and the lowest (western sub-saharan africa with an ifr of . %). the variation is systematic, as low-income regions have lower predicted ifrs than high-income regions. demography is a key driver of these results: age distributions vary substantially across regions, with sub-saharan africa and oceania having the youngest and richer regions having the oldest populations. regional variation in comorbidities also helps explain variation in predicted ifrs across regions: highincome regions display more comorbidities among the elderly than low-income settings, while the reverse is true among the young and middle-aged segments of the population. finally, because the ifr is always lower for women than for men, variation in sex imbalances in the highest age brackets (tilted toward women everywhere) also contributes to variation in the average ifr. we interpret our predicted ifr estimates as lower bounds on the true probability of dying from covid- in low and middle-income settings, as data on fatalities come from countries with advanced health systems. health system weaknesses in lower income settings likely imply that a larger proportion of severe covid- cases result in death due to suboptimal medical care, and this will likely diminish the demographic advantages of lowincome countries (lics). to account for this, we adjust our ifr estimates for health-system strength based on a region's demonstrated capacity to prevent fatalities from viral lung infections. we derive this adjustment from comparative regional hospital case fatality rates for rsv among children aged - months. we chose this demographic to derive our health system capacity measure because restricting attention to this age bracket approximately purges the rsv ifrs of crosscountry variation in the distribution of ages, comorbidities (as children under five have very low burdens of chronic diseases such as hypertension, kidney disease or other conditions of organ degradation) and sex (as sex ratios under years are more balanced than for older groups). with nearly equivalent age, sex and comorbidity rates in this demographic, we take remaining cross-country variation in the ifr for rsv to be attributable principally to health system capacity. we choose rsv acute lower respiratory infection (alri) as a proxy for covid- as they are viral lower respiratory infections with overlapping symptoms. like covid- , rsv usually causes mild symptoms, but occasionally develops into a life-threatening illness. as with all viruses, neither is treatable with antibiotics, and, until covid- , rsv was unique among the major organisms that cause death from respiratory tract infections to have neither any vaccine nor recognised treatment. normalising the ifr for childhood rsv in hics to , we apply the ratio of these ifrs between regions to scale up our demography-adjusted and comorbidity-adjusted ifr predictions. unfortunately, we lack country-level ifr estimates. however, shi et al provide data from which rsv ifrs for severe cases can be inferred by world bank income level: hics, lics, lower middle-income countries (lmics) and upper middle-income countries (umics). the ratios of the ifrs for children hospitalised with rsv between hics and lics, lmics and umics from this data are . , . and . , respectively. while we assume that all severe cases warranting hospitalisation obtain it in hics, this is not necessarily the case in other income groups, and thus these relative hospital fatality ratios require an adjustment to become infection fatality ratios. we take this adjustment from wang et al, from which the relationship between hospital case fatality rates and ifrs can be mapped for lmics and hics for childhood influenza, another comparable respiratory virus. using this mapping, we translate our rsv ifrs specifically among hospitalised children into ifrs among all severe cases, which are estimated to have ratios to hic ifrs of . , . , . for lics, lmics and umics, respectively. taking these ratios as ors rather than risk ratios (to maintain coherent probability bounds), we rescale bmj global health the predicted cifrs by these region-specific adjustments to calculate a cifr conditional on regional health system capacity (see online supplementary appendix a for details). adjusting for health system capacity increases the cifr in poorer regions by almost an order of magnitude ( figure and table ). at ages and below, the cifr is increased by a factor of - in lics, by a factor of in lmics and by a factor of - in umics. for older ages, the increase in the cifr is less stark, but the adjusted cifr is still two to four times as large as the unadjusted one. lower health system capacity thus both increases the cifr at each age and comorbidity status and flattens its age gradient. with this health system-adjusted cifr in hand, we recalculate the country-specific ifrs (and add them to figure and online supplemental figure ). the health system strength adjustment starkly increases the predicted covid- ifrs for the lowest income regions, nearly though not entirely erasing their demographic advantages: the predicted ifrs double on average in umics, almost triple in lmics and increase by a factor of . in lics. as examples, ifrs increase from . % to . % in sub-saharan africa, from . % to . % in latin america and from . % to . % in south and central asia. eastern europe is predicted to have particularly high ifrs ( . %), as it is characterised by an ageing population, high prevalence of comorbidities at a given age and low predicted health system capacity based on its income levels. our method of accounting for differences in health system capacity is crude in that we currently only have indicative numbers for rsv alri by income group, rather than national-level adjustments. however, the wide gap in childhood respiratory tract ifrs of between . -fold and . -fold between income groups has implications for covid- ifrs that are too large to ignore. we can test the validity of our core assumption, namely, that variation in age, sex and comorbidity distributions as well as health system capacity explain differences in ifrs across countries by comparing our predicted ifrs to independently measured ifrs. for this exercise, we consider all studies reporting either ifrs or infection rates for populations with available covid- fatalities, which were listed in the systematic review by meyerowitz-katz and merone or retrieved through an online search on july . out of the studies selected in this way, studies measure infection rates by testing for seroprevalence of covid- antibodies in population-based random samples. we judge this to be the best method of estimating infection rates and thus ifrs, because random sampling is required to be truly representative, and antibody seroprevalence indicates all cumulative cases, whereas 'swab' tests only detect current cases. we thus compare our predicted ifrs first and foremost to the estimates in these six studies. while five of the six random sample studies are located in hics, one is from an umic, allowing for validation of the health systemadjusted ifrs constructed in the previous section. in a second step, we use all published ifr estimates in the comparison, including those which use convenience samples, adjusted case fatality rates (cfrs) or 'swab' tests. the results are presented in figure a , where we plot the independent ifr estimates for the six random sampling studies in different countries on the horizontal axis against our predicted ifrs-using the health systemadjusted ifrs from the previous section-on the vertical axis. the independent estimates and our predictions are reported in table . comparing our estimates to these studies, we find a correlation of %, demonstrating that our method can successfully predict a considerable portion of the cross-country variation in ifrs. we note that switzerland and sweden are close to the ° line, as are the estimates from spain and iceland, which have been acknowledged to be well designed, randomised data collection efforts. for brazil, which tests the validity of our approach outside of high-income health systems, the health system-adjusted ifr also closely matches the independently estimated ifr, while the crude ifr is substantially lower at . % (consistent with our expectation that failing to adjust for health system capacity provides a lower bound on the true ifr outside of hics). belgium, on the other hand, has a very high ifr relative to our predicted number, but this source counts all suspect deaths in nursing homes as covid- deaths (as reported in https://www. bbc. com/ news/ world-europe- ), yielding the highest ifr among the included studies. figure b reports the results from a comparison with all the same studies listed in meyerowitz-katz and merone plus four additional random seroprevalence studies representative at subnational level. twenty-six studies come from hics and six from umics. the estimates displayed in this panel are much more noisy, including wide variations within single countries. nonetheless, our method does retain a positive correlation, although a lower one, even with these measured ifrs. note that we lack coverage for lics in this validation exercise. the lack of representative seroprevalence studies and covid- mortality data to estimate ifrs in such contexts is a key motivation for this study and highlights the need for modelled predictions. for example, we are aware of two serological studies measuring prevalence rates from countries in sub-saharan africa: one based on a representative sample of nampula, mozambique, and another of kenyan blood donors. however, fatality data appear unreliable: even attributing all recorded deaths from covid- in mozambique and kenya ( and total deaths, respectively) to the surveyed regions of nampula and nairobi, the estimated ifrs would be disproportionately low at . % and . %. our results illustrate the possibility of predicting covid- ifrs with a methodology that ( ) uses information readily available for most of the world-namely age and comorbidity distributions as well as proxies for health system capacity, ( ) relies on parsimonious and transparent assumptions and ( ) appears broadly consistent with the limited set of ifrs generated from random covid- testing. although we produce estimates at national level, subnational variability in distributions of comorbidities, age and sex may be important enough to require ifr estimations at subnational level. a merit of our approach is its portability to any community level where comorbidity, sex and age distributions and health system capacity (compared with france) are known. while our calculations including adjustments for health system strength still suggest somewhat lower ifrs in the least developed economies than in the most advanced economies, our estimates are significantly higher than ifrs used in other recent covid- forecasts for africa, and middle-income countries. in the absence of widespread testing or reliable vital registration systems, transparent calculations of likely ifrs provide an important input into optimal policy design under extreme uncertainty, particularly as the pandemic expands into new geographies and/or a second wave of infections arrives. twitter justin c sandefur @justinsandefur contributors all authors contributed to the design of the research. sg and tb compiled and analysed the data. tb, sg, jh and jcs contributed to writing. ia and tvc reviewed and edited the manuscript. funding this study was supported by bill & melinda gates foundation. competing interests none declared. patient consent for publication not required. provenance and peer review not commissioned; externally peer reviewed. data availability statement data are available upon request. open access this is an open access article distributed in accordance with the creative commons attribution . unported (cc by . ) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. see: https:// creativecommons. org/ licenses/ by/ . /. justin c sandefur http:// orcid. org/ - - - x demographic science aids in understanding the spread and fatality rates of covid- likelihood of survival of coronavirus disease estimating the infection and case fatality ratio for coronavirus disease (covid- ) using ageadjusted data from the outbreak on the diamond princess cruise ship estimating the burden of sars-cov- in france estimating excess -year mortality associated with the covid- pandemic according to underlying conditions and age: a population-based cohort study coronavirus disease (covid- ) daily data summary how many are at increased risk of severe covid- disease? rapid global, regional and national estimates for the potential effects of widespread community transmission of sars-cov- infection in the world health organization african region: a predictive model the global impact of covid- and strategies for mitigation and suppression. imperial college covid- response team characteristics of covid- patients dying in italy how deadly is covid- ? a rigorous analysis of excess mortality and age-dependent fatality rates in italy covid- testing, hospital admission, and intensive care among , , united states veterans aged - years respiratory syncytial virus in young children symptoms and care, respiratory syncytial virus global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in young children in : a systematic review and modelling study global burden of respiratory infections associated with seasonal influenza in children under years in : a systematic review and modelling study a systematic review and metaanalysis of published research data on covid- infection-fatality rates repeated seroprevalence of anti-sars-cov- igg antibodies in a population-based sample from första resultaten från pågående undersökning av antikroppar för covid- -virus antibody study shows just % of spaniards have contracted the coronavirus spread of sars-cov- in the icelandic population remarkable variability in sarscov- antibodies across brazilian regions: nationwide serological household survey in states % of belgians have antibodies against coronavirus inquérito sero-epidemiológico de sars-cov- na cidade de nampula -resultados preliminares preliminary report of sars-cov- antibody prevalence among blood donors in kenya key: cord- - oy zuy authors: rashid, sabina faiz; theobald, sally; ozano, kim title: towards a socially just model: balancing hunger and response to the covid- pandemic in bangladesh date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: oy zuy nan ► responsive and timely research is needed to better understand the challenges faced by poor and vulnerable populations to inform immediate interventions and policies to address this unprecedented covid- modern-day pandemic. ► there is a need to research changes through time to understand and address the continuous and longterm economic, mental and emotional impact of lockdown on the most marginalised. ► many of the bangladeshi population are vulnerable, yet the covid- response focuses on individual behaviour with limited attention to the social, economic and contextual factors that prevent the most marginalised from following national recommendations. ► in the context of structural constraints, continuation of the lockdown has to be accompanied by strong political resolve to ensure that people do not go without basic meals and have basic health information and support. ► the experiences of people living and working in slums in bangladesh needs to be captured and translated to context specific strategies for lockdown, as current measures risk starvation for many. ► in the context of covid- , the lockdown model is being imported from a different context (western or developed economies) with stronger economic bases and better social safety nets for those in need, but is there a better way forward for low resource contexts? ► economic mortalities may overtake health mortalities for the poorest who survive on daily wage labour. rapid responsive research in bangladesh is revealing the realities of lockdown for the poor and vulnerable in bangladesh, the james p. grant school of public health is undertaking responsive research to try and understand the needs of the population during covid- . the multidisciplinary research includes case studies in urban slums to capture the lived experiences and the impact of shutdown of the people living and working in dhaka during covid- . in addition, a rapid large scale urban/rural survey is being conducted via phone interviews, with follow-ups, aimed to assess the possible effects of the pandemic on several domains of a household or family such as consumption, income, health, coping strategies, psychological well-being and gender. the survey takes a dynamic approach: questions are modified based on current understandings and relevant emerging issues related to the crisis. with a focus on marginality, interviews have taken place with the transgender group of people commonly known as 'hijra' in south asian countries and with street workers including adolescence and young adults. reading these data alongside media reports and articles on the coronavirus pandemic, one is overcome with a range of emotions: depression, paralysis, anger, denial and helplessness; emotions that are reflective of being privileged and of having the luxury to dwell on them. for the vast numbers of the poor, microbusiness owners, labourers, transport workers, informal sector employees and many other groups who depend on daily wages/ earnings and have no social safety net, there is now only the pain of hunger, not figuratively, but literally. with the shutdown now extended to a month, these groups are under real threat of starvation. there are international conventions and declarations on the right to food, on the right to be free from hunger. yet the world suffers from an estimated million people dying of hunger and hunger related diseases annually, more than aids, malaria and tuberculosis combined. it is the world's biggest health problem, and with entire countries and economies now under lockdown, it risks getting much worse for those who live in difficult environments. although bangladesh has achieved a lot over recent decades, with improved availability of food due to increased production, million people-one quarter bmj global health of the population-remain food insecure, and million suffer from acute hunger. these figures will worsen after the impact of covid- . for many, every day is a battle: covid- is one addition to a long list of challenges for survival the poor and the vulnerable with their erratic and meagre earnings somehow manage to keep fighting and living and demonstrating impressive resilience, being confronted with illnesses and deaths is an everyday reality for many. while there is fear of the coronavirus, there is also the acceptance that it is yet another addition to an already long list of health challenges that they face. furthermore, with access to their sparse resources being severely constrained or denied as a result of the shutdown, for many, the immediate threat to consumption for survival, and not necessarily the pandemic, is becoming a greater concern. brac's (ngo) conducted a rapid perception survey on covid- conducted between march and april for instance found that % and % of urban and rural respondents, respectively, had no food stored at home, while % and %, respectively, had only - days food reserve. figure shows 'looting goods from a truck carrying relief' (source: photo tbs (the business standard), april ). the focus on individual behaviour prevents the poorest from following national recommendations health bodies and various governments have been promoting different measures to contain the pandemic that focus on individual behaviour with little attention to the social, economic and contextual factors. public health preventions tend to be based on the biomedical virus and individual determinants of health, whereas for millions, the stark living conditions, social and contextual inequalities and realities of how and where they live prevent them from following such recommended guidelines. there needs to be a recognition of the complexity of factors that underlie and impact on marginalised populations lives. practising social distancing, washing of hands with soap and staying at home are all very well for the privileged who can afford to do so; however, for the poor with - or more members crammed in one room within slums, sharing irregular water supply, communal latrines and cooking spaces, in some of the dirtiest and densest places on earth, such messaging needs urgent adaptation to reflect the realities of context and support is critical. the poor and vulnerable already live on the edge. the added stress of the pandemic combined with prolonged shutdowns will amplify further their despair and hopelessness. while health is a very real concern, for bangladesh to sustain the shutdown requires all of us to focus all of the country's resources on ensuring that no one goes without food. we have to believe the rest will follow, once this is ensured. if not, as nobel laureates esther duflo and abhijit banerjee highlighted with respect to the situation in india, the poor and the vulnerable will be left with no choice but to break the shutdown for their livelihood. the last interview of an adolescent street peddler stated, 'how much longer? we heard four more days. we have no food, no money'. these narratives are typical for most of the poor families we interviewed, in similar distress and concerns were echoed, much more in the urban surveys compared with the rural surveys (for now) and case studies in dhaka city urban settlements with mainly the informal workers, who are dependent on daily wages to survive. try imagining, if you can, the gut-wrenching panic and anxiety, when many of them learn it will be an additional days or more. rumours that the shutdown may continue until end of april or even may is going to lead to unimaginable consequences on the poorest and for the country as a whole. we need a socially just model to tackle this pandemic, and this requires us to acknowledge the fault lines that exist in our underlying assumptions as well as the very real inequities that exist between the poorest and others. political commitment for economic support for the poor needs urgent and effective implementation bangladesh, like many other countries, has rolled out an economic stimulus package to address the severe economic and business fallout from the pandemic. the government is also in the process of unveiling support for the poor. this scheme will also include support for farmers who are critical for ensuring the food supply chain for all of us-the rich, the middle class and the poor. while this package should really have been the first step taken by the state, it now needs to be implemented efficiently, systematically and equitably. there are numerous articles and reports detailing the mismanagement, favoured groups in communities and a complete lack of coordination between different bodies involved in distributing the initial state funded food and/or cash aid programmes. [ ] [ ] [ ] this has to stop. while there is no easy solution or strategy, for bangladesh and its high proportion of vulnerable populations, continuation of the shutdown has to be accompanied with strong political resolve to ensure that people do not go without food bmj global health and have basic health information and support, given the grounded realities of their lives. otherwise, it will be the final nail in the coffin for the poor and maybe even beyond. the trauma and enormity of what will unfold if this is not done properly cannot be emphasised enough. the shutdown or lockdown model has been imported from western or developed economies with stronger economic bases and better social safety nets for those in need. but is it the only way forward? china, hong kong, singapore, countries that were successful in containing the first wave, are now facing a resurgence largely due to infections coming from outside travellers, and some countries have begun reinstating containment measures again. how long can a shutdown be sustained in a largely different context? while this is an entirely unknown territory, iran's president for instance declared that 'low-risk' economic activities will resume from april in spite of the virus not being contained. the iranian government is thus balancing the risks of the pandemic versus further wrecking a sanctions battered economy. sadly, countries with large pools of poor populations may soon be forced to confront similar trade-offs, with all its moral and ethical implications, if there is no solution soon in sight. the political and social actions taken now at the global, national, subnational and local levels to understand and meet the needs of the urban poor are essential to addressing the current pandemic and also in preventing a post-covid- rise in people experiencing extreme poverty and death from the wider social determinants of health. if action is taken now, there is a chance to learn and build cities that are more resilient and responsive to future crises. having a responsive research agenda is the first step to informing, developing and delivering policies and strategies that are informed by data, within lower middle income countries (lmics) and in all countries and contexts where inequities exist. however, these must be developed in partnership with civil society organisations, community leaders/gatekeepers and residents who know what is needed to make a difference, now and in the future. there is also a need to engage in cross-country discussions to share learnings from previous emergency responses in urban settings and support sharing and solidarity around current promising strategies across and between different contexts. contributors sfr produced the first draft of the commentary. ko and st inputted and revised. all authors have approved and signed off the final version the commentary. funding some time for writing was funded through the ukri gcrf accountability for informal urban equity hub (also known as arise), which is a ukri collective fund award, rc grant reference: es/s x/ . the arise hub-accountability and responsiveness in informal settlements for equity-is a research consortium, aiming to enhance accountability and improve the health and well-being of marginalised populations living in informal urban settlements in kenya, sierra leone, bangladesh. the commentary expands on a piece that was published in the newspaper (daily star) in bangladesh. united nations, human rights, fao. the right to adequate food. fact sheet no. the world counts world food programme brac survey finds pc of low income people do not have food at home during shutdown nobel laureates esther duflo & abhijit banerjee bat for bolder social transfers to fight covid- govt to take action again against irregularities in relief distribution unacceptable irregularities in relief operation bangladesh's covid- stimulus: leaving the most vulnerable behind pm: dealers expelled, accused of relief mismanagement corruption mars bangladesh's covid- relief efforts countries in asia are facing new waves of coronavirus infections after lockdowns lift. the same could happen in the rest of the world iran's rouhani says low-risk economic activities to resume from april amid coronavirus competing interests none declared. patient consent for publication not required.provenance and peer review not commissioned; internally peer reviewed. key: cord- -h pcatvx authors: hanson, claudia; waiswa, peter; pembe, andrea; sandall, jane; schellenberg, joanna title: health system redesign for equity in maternal and newborn health must be codesigned, country led, adapted to context and fit for purpose date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: h pcatvx nan in this edition of bmj global health, roder-dewan and colleagues suggest ways in which we might rethink care models to close the equity gap in maternal and newborn health. their analysis article follows from the work of the lancet global health commission on high-quality health systems, proposing design reforms with quality at the centre. the authors suggest that all childbirth care services should be moved to hospitals in all countries, combined with improvements in ( ) the quality of care provided in these facilities; ( ) transportation from home to hospital; and ( ) continuity of care through hub-and-spoke arrangements. we agree in principle with the need to shift childbirth care services towards higher level facilities. the quality of care provided to women and their newborns in low and middle-income countries (lmics) is inadequate. economic development and advances in communication and transportation should redefine the paradigm of proximity to care. also kruk and colleagues estimated that more lives are lost today due to substandard care than due to limited geographical access. so it is important to rethink where and how childbirth care should be made available. however, such health system redesign needs to respond to local needs and bottlenecksthat is, redesign must centre human resources, particularly midwifery providers; respond to the local context; and be fit for purpose. to cite lynn freedman, 'the point is not that global strategies, evidence-based guidelines, or high-level monitoring and accountability initiatives are inherently wrong or unnecessary. but when they consume most of the oxygen in the room, drowning out voices and signals coming from the ground, they distort both understanding and action. ' redesigning maternal and perinatal care needs to be done with a view to strengthening district health systems in a sustainable and crisis-resilient manner-as the ongoing covid- pandemic reminds us. to prompt an open and transparent debate, informed by local insight and strategies based on evidence, we present here our own thoughts and reflections on how to take this agenda forward. first, roder-dewan and colleagues propose that the present strategy of promoting childbirth care in primary health facilities may be the primary reason for improvements in maternal and newborn survival being less than anticipated. numerous studies indicate that primary facilities, which generally have a low case load, provide substandard care. however most-if not all-of the present analysis is based on cross-sectional data; interpretation is inherently complicated by reverse causality and circular loops in thinking, as health planners wisely prioritise investments in equipment and upgrading of services of higher level and high case load facilities. as a result, we do not know the quality of the care that primary facilities could provide if they would be staffed and equipped according to standards. however, we agree that case load must be considered-although we believe there is still no consensus on what the preferred volume of cases in childbirth facilities should be. the discussion on the place of delivery is missing a debate on the skills of the providers. the skilled birth attendant strategy, which stems from the millennium development goals era, was primarily informed by experience of midwifery based on the concept that skills and competences are the most important attributes for high-quality childbirth care. however, skilled birth attendant training bmj global health in the past years has often prioritised quantity over quality by opening fast-track -year or -year training, a strategy which ignored the complexity of pregnancy care and in particular childbirth care. in a study including almost pregnant women, gabrysch and colleagues reported that, to their surprise, there was no evidence of better maternal or newborn survival for those living closest to a facility offering highquality care at birth, although there was evidence of a reduced risk of intrapartum stillbirth. this is a reminder that improving the quality of care means moving beyond the common concepts of facilities providing basic or comprehensive emergency obstetric and newborn care at primary or hospital levels, and requires a shift in focus to the provider instead. human resources are the crucial factor underlying all approaches to care organisation. midwives and nurse-midwives should be at the centre of a country-led, adapted-to-context, resilient and fit-for-purpose redesign. we note that a cochrane review of trials in highincome countries of midwife-led continuity models of care with other models of care involving women suggests that women who received midwife-led continuity models of care compared with other models of care were less likely to have potentially harmful interventions such as episiotomies or instrumental births and more likely to have a spontaneous vaginal birth and increased satisfaction. women were less likely to experience preterm birth and were at a lower risk of losing their babies. the review identified no adverse effects compared with other models. countries such as india and bangladesh are changing from training skilled birth attendants towards scale-up of midwifery training. in addition, there is more to be learnt from the integrated maternity system that exists, for example, in the uk, netherlands, scandinavia, australia and new zealand. here midwives provide cost-effective maternity care in community and hospital settings. childbirth care is offered in a range of settings to healthy women (home, hospital and midwife unit including free-standing or alongside an obstetric unit) with good outcomes. it is important to note that the largest global study of outcomes by planned place of birth found a lower caesarean section rate in midwifery-led care systems compared with other settings an important finding in view of the debate on non-rational use of caesarean section. it is timely that is the year of the nurse and the midwife: nurses and midwives must have the opportunity to be heard and to lead the further agenda on maternal and newborn health. midwifery-led childbirth care services at an intermediate level of a district healthcare system, integrated into midwifery-based continuity of care, should be an alternative approach to shifting all births to a hospital. midwifery-led continuity-based systems with midwifery-led childbirth care for low-risk women should be rigorously tested in lmic settings. second, while we agree that many referral systems do not function, better communication and referral across the tiers of a health system must be central to a country-led, adapted-to-context, resilient and fit-forpurpose redesign. the examples which roder-dewan and colleagues provide to indicate how transport to a hospital may be improved, can also stimulate thinking on how referral between levels of a healthcare system may be improved. but whether transport starts at home or at a facility, past challenges will remain if there is too little emphasis on sustainable operational systems as reports on lack of fuel or driver suggest. roder-dewan and colleagues propose a hub-and-spoke system linking primary to hospital care. this is surprising: to our knowledge such systems already exist in most lmic settings, where district health systems include linked primary care facilities and hospitals, comprising exactly such a hub-and-spoke system. a country-led, adapted-to-context, resilient and fit-forpurpose redesign should strengthen these established systems, for women, children and men; cutting across all diseases and illnesses. many district health systems are based on more than two tiers, and any change in strategy needs to build on these more nuanced systems. this strength should be harnessed. district medical officers and local health planners, with their rich local knowledge and insight, should drive the decisions on how and where high-quality childbirth care may best be delivered in their systems. third, we question the assertion that 'recent expansions in infrastructure and roads have put hospitals within reach of most families'. this claim is based on analysis from six countries (haiti, kenya, malawi, namibia, nepal and tanzania) suggesting that over % of women live within a -hour journey time to a hospital providing emergency obstetric care. the analysis assumes ideal conditions, including that motorised transport would be readily available if needed, ignoring the problems of finding transport at night or longer travel times during the rainy season as the authors admit. a -hour journey time to childbirth care is unrealistic in many settings. moreover, this is not the norm in high-income settings. in germany, it is suggested that a hospital offering childbirth care should be within - min travel time. roder-dewan and colleagues also admit the need to establish more decentralised health centres with comprehensive emergency obstetric care services to reduce the journey time. in view of the population increase, particularly in africa, establishing more hospitals is a forwardlooking strategy for maternal and perinatal health and other health needs. however, hospitals are large longterm investments. in southern tanzania, it took years from laying the first bricks of new operating theatres within health centres to establish functioning services, and even then, not all operating theatres have the staff to provide continuous care. there are examples of non-governmental organisationsupported initiatives where functioning services were developed faster and made more consistently available. however, midwifery-led birthing facilities equipped with functioning ambulance able to make transfers to a hospital with caesarean section services may be a less bmj global health complex and more flexible approach; more responsive to the needs of women and their families. geographical information systems can help find a local balance between quality and accessibility. while expanding hospital services remains a long-term vision, operational and practical medium-term strengthening is needed to fix the present quality of care and operational problems. and women should have a say: midwifery-led continuity models may provide the highest satisfaction among women and their families with lowest maternal and perinatal morbidity and mortality. the covid- pandemic is critically disrupting access to hospital care throughout the world, and this prompts us to share another perspective: hospitals are typically overcrowded and beds in postnatal wards are often shared, making infection prevention and control even more challenging than ever. at present, women and families are avoiding hospitals, in fear of infection. private transport has been severely interrupted. creating resilient health systems means that quality care is also available in crisis. in cambodia, community-based research respondents raised the lack of flexibility of the provision of childbirth care when floods were disrupting normality. women and their families should not only be consulted as research respondents but continuously, so that end users are central to defining strategies. women and their families should have a say indicating how far is too far. in conclusion, although we concur with many of the arguments and conclusions, we believe that more discussion is needed and more options need to be rigorously tried and tested to develop sustainable district health systems which are fit for purpose and respond to needs of women, their babies, their families and centred around midwifery-based continuity of care. health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap high-quality health systems in the sustainable development goals era: time for a revolution mortality due to lowquality health systems in the universal health coverage era: a systematic analysis of amenable deaths in countries implementation and aspiration gaps: whose view counts? the scale, scope, coverage, and capability of childbirth care quality of basic maternal care functions in health facilities of five african countries: an analysis of national health system surveys minimum obstetric volume in low-income countries strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialized west investing in maternal health. learning from malaysia and sri lanka scoping review to identify and map the health personnel considered skilled birth attendants in low-and-middle income countries from does facility birth reduce maternal and perinatal mortality in brong ahafo, ghana? a secondary analysis using data on pregnancies from two cluster-randomised controlled trials midwife-led continuity models versus other models of care for childbearing women world health organization. maternal, newborn, child and adolescent health perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the birthplace in england national prospective cohort study maternal and perinatal outcomes by planned place of birth among women with low-risk pregnancies in high-income countries: a systematic review and meta-analysis we do what we can do to save a woman" health workers' perceptions of health facility readiness for management of postpartum haemorrhage in low-and middle-income countries, is delivery in high-quality obstetric facilities geographically feasible? welche geburtsklinik für welche schwangere? [which maternity hospital for which pregnant women? enhancing maternal and perinatal health in under-served remote areas in sub-saharan africa: a tanzanian model how can childbirth care for the rural poor be improved? a contribution from spatial modelling in rural tanzania staying afloat: community perspectives on health system resilience in the management of pregnancy and childbirth care during floods in cambodia key: cord- - b toeik authors: wishnia, jodi; goudge, jane title: impact of financial management centralisation in a health system under austerity: a qualitative study from south africa date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: b toeik introduction: international calls for universal health coverage (uhc) have led many countries to implement health sector reforms, however, since the global recession, economic growth has slowed in many lower-income and middle-income countries. in a renewed interest in public financial management (pfm), international organisations have emphasised the importance of giving spending control to those responsible for healthcare. however, centralisation is a common response when there is a need to cut expenditure due to a reduced budget; yet failure to decentralise often hampers the achievement of important goals. this paper examines the effect of centralising financial decision-making on the functioning of the south african health system. methods: we used a case study design with an ethnographic approach. primary data collection was conducted through participant-observation and semistructured interviews, over year. member checking was conducted. results: new management implemented centralisation due to a reduced budget, a history of financial mismanagement, the punitive regulatory environment financial managers face, and their fear of poor audit outcomes. the reform, together with an authoritarian management style to ensure compliance, created a large power distance between financial and clinical managers. district managers felt that there was poor communication about the reform and that decision-making was opaque. this lowered commitment to the reform, even for those who thought it was necessary. it also reduced communal action, creating an individualistic environment. the authoritarian management style, and the impact of centralisation on service delivery, negatively affected planning and decision making, impairing organisational functioning. conclusion: as public health systems become even more financially constrained, recognising how pfm reforms can influence organisational culture, and how the negative effects can be mitigated, is of international importance. we highlight the importance of a participatory culture that encourages shared decision making and coproduction, particularly as countries grapple with how to achieve uhc with limited funds. in the last decade, international calls for universal health coverage (uhc), coupled with the sustainable development goals' inclusion of uhc, has led many countries to implement health sector reforms. however, fiscal space for public services has narrowed during this period given the recession, leading to a renewed interest in public what is already known? ► health systems are facing demands for improved access to care in the context of constrained fiscal space. ► decentralisation of financial control to managers responsible for service delivery should, in theory, improve the use of funds. what are the new findings? ► a fear of poor audit outcomes can lead finance managers to hold onto financial control; this fear is exacerbated in austerity climates and in systems with a history of financial mismanagement. ► finance and clinical managers often do not have a shared vision of the goal of the health system, and this drives tension and impacts negatively on relationships. ► this leads to an organisational culture that is competitive and dismissive of the needs of the collective. ► this further weakens the health system. ► austerity can lead to radical public financial management reforms to attempt to control expenditure. ► finance and clinical managers need to find more opportunities to coproduce the shared goals of the department to ensure policy reform is aligned to systems goals-this can be done through multidisciplinary committees. ► relational accountability, which is fostered by working more closely together, can increase acceptability of decentralised control, which would improve participation and ultimately health systems functioning. financial management (pfm), given its intention to support service delivery, while controlling expenditure. the world bank and world health organization (who) have re-emphasised the importance of giving spending control and flexibility to those responsible for healthcare such as facility managers and district health offices (dhos). the aim of this decentralisation is to achieve more efficient use of funds. the reasons why this shift in control has not been widely implemented vary from a lack of capacity at the lower levels of the health system, to poor accountability mechanisms. centralisation of financial decision making is in fact a more common response when there is a need to cut expenditure in line with a reduced budget. it is also likely to be a widespread response to the austerity that will follow the covid- pandemic. however, failure to decentralise decision-making is likely to hamper the functioning of health systems, constraining their ability to maximise value from limited resources. since the global recession, south africa (sa), like many other lower-income and middle-income countries (lmics) has been experiencing low, or no, economic growth. the government has instituted widespread austerity measures, particularly to reduce the public sector wage bill. in , the south african national department of health (ndoh) announced its intentions to implement uhc, through a national health insurance (nhi) scheme. as a result, the health system is grappling with how to responsibly manage public funds while responding to the new uhc policy goals, a problem that has come to the fore in many lmics. in this paper, we examine the effect of centralising financial decision making on the functioning of a south african provincial department of health (pdoh), in an environment of health system reform. country context sa is a middle-income country with a federal system of government. until financial year / , sa had been able to largely protect its social services sectors (eg, health, education) from the effects of slower economic growth and a decline in tax revenue. however, since , this has no longer been possible and the social sector has been negatively affected by declining budgets in real terms, despite an increasing burden of disease. the austerity climate in the country has substantially worsened since , due to attempts to recover from a period of widespread corruption. sa has a quadruple burden of disease which increases the need for health services. however, quality of care remains poor due to insufficient budgets and ineffective use of funds. sa has an ndoh, nine pdohs and dhos. figure illustrates the levels and responsibilities of the health system and shows that it is the responsibility of the pdoh to delegate financial decision-making to districts and facilities. sa's health sector has a long history of trying to decentralise governance to the dhos, with the national treasury and the ndoh encouraging pdohs to deconcentrate power. most of the pdohs have experimented with 'delegations', which legally allows a lower level official to be responsible for a task that has been assigned to a more bmj global health senior manager. however, the use of delegations remains limited. with nhi, the ndoh plans to shift financial accountability away from provinces to districts, essentially forcing decentralisation onto the health system. since the s, the field of organisational management has studied how people influence their organisation's performance. 'organisational culture' (oc), a theoretical construct within organisational management science, is generated as an organisation performs its functions, creating a pattern of shared assumptions. this culture governs the way people perceive, experience and, in turn, influence how the organisation functions. oc can answer questions about how decisions are made and offer possible reasons for why implementation is difficult despite an organisation having all the requisite infrastructure and resources ('hardware'). oc is often seen as the connector between individual and collective behaviours and therefore is a useful paradigm when trying to analyse systemic policy failure. within health systems and policy research, it is widely accepted that the functioning of a health system is influenced by the people working within it, and their relationships ('software'). however, framing this phenomenon using oc is relatively new in the field. therefore, a recent synthesis of evidence by mbau and gilson ( ) has been valuable in determining an analytical framework through which to analyse oc in lmic health systems. their framework illustrates the ways in which oc influences organisational functioning in lmics (figure ). the framework contains two layers: 'dimensions of culture' and 'organisational practices'. table describes the dimensions of culture (we have renamed three of the dimensions for clarity), and table the organisational practices. the dimensions and practices are interrelated. for example, managers, afraid of poor outcomes, may adopt an authoritarian management style to avoid uncertainty and control outcomes, resulting in a large power distance between managers and employees. a participatory management style, on the other hand, increases managers familiarity with the lower levels of the organisation, and so can reduce their fear of uncertain outcomes by improving their understanding of the challenges at lower levels. the resulting collective uncertainty avoidance degree to which the members of an organisation avoid unknown outcomes by depending on accepted practices, rules, or procedures. power distance the difference in (decision-making) power between higher and lower levels of an organisation, and whether that power difference is found to be acceptable and appropriate. institutional collectivism extent to which the organisation encourages and rewards communal action (working together). in-group collectivism level of pride, satisfaction and loyalty shown by members towards their organisation. process facilitates better communication and feedback, increasing participation in decision making. it also fosters communal action across, and commitment to, the organisation. we used a case study design, with ethnographic methods. these methods are appropriate when looking to explain 'how' or 'why' events happened, and health systems actors' perspectives on them. case studies are particularly valuable for research looking to understand oc within a particular setting, like a pdoh. case studies allow for holistic research within the real context of the participants. it therefore pairs well with ethnography, which aims to understand the reality of participants from inside their context. study setting and negotiating access the pdoh studied is situated within a poor, predominantly rural province in sa. it has a long history of financial mismanagement and is one of the poorer performers in the country in terms of service delivery. the province has experimented with widespread delegations to the dhos in the past but revoked them due to mismanagement. the austerity measures and pfm centralisation have been in place since . jw had previously worked with the province in her capacity as a health financing specialist and was known to many of the senior and middle managers. she met with one of the senior finance managers to ask whether the pdoh would be willing to participate in the study. from there, the research protocol was shared with the executive management of the province and the pdoh agreed to be involved. informed consent was obtained for all observations, interviews and audio recordings. participant selection jw received informed consent from individuals to be observed and was a participant observer in meetings, which varied from routine financial management meetings to meetings with hospital chief executive officers (ceos) at their facilities. in these meetings, she was allowed to ask questions and provided technical advice when invited to do so. jw used purposive sampling for her interviews, contacting employees responsible for financial and clinical management at the pdoh head office, dhos and public hospitals. she then used snowball sampling either through the introductions made at meetings or through a referral by an interviewee. no one explicitly refused to participate in the study, however, some never responded to several requests for an interview. she conducted interviews (table ) . data collection ran from july to june . at the start of data collection, jw attended two -day meetings to introduce the research to key stakeholders. jw collected all the data for the research. data collection was conducted using participant observations and semistructured interviews. data were collected by visiting the province for several days at a time. during these visits, jw attended meetings and conducted in-person interviews. the majority of the observations and interviews took place either within the head office, dho or a public hospital. for the observations, jw used an observation guide to make detailed meeting notes. a semistructured interview guide was used for data collection. jw used a 'grand tour' approach. grand tour is useful when you want to elicit a thick description within case study research. the grand tour questions were adapted for interviews at the different levels of the communication and feedback the extent to which, and how, staff are informed about policy reform processes. authoritarian (most negative), consultative or participatory (best practice) management. to what extent employees across the system are involved in decision making. commitment the extent to which employees support the reform. bmj global health health system. the questions were designed to prompt participants to share their experiences in their own words. some of the questions included: 'describe your average workday' and 'tell me about a time you interacted with the pdoh and how that impacted you'. interviews ranged from min to over an hour. no one else was present at the interviews. only one participant refused to be audio recorded; he felt this was necessary to be able to participate fully. while repeat interviews were not conducted, the researchers did amend the interview questions during data collection to take into account knowledge already gained from previous interviews and observations. the authors discussed when no new information was emerging and determined data saturation had been reached. data analysis jw wrote up her observation notes after each interaction. the audio files were deidentified and transcribed by an external company, and then checked for accuracy. the authors read the data, with jw coding the data according to common themes, following which the authors discussed the emergent codes. jw then analysed the codes and grouped them into high-level themes. the authors interrogated these themes, discussing the strength of the evidence for each. we selected mbau and gilson's ( ) framework as a useful way to frame the data. we used dedoose to deductively recode the data, using themes from the framework, with a total of eight codes (four dimensions of culture and four organisational practice codes). identifiers are used to anonymise the quotations. we used 'i' for data gathered via an interview, followed by either a 'p' for pdoh, 'd' for dho or 'h' for hospital. observation notes were used to inform the analysis, but we do not use verbatim quotes from these. member checking was done through a participatory workshop to discuss the research findings. the invitation was extended to everyone within the head office, the two dhos studied and the four public hospitals. the workshop was held over day, with all attendees in the same workshop. the workshop was interactive, splitting attendees into groups to consider the research findings. these groups were heterogeneous, with at least one member from the different levels of the health system, as far as possible. attendees gave input on whether the key themes were appropriate and engaged with the findings. the discussions at the workshop contributed to the proposed recommendations in this paper. this, along with the rigorous data analysis methods, have ensured the credibility and confirmability of the findings. reflexivity jw asked participants to clarify the background behind a statement, even though she was familiar with the history. this approach, combined with reflexive note taking and jg's interrogation of the data, enabled jw to separate her perceptions from the respondents' interpretations of events. jw also wrote down her thoughts on the quality of the interview and any insights that emerged. no patients or members of the public were involved in the research design, analysis nor dissemination of the findings; however, provincial managers contributed to the research focus in the planning stages, and provincial, district and hospital managers were involved in the interpretation of the findings. . this has forced managers to purchase services that they do not have the funds for (resulting in accruals), to maintain service delivery: "when you do not have any money left, you just borrow! so, we owe our suppliers from way back!" [ih ]. as accruals from the previous year must be settled first; the impact of austerity is cumulative from one year to the next. a hospital manager highlighted the impact of this narrowing fiscal envelope for service delivery: "at the beginning of the year, we had a r million gap between the authorised budget and expected expenditure, but we were only left with a r million budget shortfall at the end of the year. that means we cut expenditure by r million somewhere, either by reducing services, or compromising the quality of care." [ih ] . over the last decade, the province has been attempting to rationalise the service delivery platform (reduce the number of facilities), to bring down the running costs, but these attempts have been unsuccessful largely due to resistance from surrounding communities who did not want to lose their facility. in addition, the pdoh has experienced a proliferation of 'unfunded mandates' in the pursuit of uhc: "a decision was made that we are [ given their proximity to service delivery: "it's very stressful, […] we are trying to deliver [services] to communities, but one of the major challenges is resource constraints." [ip ]. the province has a history of financial mismanagement and poor audit outcomes: "the district managers were given financial delegations, but they would go out for meetings on consecutive days and they would leave the order books signed, and then anybody who wanted to buy anything would just fill in the particulars!" [ip ]. the national and provincial treasury have had to intervene several times: "if the department can't manage their salary payments, then provincial treasury takes that function away." [ip ] . emulating the treasury's approach, the pdoh tends to revoke financial control from the lower levels when there is evidence of mismanagement. this is implemented across the board, not just for the offending manager: "something small happens, and then they just pull the delegations away! so, it's like a knee-jerk reaction!" [ip ]. since , under new leadership, the pdoh has endeavoured to improve the financial audit outcomes by instituting a radical pfm centralisation reform. they established a 'centralisation committee', which is comprised of financial, clinical and support service managers who meet once a week to review expenditure and payment requests for the whole province. the committee is chaired by the chief financial officer (cfo), and its establishment revoked all delegations from the districts and facilities. members of the committee are senior managers within the head office, with none from the dhos or hospitals. a hospital manager empathised with the rationale for the reform: "i understand why [they instituted this reform], and maybe, i would feel inclined to do the same. health is an underfunded mandate, so, on paper, we try and prevent unauthorised expenditure because the cfo and financial managers will lose their jobs." [ih ] . several finance managers echoed the sentiment that the finance environment was very punitive: "so, if we want to see some bloodshed, one needs to look within the finance department, where i think the greatest amount of correspondence is sent out in terms of financial misconduct and i think that's because treasury has quite vigilant consequence management." [ip ]. power distance, commitment to the reform and effect on relationships clinical managers within the head office reflected on the centralisation of power: "sometimes, when i engage fellow middle managers, i feel that they are not sure of certain decisions […], decision-making power is very much controlled at the executive management level." [ip ]. it was not only clinical managers who felt aggrieved by the centralisation, finance managers in the districts also felt shackled: "i feel like head office are not giving you space. even the district managers, the senior managers, are not given a space to cooperate and prove their worth or their capabilities." [id ]. hospital managers were also dissatisfied: "to be a ceo in the department of health is a nightmare because we are given the responsibility, but you're not given the necessary authority; you don't have the financial delegations to do your job." [ih ]. many managers lamented the inefficiency of the new committee: "it can take a month for the committee to approve an order of a simple item, then there is the procurement, and then we still need the committee to approve the payment! it's a nightmare from the facility's point of view." [ip ] . managers were reluctant to support the reform, even those who felt centralisation was acceptable: "i feel the centralisation committee is necessary, but the committee does delay us. if communication were free flowing with actual turnaround times that are within reason, we wouldn't mind." [id ]. most managers felt centralisation was not the right solution and found it both inefficient and unfair to those who had not transgressed: "[they said] everything had to be centralised. i am saying, 'that is not fair, why are we getting impacted in a negative way, it is not right." [ih ] . clinical managers described the strained relationship between the finance teams and them: "there is a huge discrepancy in understanding our individual roles and our team roles. we feel very strongly, from the clinical branch, that we should give direction, and then they should say how that can be supported. this is now not me alone [that holds this view], that i am sure of! we feel very strongly they are not a support to us. they are dictators." [ip ] . in turn, finance managers bemoaned clinical managers' lack of concern for the constrained fiscal environment: "why are all clinical needs given a much higher priority than staying within the budget, when services cannot operate if we have run out of money?" [ip ]. to try and repair the relationship, the finance team at the head office assured managers that this reform was a short-term necessity to prevent continued financial disrepute. however, there has been no change to the reform in several years: "there has been this verbal commitment to differentiate the delegations, but there has been no follow through. i am told that it is going to happen now, but i have been told it is going to happen for the last year and a bit." [ih ] . once the audit outcomes begun to improve, finance managers cited fear of regression as the reason to maintain the reform: "the delegations have not been cascaded in order to manage the risk of [ however, many clinical managers suggested that agile accountability mechanisms that are able to identify and correct mistakes quickly could help reduce financial mismanagement: "if we are being wasteful or have done it incorrectly, then charge us! we will quickly do the right things!" [ih ]. district finance managers also pushed for delegated control: "they are saying we will mess up the budget, it won't balance, but i don't think that's true, [if there is a mistake] they know where to take that complaint to." [id ]. many managers reported feeling loyal to the organisation: "i love what i do so, maybe that's why, even though it is stressful, there are things that cause you to wake up and come to work. being a provider of a public service is not always easy, but i think passion drives us." [id ]. this was not limited to clinical managers, finance managers felt similarly: "if i look at my job, it's a job that i love, that i'm absolutely motivated and inspired to be doing." [ip ] . this loyalty to the organisation appeared to be a major consideration for managers remaining in the organisation during exceptionally difficult circumstances. however, the lack of a participatory management style affected organisational functioning: "i find the misalignment comes [ in this paper, we have described how centralisation was implemented in response to austerity and financial mismanagement, the punitive regulatory environment financial managers face and their fear of poor audit outcomes. the reform, together with an authoritarian management style to ensure compliance, created a large power distance. managers felt that the committee gave insufficient feedback and that decision-making was opaque. this lowered commitment to the reform, even for those who thought, given the pdohs financial history, the reform was necessary. it also reduced communal action, creating a more 'territorial'/individualistic environment. while many managers expressed their loyalty to the organisation and how this had kept them motivated, the authoritarian management style, and the impact of centralisation on service delivery, had negatively affected organisational planning and decision-making. problems with implementation are often attributed to misalignment and misunderstanding between actors in health systems. many managers in our study reported that the head office was disconnected from the rest of the health system, making them ill suited for centralised control. however, given the fear of uncertainty, finance managers remained wary of financial decentralisation, as is common during fiscally constrained periods, and therefore, the reform has remained in place. different parts of an organisation often have their own subcultures that may be in conflict with one another. however, as long as the subcultures are aligned to the overarching organisational goals, this may not be a problem. studies of hospital wards have explored how a punitive pfm regulatory environment exacerbates the harmful effect of austerity on service delivery, and can lead to irrational purchasing decisions. we have reported on the punitive subculture within the finance teams and the disagreement between finance and clinical teams on the organisation's goals. where spaces for shared decision making were created, clinical managers bmj global health often refused to participate as their contributions were not truly considered, reducing communal action, and impacting negatively on departmental performance. organisations with an authoritarian management style often rely on 'bureaucratic' and punitive accountability mechanisms to ensure adherence to policies. in contrast, 'relational' accountability theory points to the importance of positive supervisory relationships to exist alongside accountability measures for the latter to be effective. if the supervisor has a greater understanding of the challenges the supervisee is facing, a realistic compromise is possible. relational accountability requires a participatory management style and coproduction. changing to a participatory environment can, however, be difficult when an organisation's culture favours 'command and control' and top-down decision making, as seen in the province studied. our recommendations below centre on bringing diverse managers together more often, and in different settings, as a start toward building the relationships (and culture) needed for a functional organisation. sa, like many other lmics, envisions using capitation and similar methods for reimbursement under its nhi, with predetermined limits on what can be spent, and financial accountability shifting to the district health offices. in preparation for nhi reform, managers could use a similar approach, even if just for a discrete list of items, to facilitate the shift to decentralisation. for example, a cost per capita for primary healthcare (phc) services is fairly easy to determine given available data, and the province could decentralise sufficient funds to cover phc visits, to the dhos. this shifts spending power to the lower levels while still maintaining control over the spending ceiling, a core goal for successful pfm. we suggest recommendations (box ) that facilitate engagement and communication across finance and clinical managers, a key challenge especially for lmics who are under the dual pressure of austerity and uhc implementation. in following these recommendations, pfm reforms can be developed collaboratively, which can ensure both reform success and safeguarding of oc and so, an organisation's functioning. as we grapple with the covid- pandemic, the austerity climate is bound to worsen. we need to be mindful of the ways in which austerity and the pfm policies it brings, can impact on oc, and so affect organisational functioning. the world bank group has already started publishing guidance for treasuries on how to be able to respond agilely to the needs of social sectors, for example, by making it easier for facilities to access funds to procure needed goods and by allowing for more real time reporting of available cash. our paper showcases the deleterious effects of a health system that is unresponsive and authoritarian and feeds into this new body of recommendations that call for greater collaboration across finance and clinical managers. the pandemic could further tip the scales of power toward finance managers, as they attempt to control the shrinking public purse. we caution against this and highlight the system benefits of a participatory culture, especially for effective pfm. jws access to managers was linked to her existing relationships and these were mostly with senior managers. this was a possible reason for only four junior managers agreeing to be interviewed. the distance between her home province and the study province restricted how often she could conduct data collection. this was mitigated through longer data collection periods. lastly, the findings are limited to one province; while they cannot be generalised, the experiences documented are similar in other south african provincial departments of health and lmics. the pdohs centralisation reform influenced its oc, reducing opportunities for participatory decision making and polarising finance and clinical managers. this not only hindered reform implementation, but also impacted negatively on the overall functioning of the health system. the pressure placed on the department by the socio-political context of austerity and financial mismanagement, had a direct bearing on reform choice and design. as public health systems become even more financially constrained, alongside the pressure to rollout massive system restructuring to support uhc, recognising the ways in which pfm reform can influence oc, and how the negative effects can be mitigated, is of international importance. for the study setting ► include district managers and hospital chief executive officers in the provincial executive team. ► rotate provincial finance managers through district health offices (dhos) and hospitals to facilitate greater understanding of the challenges on the ground; this will allow for relational accountability. ► rotate the chair of the centralisation committee on a weekly basis. ► invite key stakeholders from the districts and facilities to sit on the centralisation committee, including members of the district centralisation committees, even if on an ad hoc/as possible basis, to build capacity at lower levels, and foster trust between the levels of the health system, in preparation for decentralisation and national health insurance. ► in time, the centralisation committee could determine a list of decisions that could be delegated to district-level committees. the time spent together should provide a foundation for relational accountability, which should improve public financial management. ► finance managers should spend time in facilities and dhos to better understand the reality on the ground. ► the time spent together on the ground would support relational accountability between clinical and finance managers. ► once the relationship between clinical and finance managers begins to strengthen, finance teams should determine an initial list of decisions that can be delegated to the lower levels of the system to support a transition to decentralisation. twitter jodi wishnia @jodi_wishnia aligning pfm and health financing: sustaining progress toward universal health coverage. health financing working paper let managers manage: a health service provider's perspective on public financial management the impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence the global financial crisis: experiences of and implications for community-based organizations providing health and social services in south africa health spending at a time of low economic growth and fiscal constraint fiscal space for health: a review of the literature: resyst the political economy of corruption elite-formation, factions and violence working paper society, work & politics institute analysing the progress and fault lines of health sector transformation in south africa south african national department of health. confronting the right to ethical and accountable quality health care in south africa federalism and decentralization in health care: a decision space approach south african national treasury. principles of public administration and financial management delegations south african national department of health. national health insurance white paper predicting corporate performance from organizational culture organizational culture and leadership the influence of organizational culture on information use in decision making within government health services in rural burkina faso organisational culture and change: implementing person-centred care building the field of health policy and systems research: framing the questions influence of organisational culture on the implementation of health sector reforms in low-and middle-income countries: a qualitative interpretive review project globe: an introduction what is ethnography? in: ethnography principles in practice. routledge designing case studies: identifying your case(s) and establishing the logic of your case study a review of the literature on case study research. cjnse trent focus for research and development in primary health care: how to use observations in a research project: trent focus group semistructured interviewing in primary care research: a balance of relationship and rigour thick description. encyclopedia of case study research thematic analysis: striving to meet the trustworthiness criteria mapping the existing body of health policy implementation research in lower income settings: what is covered and what are the gaps? the effects of the financial crisis and austerity measures on the spanish health care system: a qualitative analysis of health professionals' perceptions in the region of valencia it makes me want to run away to saudi arabia': management and implementation challenges for public financing reforms from a maternity ward perspective accountability mechanisms and the value of relationships: experiences of front-line managers at subnational level in kenya and south africa an assessment of organisational values, culture and performance in cape town's primary healthcare services agile treasury operations during covid- the world bank acknowledgements we would like to acknowledge the pdoh and all participants for their contribution.contributors both authors conceived of and planned the paper. jw is the principal researcher and conducted data collection and primary data analysis. jg reviewed the data analysis results and provided expert guidance. jw was the primary manuscript writer, with jg providing detailed input. both authors approved the final version of the manuscript.funding jw's research is funded by the south african research chair initiative.competing interests none declared.patient and public involvement patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.patient consent for publication not required.ethics approval ethical approval was granted by the university of witwatersrand's human research ethics committee (medical) (m ) and the pdohs research committee.provenance and peer review not commissioned; externally peer reviewed.data availability statement all data relevant to the study are included in the article or uploaded as online supplemental information. all relevant data are included in the paper.open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. jodi wishnia http:// orcid. org/ - - - jane goudge http:// orcid. org/ - - - key: cord- - tcikxl authors: paul, elisabeth; brown, garrett w; ridde, valery title: covid- : time for paradigm shift in the nexus between local, national and global health date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: tcikxl nan ► the covid- pandemic has triggered unprecedented measures worldwide, which have often been adopted in an 'emergency' mode and are largely reactionary ► alternatively, covid- needs to be appraised as part of a much bigger health picture, adopting a "systems approach" that enables interactions with other acknowledged and preventable health conditions, which often receive disproportionately low attention ► to do so requires a paradigm shift in global health governance, from a specific reactional paradigm to a systemic, coordinated and preventive paradigm ► it is necessary to adopt a holistic approach to health reflecting both a security approach and a health development approach, tackling upstream causes and determinants, aimed at helping populations reduce their individual risk factors and augment their natural immunity ► such preventive health policies must be tailored to local specificities and local environments, and health systems must be strengthened at the local level so as to be able to respond to population needs and expectations ► the current crisis calls for a paradigm shift in public and global health policies; and in the in the nexus between local, national and global health policies and systems the who declared the novel coronavirus disease (covid- ) an 'emergency of international concern' on january and a pandemic on march. according to who's situation report - , as of april , the epidemic has caused deaths worldwide. while it is seemingly nearing its end in china, where it was first reported, it is still on the rise in europe, in the usa and in other parts of the world, including in many low-income and middle-income countries (lmics). the pandemic has triggered unprecedented measures worldwide. many countries have installed travel bans, confinement and lockdown policies. these responses have been adopted in an 'emergency' mode, and are largely reactionary, aimed at mitigating the spread of the disease while waiting for a specific cure and/or vaccine to be developed. here we do not want to underestimate the risks caused by the pandemic, nor to question the measures taken by the who and governments. but we would like to express our concerns regarding four covid- -related issues, and advocate for a 'paradigm shift'that is, a scientific revolution encompassing changes in the basic concepts and experimental practices of a scientific discipline -to prepare for future crises. a shift in focus: covid- in the broader global health picture it is important to remember other acknowledged and preventable health conditions, when compared with the focus that covid- has triggered at global and national levels. respiratory diseases have been leading causes of death and disability in the world before covid- . it is estimated that, globally, four million people die prematurely from chronic respiratory disease each year; in particular, one million die annually from chronic obstructive pulmonary disease; pneumonia kills millions of people annually and is a leading cause of death among children under years old; each year . million die from tuberculosis; and lung cancer kills . million people a year and is the deadliest cancer. the who estimates that seasonal influenza kills up to people a year. in , an estimated people died of malaria. in , about women died during and following pregnancy and childbirth-that is approximately women each day. in the usa alone, a lower limit of bmj global health deaths per year was associated with preventable harm in hospitals. whereas infectious diseases seem to inspire the most terror among the public and policymakers, noncommunicable diseases are responsible for almost % of all deaths. depression affects million people globally and is the leading cause of disability worldwide, and nearly people die from suicide every year. the global boom in premature mortality and morbidity from non-communicable diseases has now reached a point where some have even suggested it to be a pandemic. moreover, climate change (through increased heat waves and disasters) and atmospheric and environmental pollution are expected to increase deaths and injuries, especially in lmics. in some debates, climate change has become more than a risk factor, with increasing calls for the who to declare it a public health emergency. from a public health perspective, covid- needs to be appraised as part of a much bigger health picture. for instance, beyond the lethality and direct mortality rates of covid- , attention should be paid to the interaction with other pathogens, as well as to the more indirect effects of its mitigation measures. indeed, the pandemic and its containment measures interact with, and impact on, other health conditions and will have system-wide effects, highlighting the importance of adopting a 'systems approach' to its resolution. a paradigm shift in global health governance the global health community, national security agencies and all governments have known that a pandemic like covid- was likely to come, yet global health policy has remained woefully unprepared nor fit-for-purpose. in , the g members proclaimed that ebola had been a 'wake-up call' for the need for better global cooperation. it was also recognised that antimicrobial resistance (amr) threatened to kill million people by , thus demanding urgent action. yet little has been done to address these existing global health governance shortcomings. for example, the lauded g and g response, the global health security agenda (https:// ghsagenda. org/), continues to speak in the terms of costly 'countermeasures' versus prevention and health system strengthening. moreover, the pandemic emergency financing facility (pef) (https://www. worldbank. org/ en/ topic/ pandemics/ brief/ pandemic-emergency-financingfacility), meant to deliver up to $ million in epidemic assistance to curb expansion into a pandemic, sits idle as a complicated 'loan mechanism' at the world bank, available to only a few countries (eg, china and india do not qualify for the money). there is also serious ambiguity about how the pef intersects and/or complements the who's contingency fund for emergencies (cfe) (https://www. who. int/ emergencies/ funding/ contingency-fund-for-emergencies). the cfe is available to more countries for more risks, and more quickly, but represents far less money than the pef (which, in theory, should come after the cfe, if you happen to prequalify for the loan). the 'one health' approach, which was meant to offer a more responsive research and policy agenda to combat zoonotic diseases, remains sluggish at best and underdeveloped in terms of including environmental factors, such as soil and water, which play a crucial part in amr and other threats. in terms of pathogen monitoring and response, the international health regulations, which are meant 'to help the international community and governments prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide', are not fully implemented by many countries due to limited financial resources and political will, and have been violated in response to the covid- outbreak. what is more confounding is that many highincome countries like france have failed to fully implement the international health regulations, particularly in their overseas territories. in addition, other disease control mechanisms, like the who global influenza surveillance and response system (https://www. who. int/ influenza/ gisrs_ laboratory/ en/), remain inadequate and underfunded, with too few who laboratories and a market-based model where a global public good (pooled influenza knowledge) is turned into a private good (pharmaceutical profit), with historical inequities in terms of public health. moreover, many countries, like china, are incentivised not to raise the epidemic alarm too soon due to fears of diminished direct foreign investment (like with severe acute respiratory syndrome, h n and now covid- ) and fears that the government will be perceived as weak. these conditions of incapacity at the international level are exacerbated by a weakened who, whose budget has been radically reduced and ring-fenced. for example, the who used to receive three-quarters of its financing from assessed contributions levied on members. however, a change to a zero real growth policy for its regular budget in the s has meant it now only receives a quarter of its budget from member contributions. as a result, the who is dependent on extra-budgetary ring-fenced 'pet project' funding from donors to fill an increasingly shrinking budget. as the money flows to other multilateral health initiatives, the who's authority dissipates, with numerous organisations like the institute for health metrics and evaluation, the bill and melinda gates foundation and médecins sans frontières able to command greater epistemic authority, financial influence and response effectiveness. however, this expansion of initiatives creates a condition of policy fragmentation, which significantly weakens coordinated global public health. one real result of fragmentation of global health governance is an inefficient division of labour, where hundreds of actors such as the who, global fund, president's emergency plan for aids relief, united nations programme on hiv and aids, united states agency bmj global health for international development, world bank, the gates foundation and the clinton foundation (to name only a few) produce parallel programmes or bric-à-brac vertical health silos that have neither generated overall system strengthening in high burden countries nor allowed for effective global health policy. this creates two failures. first, contrary to sector-wide approaches, vertical 'pet-project' global initiatives often fail to promote sustainable long-term local health system strengthening, which is the best preventive defence for disease control (of all types, not just infectious diseases). second, the global level is woefully unprepared for epidemics, since global policy has remained reactionary, symptom-based and dependent on vaccine discoveries without full appreciation of other upstream determinants of disease and access to those vaccines. given the state of global health governance and inadequate investments in health system strengthening-as well as the failure, by many actors, to adopt a 'systems approach' to problem resolution -the spread and danger of covid- is not surprising. what is required, we argue, is to shift global health policymaking from a specific reactional paradigm to a systemic, holistic and preventive paradigm. there is no doubt that this approach will require serious resources, governance reform and political will. nevertheless, the global economic costs of covid- have already reached into at least a trillion dollars. thus, serious efforts to improve global and local health systems would be a small fraction of this cost, with a tried and true cost-saving philosophy that 'an ounce of prevention is worth a pound of cure'. beyond the 'pasteurian paradigm': a holistic view of health the emergency responses to covid- so far are based on the so-called 'pasteurian paradigm', which states that each disease is due to one pathogen; thus, for each disease there is one cure, targeting the responsible pathogen. in this case, laboratories are racing to find the cure or the vaccine against covid- -a vaccine which will come too late for the current epidemic, and will have limited efficacy if the virus mutates in the coming months or years. yet it is easy to see how the more pathogens there might be in the future (which there will be) the less this paradigm makes sense. moreover, the pasteurian paradigm has imposed its preferred research methodnamely, randomised control trials that try to isolate one variable from all possible variables-as the gold standard of science, relegating other approaches as near charlatanism. however, there is a multitude of evidence indicating that beyond a single pathogen, the development of a disease, as well as its outcome, is considerably affected by the physical and social parameters in which it operates, and that this is considerably affected by social, political, environmental and individual factors. this seems widely known by the public as far as chronic non-communicable diseases are concerned, but is also the case for infectious diseases, especially for emerging infections, in which the pathogenic role of social inequalities is recognised. moreover, the traditional frontiers between communicable and non-communicable diseases are being blurred by evidence of 'biosocial contagion'. in this light, the globalised world is now facing a 'syndemic'-that is, a synergy of epidemics that 'co occur in time and place, interact with each other to produce complex sequelae, and share common underlying societal drivers'. covid- is no exception, since its mortality rate varies significantly according to age, sex and comorbidities. as an alternative, we argue that it would be more effective, efficient and equitable to adopt a holistic approach to health. how to tackle the silent killers and how to prepare populations-including the most vulnerable -against future epidemics should be on the top of national and global health policy and research agendas. this should reflect both a security approach (fighting symptomatic issues) and a health development approach (tackling upstream causes and determinants). in doing so, the objectives should not be merely be the response mode, but a more concerted effort to limit environmental factors, protect biodiversity, reduce social health inequities, strengthen local health systems for preventive health, help populations reduce their individual risk factors and augment their natural immunity-notably through various 'healthy behaviours' and diets that are proven to strengthen the general immune system. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] like what recently took place in the field of evaluation of complex systems and policies, a 'realist' revolution of medical research is probably needed to help support this. it is ultimately important that the resulting policies are not copy-pasted from other countries, but adapted to each context, and backed by strong local health systems. by definition, preventive health policies must be tailored to local specificities, including local environments, and health systems must be strengthened at the local level so as to be able to respond to a population's needs and expectations. this is also the case for the response to covid- . viruses and epidemics have always existed, and will always exist, and should be anticipated. coronaviruses are a well-known family of viruses, and even if this one is particularly aggressive, its genome has been rapidly identified. the difference with this epidemic which is causing the semicollapse of health systems is that it has revealed a profound lack of national prevention and preparedness. in response to the epidemic, the most hit countries so far have faced a lack of equipment and critical care beds. in the uk and france, as just two examples, decades of austerity policies and an obsession with evaluating health facilities based on technical efficiency (ie, minimising inputs and increasing outputs) have considerably decreased the capacity of health systems to respond to above-average frequentation. the covid- emergency responses of many states have revealed important inconsistencies. in many european countries, the authorities have adopted a one-sizefits-all policy and imposed the same measures everywhere. more worryingly, some governments-notably in africahave not performed their own adapted risk assessment before copy-pasting strategies from abroad. this is problematic, since it makes little sense to use a predictive model developed from a country where the median age is and translate it to a country with a median age of , without adjusting the parameters. in addition, current policies fail to account for regional or transborder contextual parameters, where either more stringent or relaxed measures could be more suitable depending on geographical determinants. the universal lockdown of a whole country may not be necessary when there are only one or two epidemic outbreaks separated by hundreds of miles, especially if containment is quick and determined. what we suggest, in order to be effective, is that policies should fit each context and be adaptive at the territorial or ecosystem level, versus being unreflectively and uniformly bounded by national jurisdictions. this is the best way to not impose measures that are too coercive, which may face legal constraints and may be counterproductive, eroding public trust and cooperation. in the post-covid- recovery phase, we hope the lessons learnt from local, national and global responses to this pandemic will foster support, by policymakers and by the public, for tailored policy responses that support stronger and more integrated local health systems. in summary, the current crisis calls for a paradigm shift in public and global health policies. we will not be prepared for the next epidemic unless we take bold steps. first, global health policies should not be designed on a response mode to case-by-case threats, but should adopt a systems approach that can support a holistic picture of global disease burdens, risks and health conditions, as well as better consider the system-wide effects of adopted measures. second, countering current fragmentation in global health governance will require a substantial shift in global health policymaking from a reactional paradigm to a systemic and preventive paradigm, with meaningful commitments to human health security. third, there is a need to shift our focus from short-term curative policies based on the pasteurian paradigm, to long-term preventive and promotional policies based on a holistic view of people's health, which notably implies limiting environmental factors, reducing social health inequities, helping populations reduce their individual risk factors and augmenting their natural immunity. lastly, such holistic, preventive policies must be adapted to local contexts and implemented through strong local health systems able to have the 'cushion' capacity to respond to emergencies. twitter valery ridde @valeryridde acknowledgements we thank seye abimbola for inviting us to submit this commentary and for giving us critical suggestions for improvement, and eric muraille for advising on references on immunity. contributors ep and gb both had an initial idea for this paper and joined forces to arrive to this joint paper. they wrote the first draft and vr contributed to improving it. all authors contributed to the development of ideas, commenting on drafts and approved the final version. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests ep and vr have conducted consultations for various international and donor agencies. gb and vr have received funding from several research funding agencies. however, this article has been written in total independence of these contracts. patient consent for publication not required. provenance and peer review commissioned; internally peer reviewed. world health organization. coronavirus disease (covid- ) situation report - world health organization the structure of scientific revolutions forum of international respiratory societies. the global impact of respiratory disease -second edition up to people die of respiratory diseases linked to seasonal flu each year world bank group and the united nations population division a new, evidence-based estimate of patient harms associated with hospital care world health organization. noncommunicable diseases time to deliver -report of the who independent high-level commission on noncommunicable diseases are we facing a noncommunicable disease pandemic? change : impacts, adaptation, and vulnerability. part a: global and sectoral aspects. contribution of working group ii to the fifth assessment report of the intergovernmental panel on climate change intergovernmental panel on climate change who should declare climate change a public health emergency Évaluer les effets des différentes mesures de lutte contre le covid- , mission impossible? alliance for health policy and systems research and world health organization the g summit: a missed opportunity for global health leadership. global policy global emergency financing and health system strengthening environment: the neglected component of the one health triad world health organization do not violate the international health regulations during the covid- outbreak viral sovereignty: the downside risks of securitising infectious diseases as new coronavirus spread, china's old habits delayed fight. the new york times reforming the world health organization knowledge, moral claims and the exercise of power in global health governance challenges in global health ebola spending: will lack of a positive legacy turn dollars into dolour? the guardian global health governance -the next political revolution global health: new leadership for devastating challenges strengthening health systems in low-income countries by enhancing organizational capacities and improving institutions working party on aid effectiveness, task team on health as a tracer sector (oecd/wp eff/tt-hats). progress and challenges in aid effectiveness. what can we learn from the health sector? this is how much the coronavirus will cost the world's economy, according to the un why are some people healthy and others not? the determinants of health of populations the health gap: the challenge of an unequal world: the argument social inequalities and emerging infectious diseases can epidemics be non communicable? reflections on the spread of 'noncommunicable' diseases the global syndemic of obesity, undernutrition, and climate change: the lancet commission report existing conditions of covid- cases and deaths the migrant crisis and health systems: hygeia instead of panacea why biodiversity is key to our survival [internet]. the conversation vitamin d supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data vitamin d : a helpful immuno-modulator the unspecific side of acquired immunity against infectious disease: causes and consequences how poverty affects diet to shape the microbiota and chronic disease can physical activity ameliorate immunosenescence and thereby reduce age-related multi-morbidity? stress-induced immune dysfunction: implications for health the impact of diet on asthma and allergic diseases historical concepts of interactions, synergism and antagonism between nutrition and infection realistic evaluation. london: sage the coming plague: newly emerging diseases in a world out of balance. farrar, straus and giroux global preparedness monitoring board. a world at risk: annual report on global preparedness for health emergencies world health organization (acting as the host organization for the global preparedness monitoring board) healthcare resource statistics -beds why a one-size-fits-all approach to covid- could have lethal consequences [internet]. the conversation covid- -the law and limits of quarantine us emergency legal responses to novel coronavirus: balancing public health and civil liberties key: cord- -iikfjqz authors: guerra, carlos a; tresor donfack, olivier; motobe vaz, liberato; mba nlang, josé a; nze nchama, lucas o; mba eyono, jeremías n; riloha rivas, matilde; phiri, wonder p; schwabe, christopher; aldrich, edward; ratsirarson, josea; fuseini, godwin; garcía, guillermo a title: malaria vector control in sub-saharan africa in the time of covid- : no room for complacency date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: iikfjqz nan the covid- pandemic can potentially bring public health interventions in lowincome countries to a collapse. in sub-saharan africa (ssa), the saturation of health systems can expose pre-existing fragilities and exacerbate the myriad health problems afflicting human populations. in particular, ssa bears the brunt of malaria, which caused around million cases and deaths in , mostly in young children. the challenges for health systems of coping with covid- and malaria at the same time are onerous due to complex interactions between both diseases. malaria and covid- can be symptomatically similar, complicating differential diagnosis. therefore, malaria infections may go undiagnosed in people presenting fever and testing positive for covid- , potentially causing malaria cases to go untreated. in another scenario, symptomatic, malaria-infected individuals could be deterred from seeking healthcare due to fear of covid- infection or could be denied treatment if health centres and hospitals were overwhelmed. perhaps most importantly, the increasing demand for resources to curb covid- and the curtailment of economic activities driven by the pandemic could lead to substantial reductions in government revenues, undermining their ability to finance essential social services, including life-saving malaria vector control interventions. here, we focus our discussion on vector control for preventing malaria in ssa in the context of the current pandemic, neither neglecting the importance of other essential malaria health services and interventions nor the importance of malaria in other endemic areas. the scaling-up of vector control, chiefly insecticide-treated nets (itn) and indoor residual spraying (irs), was the main driver for the significant reductions of malaria burden in ssa in the past two decades. vector control is normally targeted to the populations at the highest risk of malaria transmission. irs should be delivered annually before the beginning of the transmission seasons. itn, on the other hand, should be distributed through triennial mass campaigns and maintained over time through continuous distribution channels such as schools and antenatal clinics. during the pandemic, these interventions may be hindered by reallocation of limited resources to covid- response and disruptions in supply chains of irs insecticides and itn. moreover, vector control implementation may be hampered by social distancing and mobility restrictions as well as by limited community acceptance of these interventions over fears of viral contagion (irs, in particular, requires workers to enter houses to spray the inner walls, hence it can be perceived as invasive). ► in sub-saharan africa (ssa), the covid- pandemic could cause major disruptions to the delivery of malaria vector control interventions. ► such disruptions could potentially lead to significant increases in malaria morbidity and mortality in the region. ► the challenges for sustaining malaria vector control are multiple, from funding shortages to obstacles during implementation. ► the latter are more difficult to appreciate and are described from experience in the field. ► there is a need for major commitment from governments, organisations and individuals to avert a malaria public health disaster in ssa. modelling has estimated that, given worst-case scenarios of disruptions of malaria interventions, including itn and irs, there could be up to a fourfold increase in malaria mortality in the region within the next year or more malaria deaths in than all malaria deaths reported globally in . this would represent rolling back years of progress in malaria control. even considering less extreme scenarios, the burden of malaria in ssa during the pandemic will remain greater than that of covid- itself, and plausibly worse than it would have been in the absence of the pandemic. the ultimate objective for malaria-endemic countries should be to sustain vector control interventions at high coverage to allow for community-level protection (canonically, the recommended coverage has been to protect at least % of the population). some key strategies to achieve this critical goal are proposed (box ). we obtained available country-specific information on the scheduling and completion of vector control campaigns in ssa in (table ) . with respect to irs, these data show that, by the end of august, at least countries had completed irs rounds, spray campaigns were ongoing in and had definitive plans for implementing rounds later in the year. sixteen other countries had scheduled irs rounds this year but no information on these was publicly available. regarding itn, at least seven countries had successfully completed distribution by the end of august . twelve other countries had partially completed campaigns or had rescheduled them for later in the year. a total of . million itn had been distributed, protecting . million people in the targeted areas and at least another . million itn are planned for distribution, targeting another . million people. at the time of writing, five countries specifically reported delays due to covid- and one had postponed distribution for . another countries had planned itn distributions in , but we could find no information on these campaigns. importantly, . million itn had been procured in the first half of , a figure comparable to the average net procurement by quarter in ( million) but lower than in ( million). these figures are encouraging as they show that countries are pushing for sustaining vector control despite the dire circumstances determined by the covid- crisis. they also reveal, however, that much work is still needed to protect the lives of millions of people at risk of malaria in ssa. for instance, in nigeria, the ssa country with the highest population at risk of malaria (> million people), only . % of the . million nets in the box strategies required for sustaining malaria vector control interventions during the covid- pandemic ► ensure that funding for malaria control activities remains in place considering increased demand of additional resources to carry out activities. ► secure timely procurement of commodities (mainly insecticidetreated nets and indoor residual spraying insecticides) and personal protective equipment for frontline workers. ► implement training programmes according to new guidelines that consider the risks of covid- transmission during control activities and ensure compliance of frontline workers with established covid- prevention protocols. ► reinforce social behaviour change and communication campaigns to increase acceptance of vector control by the community. ► facilitate remote technical assistance for the implementation of interventions. ► implement adaptive management of vector control allowing recurrent review of strategic plans in light of unforeseen circumstances during the pandemic. ► engage community leaders and authorities in strategic plans in order to facilitate community acceptance of interventions. bmj global health distribution plans have been so far distributed. disruptions to ongoing campaigns would block million people access to a life-saving bed net. mozambique has scheduled both irs and itn in , yet none of the campaigns had started at the time of writing. the mozambican population targeted to receive itn is . million, or roughly % of the population at risk of malaria in the country. the stakes are high. what the figures fail to convey are the intricate difficulties that malaria control programmes are facing when implementing vector control interventions during the pandemic. our own work on bioko island, equatorial guinea, helps illustrate these challenges to better grasp the complexity of the situation. between february and july , both irs and itn campaigns were conducted on bioko given that government and donor funding were prioritised while additionally supporting the covid- response. the vector control teams were trained for best practices to reduce the risk of viral infection, including transmission prevention strategies, social distancing during activities and sanitisation protocols. all field workers were equipped with requisite personal protective equipment. in march , the government declared a countrywide state of emergency and interdicted mobility between districts. later on in the campaign, several irs operators tested positive for covid- and had to isolate, significantly reducing the workforce. social distancing measures required more time and resources to mobilise teams. in addition, increased community refusal to spray operations and mobility interdiction forced repeated changes to deployment plans. thanks to the ability to quickly adapt operations in response to these changing circumstances, vector control interventions on bioko island were neither seriously delayed nor interrupted, but the irs campaign did suffer significant setbacks, with decreased productivity (each worker sprayed . houses per day in compared with an average of . houses per worker per day in the previous three rounds) and suboptimal coverage ( . % of households were sprayed in targeted communities in compared with a . % average coverage in the previous three rounds). given the less intrusive nature of itn distribution, no major difficulties were encountered, achieving an overall coverage of . % of the targeted households. these accounts attest to the huge challenges faced by vector control teams due to the covid- pandemic that can threaten the completion of campaigns. the risk of malaria resurgence often remains high in places where gains against the disease have been achieved, such as is the case in much of ssa. this is due to the high intrinsic potential for malaria transmission, which determines that these gains are usually fragile and underscores the need to sustain vector control. to this end, the commitment from governments, funding agencies, non-governmental organisations and individuals to malaria control has been and continues to be instrumental during the pandemic. national malaria control programmes must commit to maintaining activities, while governments must show strong leadership and secure the necessary funds to guarantee implementation and the procurement of commodities. funding agencies must not falter in providing critical financial resources in light of the increasing demand for supplies and the unprecedented economic contraction. international organisations must work harder to deliver the technical support required to devise new strategies and to develop necessary tools. individuals who implement vector control must be lauded for their efforts, as they are putting their safety at risk to prevent malaria and safeguard the lives of millions of people living in malaria-endemic areas. the worst may well be yet to come in the covid- pandemic and its impact may take years to dissipate. meanwhile, ssa countries cannot afford to relax their efforts at malaria control to avoid woeful health consequences from this disease on top of the potential devastation of covid- . this pandemic is very far from over and other severe pandemics will likely follow before countries achieve malaria elimination. if covid- is to teach us something about malaria, it should be how to keep up the fight against this old scourge during the hardest of times. this could also serve as an opportunity to boost the priority that malaria control deserves in the global public health agenda in normal times. twitter carlos a guerra @mcditweets mapping the global prevalence, incidence, and mortality of plasmodium falciparum, bmj global health - : a spatial and temporal modelling study organisation for economic co-operation and development (oecd) covid- in africa. regional socio-economic implications and policy priorities the effect of malaria control on plasmodium falciparum in africa between indoor residual spraying: an operational manual for indoor residual spraying (irs) for malaria transmission control and elimination achieving and maintaining universal coverage with longlasting insecticidal nets for malaria control the potential impact of health service disruptions on the burden of malaria: a modelling analysis for countries in sub-saharan africa the potential public health consequences of covid- on malaria in africa us president's malaria initiative the alliance for malaria prevention malaria outbreak in riaba district, bioko island : lessons learned malaria resurgence: a systematic review and assessment of its causes covid- : the worst may be yet to come projecting the transmission dynamics of sars-cov- through the postpandemic period infectious diseases that could be the next pandemic acknowledgements we would like to express our gratitude to meghan tammaro and kate stillman for sharing country-level information on completion of irs rounds from the pmi vectorlink project. we are grateful to mark donahue for providing critical comments to improve the clarity of the manuscript. we thank the national malaria control programme and the ministry of health and social welfare of equatorial guinea, as well as marathon oil, noble energy, ampco (atlantic methanol production company) and the ministry of mines and energy of equatorial guinea for their continued support of the fight against malaria on bioko island.contributors cag conceived the idea of the manuscript and wrote the first draft. cag and gg assembled country data on irs and itn campaigns in sub-saharan africa. otd, lmv, jamn, lonn, jnme, mrr and gf implemented vector control interventions and contributed with details of the challenges in the field. all authors contributed to the final draft of the manuscript.funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.competing interests none declared. provenance and peer review not commissioned; internally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. carlos a guerra http:// orcid. org/ - - - guillermo a garcía http:// orcid. org/ - - - key: cord- -p a chn authors: kelly-cirino, cassandra; mazzola, laura t; chua, arlene; oxenford, christopher j; van kerkhove, maria d title: an updated roadmap for mers-cov research and product development: focus on diagnostics date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: p a chn diagnostics play a central role in the early detection and control of outbreaks and can enable a more nuanced understanding of the disease kinetics and risk factors for the middle east respiratory syndrome-coronavirus (mers-cov), one of the high-priority pathogens identified by the who. in this review we identified sources for molecular and serological diagnostic tests used in mers-cov detection, case management and outbreak investigations, as well as surveillance for humans and animals (camels), and summarised the performance of currently available tests, diagnostic needs, and associated challenges for diagnostic test development and implementation. a more detailed understanding of the kinetics of infection of mers-cov is needed in order to optimise the use of existing assays. notably, mers-cov point-of-care tests are needed in order to optimise supportive care and to minimise transmission risk. however, for new test development, sourcing clinical material continues to be a major challenge to achieving assay validation. harmonisation and standardisation of laboratory methods are essential for surveillance and for a rapid and effective international response to emerging diseases. routine external quality assessment, along with well-characterised and up-to-date proficiency panels, would provide insight into mers-cov diagnostic performance worldwide. a defined set of target product profiles for diagnostic technologies will be developed by who to address these gaps in mers-cov outbreak management. ► the middle east respiratory syndrome-coronavirus is a high-priority pathogen identified by the who r&d blueprint because of its high fatality rate, large geographical range of the dromedary camel reservoir and lack of medical interventions. ► accurate and accessible diagnostic tests are essential to outbreak containment and case management, as well as surveillance in both humans and animals, but available diagnostic tests are limited by inconsistent quality assessment, specimen acquisition issues and infrastructure requirements. ► diagnostic research and development (r&d) needs to include point-of-care testing options, syndromic panels for differential diagnosis, a greater understanding of viral and antibody kinetics, improved access to clinical specimens, and establishment of international reference standards. diagnostics play a central role in the early detection and control of outbreaks and can enable a more nuanced understanding of the disease kinetics and risk factors for the middle east respiratory syndrome-coronavirus (mers-cov), one of the high-priority pathogens identified by the who. in this review we identified sources for molecular and serological diagnostic tests used in mers-cov detection, case management and outbreak investigations, as well as surveillance for humans and animals (camels), and summarised the performance of currently available tests, diagnostic needs, and associated challenges for diagnostic test development and implementation. a more detailed understanding of the kinetics of infection of mers-cov is needed in order to optimise the use of existing assays. notably, mers-cov point-of-care tests are needed in order to optimise supportive care and to minimise transmission risk. however, for new test development, sourcing clinical material continues to be a major challenge to achieving assay validation. harmonisation and standardisation of laboratory methods are essential for surveillance and for a rapid and effective international response to emerging diseases. routine external quality assessment, along with well-characterised and up-to-date proficiency panels, would provide insight into mers-cov diagnostic performance worldwide. a defined set of target product profiles for diagnostic technologies will be developed by who to address these gaps in mers-cov outbreak management. the middle east respiratory syndrome-coronavirus (mers-cov) is an emerging virus associated with severe respiratory illness, first detected in in saudi arabia. provides an overview to the current status of mers-cov diagnostics, including feedback from subject matter expert and developer interviews on the common challenges with test development and implementation, and identifies gaps for further research and development (r&d). mers-cov is a zoonotic virus, and dromedary camels (camelus dromedarius) are the reservoir host and the source of zoonotic transmission to humans. [ ] [ ] [ ] dromedaries appear to be only mildly symptomatic following infection and present a significant reservoir risk for spillover events. mers-cov rna has been detected in dromedary camels in a number of countries, including egypt, oman, qatar and saudi arabia, with evidence suggesting that mers-cov is also widespread in the middle east, africa and south asia. - infection in camels is notifiable to the oie. individuals with close and frequent contact with dromedaries are at a higher risk for mers-cov infection than the general population. clinical indications and management coronaviruses are a family of viruses that can cause diseases in humans, ranging from the common cold to severe acute respiratory syndrome (sars). the clinical spectrum of mers ranges from no symptoms (or asymptomatic infection), mild symptoms including fever, cough, gastrointestinal illness and shortness of breath, to severe disease including pneumonia, acute respiratory distress syndrome and death. severe cases of mers can result in respiratory failure, requiring mechanical ventilation and support in intensive care. risk factors for severe disease include a weakened immune system, older age (> years), and comorbidities such as diabetes, cancer, renal disease and chronic lung disease. human-tohuman transmission spreads through close and unprotected human contact, and more than half of reported mers cases have occurred through nosocomial transmission. [ ] [ ] [ ] [ ] to prevent nosocomial infections, who and others recommend using standard infection and prevention control measures when caring for patients. [ ] [ ] [ ] who also recommends that contact tracing of all symptomatic and asymptomatic close contacts of the primary patient should be conducted routinely. the molecular epidemiology for mers-cov has not changed significantly since the initial human cases were detected in . the current virus remains % identical to the sequences seen in the first human cases from as well as archived camel sera from , with no increase in pathogenicity observed in the animal host. [ ] [ ] [ ] as genetic mutations could impact detection, bmj global health immunotherapy and vaccine development efforts, sequencing of mers-cov strains from camels and humans (after a zoonotic spillover) is important and is regularly being conducted in affected member states (who, personal communication, ). there are currently no prophylactic or therapeutic interventions of proven efficacy for any coronavirus infections. without a specific therapy for mers, treatment is supportive. effective mers therapeutics are still in the early stages of research and evaluation. several broad-spectrum antiviral agents including nitazoxanide, viral methyltransferase inhibition and nucleotide prodrugs have shown in vitro activity against mers-cov. early results for novel mers-specific therapeutics that inhibit viral replication or have specific neutralising activity are promising. the who r&d blueprint for mers has called for three types of vaccines: ( ) dromedary camel vaccine to prevent zoonotic transmission, ( ) human vaccine for long-term protection of persons at high exposure risk and ( ) human vaccine for reactive use in outbreak settings. mers-cov vaccines are in the early stages of development, with one candidate vaccine in phase i clinical trials (nct ). neutralising monoclonal antibodies have been designed to target the mers-cov spike protein, with chadox and modified vaccinia ankara vectors also strong vaccine candidates, but none have yet advanced to clinical trials. to accelerate the process, the coalition for epidemic preparedness innovation has recently launched a call for proposals for the development of a human mers-cov vaccine in order to engage with developers interested in supporting these efforts. the who laboratory guidelines recommend nucleic acid amplification tests (naat) for diagnosis, using serology for diagnosis only when naat is not available. in suspected patients, a single negative test result does not exclude diagnosis. repeat sequential sampling and testing is strongly recommended. the kinetics of mers-cov infection has been shown to vary widely across cases, - prompting a more detailed investigation of viral and antibody dynamics across the broad range of sample types, disease states and host factors. the best naat test sensitivity is achieved using specimens from the lower respiratory tract (sputum, tracheal aspirates or bronchoalveolar lavage), where mers-cov replication occurs at higher and more prolonged levels of mers-cov rna, typically between and copies/ml. mers-cov viral load is generally higher for severe cases, with more prolonged viral shedding than mild cases. viral load concentrations, which may be undetectable at early-stage infection, generally peak in the second week after symptom onset, and then drop to undetectable in survivors by the fourth week from onset. upper respiratory tract specimens (nasopharyngeal or oropharyngeal swabs) may also be used, but demonstrate ×- × lower viral load and can test negative for mild cases. if possible, both upper and lower respiratory tract sampling are advised. specimens outside the respiratory tract are not recommended for diagnosis, as they can test negative in both severe and mild presentation. viral rna has been detected in stool samples ( copies/ml), serum samples ( copies/ml) and urine ( copies/ml), more likely an indicator of severity as it typically precedes a poor clinical outcome. serological diagnosis can be made using paired samples, more often used for research rather than diagnostic purposes, preferably with the initial sample collected in the first week of illness and the second collected - weeks later. if only a single serum sample can be collected, this should occur at least - weeks after onset of symptoms for determination of a probable case. table presents an overview of the implementation requirements for mers-cov diagnostics (detailed commercial product information is presented in online supplementary tables s and s ). molecular diagnostics such as naat (eg, pcr) typically require sophisticated laboratory infrastructure including biosafety cabinets, while most serological tests (elisa, indirect immunofluorescence test (iift)) can be run on the benchtop in a more modest laboratory environment, depending on sample preparation precautions. point-of-care (poc) tests are designed to be used outside of a traditional laboratory; near-poc tests are defined for rapid use in a laboratory near the patient, but are more automated and easy to use than the traditional laboratory test. poc tests such as low-complexity rapid diagnostic tests (rdts) can be used at the bedside, typically with non-invasive samples after minimal training. inhouse tests are described in sections below; commercial sources are listed in online supplementary tables s and s . naats are currently the standard for mers-cov diagnosis, as these tests (typically reverse transcriptase pcr (rt-pcr)) have the highest sensitivity at the earliest time point during the acute phase of infection. following the who guidelines, two different targets on the mers-cov need to be detected by rt-pcr to confirm a case. mers-cov assays to detect the upstream envelope gene (upe) followed by confirmation of open reading frame a (orf a), b (orf b) genes or nucleocapsid (n) genes for confirmation have been developed. most commercial pcr tests perform parallel screening for the upe gene with confirmation by the orf a, orf b or n genes (most commonly upe + orf a). initial naat tests for mers-cov were developed as inhouse tests, following the first detection of mers-cov in the middle east. [ ] [ ] [ ] [ ] inhouse tests are not necessarily subject to quality control or regulation, and may not be rigorously validated; in some cases, inhouse tests are eventually developed into commercial products through collaboration and licensing efforts. - commercial assays may undergo an international and/or incountry regulatory process; once on the market they can be independently evaluated for sensitivity, specificity and limit of detection. as of , there are several commercial naat tests available for mers-cov, including duplex and multiplex panels (see online supplementary table s ). serology is not widely performed for diagnosing acute mers-cov infection; however, it has been a useful tool bmj global health to determine the extent of infection around clusters and in seroepidemiological studies in animals and humans. seroconversion typically occurs during the second and third week after symptom onset; data suggest that low antibody titre in the second week or delayed seroconversion is more closely associated with mortality than high viral load. mers-cov seroconversion may not be observed for some patients, notably with mild or asymptomatic infection, and can show cross-reactivity with antibodies to other coronaviruses. serological methods for the detection of antibodies against mers-cov include elisa, iift and neutralisation tests. mers-cov serological assays can employ commercial reagents or proprietary monoclonal antibodies as capture agents. many mers-cov elisa tests are labelled for research use only, with little or no clinical validation data available. similar to the elisa, iift is used when it is difficult to evaluate specific antigens individually by enzyme immunoassays or there is a preference for broader analysis of an immobilised specimen. iift microscopy assay can probe the entire antigen spectrum of the specimen, and is often designed for simultaneous detection of antibodies against biochemically distinct antigens. neutralisation is a method for detecting anti-mers-cov antibody activity via inhibition of infection or replication, performed as plaque reduction neutralisation, microneutralisation (mn) and pseudoparticle neutralisation (ppnt). mn is labour-intensive and slow, requiring at least - days for results; neutralisation techniques other than ppnt require biosafety level containment as they involve live virus cultures. rdts can leverage the same antibody/antigen capture agents as elisa but in a lateral flow strip cartridge. this enables a fast - min time to result, but with a -fold lower detection sensitivity than elisa. follow-up confirmatory testing is therefore required. rdts are typically paired with minimally invasive specimen collection (blood, oral fluid, nasal swabs) so that they can be used with minimal training outside of laboratory settings. early prototypes for mers-cov rdts have been developed, with commercial rdts for detection of mers-cov in camels and humans available (online supplementary table s ). the human mers-cov rdt does not appear to be widely used, perhaps due to the more invasive processing required for lower respiratory specimens, as well as sensitivity issues for upper respiratory specimens. the camel mers-cov rdt is used with upper respiratory specimens; however, test sensitivity varies depending on specimen sampling and infection kinetics. multiplex panels at the early stages, the symptoms of mers-cov infection can mimic diseases such as influenza, pneumonia, sars and other respiratory infections. a syndromic approach involves testing for pathogens based on a syndrome such as fever or acute respiratory distress; a shift from individual tests to multiplex panels can quickly identify or eliminate likely pathogens from a single specimen. for analysis of circulating reservoirs, multiplex microbead-based immunoassays have been used to detect igg antibodies for multiple pathogens. multiplex, syndromic panels that include mers-cov have been demonstrated using pcr-based panels including mers-cov, showing similar limits of detection to single assays. commercial respiratory panel tests including mers-cov have also recently been developed (see online supplementary table s ). there is a need for international consensus and adoption of minimum standards for tests used in diagnosis, surveillance and research, following who's recommended algorithm for human cases and oie recommendation for animal health. harmonisation of the testing process can be achieved by building consensus and capacity across international and incountry laboratories. in order to enable and sustain the capacity for a rapid outbreak response, laboratories must have access to high-quality reagents and instrumentation, along with technical support and cold-chain transport when necessary. in addition, international reference panels would achieve a more standardised training for external quality assessment (eqa) and quality control. building on mandatory case reporting, an international mers-cov data sharing platform that includes case exposure history and sequence data would greatly facilitate the knowledge base across the mers-cov community. [ ] [ ] [ ] [ ] clinical validation understanding mers-cov viral dynamics across a broad range of specimen types is critical to establishing the limits of detection and timing of diagnostics in order to make the greatest impact for diagnosis, case management and surveillance. ensuring a test has appropriate sensitivity and specificity is a major challenge in the development of diagnostics for novel and rare pathogens, as there is often a very limited supply of well-characterised clinical material. especially during the early stage of an outbreak, clinical evaluation must often be performed in the affected countries by laboratories working closely with the ministries of health. typically only a small number of patient specimens are shared outside of the affected countries due to strict import and export regulations, particularly for 'dual-use' pathogens. specifically, the provisions of the nagoya protocol have significant impact on the access to genetic materials for both commercial and non-commercial applications. in particular, the development and validation process for new diagnostics could be accelerated if well-characterised specimens and reference standards could be more easily obtained. eqa can be useful for evaluation of test performance, as shown with evaluations of both inhouse and commercial assays for mers-cov, [ ] [ ] [ ] and bmj global health more recently a global proficiency testing programme used to assess laboratory detection of mers-cov. even after validation, a substantial amount of reference material is required for quality control; often manufacturers must develop their own calibration standards to maintain supply and to control lot-to-lot variability. international reference standards and qualified specimen panels can accelerate the development and validation of diagnostic tests. in particular, the who international biological reference preparations (as provided by member states) serve as reference sources for ensuring the reliability of in vitro biological diagnostic procedures used for diagnosis of diseases and treatment monitoring, including mers-cov. several international institutes also provide specimens for validation; these groups typically have a defined pathogen/disease focus with a corresponding archive of biological reference materials; however, the supplies may be limited (see online supplementary material ). currently, mers-cov diagnosis by pcr requires a laboratory with sophisticated facilities and biosafety cabinets. the turnaround time to receive a test result can take days to weeks, depending on laboratory proximity, sample transport options and laboratory processing capacity, and infrastructure requirements place most pcr systems in reference laboratories, which may not be ideal for diseases like mers-cov that recommend immediate isolation for infections detected across a variety of settings. a more nimble approach is needed for mers-cov case detection and triage, and at border crossings for animal surveillance, quarantine and targeted vaccination. the fao-oie-who mers technical working group has given a clear call for the development of an rdt to improve identification and isolation of primary human cases in healthcare facilities. serological rdts are ideal for low infrastructure settings such as a primary health clinic, home or field testing. however, specimen collection remains a key challenge for mers-cov, as the recommended lower respiratory specimens are difficult to obtain outside of a hospital setting. upper respiratory specimens such as nasal swabs are easy to obtain and work well in conjunction with rdts for camels, but these specimens generally have low virus titre in humans, thus limiting current use of rdts to animal testing. improvement of the current rdt detection chemistry, if feasible, may support the future use of these tests in humans, at least for rapid triage in highly infectious cases. poc and near-poc microfluidic platforms enable a more flexible, but still highly sensitive approach for near-patient naat testing in decentralised settings. near-poc naat platforms are compact and self-contained, with automated sample preparation for processing in minimal laboratory settings, which most healthcare workers can be trained to operate within a day. [ ] [ ] [ ] recent publications describe mers-cov assays designed for poc pcr, loop-mediated isothermal amplification assay and paper-based sensor detection ; however, no mers-cov assays are currently available for the existing near-poc platforms. given that pcr is now the standard for mers-cov diagnosis, it would be highly desirable to have an automated, self-contained naat assay that can be readily deployed in a field or clinic setting. syndromic testing can be valuable during the early stages of an outbreak, in order to distinguish mers-cov from other respiratory infections or identify cases of coinfection. a syndromic panel could be effective in expediting pathogen and outbreak identification, especially with technologies that can screen for multiple pathogens simultaneously. using the panel approach, a definitive diagnosis could enable timely decisions about triage, treatment, infection control and contact tracing. while the per-test cost rises with test complexity, including additional reagents and more sophisticated instrumentation, a rapid and efficient diagnosis scheme can impact intervention and infection control and can be cost-saving overall. as respiratory diseases are both regional and seasonal, - region-specific panels may be more cost-effective. multiplex panels offer the alternative for a 'bundled' testing paradigm; however, if not routinely used (if the market is small), then developers may be reluctant to support the test for diagnostic use, which requires additional investment for validation and regulation. surveillance can be an effective method to identify the initial stages of outbreak, but it requires routine and effective sampling. the impact of surveillance testing depends on the test sensitivity and specificity, sampling rates, kinetics of the disease, and whether the target is animal or human populations. most surveillance sampling is performed in the field, either through population-based or 'hot spot' sampling. for mers-cov, it may be difficult and expensive to implement routine surveillance in dromedary camel stock, as they represent a significantly large reservoir but may suffer only mild effects from mers-cov infection, if any. the ideal surveillance tool would be a highly sensitive and field-appropriate screening test. per-test cost is also an important factor along with ease of implementation. this review has identified diagnostics currently available for mers-cov and highlighted ongoing challenges caused by critical gaps in diagnostics to support outbreak management. rdts offer the potential for rapid poc screening for mers-cov; however, there are practical limits to implementing lower respiratory sample acquisition outside of a hospital setting, limiting feasibility. poc or near-poc naat platforms provide an opportunity for implementation of automated, self-contained bmj global health testing in hospitals and clinics with limited training in endemic-prone areas. expansion of test menu options for existing poc or near-poc naat platforms will strengthen incountry response capacity to endemic diseases and simultaneously ensure countries are prepared for future pandemics. syndromic multiplex panels may expedite differential diagnosis of mers-cov from other endemic respiratory diseases, but further analysis is needed to inform implementation and cost-effectiveness in the context of regional and seasonal detection. there is also a need for more sensitive serological assays with lower cost and minimum cross-reactivity that can be used as surveillance tools. a more detailed understanding of mers-cov viral and antibody kinetics is needed across the broad range of sample types in order to optimise the use of existing assays and to address ongoing technical challenges in the detection of mild and asymptomatic infections. surveillance continues to be important for the detection of mers-cov spillover events; however, questions remain on the cost-effectiveness of routine screening of the large reservoir camel population. in addition, support towards sample biobanks with well-characterised specimens and reference standards will facilitate diagnostic development and quality assurance for mers-cov diagnostics worldwide. in order to achieve the goals of the r&d blueprint efforts, who is identifying key target product profiles for diagnostics in order to mobilise funding and resources to support the development and implementation of the most critically needed tests. isolation of a novel coronavirus from a man with pneumonia in saudi arabia who | middle east respiratory syndrome coronavirus (mers-cov). who mers-cov r&d blueprint plan of action r&d blueprint for action to prevent epidemics progress on the global response, remaining challenges and the way forward evidence for camel-tohuman transmission of mers coronavirus human-dromedary camel interactions and the risk of acquiring zoonotic middle east respiratory syndrome coronavirus infection middle east respiratory syndrome coronavirus neutralising serum antibodies in dromedary camels: a comparative serological study middle east respiratory syndrome coronavirus (mers-cov) origin and animal reservoir risk factors for mers coronavirus infection in dromedary camels in burkina faso cross-sectional surveillance of middle east respiratory syndrome coronavirus (mers-cov) in dromedary camels and other mammals in egypt mers coronaviruses in dromedary camels geographic distribution of mers coronavirus among dromedary camels middle east respiratory syndrome coronavirus (mers-cov) serology in major livestock species in an affected region in jordan absence of middle east respiratory syndrome coronavirus in camelids antibodies against mers coronavirus in dromedary camels serological evidence of mers-cov antibodies in dromedary camels (camelus dromedaries) in laikipia county middle east respiratory syndrome coronavirus infection in dromedary camels in saudi arabia middle east respiratory syndrome coronavirus quasispecies that include homologues of human isolates revealed through whole-genome analysis and virus cultured from dromedary camels in saudi arabia longitudinal study of middle east respiratory syndrome coronavirus infection in dromedary camel herds in saudi arabia middle east respiratory syndrome (mers) coronavirus seroprevalence in domestic livestock in saudi arabia lack of middle east respiratory syndrome coronavirus transmission from infected camels mers coronavirus in dromedary camel herd, saudi arabia cross-sectional study of mers-cov-specific rna and antibodies in animals that have had contact with mers patients in saudi arabia human infection with mers coronavirus after exposure to infected camels, saudi arabia dromedary camels in northern mali have high seropositivity to mers-cov middle east respiratory syndrome coronavirus (mers-cov) in dromedary camels in nigeria middle east respiratory syndrome coronavirus (mers-cov) in dromedary camels serologic evidence for mers-cov infection in dromedary camels middle east respiratory syndrome coronavirus in dromedary camels: an outbreak investigation mers-cov situation update, map . mers-cov livestock field surveys by country epidemiological investigation of middle east respiratory syndrome coronavirus in dromedary camel farms linked with human infection in abu dhabi emirate middle east respiratory syndrome coronavirus antibody reactors among camels in dubai identification of diverse viruses in upper respiratory samples in dromedary camels from united arab emirates mers cov: oie -world organisation for animal health occupational exposure to dromedaries and risk for mers-cov infection risk factors for primary middle east respiratory syndrome coronavirus infection in camel workers in qatar during - : a case-control study middle east respiratory syndrome (mers) | symptoms & complications | cdc middle east respiratory syndrome coronavirus disease in children middle east respiratory syndrome coronavirus disease is rare in children: an update from saudi arabia transmission of merscoronavirus in household contacts hospital-associated outbreak of middle east respiratory syndrome coronavirus: a serologic, epidemiologic, and clinical description the role of super-spreaders in infectious disease super-spreading events of mers-cov infection mers-cov outbreak following a single patient exposure in an emergency room in south korea: an epidemiological outbreak study development of medical countermeasures to middle east respiratory syndrome coronavirus who | infection prevention and control (ipc) guidance summary. who who recommended surveillance standards an observational, laboratorybased study of outbreaks of middle east respiratory syndrome coronavirus in jeddah and riyadh, kingdom of saudi arabia microevolution of outbreakassociated middle east respiratory syndrome coronavirus, south korea middle east respiratory syndrome coronavirus: virology, pathogenesis, and epidemiology middle east respiratory syndrome coronavirus vaccines: current status and novel approaches challenges presented by mers corona virus, and sars corona virus to global health a roadmap for mers-cov research and product development: report from a world health organization consultation nitazoxanide, a new drug candidate for the treatment of middle east respiratory syndrome coronavirus toward the identification of viral cap-methyltransferase inhibitors by fluorescence screening assay broad-spectrum antiviral gs- inhibits both epidemic and zoonotic coronaviruses coronaviruses -drug discovery and therapeutic options a novel neutralizing monoclonal antibody targeting the n-terminal domain of the mers-cov spike protein vaccine development for emerging virulent infectious diseases rapid development of vaccines against emerging pathogens: the replication-deficient simian adenovirus platform technology report from the world health organization's third product development for vaccines advisory committee (pdvac) meeting middle east respiratory syndrome vaccines chadox and mva based vaccine candidates against mers-cov elicit neutralising antibodies and cellular immune responses in mice emerging infectious diseases: a proactive approach laboratory testing for middle east respiratory syndrome coronavirus kinetics of serologic responses to mers coronavirus infection in humans viral load kinetics of mers coronavirus infection viral shedding and antibody response in patients with middle east respiratory syndrome coronavirus infection the role of laboratory diagnostics in emerging viral infections: the example of the middle east respiratory syndrome epidemic mers coronavirus: data gaps for laboratory preparedness predictors of mortality in middle east respiratory syndrome (mers) mers-cov diagnosis: an update clinical features and virological analysis of a case of middle east respiratory syndrome coronavirus infection kinetics and pattern of viral excretion in biological specimens of two mers-cov cases spread of mutant middle east respiratory syndrome coronavirus with reduced affinity to human cd during the south korean outbreak who | laboratory biosafety manual -third edition challenges and opportunities for the implementation of virological testing in resource-limited settings advances in addressing technical challenges of point-of-care diagnostics in resource-limited settings who | laboratory testing for middle east respiratory syndrome coronavirus. who mers-cov lab detection of a novel human coronavirus by real-time reverse-transcription polymerase chain reaction performance and clinical validation of the realstar mers-cov kit for detection of middle east respiratory syndrome coronavirus rna real-time reverse transcription-pcr assay panel for middle east respiratory syndrome coronavirus development of dual taqman based one-step rrt-pcr assay panel for rapid and accurate diagnostic test of mers-cov: a novel human coronavirus, ahead of hajj pilgrimage development and validation of a rapid immunochromatographic assay for detection of middle east respiratory syndrome coronavirus antigen in dromedary camels an isothermal, label-free, and rapid one-step rna amplification/detection assay for diagnosis of respiratory viral infections comparison of eplex respiratory pathogen panel with laboratory-developed real-time pcr assays for detection of respiratory pathogens clinical validation of commercial real-time reverse transcriptase polymerase chain reaction assays for the detection of middle east respiratory syndrome coronavirus from upper respiratory tract specimens a sensitive and specific antigen detection assay for middle east respiratory syndrome coronavirus a highly specific rapid antigen detection assay for on-site diagnosis of mers seroepidemiology for mers coronavirus using microneutralisation and pseudoparticle virus neutralisation assays reveal a high prevalence of antibody in dromedary camels in egypt seroepidemiology of middle east respiratory syndrome (mers) coronavirus in saudi arabia ( ) and australia ( ) and characterisation of assay specificity lateral flow assays development of monoclonal antibody and diagnostic test for middle east respiratory syndrome coronavirus using cell-free synthesized nucleocapsid antigen middle east respiratory syndrome (mers) coronavirus and dromedaries identification of mycoplasma suis antigens and development of a multiplex microbead immunoassay serosurveillance of viral pathogens circulating in west africa two-tube multiplex real-time reverse transcription pcr to detect six human coronaviruses a multiplex liquid-chip assay based on luminex xmap technology for simultaneous detection of six common respiratory viruses surveillance and testing for middle east respiratory syndrome coronavirus using healthmap to analyse middle east respiratory syndrome (mers) data progress in promoting data sharing in public health emergencies who | influenza surveillance outputs data sharing: make outbreak research open access the weapon potential of a microbe biological agents: weapons of warfare and bioterrorism explanation of the nagoya protocol on access and benefit sharing and its implication for microbiology global scientific research commons under the nagoya protocol: towards a collaborative economy model for the sharing of basic research assets first international external quality assessment of molecular diagnostics for mers-cov external quality assessment of mers-cov molecular diagnostics during the korean outbreak external quality assessment for the molecular detection of mers-cov in china proficiency testing for the detection of middle east respiratory syndrome coronavirus demonstrates global capacity to detect middle east respiratory syndrome coronavirus point-of-care testing for infectious diseases: diversity, complexity, and barriers in low-and middle-income countries diagnostic point-of-care tests in resource-limited settings response to emergence of middle east respiratory syndrome coronavirus an orthopoxvirusbased vaccine reduces virus excretion after mers-cov infection in dromedary camels evaluation of the whole-blood alere q nat point-of-care rna assay for hiv- viral load monitoring in a primary health care setting in mozambique point-of-care cepheid xpert hiv- viral load test in rural african communities is feasible and reliable performance of the samba i and ii hiv- semi-q tests for viral load monitoring at the point-of-care one-pot reverse transcriptional loop-mediated isothermal amplification (rt-lamp) for detecting mers-cov multiplex paperbased colorimetric dna sensor using pyrrolidinyl peptide nucleic acid-induced agnps aggregation for detecting mers-cov, mtb, and hpv oligonucleotides the impact of co-infection of influenza a virus on the severity of middle east respiratory syndrome coronavirus wpro | second meeting on laboratory strengthening for emerging infectious diseases in the asia pacific region point-counterpoint: large multiplex pcr panels should be first-line tests for detection of respiratory and intestinal pathogens cost analysis of multiplex pcr testing for diagnosing respiratory virus infections impact of a rapid respiratory panel test on patient outcomes pcr for detection of respiratory viruses: seasonal variations of virus infections global mortality estimates for the influenza pandemic from the glamor project: a modeling study prevalence and seasonal distribution of respiratory viruses during the - season in istanbul development of a respiratory virus panel test for detection of twenty human respiratory viruses by use of multiplex pcr and a fluid microbead-based assay acknowledgements we gratefully acknowledge input to the roadmap from all those who attended the fao-oie-who global technical meeting on mers-cov in september . the opinions expressed in this article are those of the authors and do not necessarily reflect those of the institutions or organisations with which they are affiliated. editorial assistance for later drafts was provided by rachel key: cord- -w typ k authors: chow, clara kayei; nguyen, tu ngoc; marschner, simone; diaz, rafael; rahman, omar; avezum, alvaro; lear, scott a; teo, koon; yeates, karen e; lanas, fernando; li, wei; hu, bo; lopez-jaramillo, patricio; gupta, rajeev; kumar, rajesh; mony, prem k; bahonar, ahmad; yusoff, khalid; khatib, rasha; kazmi, khawar; dans, antonio l; zatonska, katarzyna; alhabib, khalid f; kruger, iolanthe marike; rosengren, annika; gulec, sadi; yusufali, afzalhussein; chifamba, jephat; rangarajan, sumathy; mckee, martin; yusuf, salim title: availability and affordability of medicines and cardiovascular outcomes in high-income, middle-income and low-income countries date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: w typ k objectives: we aimed to examine the relationship between access to medicine for cardiovascular disease (cvd) and major adverse cardiovascular events (maces) among people at high risk of cvd in high-income countries (hics), upper and lower middle-income countries (umics, lmics) and low-income countries (lics) participating in the prospective urban rural epidemiology (pure) study. methods: we defined high cvd risk as the presence of any of the following: hypertension, coronary artery disease, stroke, smoker, diabetes or age > years. availability and affordability of blood pressure lowering drugs, antiplatelets and statins were obtained from pharmacies. participants were categorised: group —all three drug types were available and affordable, group —all three drugs were available but not affordable and group —all three drugs were not available. we used multivariable cox proportional hazard models with nested clustering at country and community levels, adjusting for comorbidities, sociodemographic and economic factors. results: of participants, there were with high cvd risk from countries (mean age . , % female). of these, . % were from group , . % from group and . % from group . compared with participants from group , the risk of maces was higher among participants in group (hr . , % ci . to . ), and among participants from group (hr . , % ci . to . ). conclusion: lower availability and affordability of essential cvd medicines were associated with higher risk of maces and mortality. improving access to cvd medicines should be a key part of the strategy to lower cvd globally. ► our previous study, using data from cross-sectional surveys at baseline in prospective urban rural epidemiology study, showed that those with cardiovascular disease (cvd) living in communities where medicines are unavailable or unaffordable are less likely to be on treatment or to have their blood pressure controlled. ► however, no study has prospectively documented the impact of availability and affordability of cvd medicines on cvd outcomes. what are the new findings? ► we found that essential cvd medicines were unavailable and unaffordable for a large proportion of communities where the individuals with a high risk of cvd were living, particularly in lower-middleincome and low-income countries. ► after accounting for sociodemographic and economic factors, education and comorbidities, the unavailability and unaffordability of essential cvd medicines were associated with a higher risk of major adverse cardiovascular events. ► our analyses are unique because we used standardised methods to assess availability, affordability and event rates in countries and urban and rural communities. access to affordable and effective medicines has contributed to the decline in hics, but they are either unavailable or unaffordable for many people living in middleincome countries and lics. the who and world heart federation have set a goal towards achieving the target that at least % of eligible people receive drug therapy and counselling to prevent heart attacks and stroke. we have previously shown, using data from crosssectional surveys at baseline in the prospective urban and rural epidemiology (pure) study, that those with cvd living in communities where medicines are unavailable or unaffordable are less likely to be on treatment or to have their blood pressure (bp) controlled. however, no study has followed up populations in hic, middleincome countries and lics over time to quantify any impact of availability and affordability of cvd medicines on cvd outcomes. follow-up data from pure are now available, making it possible, for the first time using consistent methods in hics, middle-income countries and lics, to answer this question. we analysed data from the pure study, which has now recruited participants aged - years from countries. follow-up data are now available for participants from countries (follow-up is still ongoing in the remaining participants). we included participants with complete follow-up data for this analysis. we also used the linked epoch (the environmental profile of a community's health) data (n= ), which captures objective and subjective measures of environmental and societal factors that can influence cvd in the communities where pure is undertaken. the epoch instrument comprised of two parts: epoch is an objective environmental audit tool in which trained researchers directly observe and systematically record physical aspects of the environment using a pro-forma, with standardised operational definitions, and epoch is an interviewer administered questionnaire that captures perceptions about the community from pure participants living in that community. participants were defined as having high risk of cvd if they had any of the following conditions: history of hypertension, coronary artery disease, stroke, diabetes, age > , former or current smoker. pure recruited participants from different hics, middle-income countries and lics, making it possible to investigate the impact of availability and affordability of cvd medicines on adverse health outcomes across communities at varying economic levels. the countries included in the pure study represented countries in various stages of economic development (table ) . the countries were grouped based on the world bank income classification in when the study was initiated. we recognise that a few countries changed their income category over the course of the study but for simplicity, all countries remain in their original income categories. details of the pure study design were described in previous publications. - data collection data on availability and costs of medicines were obtained using the epoch instrument. one community pharmacy in each community was visited to collect information about availability and costs of medicines. field researchers were instructed to gather information for a list of medications and if more than one medication trade brand existed, to collect information about the most common trade name for each of these medicine classes as identified by the pharmacist. as previously described, the baseline data collection for pure was conducted by trained interviewers using standardised questionnaires to obtain information at the household and individual levels. at the household level, this included information on income and expenditure on food per month, and at individual level, this included sociodemographic information, medical history, cvd risk factors and medicine use. medication lists were collected for all participant at baseline. regular medication use was defined as taking medicine at least once per week in the last month. medications were recorded by trained staff who were instructed to directly inspect the medication or prescriptions. medicines were centrally coded into medicine classes. in this study, medications were defined as essential cvd medicines: captopril, enalapril, ramipril, metoprolol, atenolol, amlodipine, hydrochlorothiazide, simvastatin, atorvastatin and aspirin. these medications were categorised into three types: ( ) bp lowering drugs (captopril, enalapril, ramipril, metoprolol, atenolol, amlodipine and hydrochlorothiazide), ( ) antiplatelets (aspirin) and ( ) statins (atorvastatin and simvastatin). what do the new findings imply? ► these findings highlight the importance of ensuring the availability and affordability of essential cvd medicines globally, especially in lmics. this is in line with the who's 'global action plan for the prevention and control of ncds - ' which has a set target of % availability of affordable essential medicines for ncds, with least % of the eligible people receiving such treatment. ► the study findings imply that affordability in particular is crucial in high, middle-income and low-income settings, and hence likely that without affordable access to essential cardiovascular medicines, it will continue to be a barrier to good medication compliance and cardiovascular outcomes. definitions of availability and affordability of the essential cvd medicines we used standardised definitions to measure availability and affordability. they are limited measures, and do not account for other factors related to access to these medications such as cost/distance to travel to pharmacies, the provision of free medications to some or all people in some communities. medications were available if they were on the shelf of the pharmacy at the time of the visit, and cost was the price medications were sold for. we defined our main two exposures as follows. availability of essential cvd medicines was defined as the presence of all three types of essential cvd medications (bp lowering drugs, antiplatelets and statins) at any dose in the selected pharmacy on the day of the survey. affordability of essential cvd medicines was assessed using the total monthly costs of all three types of essential cvd medication types at standard doses and recommended frequencies. the lowest-cost drug in each of these three types of essential cvd medicine was chosen for the estimation of the total monthly cost. combined costs of the three types were defined as affordable if they constituted less than % of a household's capacity to pay as per previous publications from pure. household capacity-to-pay is the household income remaining after basic subsistence needs, defined as the household monthly income spent on food, have been met. definition of outcomes primary outcomes were major adverse cardiovascular events (maces)-a composite of cvd mortality, stroke, myocardial infarction and heart failure), and all-cause mortality. participants and their family were contacted at regular intervals to obtain information on specific events. follow-up of participants was performed at least every years. all follow-up visits were conducted by visiting households, by telephone calls or by inviting the participants to the central research offices to complete the follow-up visit. events were characterised centrally in each country by trained physicians, using standardised definitions, verbal autopsies and review of documents. all statistical analyses were performed with sas v. . and r. continuous variables were presented as mean (sd or median, range), and categorical variables as frequency and percentage. data were, in some instances, presented as groups by overall country economic status for ease of presentation, however it is acknowledged that socioeconomic heterogeneity exists within many countries also. models hence account for household and individuallevel socioeconomic measures. we examined the combination of availability and affordability through a combined variable. participants were classified into three groups according to the availability and affordability of the three types of medications (bp lowering, statin and antiplatelets): group -individuals from communities where all three were available and affordable, group -individuals from communities where all three were available but not affordable to them and group -individuals from communities where all three were not available. group was used as the reference group. we also performed additional analysis on the association between the number of essential cvd medicines available and maces. multilevel cox proportional hazard models that account for nested clustering at country and community levels were applied to calculate the hrs and their % cis for maces and all-cause mortality. the clustering was incorporated using a frailty model, which involves introducing a shared random effect into the proportional hazard model for participants from the same cluster. nesting of community within country was incorporated by nesting the community random effect within the country random effect. we adjusted for covariates as in previous publications from the pure study, including age, gender, educational level, smoking status, history of hypertension, coronary heart disease, stroke, diabetes, number of people in household, rural/urban living and the global wealth index country specific tertiles. the wealth index was created using information collected on the household possessions from the pure baseline questionnaire. items included electricity, car, computer, television, motorbike, livestock, fridge, other four-wheeler vehicle, washing machine, stereo, bike, kitchen mixture, phone, land and kitchen window. binary classification of yes/no was created for each item and then a principal component analysis was used to extract the component with largest eigenvalue. each household was then assigned to a score based on factor loadings. data from india were presented separately from other lics to be consistent with previous publications from the pure study. india was seen to be very different from all of the other lics with respect to availability of cardiovascular medicines due to the large domestic pharmaceutical industry and the practice that many medicines are available over the counter and without prescription, as well as to particular policies, such as selective process controls. patient and public involvement patients or the public were not involved in the design, or conduct, or reporting or dissemination plans of our research. there were adults with follow-up data in the pure database at the time of analysis (august ) and among these adults were defined as having high risk of cvd, from communities and countries (table ) . among those identified as high risk, ( . %) had two or more risk factors, and ( . %) had only one single factor among the defined risk factors. the mean age was . years, . % were female. baseline characteristics of these participants are presented in table . participants from communities with no medications available had the highest prevalence of poor education, low wealth index, rural living and had lower use of preventative medications at baseline (table ) . the percentages of individuals with high cvd risk from communities where all three types of cvd medicines were available were . % overall, . % in hics, . % in umics, . % in lmics, . % in lics and . % in india. the percentages of high cvd risk individuals from communities where all three types of cvd medicines were available and affordable (group ) was . % overall, . % in hics, . % in umics, . % in lmics, . % in lics and . % in india (figure ). overall, bp lowering medication had the highest rate of availability ( . % of the communities), followed by antiplatelets ( . %), and . % for statins. the availability of these three types of essential cvd medicines was consistently lower in lics compared with countries with higher income, particularly for statins (except for india, where medicines were relatively widely available) (online supplemental table s and s ). after years of follow-up in this high-risk population, the incidence of maces was . % ( / ) in participants in group (age standardised rate . %), . % ( / ) in participants in group (age standardised rate . %) and . % ( / ) in participants in group (age standardised rate . %). using group as the reference group, the risk of maces was greater in group (all three types of cvd medicines were available but not affordable), with the adjusted hr= . , % ci . to . , p< . and in group (all three types of cvd medicines were not available), with the adjusted hr= . , % ci . to . , p= . . ( figure ) the all-cause mortality rate was . % ( / ) in all high-risk participants. it was higher, at . % in group (age standardised rate . %), and at . % in group (age standardised rate . %), compared with . % in group (age standardised rate . %). in cox proportional hazard models with participants from group (all three types of cvd medicines were available and affordable) as the reference group, the risk of allcause mortality was also greater with both lack of availability and/or affordability. compared with group , the risk of all-cause mortality was greater in group , with the adjusted hr= . , % ci . to . , p< . and in group , with the adjusted hr= . , % ci . to . , p= . ( figure ) . the percentages ( % ci) of maces and mortality by availability and affordability during follow-up are presented in online supplemental appendix table s . unadjusted hrs for maces and all-cause mortality by availability and affordability are shown in online supplemental appendix table s . similar results were found through sensitivity analyses using different age thresholds (> or> , online online supplemental appendix tables s -s ). the number of medicines available among the studied medications varied considerably (online supplemental appendix figure s ). for each additional drug available, the hazard of maces reduced by % ( % ci . to . , p< . ) (online supplemental appendix figure s ). affordability was a key factor across countries from all income categories. for people living in hics, the impact of affordability on maces appeared even higher compared with those living in middle-income countries and lics. online supplemental appendix figure s presents the adjusted hrs of affordability (not affordable vs affordable) on time to maces for each economic group. in this study, we found that essential cvd medicines were unavailable and unaffordable for a large proportion of communities where the individuals with high risk of cvd were living, particularly in lmics and lics. the unavailability and unaffordability of essential cvd medicines was associated with increased risk of maces after accounting for sociodemographic and economic factors, education, comorbidities and accounting for clustering. low availability and affordability to cardiovascular medicines in lics and middle-income countries have been reported in several studies. in a study published in , van mourik et al found that the overall availability of cardiovascular medicines in countries at all levels of development was poor ( . % in public sector, . % private sector) and cardiovascular medicines were least affordable in the poorest countries. in a survey of availability and affordability of selected essential medicines for chronic diseases in lics and middle-income countries conducted by mendis et al in , the availability of some essential cvd medicines was extremely low in some countries (eg, hydrochlorothiazide: . % in pakistan, . % in bangladesh; captopril: . % in nepal, . % in malawi; enalapril: . % in malawi; and statin: ranged from . % to % in the all the surveyed countries), and the affordability of these medicines was also poor. in another study of hypertension management in lics and middle-income countries, only . % of people with hypertension received antihypertensive treatment, and in only . % was it controlled. in a recent study conducted by husain et al based on the who online repository of national essential medicines lists for countries, the average availability of the essential cvd medications was % in lics and lower-middle-income countries (lmics) and % in hics and upper-middleincome countries (umics). they also found that affordability was lower in lics and lmics than hics and umics for both brand and generic medications. in our previous publications from the pure study, overall hypertension control was worst in lics and lmics ( . %), with poor access to medicines among the reasons for the low frequency of treatment and control of hypertension in these countries. the data in the majority of these studies are now dated, we need repeat assessments to track medication availability and affordability as these could change over time. interestingly, in contrast to our anticipation, the crude rates of maces and all-cause mortality were actually higher in group compared with group . group comprised of participants with high risk of cvd that lived in communities where essential cvd medicines were available but unaffordable to them. this may be due to the higher prevalence of comorbidities such as hypertension and diabetes in this group. in addition, the proportion of urban living was also higher in group compared with group ( . % vs . %, respectively). urban living may be associated with other factors that can increase the risk of maces and all-cause mortality such as anxiety, depression, sedentary lifestyle, high consumption of fast food and diseases related to air pollution, especially in lics and middle-income countries. this finding may also highlight the fact that affordability was a key factor. even when the medications are available in the communities, people still could not access them if they could not afford them. in this study, the impact of affordability on maces in people living in hics was even higher compared with those living in lics and middle-income countries, as shown in the online supplemental appendix figure s . our analyses are unique because we used standardised methods to assess availability, affordability and event rates of maces and all-cause mortality from countries and urban and rural communities worldwide. our results support previous findings that in lics and middle-income countries, the availability and affordability of key medicines for the prevention of cvd are low and provide evidence that this affected adversely on outcomes in populations at risk of cvd. as noted in previous publications from the pure study, our results capture only part of the costs of treatment, as we are unable to take into account other costs (such as professional fees or travel or time taken of work to visit a doctor) and hence, we could have overestimated its affordability. in addition, we were also unable to account for policies and other activities of non-governmental organisations in various regions of the world that may provide free medications to some participants in some countries, which may influence medication use and access to variable degrees. we do not have information about how household incomes might have changed during follow-up, which may be important given the economic impact of illness. also, availability and affordability were only assessed at baseline (but this is inevitable in such a large study in which we aimed to relate these to long-term outcomes) and may have changed over time. moreover, during the study time, several countries transitioned to other income categories, for example, india: lic-lmic ( ), china: lmic-umic ( ), colombia: lmic-umic ( ), iran: lmic-umic ( ). along with these transitions, their health systems may have changed as well. the availability and affordability of medicines were assessed at the community pharmacy level, therefore it may not necessarily reflect the availability and affordability at different points of care such as pharmacies at public health facilities or private health facilities. the criteria that epoch used to collect medicine price entailed surveying the most common trade name for each of these medicine classes identified by the pharmacists. while our method attempted to identify the most available medicine in the pharmacy and its cost, there is variation in availability and price particularly between generic and brand drugs across pharmacies. availability of a particular cvd medicine may also depend whether the country essential medicine lists include the medicines in the first place. in addition, there may be other aspects of access to healthcare that may have changed, such as number of health workers, availability of diagnostic and therapeutic interventions and we do not have data on these. the criteria used to define high risk patients resulted in having a mixed group of patients that are not at the same level of risk. for the various reasons described above, the hrs calculated in these analyses could be underestimated compared to an analysis in which availability and affordability was more more accurately measured. the medicines studied in this paper have been shown to be effective in primary and secondary prevention of cvd events and to reduce mortality, and are recommended in most clinical guidelines but were unavailable in a large proportion of communities in lics and middle-income countries and even when available they were not always affordable. in a previous publication from the pure study, both low availability and affordability were associated with low use of cvd medicines. this points to a plausible explanation of the association with maces and mortality. according to the who, essential medicines are those that satisfy the priority healthcare needs of the population. essential medicines should be available within functioning health systems at all times, in adequate amounts, in the appropriate dosage, with assured quality and at an affordable price to individuals and communities. the who's global action plan set a target of % availability of affordable essential medicines for noncommunicable diseases worldwide, and at least % of those in need of these medicines by . this requires addressing the most common reasons for medicines shortages, catalogued in a review conducted by acosta et al. these include market-related factors (such as increased demand, voluntary withdrawal, unexpected changes in clinical practice, loss of market interest and relocation of production facilities), supply chain management (structure of the network or supply chain in the country, supply of raw materials and excipients), manufacturing processes (quality concerns, changes in the product formulation, industrial development capacities, production problems), reduced public health funding, political and ethical issues (such as regulatory problems, public policy and social conflicts). in lics and middleincome countries, the rising prices of medicines, often paid out-of-pocket, mean that they account for up to % of total healthcare expenditure and can lead to illnessinduced poverty and reduce access to the needed treatment. more research effort and strategies are needed to improve affordability to essential medicines. in a recent publication from the heart outcomes prevention and evaluation (hope- ) study in individuals with new or poorly controlled hypertension from communities in colombia and malaysia, free distribution of a fixed dose combination of two antihypertensive drugs and statins substantially improved the framingham risk score and improved the control of hypertension and low-density lipoprotein (ldl) cholesterol in the participants. ensuring access to essential medicine plays a major role in the prevention and control of cvd, which is both important to prevent long-term adverse outcomes and also essential during the current covid- pandemic situation. according to a recent review, the presence of pre-existing cvd was consistently associated with significantly worse outcome in patients with covid- . conclusions less availability and affordability of essential cvd medicines were associated with increased risk of mace and all-cause mortality in this global population from countries of varying income levels. these findings highlight the importance of ensuring that essential cvd medicines are available and affordable for those at high risk of cvd everywhere. factors associated with availability and affordability of essential cvd medicines must be identified for appropriate care globally. bmj global health programming. we wish to acknowledge the additional persons provided in the supplementary appendix who have contributed to the pure study. contributors sy designed the pure study, obtained the funding and oversaw its conduct since its inception years ago. ckc conceived the analysis plan for the current study. ckc and sm wrote the analysis plan. ckc, sm and tnn conducted all study analyses and interpretation of the results. ckc and tnn wrote the various drafts. sr coordinated the worldwide study. all other authors coordinated the study in their countries and all reviewed and commented on drafts of the paper. global updates on cardiovascular disease mortality trends and attribution of traditional risk factors goal : sustainable development knowledge platform availability and affordability of cardiovascular disease medicines and their effect on use in highincome, middle-income, and low-income countries: an analysis of the pure study data the availability and affordability of selected essential medicines for chronic diseases in six low-and middle-income countries reducing cardiovascular mortality through prevention and management of raised blood pressure: a world heart federation roadmap availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the pure study data environmental profile of a community's health (epoch): an instrument to measure environmental determinants of cardiovascular health in five countries risk management package for low-and medium-resource settings use of secondary prevention drugs for cardiovascular disease in the community in high-income, middleincome, and low-income countries (the pure study): a prospective epidemiological survey the prospective urban rural epidemiology (pure) study: examining the impact of societal influences on chronic noncommunicable diseases in low-, middle-, and high-income countries cardiovascular risk and events in low-, middle-, and high-income countries environmental profile of a community's health (epoch): an ecometric assessment of measures of the community environment based on individual perception who model list of essential medicines availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries: a prospective epidemiological study practical measurement of affordability: an application to medicines shared frailty models. in: analysis of multivariate survival data prognostic validation of a non-laboratory and a laboratory based cardiovascular disease risk score in multiple regions of the world availability, price and affordability of cardiovascular medicines: a comparison across countries using who/hai data the state of hypertension care in low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from · million adults access to cardiovascular disease and hypertension medicines in developing countries: an analysis of essential medicine lists, price, availability, and affordability prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries global action plan for the prevention and control of ncds medicine shortages: gaps between countries and global perspectives a communitybased comprehensive intervention to reduce cardiovascular risk in hypertension (hope ): a cluster-randomised controlled trial cardiovascular disease and covid- competing interests none declared. ethics approval ethics approvals were obtained at each study centre, and all participants provided written informed consent.provenance and peer review not commissioned; externally peer reviewed.data availability statement data are available upon request. the study data are available from the corresponding author upon request.supplemental material this content has been supplied by the author(s). it has not been vetted by bmj publishing group limited (bmj) and may not have been peer-reviewed. any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by bmj. bmj disclaims all liability and responsibility arising from any reliance placed on the content. where the content includes any translated material, bmj does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. tu ngoc nguyen http:// orcid. org/ - - - rajesh kumar http:// orcid. org/ - - - martin mckee http:// orcid. org/ - - - key: cord- -zol k p authors: hill-cawthorne, grant; negin, joel; capon, tony; gilbert, gwendolyn l; nind, lee; nunn, michael; ridgway, patricia; schipp, mark; firman, jenny; sorrell, tania c; marais, ben j title: advancing planetary health in australia: focus on emerging infections and antimicrobial resistance date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: zol k p with rising population numbers, anthropogenic changes to our environment and unprecedented global connectivity, the world economic forum ranks the spread of infectious diseases second only to water crises in terms of potential global impact. addressing the diverse challenges to human health and well-being in the st century requires an overarching focus on ‘planetary health’, with input from all sectors of government, non-governmental organisations, academic institutions and industry. to clarify and advance the planetary health agenda within australia, specifically in relation to emerging infectious diseases (eid) and antimicrobial resistance (amr), national experts and key stakeholders were invited to a facilitated workshop. eid themes identified included animal reservoirs, targeted surveillance, mechanisms of emergence and the role of unrecognised human vectors (the ‘invisible man’) in the spread of infection. themes related to amr included antimicrobial use in production and companion animals, antimicrobial stewardship, novel treatment approaches and education of professionals, politicians and the general public. effective infection control strategies are important in both eid and amr. we provide an overview of key discussion points, as well as important barriers identified and solutions proposed. with rising population numbers, anthropogenic changes to our environment and unprecedented global connectivity, the world economic forum ranks the spread of infectious diseases second only to water crises in terms of potential global impact. addressing the diverse challenges to human health and well-being in the st century requires an overarching focus on 'planetary health', with input from all sectors of government, non-governmental organisations, academic institutions and industry. to clarify and advance the planetary health agenda within australia, specifically in relation to emerging infectious diseases (eid) and antimicrobial resistance (amr), national experts and key stakeholders were invited to a facilitated workshop. eid themes identified included animal reservoirs, targeted surveillance, mechanisms of emergence and the role of unrecognised human vectors (the 'invisible man') in the spread of infection. themes related to amr included antimicrobial use in production and companion animals, antimicrobial stewardship, novel treatment approaches and education of professionals, politicians and the general public. effective infection control strategies are important in both eid and amr. we provide an overview of key discussion points, as well as important barriers identified and solutions proposed. the st century confronts us with profound global challenges such as food, water and energy security, reduced resilience of our planet's life-giving ecosystems and threats from emerging and antimicrobial-resistant infections. according to the world economic forum, the spread of infectious diseases is now ranked second only to water crises as the global risk with the greatest likelihood and potential impact, while the one world one health concept recognises that human and animal health are intimately linked and ultimately dependent on healthy ecosystems. in , the rockefeller foundation invested us$ million to establish the pillars of a new discipline called planetary health, which identifies the need for integration of social, economic, environmental and health knowledge. in a similar vein, the wellcome trust launched the our planet, our health initiative, investing £ million over years to explore the link between human health and environmental change. the united nations' sustainable development goals (sdgs) also emphasise the dependence of human health on the resilience of the planet's ecosystems, with specific targets that prioritise and focus global action. within australia, the 'foundations for the future: a long-term plan for australian ecosystem science' report, published in , stated that: 'our natural and managed ecosystems form the world we live, play and work in; the settings for our industry; and the distinctive natural heritage that characterises the australian nation. they are the basis of our current and future prosperity, and our national well-being'. however, a national summary box ► the emergence and spread of infectious diseases, including antimicrobial-resistant infections, pose a major health security threat. ► a more holistic approach to emerging infectious diseases (eid) and antimicrobial resistance (amr) is essential to encourage 'resilience thinking'. the main themes identified were: animal reservoirs of emerging human pathogens, pathogen surveillance, mechanisms of disease emergence and disease spread by asymptomatic individuals (the so-called 'invisible man'). tables and summarise relevant participant responses. the severe acute respiratory syndrome coronavirus (sars-cov) outbreak in highlighted the importance of animal reservoirs as a source of human infection. henipavirus outbreaks, including hendra on the australian eastern seaboard and nipah in malaysia and bangladesh, demonstrated the importance of bats as viral reservoir species and of domestic animals (horses and pigs, respectively) as amplifying hosts. for the middle east respiratory syndrome coronavirus (mers-cov), domestic camels have been implicated as the likely amplifying hosts. fortunately, serological testing of camels in australia, which is home to the largest population of wild camels in the world, has revealed no evidence of mers-cov infection to date. bats may also carry ebolavirus, but its environmental reservoirs remain uncertain. in general, the inter-relationships between animal reservoirs and amplifying hosts, as well as the circumstances that lead to pathogen overspill or backspill between wildlife, livestock and humans are poorly characterised. in the absence of systematic pathogen surveillance in wildlife and domestic animals, human cases often act as bmj global health across the usa. the risk of infections spreading from wildlife reservoirs into human populations is exacerbated by the expansion of agriculture and mining into natural environments, road infrastructure, deforestation, subsistence hunting and co-location of wild and domestic animals in so-called wet markets. strategically, targeted surveillance of the environment, domestic and wild animals, infection vectors and vulnerable human populations will facilitate early detection and better control of disease emergence risk. the importance of pathogen surveillance has been emphasised by both the ebola interim assessment panel chaired by dame barbara stocking and the independent panel on the global response to ebola chaired by professor peter piot. the stocking report recognised poor implementation of international health regulations (ihr), which were approved by the world health assembly in , as well as the need for global solidarity to build local capacity, which has been incorporated in target .d of the sdgs: 'strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks'. ihr implementation requires strong government commitment to establish and maintain public health laboratory and service provider capacity. the us committed us$ billion towards the global health security agenda, while the uk created a £ billion fund in partnership with the bill and melinda gates foundation to tackle malaria and other infectious diseases. the australian government committed $a million over years - to the indo-pacific centre for health security, assisting core capacity strengthening and complementing who's regional strategy for emerging diseases and public health emergencies in the asia-pacific (asia pacific strategy for emerging diseases; apsed iii ). the synthesis of data on the ecology and evolutionary biology of various organisms provide enhanced understanding of pathogen emergence, but information on the social mechanisms that underpin disease outbreaks and persistence remains rudimentary. for example, the reasons for increasing rates of human non-typhoidal salmonellosis in australia (noted at the workshop), at a time when rates were falling in most comparable countries, were poorly understood. integration of food, animal and human surveillance data could provide the insight needed to improve control of these infections. the impact of climate change, particularly on water and vector-borne diseases, was highlighted as a key concern. viruses spread by aedes aegypti and a. albopictus mosquitoes (zika, dengue and chikungunya) pose a significant risk to global health. so far, australia has successfully restricted these mosquito populations, but the likelihood of their permanent establishment will increase with climate change. mosquito surveillance in australia is undertaken on a state-by-state basis with coordination by the national arbovirus and malaria advisory committee. more comprehensive and better standardised surveillance programmes will facilitate accurate mapping of mosquito populations and better tracking of endemic and imported viruses. the 'invisible man' presymptomatic or asymptomatic individuals can unwittingly spread infection. salient examples include the spread of hiv from asymptomatically infected individuals, the hours presymptomatic period during which patients with influenza are infectious and unrecognised colonisation with multidrug-resistant organisms. outbreak control strategies usually depend on syndromic diagnosis and cluster identification to guide intervention strategies. when outbreaks are fuelled by unrecognised human vectors, the importance of routine infection control precautions becomes evident and pre-emptive control measures such as quarantine of high-risk individuals or large-scale social distancing may be appropriate. such measures are difficult to implement. risk assessment and modelling to predict the most likely eventualities in advance and develop realistic scenarios to aid public health response preparedness are important to guide mitigation strategies. strengthening of public health systems, especially in low-income and middle-income countries, is essential to achieve core ihr capacities. the australian government's health for development strategy - articulated most of the important elements required for a comprehensive regional response, but australia's bmj global health international aid budget has declined to its lowest level in many decades; falling well short of international targets. effective implementation of the joint external evaluation process in the asia-pacific region has provided a valuable overview of country-level preparedness, but it needs to be combined with the world organisation of animal health (oie) evaluation of performance of veterinary services assessment to improve one health surveillance, while ongoing monitoring is essential to ensure that identified capacity gaps are addressed and best practices shared. it is predictable that eids will escalate in frequency. although much effort has been expended in developing pandemic preparedness policies, recent experiences with sars and mers-cov demonstrated that even the most advanced medical systems require continued vigilance linked to careful scenario response planning. [ ] [ ] [ ] epidemic outbreaks, or even the perceived threat of an epidemic, usually lead to a flurry of activity, but lessons learnt and interim policies developed are rarely consolidated during interepidemic periods. successful policy implementation requires an expert panel that represents all relevant disciplines, to work with the commonwealth office of health protection to draft national guidelines and monitor implementation of actions to reduce the likelihood and negative impact of eids. it could also oversee the drafting of generic research proposals to test interventions and generate enhanced insight during epidemic outbreaks. methodologies for better decision-making during emergencies require refinement. [ ] [ ] [ ] the rockefeller-lancet commission identified three important strategies, adopting a threshold approach, scenario planning and resilience thinking. these require pre-emptive scoping of relevant risks, as well as possible scenarios and outcomes associated with identified courses of action. effective public communication in times of uncertainty poses a major challenge. the australian media were more measured than media outlets in the usa during the ebola virus outbreak, but news reports still generated considerable public anxiety. detailed scenario planning will help to identify priority actions and communication strategies to reassure the public that the situation is under control and that perceived risks are manageable. optimal communication will require close liaison between researchers, public health officials (for human, animal and environmental health), policymakers and the media. within australia, there is no formal framework within academic institutions or government to facilitate and support cross-disciplinary collaboration, although the national framework for communicable disease control does encourage a one health approach to pandemic preparedness. increased amr awareness has been encouraging, but like climate change progress is slow, given the multiple vested interests and differences in risk/benefit perception. much can also be learnt from the roadmap developed by the us centers for disease control and prevention (cdc) to assist one health operationalisation. the australian national antimicrobial resistance strategy - , jointly developed by the departments of health and agriculture and water resources, represents an example of how these silos can be linked, but implementation remains challenging. table summarises participant responses to open-ended questions focused on amr. the main discussion themes included antimicrobial use in production animals, amr in companion animals, antimicrobial stewardship and public education. table provides an overview of key barriers and potential solutions identified. the ecological effects of antimicrobial selection pressure, including its effects on the human and animal microbiome, are poorly understood. antimicrobial use in production animals has been restricted in australia following the recommendations of the swann report. when avoparcin use in feedlot cattle was shown to increase the prevalence of enterococcus faecium resistance to vancomycin (a glycopeptide antibiotic used for the treatment of human infections), it was voluntarily withdrawn from the australian market. fluoroquinolones were never approved for use in production animals in australia, which probably explains the low levels of fluoroquinolone resistance observed in campylobacter, salmonella and escherichia species compared with other countries where agricultural use is unrestricted. globally, the pork and chicken industries are the biggest users of antimicrobials. recent descriptions of highly resistant bacteria found on chicken and swine farms in china, linked to outbreaks of human infection with bacteria containing similar plasmid-mediated resistance, offer a stark example of the health risks associated with unregulated antimicrobial use in production animals. however, it was acknowledged that the responsible use of antimicrobials to address concerns about food security and animal welfare require careful consideration. companion animals are important to australians; % of households own pets and the pet industry contributes nearly us$ . billion to the australian economy, employing people. the health benefits of pet ownership are estimated to save the healthcare system approximately us$ . billion per year. despite the intensity of interaction, there has been surprisingly little research into the transmission of amr between pathogens of humans and their pets. a better understanding of antimicrobial use in companion animals is needed, since there is no regulatory guidance and pets fall outside the agriculture and health portfolios. australian doctors prescribe more than twice the amount (in defined daily doses per population per day) of antibiotics compared with their counterparts in the bmj global health table responses to open-ended questions on antimicrobial resistance (amr) nightmare scenario ► global spread and dominance of totally antimicrobial resistant pathogensreturning to the preantibiotic era priorities for future research/policy ► environmental impact of antimicrobial use in humans, animals and crops ► emerging bacterial resistance to biocides and disinfectants. ► amr transmission from and to companion animals. ► balancing food production capacity with amr concerns. ► need for comprehensive amr surveillance; understanding the selection, expansion and spread of multidrug-resistant mobile genetic elements (mapping the mobile gene pool). ► antibiotic stewardship-understanding why doctors prescribe and patients demand, antimicrobials inappropriately. ► better infection control within health and aged care facilities. ► point-of-care diagnostics (including rapid species identification and drug susceptibility testing). ► use of highly selective bacteriophage therapy. ► adaptive clinical trial designs for rapid assessment of multidrug regimens ► alternative drug development funding models that considers the public good. ► non-antimicrobial approaches to controlling infections. ► are there effective treatment strategies that will reduce selective pressure and on-going evolutionary 'escape', such as increasing bacterial susceptibility to immune attack or reducing the risk/impact of invasive bacterial infection only? ► what are the key characteristics of a healthy microbiome and the short and long term impacts of antimicrobial induced changes? issues that require public consultation ► restricting antimicrobial access to reduce inappropriate use, for example stronger regulation or increases in price ► how best to educate the general public and prescribers about the dangers (personal and environmental) of inappropriate antimicrobial use. ► balancing animal and human welfare considerations. ► balancing distributive justice and community versus individual cost-benefit. amr, antimicrobial resistance. netherlands. at least % of prescriptions are judged by experts to be clinically inappropriate, inadequate or unnecessary. litigation risk aversion, diagnostic uncertainty, time pressure and perceived patient demand are among the reasons why doctors overprescribe antibiotics. evidence of previously unrecognised harm related to impacts on the human microbiome, as well as the social and ecological harm from amr, should inform development of novel strategies to optimise antimicrobial use. a public policy research agenda, informed by social scientists and psychologists, should explore how best to reform policy settings, devise appropriate incentives and disincentives, develop innovative public and professional education programmes and use social media to improve public understanding and influence responsible regulation expectations. both the general public and professional groups require an enhanced appreciation of basic infection control principles. based on scenarios of increasing amr prevalence for six pathogens, it has been estimated that by , million lives per year and trillion usd of economic output may be lost due to amr infections. a divisive debate has focused on the relative impacts of human versus animal or agricultural use of antimicrobials, but constructive collaboration is essential to elucidate and mitigate the key drivers of amr. a major advance in promoting a one/eco health approach to amr in australia was achieved through the joint support of the australian chief medical and veterinary officers to develop and implement a national amr strategy. this is the first joint ministerial initiative between the australian government departments of health and of agriculture and water resources. the who's antimicrobial resistance: global report on surveillance ( ) identified a policy package with broad goals that included strengthened surveillance and laboratory capacity. however, without adequate funding and accountability measures, such farsighted policies will continue to fall short, especially in the asia-pacific region where antimicrobial use is essentially unregulated and strong financial incentives exist to retain the status quo. the who western pacific region's action agenda is a step towards tackling these problems, but the agenda includes no plans for bmj global health lack of funding for cross-disciplinary research was identified as a significant barrier; participants believed that this was exacerbated by the separation of the two major australian public research funding bodies-the national health and medical research council (medical) and the australian research council (non-medical). breaking down traditional medical, veterinary and biological research silos is crucial, with dedicated funding to support cross-disciplinary initiatives. few new antimicrobials have been developed in recent years, as antimicrobials do not deliver attractive returns on investment. private-public partnerships have been used with success to develop vaccines for neglected diseases, but this requires generous philanthropic support. new economic models should reward antimicrobial discovery (or novel non-antibiotic approaches to reducing amr) as a public good, delinking the return on investment from the volume of sales. the association of british pharmaceutical industries antibiotics network has suggested an insurance-based model that guarantees an annual license fee, providing a more predictable return on investment. while the development of new antimicrobial drugs is important in the short term, history has shown that resistance will develop frameworks for the optimal and ethical application of new technologies, such as social network surveillance and advanced pathogen genomics. provide leadership within the asia pacific region and link with international efforts ► strengthen linkages with and support of regional who offices (western pacific and southeast asia), especially the 'health security and emergencies' and 'communicable diseases' sections and other regional mechanisms and forums, including the south pacific commission, the east asia summit and the asia pacific economic cooperation, as well as global initiatives such as global health security agenda and the development banks. ► encourage adequate funding of dfat's regional health security strategy. ► link with one/eco/planetary health communities in other countries, encourage a 'united front' and support international efforts *this was recently completed, but many of the core elements remain to be executed. develop in response to selection pressure and spread without appropriate infection control measures. alternative therapeutic strategies, such as bacteriophage treatment may be successful if linked to rapid and accurate pathogen identification. attempts to reduce selection pressure fuelled by indiscriminate microbial killing, includes highly targeted bacteriophage-based approaches, modification of disease causing microbes to make them more susceptible to immune attack and developing strategies that prevent or selectively treat invasive disease only. rapid point-of-care tests that differentiate viral and bacterial infections, and provide antimicrobial susceptibility profiles, would assist more targeted use of conventional antibiotics. the challenge posed by eids and amr requires careful consideration of effective mechanisms for prevention and response. table summarises the processes and activities identified for a coordinated australian response to the threat of eids, supported by the recently released national action plan for health security. while the national amr strategy emphasises bmj global health the need for a coordinated one health approach, implementation within existing government structures remains challenging without significant internal reform. public education should also target politicians and key decision-makers, since implementation requires strong political will and requisite funding. global risks one world, one health: beyond the millennium development goals influenza coordination, unicef, the world bank safeguarding human health in the anthropocene epoch: report of the rockefeller foundation-lancet commission on planetary health wellcome trust launches our planet, our health initiative sustainable development goals [internet]. sust aina bled evel opment. un. org foundations for the future: a long-term plan for australian ecosystem science from public to planetary health: a manifesto ecological dynamics of emerging bat virus spillover antibodies against mers coronavirus in dromedary camels absence of mers-cov antibodies in feral camels in australia: implications for the pathogen's origin and spread a new approach for monitoring ebolavirus in wild great apes emerging infectious diseases of wildlife--threats to biodiversity and human health west nile virus: success of public health response underlines failure of the system ecology of zoonoses: natural and unnatural histories who. stocking b. final report of the ebola interim assessment panel will ebola change the game? ten essential reforms before the next pandemic. the report of the harvard-lshtm independent panel on the global response to ebola fact sheet: the global health security agenda chancellor george osborne and bill gates to join forces to end malaria aspx? w= tb cagpkpx% fls k% bg zkeg% d% d pacific strategy for emerging diseases and public health emergencies (apsed iii): advancing implementation of the international health regulations dengue and climate change in australia: predictions for the future should incorporate knowledge from the past australian department of foreign affairs and trade a new strategy for global development improving emergency preparedness and response in the asia-pacific public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in toronto mers-cov outbreak following a single patient exposure in an emergency room in south korea: an epidemiological outbreak study developments in non-expected utility theory: the hunt for a descriptive theory of choice under risk an axiomatic approach to choice under uncertainty with catastrophic risks decision-making under great uncertainty: environmental management in an era of global change national framework for communicable disease control department of health. uk five year antimicrobial resistance strategy tackling drug-resistant infections globally one health": a policy perspective commonwealth of australia. responding to the threat of antimicrobial resistance report of the joint committee on the use of antibiotics in animal husbandry and veterinary medicine avoparcin used as a growth promoter is associated with the occurrence of vancomycin-resistant enterococcus faecium on danish poultry and pig farms low-level fluoroquinolone resistance among campylobacter jejuni isolates in australia control of fluoroquinolone resistance through successful regulation global trends in antimicrobial use in food animals emergence of plasmid-mediated colistin resistance mechanism mcr- in animals and human beings in china: a microbiological and molecular biological study species shift and multidrug resistance of campylobacter from chicken and swine, china, - australian companion animal council health benefits and health cost savings due to pets: preliminary estimates from an australian national survey australian commission on safety and quality in health care. antimicrobial prescribing practice in australia cultures of resistance? a bourdieusian analysis of doctors' antibiotic prescribing antimicrobial resistance: global report on surveillance . who. world health organization action agenda for antimicrobial resistance in the western pacific region s partnership model association of the british pharmaceutical industry. antimicrobial resistance. house of commons science and technology select committee australia's national action plan for health security aust-nat-action-plan-health-security- - . pdf . marais bj. ethics; the third dimension acknowledgements the authors would like to thank kerri anton for developing and designing the layout and structure of the workshop, and christine aitken for event organisation. we also thank participants from all the different sectors that took part, including martin kirk (national centre for epidemiology & population health at the australian national university, canberra, australia), elizabeth harry (the ithree institute, the university of technology sydney, australia) and ben howden (microbiological diagnostic unit public health laboratory, the doherty institute for infection and immunity, melbourne, australia) who contributed to the closed group discussion. the meeting was supported by the university of sydney contributors bm and gh-c conceptualised the manuscript and led the workshop. all authors contributed to the workshop and assisted with the development of the content and review of the manuscript.funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests none declared.patient consent for publication not required.provenance and peer review not commissioned; internally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. key: cord- -e fhlo authors: semaan, aline; audet, constance; huysmans, elise; afolabi, bosede; assarag, bouchra; banke-thomas, aduragbemi; blencowe, hannah; caluwaerts, séverine; campbell, oona maeve renee; cavallaro, francesca l; chavane, leonardo; day, louise tina; delamou, alexandre; delvaux, therese; graham, wendy jane; gon, giorgia; kascak, peter; matsui, mitsuaki; moxon, sarah; nakimuli, annettee; pembe, andrea; radovich, emma; van den akker, thomas; benova, lenka title: voices from the frontline: findings from a thematic analysis of a rapid online global survey of maternal and newborn health professionals facing the covid- pandemic date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: e fhlo introduction: the covid- pandemic has substantially impacted maternity care provision worldwide. studies based on modelling estimated large indirect effects of the pandemic on services and health outcomes. the objective of this study was to prospectively document experiences of frontline maternal and newborn healthcare providers. methods: we conducted a global, cross-sectional study of maternal and newborn health professionals via an online survey disseminated through professional networks and social media in languages. information was collected between march and april on respondents’ background, preparedness for and response to covid- and their experience during the pandemic. an optional module sought information on adaptations to care processes. descriptive statistics and qualitative thematic analysis were used to analyse responses, disaggregating by low-income and middle-income countries (lmics) and high-income countries (hics). results: we analysed responses from maternal and newborn health professionals. only one-third received training on covid- from their health facility and nearly all searched for information themselves. half of respondents in lmics received updated guidelines for care provision compared with % in hics. overall, % of participants in lmics and % in hics felt mostly or completely knowledgeable in how to care for covid- maternity patients. facility-level responses to covid- (signage, screening, testing and isolation rooms) were more common in hics than lmics. globally, % of respondents reported somewhat or substantially higher levels of stress. there was a widespread perception of reduced use of routine maternity care services, and of modification in care processes, some of which were not evidence-based practices. conclusions: substantial knowledge gaps exist in guidance on management of maternity cases with or without covid- . formal information-sharing channels for providers must be established and mental health support provided. surveys of maternity care providers can help track the situation, capture innovations and support rapid development of effective responses. introduction the covid- pandemic has substantially impacted maternity care provision worldwide. studies based on modelling estimated large indirect effects of the pandemic on services and health outcomes. the objective of this study was to prospectively document experiences of frontline maternal and newborn healthcare providers. methods we conducted a global, cross-sectional study of maternal and newborn health professionals via an online survey disseminated through professional networks and social media in languages. information was collected between march and april on respondents' background, preparedness for and response to covid- and their experience during the pandemic. an optional module sought information on adaptations to care processes. descriptive statistics and qualitative thematic analysis were used to analyse responses, disaggregating by low-income and middleincome countries (lmics) and high-income countries (hics). results we analysed responses from maternal and newborn health professionals. only one-third received training on covid- from their health facility and nearly all searched for information themselves. half of respondents in lmics received updated guidelines for care provision compared with % in hics. overall, % of participants in lmics and % in hics felt mostly or completely knowledgeable in how to care for covid- maternity patients. facility-level responses to covid- (signage, screening, testing and isolation rooms) were more common in hics than lmics. globally, % of respondents reported somewhat or substantially higher levels of stress. there was a widespread perception of reduced use of routine maternity care services, and of modification in care processes, some of which were not evidence-based practices. coronavirus disease (covid- ) has affected . million cases as of may and caused more than deaths globally, with an estimated case fatality rate of . %. this highly infectious disease is transmitted through close contact with what is already known? ► in addition to lack of healthcare worker protection, staffing shortages, heightened risk of nosocomial transmission and decreased healthcare use described in previous infectious disease outbreaks, maternal and newborn care during the covid- pandemic has also been affected by large-scale lockdowns/curfews. ► the two studies assessing the indirect effects of covid- on maternal and child health have used models to estimate mortality impacts. ► experiences of frontline health professionals providing maternal and newborn care during the covid- pandemic have not been empirically documented to date. infected persons or via contaminated surfaces. vertical transmission (antenatally or intrapartum) remains a possible concern, and covid- effects during the first and second trimesters of pregnancy are unclear. breastfeeding continues to be encouraged with appropriate hygiene measures, including wearing face masks. the limited available evidence suggests that pregnant women do not face higher risks of infection and disease severity. [ ] [ ] [ ] a meta-analysis of pregnant women with covid- showed higher risk of preterm birth, pre-eclampsia and caesarean section. symptoms among newborns seem to be mild, though one study reported a higher perinatal death risk. more data and larger sample sizes must be collected to draw definitive conclusions. it is prudent to protect pregnant women from covid- through both individual-level and population-level measures, considering the increased risk of infection with other respiratory viruses such as influenza, and the increased mortality linked with h n . however, recommendations to avoid infection remain similar for pregnant women and the general public. some countries, such as the uk, categorised pregnant women as a vulnerable group and issued stricter measures for them. the pandemic's indirect effects will likely surpass the direct infection effects on women and newborns. previous outbreaks severely reduced health systems' capacity to provide essential maternal and newborn health (mnh) care, with negative impacts on health outcomes. [ ] [ ] [ ] ebola virus disease (evd), severe acute respiratory syndrome and middle east respiratory syndrome (mers) outbreaks highlighted challenges in countries' preparedness to face outbreaks, amplified by weak existing systems. these include lack of protection of healthcare workers leading to disruptions in staffing, heightened risk of nosocomial transmission and elevated stress among service providers. other indirect consequences of outbreaks include limited capacity for public health surveillance and lower use of healthcare. [ ] [ ] [ ] during the covid- pandemic, large disruptions to healthcare provision and utilisation also stem from unprecedented largescale measures implemented by countries (eg, lockdowns, curfews and transport restrictions). indirect influences of previous outbreaks persisted long after their containment, but much of the evidence available about mnh is modelled or uses secondary data such as population-based surveys and routine health information systems that are originally collected for purposes other than studying the effect of the outbreak on mnh and fail to prospectively document these impacts over time. to date, studies assessing potential indirect effects of the covid- pandemic on sexual, reproductive, maternal and child health in low-income and middleincome countries (lmics) have used modelling approaches. roberton and colleagues modelled three scenarios projecting a decrease in the coverage of basic life-saving interventions. they estimated an increase in maternal deaths between and , and - additional deaths of children under years. similar conclusions were drawn by riley et al, who projected that a modest decline in the use of sexual and reproductive healthcare services in lmics will result, over a year, in million additional women with unmet need for modern contraceptives, million additional unwanted pregnancies and over million additional unsafe abortions. it is therefore critical that the precise nature of both direct and indirect impacts of covid- , and the adaptations and innovations tested to reduce its impact are prospectively captured and described. health professionals' views and experiences when providing care to women and newborns during this pandemic have not been empirically documented to date, and there is a necessity for prospectively assessing the effects of the covid- pandemic on mnh services. the objective of this paper is to synthesise key themes identified in the first round of a global online survey of health professionals working in mnh along four dimensions: preparedness for covid- , response to covid- , personal experience in the workplace and changes in care provision and processes. this online survey is part of a larger study seeking to: ( ) understand how health professionals and health facilities prepare and respond to covid- in regard to the care provided to women and their babies; and ( ) document and analyse the effect of the covid- pandemic on the services available to pregnant, labouring and what are the new findings? ► respondents in high-income countries more commonly reported available/updated guidelines, access to covid- testing and dedicated isolation rooms for confirmed/suspected covid- maternity patients. ► levels of stress increased among health professionals globally, including due to changed working hours, difficulties in reaching health facilities and staff shortages. ► healthcare providers are worried about the impact of rapidly changing care practices on health outcomes: reduced access to antenatal care, fewer outpatient visits, shorter length of stay in facilities after birth, banning birth companions, separating newborns from covid- positive mothers and postponing routine immunisations. what do the new findings imply? ► covid- illustrates the susceptibility of maternity care services to emergencies, including by reversing hard-won gains in healthcare utilisation and use of evidence-based practices. ► maternity care differs from other services, inasmuch as healthy women are being brought into health facilities that are operating suboptimally, and potentially increasing risk of infection, from covid- and other healthcare-associated infections. ► these rapid findings can inform countries of the main issues emerging and help develop effective responses, but similar efforts are needed to understand women's experiences. postpartum women and their newborns, including as a result of increasing pressures on the healthcare system. this is a cross-sectional study of health professionals providing mnh care services. the target population was health professionals directly providing maternal (antenatal, intrapartum and/or postnatal) or newborn care, including midwives, nurses, obstetricians/gynaecologists, neonatologists, paediatricians, anaesthetists, general practitioners, medical officers, clinical officers, community health workers, lactation counsellors, paramedics, health technicians and health professionals in training. due to the unavailability of a global sampling frame for this study population, sampling was non-random and not intended to generate generalisable nationally representative results of either health professionals or facilities. rather, our intention was to collect and synthesise the voices and experiences of mnh professionals from various countries, contexts, services and facility types at the early stage of the covid- pandemic. an invitation to complete the survey was distributed using personal networks of the multicountry research team members, maternal/newborn platforms and social media (eg, facebook, twitter and whatsapp). respondents were encouraged to share the survey with other colleagues in an attempt to snowball the sample population. respondents provided informed consent online by checking a box affirming that they voluntarily agreed to participate in the survey. a questionnaire was developed in english by an international team of collaborators including health professionals, experts in health systems, infectious diseases, infection prevention and control, maternal health epidemiologists and public health researchers from various global settings. it was piloted by asking five mnh professionals from different settings to complete the questionnaire and provide feedback, which was used to assess face validity and refine the wording of questions and response options. the final version was translated into languages that were made available consecutively (french and arabic were available at launch; italian, portuguese, spanish, japanese, german and dutch were available within days; chinese, russian and kiswahili were added after weeks). we collected data on respondents' background, preparedness for covid- , response to covid- and own work experience during the pandemic. all respondents were invited to participate in an optional module that asked about adaptations to care processes and respondents' perceptions regarding changes in the uptake of care by women and newborns. the questionnaire is provided in online supplementary file . we use responses collected between march and april . we cleaned received responses by removing duplicate submissions (n= ), refusals to participate (n= ) and submissions made by those not directly providing maternal or newborn care (eg, lecturers and public health officials; n= ). quantitative analysis involved descriptive statistics (frequencies and percentages) using stata/se v. . responses were stratified by country income levels according to world bank classification. we conducted a qualitative thematic analysis of free-text answers to derive common themes of respondents' experiences and changes in the work environment and care process by country income levels. when possible, we triangulated qualitative and quantitative results to validate emerging themes. from the remaining responses, we dropped from the analysis responses with missing answers on more than % of questions. the extent of missingness to closeended questions ranged from . % to . % and that to open-ended questions from % to % of respondents. missing answers to the 'country' question were recoded based on the 'region' answer for responses; for example, a respondent with a missing response for country but region reported as maharashtra was coded as from india. the sample included mnh care professionals, % of whom participated in the questionnaires' optional module (n= ). participants worked in countries and % were from high-income countries (hics; table ). online supplementary file includes a map showing respondents' geographic distribution and the total number of confirmed cases as of the midpoint of our data collection period ( april ). most were obstetricians/gynaecologists or midwives ( % and %, respectively), and around % worked in public sector facilities. nearly half of respondents from hics ( %) reported that their facilities had seen covid- confirmed or suspected maternity patients, compared with % of respondents from lmics. most respondents ( %) received information on covid- , including on transmission, treatment, prevention, screening and updated policies, and only one-third attended trainings/drills on the response to covid- (table ) . several perceived that trainings would make them 'feel better prepared' to respond to women's needs during the outbreak. half of lmic-based respondents received updated guidelines reflecting measures for the outbreak when providing mnh care, compared with % of those from hics (table ) . this was a source of concern for some bmj global health respondents from tanzania, rwanda, uganda and india, as remarked by an obstetrician/gynaecologist from uganda: 'i am worried that no national guidelines [are] rolled out yet regarding care for pregnant women and newborns'. some midwives in hics requested clearer guidelines on home-based midwifery care. nearly all respondents searched personally for information on covid- ( %) and received informal guidance from colleagues ( %, table ). some lmic-based participants worried about lack of access to/availability of evidence on covid- effects during pregnancy and possible transmission to fetus and/or newborn. only % of participants perceived that they were completely knowledgeable of providing care to covid- maternity patients (table ) . personal experiences facilities adopted several measures in response to covid- . most hic-based respondents noted that their low-income and middle-income countries ( ) ( ) high-income countries ( ) ( ) region east asia and pacific ( ) ( ) europe and central asia ( ) ( ) latin america and caribbean ( ) ( ) middle east and north africa ( ) ( ) north america ( ) ( ) south asia ( ) ( ) sub-saharan africa ( ) ( ) cadre midwife ( ) ( ) nurse-midwife ( ) ( ) nurse ( ) ( ) obstetrician/gynaecologist ( ) ( ) neonatologist general practitioner ( ) ( ) medical doctor (no specialisation) ( ) ( ) medical student/intern/resident ( ) ( ) community health worker/outreach worker ( ) ( ) other ( ) ( ) position head of facility ( ) ( ) head of department or ward ( ) ( ) head of team ( ) ( ) team member ( ) ( ) locum or interim member ( ) ( ) other † ( ) ( ) type of care provided (multiple responses allowed) outpatient anc ( ) ( ) home-based childbirth care ( ) ( ) ( ) private for profit ( ) ( ) non-governmental ( ) ( ) faith-based or mission ( ) ( ) other ( ) ( ) type of area large city (more than million inhabitants) ( ) ( ) small city ( to million inhabitants) ( ) ( ) town (fewer than inhabitants) ( ) bmj global health care (anc) outpatients and inpatients were screened either in person or over the phone before appointments/admission. the ability to test maternity patients for covid- was limited in lmics ( %), rural areas ( % in lmics; % in hics) and completely unavailable in refugee and/or displaced persons camps (n= , data not shown). healthcare workers reported various concerns regarding care provision during the outbreak. respondents perceived the lack of covid- symptom screening and testing as threats to staff and patient safety. a midwife from canada wrote, 'i'm worried about being infected by someone who is asymptomatic, and then being a vector to others'. personal protective equipment (ppe) deficiencies also compromised patients' and healthcare providers' safety across all settings but more prominently in lmics ( most respondents noted that covid- affected their work ( %) and that their stress levels were higher than usual ( % , table ). an obstetrician from mozambique described, 'my stress level is immeasurable. every time a pregnant woman with flu-like symptoms [visits the health facility], i feel almost completely lost. i need to be equally protected and i don't feel any protection from whoever [is responsible of protecting me]'. challenges included shortage of qualified staff, either because of symptoms, self-isolation after potential exposure, or inability to reach their workplace, as a midwife in uganda described: '[t]ransport to work is a big challenge due to lockdown; many staff live far away from the hospital. staff who manage to come to work hurry to leave early to observe the curfew time of . p.m.'. this shortage led to an increase in workload and frequent changes in schedules. certain healthcare facilities increasingly relied on locum workers and students to fill staffing shortages. some respondents requested more support from management as exhaustion increased. a department head in uganda reported, '[t] here are no more clear work schedules as i get to attend many unscheduled/emergency meetings. staff are very anxious and panicky and need talking to all the time, which is exhausting'. some participants from lmics such as india, bangladesh, bolivia and syria expressed concerns regarding 'patients and relatives not following instructions given by staff members', such as social/physical distancing and hygiene. a nurse from syria attributed this to a 'lack of awareness and knowledge, and indifference among beneficiaries'. changes to care provided to women and newborns bmj global health they are sick'. most respondents noted shorter visiting hours and fewer allowed visitors, while others reported screening visitors for symptoms or banning visits altogether. the number of labour companions was limited to one person (also allowed to accompany the mother after birth), or none at all. an obstetrician from the czech republic remarked that: '[the] gynaecological and obstetrical society recommended to ban partners and doulas from accompanying a woman at birth -outrageous!!!'. among the reported changes, some facilities implemented social/physical distancing in waiting areas and in hospital rooms by reducing the number of beds. however, this was difficult to achieve in small facilities; an obstetrician/gynaecologist from india noted: '[it is] not practically possible [to place each patient in a separate birthing room] in our set up'. non-essential services including elective gynaecological procedures and infertility treatments were postponed or cancelled. several facilities restricted routine anc to the management of high-risk patients. a respondent from new york reported a 'significant decrease in number of anc visits', whereby new policies recommended reducing face-to-face visits during pregnancy 'from to [visits] , to four [visits]'. other changes include eliminating waiting areas, spacing appointments to reduce contact between patients and cancelling group activities such as health education sessions. the pandemic entailed adaptations to care process and content, subsequently affecting quality. anc and postnatal care (pnc) provision and breastfeeding counselling shifted to telemedicine. participants in lmics acknowledged that women's inadequate access to communication infrastructure prevents equitable healthcare provision. respondents were concerned over uncertain impacts of reduced contacts on the quality of care. a midwife from the uk wrote: '[w]hilst i completely see the need to restrict face-to-face care to protect staff and patients, my heart just breaks for women and families who we won't be able to offer the full range of midwifery support to… that is, breastfeeding support, daily visits, and just generally our time'. across all settings, the demand for home births increased and new practices aimed to reduce labour inductions. in certain hics, induction of labour was discouraged before weeks of gestation, using nitrous oxide for pain relief diminished to reduce risk of transmission through aerosols, and waterbirths were suspended. caesarean sections were commonly performed among women diagnosed with covid- and some facilities dedicated theatres specifically for this purpose. elective caesarean sections decreased among 'healthy' maternity patients. however, some facilities aimed to reduce labour duration and time spent in the labour room by augmentation. respondents speculated about a potential rise in caesarean section rates in their facilities, as noted by an obstetrician/gynaecologist from india: 'we will not allow as much time in second stage [of labour], this is likely to push up our caesarean rate'. respondents frequently mentioned shortened length of stay in facilities after childbirth; for example, a reduction 'to - from or more [hours]' (midwife from canada). a midwife from the uk wrote, '[the] lack of time and staff will lead to mothers and babies going home with very little feeding support or knowledge which will have a short and long term impact on their health and ability to deal with infections'. routine postnatal checks were postponed or substituted with telemedicine in some cases as reported by a nursemidwife from the usa, '[w]e are postponing the routine postpartum visit until weeks postpartum, and are prescribing most contraceptives over the phone and breastfeeding support is all done virtually'. changes to newborn pnc were infrequent and included monitoring and isolating babies of mothers with covid- . three respondents from india noted that vaccination schedules were disrupted or postponed. mnh professionals feared that changes in standards of care would lead to poor health outcomes among women and newborns and subsequently to the loss of achieved progress. 'i am worried about the implications of policies that call for separating newborns from covid- positive mothers immediately after birth, without allowing for skin-toskin or delayed cord clamping', wrote a nurse-midwife from the usa. this paper uses a rapid collection of data from health professionals providing care to women and newborns globally during initial stages of the covid- pandemic. we describe preparedness for covid- , response to covid- , personal experience in the workplace and changes in care provision and processes. healthcare providers commonly resort to personal searches and informal networks to fulfil information needs. accessing unreliable information related to covid- is likely, particularly on social media. facility-specific creation and distribution of guidelines for managing maternity patients is somewhat lagging behind despite frequent updates by ministries of health and professional associations. [ ] [ ] [ ] [ ] [ ] [ ] [ ] information sharing channels must be established to secure providers' timely access to accurate information. [ ] [ ] [ ] midwives supporting pregnant and labouring women during the pandemic, particularly independent practitioners, need clear guidelines for providing home-based care. response sharp discrepancies in facility-level responses to covid- between hics and lmics could stem from the differential progression of the outbreak (online supplementary file ) or be partly attributed to limited health system capacities and resources in some countries. an attenuated outbreak is speculated in africa, yet it is equally possible that trends similar to those witnessed in europe will occur. this indicates an urgent need to mobilise resources, improve testing capacities and upgrade responses, with the needs and complexities of mnh care provision in mind. absence of testing in refugee and/or displaced persons camps raises concerns. overcrowding and inadequate water and sanitation in underserved settlements are barriers to basic infection prevention measures. [ ] [ ] [ ] [ ] displaced women's and newborns' access to mnh services is suboptimal, and they experienced poor outcomes before the pandemicinduced disruptions of essential care. [ ] [ ] [ ] [ ] efforts should ensure that displaced populations are protected, with adequate access to testing, treatment and quality mnh care to halt anticipated exacerbations of negative health outcomes. personal experiences mnh care workers during the pandemic experience increased stress and anxiety, consistently with experiences from previous outbreaks. stress levels in lmics were comparable with those in hics, although countries were battling different outbreak stages (online supplementary file ). this might be due to uniformly reported shortages in skilled workforce leading to higher workloads and staff burnout. wilson et al suggest measures to prevent burnout among maternity care providers along prioritising adequate emotional, social and mental health support, including from managers. as our findings show, this adds burdens to management staff, a group that deserves special focus during this outbreak. reliance on students increases their vulnerability to stressors considering their lack of experience, and senior colleagues should actively advocate for their well-being. future research should explore the availability and effectiveness of mental and social support to mnh care providers during the pandemic. insufficient ppe intensifies the fear of nosocomial transmission. in some facilities, ppe supplies are prioritised for departments treating covid- cases and do not reach maternity wards. mnh care workers and patients could experience uneven risks of nosocomial infection during outbreaks. in some countries, obstetricians/ gynaecologists commonly work in multiple facilities, and their risk of exposure might be exacerbated by the higher number of contacts they experience in this dual practice. although ppe are essential, their rational use is recommended by the who given universal shortage. these guidelines must be clearly communicated to mnh care providers and patients. health workers caring for women around the time of birth might be used to wearing some ppe; yet, it can make them feel dehumanised, and the donning and doffing of ppe might delay emergency service provision. changes in care provision and processes care practices are rapidly changing and their consequences on health outcomes are uncertain. our findings support narratives told by healthcare providers, and align with disruptions witnessed during previous outbreaks, [ ] [ ] [ ] which have increased maternal and neonatal mortality. currently, there are signs of similar trends in two maternity hospitals in uganda. our knowledge of the impact of these changes is restricted to predictions resulting from modelling, which strongly suggest a threat to achieved improvements in lmics. the actual impact is yet to be quantified, and the effect in hics remains unclear. prioritising measures depending on contextual needs can mitigate the pandemic's indirect consequences. previous outbreaks of infectious diseases such as evd in west africa and mers in south korea have imposed barriers to healthcare access and utilisation, including fear of nosocomial transmission, healthcare facilities' closure and loss of trust in the healthcare workforce. our findings show that in the case of covid- , fear of disease spread was perceived to reduce healthcare use, and unprecedented societal measures such as lockdowns, curfews and transport restrictions emerge as new challenges to healthcare provision and utilisation. although some changes to care content and process matched updated guidelines other modifications diverge from available evidence. these include eliminating birth companions, banning visitors, performing caesarean section on all covid- positive women, augmenting labour or performing unindicated caesarean sections to control timing of deliveries, separating newborns from covid- positive mothers, not allowing breast feeding and reducing length of stay with fewer home-based follow-ups. such practices deny women's access to quality care and jeopardise their wellbeing and that of their babies. unlike curative services, maternity care provides holistic support to women going through a normal physiological process; both overintervention and underintervention can result in a massive preventable burden. additionally, and although only reported in india in our survey, alarming disruptions or delays in routine immunisation are also implemented in other lmics. during evd outbreak, vaccination activities were similarly disrupted for safety purposes, leading to substantial declines in immunisation coverage. catch-up campaigns should be prioritised following the relaxation of preventive measures. introducing new models of care such as telehealth guidance was described as a 'virtually perfect solution' to continuing care provision. however, this model is not compatible with all healthcare services and providers dread its impact on care quality. patient and community resistance to outbreak control measures and mutual incomprehension between patients and providers could shape the impact of covid- on mnh care. health-seeking behaviours rely on provider-patient relationships and common cultural, economic and social understanding of health and hygiene. [ ] [ ] [ ] [ ] hierarchical issues may affect mnh care quality as shown in west african urban areas and malagasy hospitals. understanding social and cultural responses to epidemics is essential to mitigate disasters and avoid a top-down management of outbreak guidelines that may miss the mark of preexisting factors. the lack of representativeness and related sample bias are limitations of this sampling approach. our sample might over-represent higher qualified cadres of health professionals in settings with limited use of technology among lower cadres of staff, and under-represent overstretched staff, or those with limited or no access to internet connection, as we received few responses from professionals working in lower level facilities, particularly in lmics. some cadres were less represented (eg, neonatologists and paediatricians). the sample's representativeness is affected by the availability of the survey in three languages (english, french and arabic) for a longer time than the remaining nine languages. the questionnaire asks about facilities where respondents work, which is not relevant to independently practising professionals, especially midwives; this might have discouraged some of them from completing the survey. finally, data were collected across countries going through different stages of the outbreak; in some countries, responding to such surveys is discouraged or forbidden by authorities (eg, china). this is the first study describing the preparedness for, response to, and effect of the covid- pandemic on mnh care provision. the multicountry survey creates an innovative platform for lessons to be documented and shared. our findings, ideally combined with an understanding of women's perspectives, hold enormous potential for establishing a timely, evidence-based decision-making platform. continued collection, rapid synthesis and timely dissemination of health workers' voices to planners, programmers and policymakers is crucial to guide the development and implementation of contextually relevant guidance. the covid- pandemic illustrates a susceptibility to emergencies, which is not restricted to healthcare systems in lmics. this crisis is challenging health systems and providers and disrupting access to basic services worldwide. health system preparedness might have been equally inadequate in lmics and hics in some aspects, such as shortage in skilled staff, training provision and ppe sufficiency. however, it is likely that hics were able to respond more effectively due to better health system resilience such as existing coordination systems to develop and implement changes to protocols. findings from this study will be useful in supporting the development of effective responses to main identified issues, during various stages of the covid- pandemic and more broadly during future health system shocks. coronavirus disease (covid- ) situation report- characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention antibodies in infants born to mothers with covid- pneumonia evidence for and against vertical transmission for sars-cov- (covid- ) faq breastfeeding and covid- managing covid- -positive maternal-infant dyads: an italian experience royal college of obstetricians & gynaecologists. coronavirus (covid- ) infection in pregnancy covid- infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of new york city hospitals clinical features and obstetric and neonatal outcomes of pregnant patients with covid- in wuhan, china: a retrospective, single-centre, descriptive study outcome of coronavirus spectrum infections (sars, mers, covid- ) during pregnancy: a systematic review and meta-analysis neonatal early-onset infection with sars-cov- in neonates born to mothers with covid- in wuhan, china a call for action for covid- surveillance and research during pregnancy q&a on covid- , pregnancy and childbirth ebola virus disease outbreak in guinea: what effects on prevention of mother-to-child transmission of hiv services? operational guidance for maintaining essential health services during an outbreak effect of ebola virus disease on maternal and child health services in guinea: a retrospective observational cohort study years on: the spanish flu, pandemics and keeping nurses safe healthcare providers on the frontlines: a qualitative investigation of the social and emotional impact of delivering health services during sierra leone's ebola epidemic counting indirect crisis-related deaths in the context of a low-resilience health system: the case of maternal and neonatal health during the ebola epidemic in sierra leone what makes health systems resilient against infectious disease outbreaks and natural hazards? results from a scoping review assessing global preparedness for the next pandemic: development and application of an epidemic preparedness index ebola outbreak on reproductive health services in a rural district of guinea: an ecological study family planning during and after the west african ebola crisis estimating the potential impact of covid- on mothers and newborns in low-and middle-income countries early estimates of the indirect effects of the covid- pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study estimates of the potential impact of the covid- pandemic on sexual and reproductive health in low-and middle-income countries protecting hard-won gains for mothers and newborns in low-income and middle-income countries in the face of covid- : call for a service safety net world bank country and lending groups understanding the information needs of health professionals. in: toxicology and environmental health information resources: the role of the national library of medicine youtube as a source of information on covid- : a pandemic of misinformation? the covid- social media infodemic a kenya practical guide for continuity of reproductive, maternal, newborn and family planning care and services in the background of covid- pandemic clinical guide for the temporary reorganisation of intrapartum maternity care during the coronavirus pandemic perinatal-neonatal management of covid- infection -guidelines of the federation of obstetric and gynecological societies of india (fogsi), national neonatology forum of india (nnf), and indian academy of pediatrics (iap) federal ministry of health -nigeria, nigeria centre for disease control. covid- guidelines for pregnant women and nursing mothers -nigeria health advisory: covid- guidance for hospital operators regarding visitation updated guidance regarding obstetrical and pediatric settings guidance for provision of midwife-led settings and home birth in the evolving coronavirus (covid- ) pandemic royal college of obstetricians & gynaecologists. guidance for deployment of obstetrics and gynaecology staff during the covid- pandemic coronavirus disease (covid- ) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health not a luxury: a call to maintain sexual and reproductive health in humanitarian and fragile settings during the covid- pandemic caring for the carers: ensuring the provision of quality maternity care during a global pandemic midwives step up to support pregnant women during pandemic the challenges of supporting pregnant women during covid- , from a midwife giving birth amid a pandemic in belgium: the challenges faced by mothers and midwives covid- : what implications for sexual and reproductive health and rights globally? covid- pandemic in west africa managing covid- in low-and middle-income countries covid- pandemic: syria's response and healthcare capacity covid- in humanitarian settings and lessons learned from past epidemics the world's largest refugee camp prepares for covid- reproductive, maternal, neonatal and child health in conflict: a case study on syria using countdown indicators health risks of rohingya refugee population in bangladesh: a call for global attention a study of refugee maternal mortality in countries maternal health and pregnancy outcomes among women of refugee background from asian countries impact of the ebola outbreak on health systems and population health in sierra leone world health organization. mental health and psychosocial considerations during the covid- outbreak occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis causes and effects of occupational risk for healthcare workers on the maternity ward of a tanzanian hospital nosocomial transmission of ebola virus disease on pediatric and maternity wards: bombali and tonkolili implications of dual practice among health workers: a systematic review rational use of personal protective equipment for coronavirus disease (covid- ) the experiences of health-care providers during the covid- crisis in china: a qualitative study covid- and mnch: beyond the models, what are we hearing from countries? the health impact of the - ebola outbreak effects of the west africa ebola virus disease on health-care utilization -a systematic review health-care access during the ebola virus epidemic in liberia women and babies are dying but not of ebola': the effect of the ebola virus epidemic on the availability, uptake and outcomes of maternal and newborn health services in sierra leone covid- response in uganda: notes and reflections changes in health care utilization during the mers epidemic covid- technical brief for maternity services women's rights in childbirth must be upheld during the coronavirus pandemic a chaotic week for pregnant women in new york city reflections on covid- vaginal delivery in sars-cov- -infected pregnant women in northern italy: a retrospective analysis coronavirus: baby blues as some mothers in france separated from newborn amid covid- fears the scale, scope, coverage, and capability of childbirth care covid- disrupts vaccine delivery world health organization. guiding principles for immunization activities during the covid- pandemic virtually perfect? telemedicine for covid- les difficiles relations entere soignants et soigne dans cinq capitales d'afrique de l'ouest enfants et santé madagascar -approches anthropologiques comparées. paris: Éditions l'harmattan patient and provider perspectives on how trust influences maternal vaccine acceptance among pregnant women in kenya trust in health care: theoretical perspectives and research needs maladies et violences ordinaires dans un hôpital malgache understanding social resistance to the ebola response in the forest region of the republic of guinea: an anthropological perspective biology and culture are inseparable -considerations for the "exit strategy" expert group from the field of medical anthropology what is a resilient health system? lessons from ebola acknowledgements we would like to thank the study participants who took time to respond to this survey despite the difficult circumstances and increased workload. we acknowledge the institutional review committee at the institute of tropical medicine for providing helpful suggestions on this study protocol and for the expedited review of this study. we would like to thank all study collaborators and colleagues who distributed the invitation for this survey and provided suggestions on the questionnaire, including the coauthors of this paper, dr susannah woodd and dr jean-paul dossou. we are immensely grateful to all those who volunteered to translate the survey, including contributors lb conceptualised the study and obtained funding. all authors contributed to the design of the study and development of the survey tool. as analysed the data. ca, lb, eh and as wrote the original draft of the manuscript. all authors contributed to the development of the manuscript and read and approved the final version. the corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. as is the guarantor. key: cord- -tjxt vd authors: jackson-morris, angela; nugent, rachel title: tailored support for national ncd policy and programme implementation: an over-looked priority date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: tjxt vd many low-income and middle-income countries (lmics) are unlikely to achieve sustainable development goal . to reduce premature deaths from non-communicable diseases (ncds) by one-third by . for some, the prospect is receding: between and , the decline in premature deaths for the major ncds slowed compared with the prior decade. barriers to implementing effective strategies are well known, yet the value of tailored technical support to countries has been overlooked and downplayed. tailored technical support is specialist guidance for country-specific application of technical tools, and capacity enhancement when needed, that enables an lmic to advance its ncd priorities and plans. we present a model identifying pivotal junctures where tailored technical support can help surmount implementation obstacles. we draw on our experience preparing ncd investment cases with health ministries, development partners and technical agencies. national investment cases produce evidence based, locally tailored and costed packages of ncd interventions and policies appropriate to national needs and circumstances. they can include analysis of financing needs and point towards sustainable funding mechanisms. enhancing the ncd-specific knowledge of government and civil society organization leads can capitalise on existing expertise, aid integrative health system developments and unlock capabilities to use global tools and guidance. investment cases form a platform to develop or review ncd plans and (re)prioritise action, then apply implementation science to trouble-shoot obstacles. partnering national stakeholders with technical support in this process is critical to develop and implement effective ncd strategies. low-income and middle-income countries (lmics) experience many barriers in carrying out their non-communicable diseases (ncds) strategies. this is evident in the deceleration that has occurred in reducing premature mortality from major ncds since and is painfully manifest in the conclusions of the latest who national country capacity survey. this survey found that generally integrated ncd policies were of inadequate breadth, 'best buy' interventions vastly underused, ncd surveillance systems insufficiently robust, lack of clinical guidelines for leading ncds, cancer-screening programme reach was often inadequate, essential ncd technologies and medicines remained widely unavailable, and palliative care was sparse. these weaknesses predated the covid- pandemic, however, severe acute respiratory syndrome coronavirus (sars-cov- ) brutally exposed the limitations of many countries' health systems as well as the significant vulnerability of the large numbers of people living with ncds that insufficient action has created. key barriers to ncd strategy implementation have been well articulated in the last decade. the who independent high-level commission on ncds highlights the need for political support to advance the ncd agenda, and need to develop sustainable financing for programmes, service delivery and human resources. in a brief sentence in this report, some commissioners highlighted the need for more tailored support to lmic to implement ncd strategies. we contend that tailored technical support is actually pivotal to enable summary box ► barriers to implementing effective noncommunicable disease (ncd) strategies are well known, yet the value of tailored technical support to countries has been overlooked and downplayed. ► we present a model of steps focused at key ncd implementation junctures that often require tailored technical support to ensure progress. ► national investment cases provide countries with evidence based, locally tailored and costed packages of ncd interventions and policies appropriate to national needs and circumstances. ► tailored technical support can empower national stakeholders to put investment cases into operation by partnering local expertise with specialist guidance for specific policies and programmes, using implementation science to surmount implementation obstacles and building national ncd capacity. the report's more prominent recommendations to be put into practice, and provision of such support requires serious consideration-and urgently-if we are collectively to move closer to achieving sustainable development goal (sdg) . in years time. the terms 'technical support'/'technical assistance' are widely used in health and development although definitions and emphases vary. common features are external provision of specialist knowledge, partnership with local stakeholders and capacity-building. tailored technical support is meant here as provision of specialist guidance to support country-specific application of technical tools, and capacity enhancement when needed, to enable an lmic to advance its ncd priorities. drawing on our experience preparing ncd investment cases and designing ncd strategies and implementation by partnering with health ministries in multiple countries, we present a model to suggest how national ncd implementation may be strengthened. the model (figure ) identifies a series of critical components that precede effective implementation: working with national stakeholders to select the most effective and cost-effective policy and programme priorities for a specific national context; identifying how to fund these sustainably; ensuring the system has capacity to lead and deliver the priorities; reviewing/renewing national strategy to reflect the chosen priorities; and creating a costed, actionable implementation plan. we propose that providing tailored technical support at these critical junctures when needed, working in partnership with national stakeholders, can galvanise ncd implementation. the components may be viewed as steps that can be applied sequentially or the model can identify the missing components in a specific context where some are already in place. thus, a country may use an investment case to review and reprioritise an existing strategy; some countries may have stronger ncd stakeholder capacity and may not need to address this; some may have sustainable funding mechanisms under development yet can beneficially align these to the newly identified priority interventions and revised strategy. in this way the model may be flexibly used, recognising that lmics are at different starting points and relating to their particular circumstances and contexts. for many countries, an investment case is the starting point. an investment case uses economic and political analysis to provide countries with an evidence-based agenda for implementing ncd policies that provide best valuefor-money and is feasible in that country. the process of conducting an investment case has been described elsewhere and involves careful review of existing ncd programmes and policies, discussions with national stakeholders to determine how to augment existing programmes in scale and scope, costing these and calculating return on investment-for population health and the national economy. each step entails detailed discussions with the ministry of health and, importantly, the other ministries that have a stake in the results in relation to the economy, agriculture, industry and education. civil society and private stakeholders are also engaged, collectively providing an understanding on how to align interests and take forward the priority actions. this inclusive process is a key for establishing credibility and laying the groundwork for policy and delivery to evolve. the impact of individual investment cases varies from country to country and can be hard to measure and harder to attribute. testimonials from policy-makers who have commissioned and used investment cases, as well as the large backlog of country requests for investment figure pivotal points for tailored technical support to support ncd implementation. ncd, non-communicable disease. bmj global health cases, lends authenticity to their value. notably, many country requests for investment case support have been made but are yet unfunded. while not every investment case results in immediate or attributable impact, a growing set of examples shows that investment cases can be game-changing to obtain political 'buy-in' and can catalyse multisectoral dialogue on funding solutions. the evidence from these experiences is that investment cases can catalyse a cascade of national actions such as expanding existing service coverage or implementing new prevention policies. the republic of georgia demonstrates how a well-timed investment case can unblock policy action. in , the health ministry was able to introduce the results of a pilot tobacco control investment case into debate over stalled tobacco control legislation. after the investment case was presented the georgian parliament agreed on multiple policy changes to reduce tobacco use in the country. similarly, investment case results were cited in the tobacco control legislation presented to the armenian parliament. other times the results do not lead directly to legislation but generate interest from advocacy groups and ministries of finance and advances dialogue about the implementation gaps. an example of such awarenessraising comes from the samoan tobacco control investment case. during the cabinet briefing on the investment case findings, the prime minister directed the minister of finance to immediately raise tobacco taxes. in kenya, a recently completed ncd investment case drew attention to the high price tag of increasing ncd treatment coverage. as for many countries, action on their investment case recommendations now awaits an accompanying funding strategy. an investment case coalesces stakeholders, creates a sense of urgency and fosters 'buy in', and identifies clear investment priorities. these are prerequisites to achieving sustainable funding for ncd strategy implementationwhether from the ministry of finance or external sources. an investment case quantifies the health and economic benefits of implementing ncd prevention and control, yet those results are theoretical without a financing plan to show policymakers and development partners how the strategies can be realised. the financing plan assesses the prospects for generating additional funding from the domestic budget, whether through revenue growth such as higher taxes or resource reallocation, and possible innovative financing sources, such as development bonds or social investment partnerships. the choice of financing mechanisms may be constrained for many low-resource countries and must be determined by responsible national financial officials in line with their development strategies. but once the ncd investment case is in hand, priority interventions are agreed, and financing is assured, how is effective implementation achieved? the who global coordinating mechanism working group on financing for ncds developed a tool to assist countries to assess options, yet national capacity to employ this may be stymied without specialist guidance. unexpected knowledge gaps can become major impediments if data and skills are unavailable in-country. such gaps commonly emerge around data analysis, programme costing, budgeting, fiscal and legal policy formulation, demand forecasting, procurement of medical supplies and resource mobilisation. these policy and programme development components require specialised technical skills and can be provided through tailored technical support alongside capacity development so functions can be sustained as programmes mature. figure shows the linked foundations of effective ncd policy and programme implementation: evidence-based priority setting, strengthening ncd-specific understanding among stakeholders, and ensuring recommended actions can be funded. each step may require targeted technical support. for example, a investment case developed by the jamaican government with support from the united nations development program (undp) examined the return on investment from scaling up ncd clinical interventions and implementing or intensifying prevention policies. the results showed a potential saving of us$ million and lives in jamaica between and from implementing the intervention package. this analysis spurred an immediate response from the government's top echelons to implement the ncd programme to accelerate their ambitious economic growth targets. the experience highlighted specific knowledge and skill gaps that had hitherto hindered the health ministry from achieving high level policy attention, despite having an ncd strategy and strong inter-governmental apparatus. gaps had included lack of costing for ncd programme components, need for greater interministry coordination (promptly acted on following the investment case), and greater awareness of the contribution that improved health would make to economic goals. until the current pandemic, the links between communicable and ncds had been overlooked by many global and national health officials, and there is now urgency to determine how to protect people with ncds and to create stronger population resilience. investment cases can assist governments by identifying synergies between addressing chronic disease and pandemic resilience, such as health system strengthening measures to ensure services to treat and manage ncds functioning during pandemics, averting excess ncd mortality and acute admissions. this evidence can then be used to identify sustainable financing mechanisms. global guidelines, protocols and tool-kits offer highquality support to national ncd planning. yet it is a leap of faith to envisage that managers can take these 'off bmj global health the shelf' and apply them, even when there is high-level 'buy-in' to address ncds, or that civil society organisations can identify how they can contribute. this is evident from the increased number of ncd plans that sit in place alongside a low level of health system readiness to deliver policies, programmes and services. ironically, given the scarcity of ncd funding, bottlenecks are created whereby available ncd funds remain unspent. growth in the number of ncd-trained national health and policy professionals is encouraging. some mics offer ncd specialist training in academic and workforce curricula. yet an ncd skill deficit is common and ncd departments are often still small and pulled in many directions. the current paradigm must shift from: 'i'm a [hiv/maternal health person] and new to ncds', to each lmic having a cadre of national officers confident in their ncd expertise. adding this to their experience in the existing (dominant) priorities, such as communicable disease, maternal and reproductive health, will be a major step towards health system integration solutions. empowering civil society as partners in the ncd agenda is a vital complement to this. strengthening national ncd capacity is a mediumterm goal. just as with the hiv/aids pandemic and covid- , there is a critical need to support countries while health crises are underway. national stakeholders (government, civil society and private sector) collectively possess the strongest understanding of their context, a wealth of data and crucially-staff, policy-makers and politicians to lead action. even where national ncd capacity is stronger, provision of technical support on the policy, system and programmatic mechanisms that can address specific conditions and risk factors can enhance and accelerate progress and reduce health and economic losses. much has been and can further be learnt from earlier experience in collectively advancing global and national health. best results come when national stakeholders are 'in the driver's seat' with tailored technical support on board as mechanic/navigator, providing specific assistance to facilitate an effective journey. both national stakeholders and external technical experts are needed. for example, it has been useful to partner government economists and lawyers with global counterparts who specialise in specific risk factors or conditions to develop fiscal and regulatory measures that are resistant to challenges from global commercial and industrial interests. such collaborations have been notable in tobacco control, partly owing to the complex, globalised legal, fiscal and commercial influences on the issue at national level, but also because funders recognised unmet need among national governments and prioritised technical assistance and national capacity building. global specialists can also introduce new techniques or technologies to build national capacity to apply these to ncds. figure provides an example of this synergistic partnership in relation to ncd policies and programmes developed by the st helena government in - . escalating ncd prevalence and cost of treating ncds on the island and evacuating emergency and complex patients for care overseas generated the political will to reorient bilateral funding towards ncds. significant value was added by partnerships that married local contextual expertise with solid evidence from other sources and highly specific support to co-produce solutions to what would otherwise be implementation challenges. this illustrates the 'design and delivery of specific ncd priority strategies' and 'health system strengthening for implementation and integration' components of figure the model we have put forth to move from investment cases and sustainable financing development to ncd strategy development/review and implementation planning can be informed by using an implementation science framework. implementation science addresses the need to develop, test, evaluate and retest the interventions and processes that constitute an ncd programme. knowledge will emerge about 'what works' and should be shared widely to aid effective delivery. there are various implementation science models, with the shared aim of improving knowledge in context to support effective implementation. the consolidated framework on implementation research (cfir) identified five key aspects of implementation that influence intervention outcomes. these relate to characteristics of the intervention itself, factors related to the context ('outer setting'), the implementers ('inner setting', including the partnership between national stakeholders and technical support providers), and the implementation process. specific constructs within these can be systematically analysed to identify barriers and facilitators for successful implementation, and these may then be translated into questions that can be answered through research and used to refine plans, programmes, and policies to better address needs, gaps or inequalities. thus, an investment case may identify a specific intervention as a cost-effective priority based on national data; implementation research can then indicate how this may impact population groups differently and suggest ways bmj global health that the implementation process and supporting actions should be tailored. for illustration, the better health programme (bhp) is a collaborative technical support programme supported by the uk foreign commonwealth office. bhp is applying implementation science to identify which of the obesity prevention strategies identified elsewhere as successful will be effective and acceptable in kuala lumpur's poorest communities. 'discrete choice experiments', 'knowledge, attitude and practices' surveys, interviews and focus groups are being used to elicit stakeholder needs, preferences and constraints to inform design, delivery and modification of interventions on how to enable healthier food and drink consumption and increase physical activity. support to apply an implementation science lens to ncd plans can in the short-term bridge the divide between plans and implementation, employ available evidence in a contextrelevant manner, and in the medium-term build national capacity to apply the techniques. the analysis presented in this paper: the need to put in place-specific components to strengthen national implementation of ncd strategies and programmes, and to provide tailored technical support to enable this, relates to two particular aspects that the cfir identified as influential on implementation outcomes. within the 'inner setting' (the national context for ncd implementation), the 'structural characteristics' of the lead organisation (government/ministry) includes its 'social architecture', age, maturity and size, and these characteristics can influence its ability to successfully implement policies and plans. within the 'outer setting' (external influences that can encourage a government to act to address ncds), 'cosmopolitanism' describes the degree that an organisation is networked with other external organisations. our contention is that the current status of underdevelopment of ncd capacity at national level (priority, funding, capacity) may combine with an absence of external technical support and thus create a cycle of poor implementation. while perhaps politically unfashionable to highlight direct support needs, we contend that at the present time technical support is essential to empower national health providers and policy-makers to operationalise effective ncd strategies. support is needed to develop three fundamental, interconnected building-blocks: investment cases, sustainable financing mechanisms and national ncd technical leadership; to employ implementation science to create actionable ncd solutions from national plans; and tailored guidance to maximise the impact of specific policies, programmes and system developments. in the complex world of global health organisations, there are various institutions, foundations and agencies that can provide components of the required support, depending on their technical capabilities in relation to specific issues, delivery capacity and infrastructure and relationships in different countries. serious progress on sdg . in lmics requires bilateral and multilateral donor organisations and philanthropic foundations to enable these implementation support partnerships. twitter angela jackson-morris @angiembjm and rachel nugent @rachelnugent contributors aj-m initiated the conceptual model. rn and aj-m refined and further developed this. aj-m and rn coproduced and revised the manuscript. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests none declared. patient consent for publication not required. provenance and peer review not commissioned; externally peer reviewed. data availability statement all data relevant to the study are included in the article or uploaded as supplementary information. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. angela jackson-morris http:// orcid. org/ - - - rachel nugent http:// orcid. org/ - - - world health statistics : monitoring health for the sustainable development goals assessing national capacity for the prevention and control of noncommunicable diseases: report of the global survey world health organisation. it's time to walk the talk the investment case as a mechanism for addressing the ncd burden: evaluating the ncd institutional context in jamaica, and the return on investment of select interventions investing in non-communicable disease prevention and management to advance the sustainable development goals investing in the prevention and control of non-communicable diseases for sustainable development: countries discussed the role of investment cases power dynamics, capacities and incentives that frame the implementation of ncd policies: lessons learned from conducting institutional and context analyses world health organisation. global ncd investment case encouraged the norwegian government's development of its ncd strategy and funding studying investment in tobacco control in low-and middle-income countries world health organization. launch of ncd investment case in armenia the cost of tobacco use on a nation. the samoa observer world bank group working paper: combating noncommunicable diseases in kenya: an investment case final report and recommendations from the working group on ways and means of encouraging member states and non-state actors to realize the commitment included in paragraph (d) of the political declaration of the high-level meeting of the united nations general assembly on the prevention and control of non-communicable diseases world health organisation. best buys and other recommended interventions for the prevention and control of noncommunicable diseases world health organisation. who steps surveillance manual. the who stepwise approach to non-communicable disease risk factor surveillance the relationships between democratic experience, adult health, and cause-specific mortality in countries between and : an observational analysis tobacco tax reforms to support economic development in west africa bloo mber gphi lant hrop ies t obac coreport. pdf national institute for health -fogarty international center fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science asking the right question: implementation research to accelerate national noncommunicable disease responses global better health programme key: cord- - h hhm authors: mazingi, dennis; ihediwa, george; ford, kathryn; ademuyiwa, adesoji o; lakhoo, kokila title: mitigating the impact of covid- on children's surgery in africa date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: h hhm nan an outbreak of the disease known as covid- , which originated in wuhan in the hubei province of china, has rapidly spread to all continents of the globe. first detected via local hospital surveillance systems as a 'pneumonia of unknown aetiology' in late december , the disease has since been declared a public health emergency of international concern by the who and reached pandemic status. it is uncertain what the eventual toll of the pandemic will be in africa; however, there has been a suspicion that the looming pandemic may hit harder than it has the rest of the world. africa has baseline weaknesses in healthcare resource allocation, and her fragile healthcare systems are particularly vulnerable to being overwhelmed by this illness. available statistics, to date, however, seem to show that the pandemic has been slow to begin. as of may, cases and deaths have been reported across the whole african continent, constituting % of all cases in the globe. african nations have had an opportunity to prepare for the coming onslaught, learn from the experience in other countries and choose interventions that are tailor-made for the unique socioeconomic context. while old age has consistently been associated with a higher risk of poor outcome, children appear to have escaped the worst of the disease. in a recent series from the chinese center for disease control and prevention, less than % of the cases were children below years of age. children of all ages may be affected, but they typically manifest mild or asymptomatic disease. this has important implications for the african pandemic: sub-saharan africa is the youngest continent in the globe with % of its population below the age of years. the demography of africa appears to portend a favourable course through the pandemic; however, it is unknown how the high prevalence of hiv infection, tuberculosis, malnutrition and the scourge of poverty will affect the human impact of the disease. the covid- pandemic has placed unprecedented strain on health services around the world, and paediatric surgical services are no exception. responses from surgical societies around the world thus far have focused on maintaining provision of emergency and urgent elective services while protecting healthcare workers (hcws). there is a risk of healthcare resources being diverted away from surgical care, potentially impeding progress towards global surgery goals for . paediatric surgical care may only be tangentially affected by this pandemic; however, there are unique considerations that deserve special attention. this article explores the wider implications for children's surgery in africa, drawing lessons from the past and giving recommendations for the current pandemic and future (table ). non-essential surgical and non-surgical activities should be curtailed to provide surge capacity for the expected pandemic-related influx. this is consistent with guidelines from many surgical societies worldwide ; however, heavy-handed shutdown policies have been discouraged in the african context because they risk exacerbating the already formidable surgical disease burden with disastrous consequences. elective surgical activity has been postponed in zimbabwe, south africa, kenya and malawi, among many other countries. negative effects should be anticipated if the past is anything to go by. during the severe acute respiratory syndrome-related coronavirus (sars-cov)- outbreak in toronto, stringent restrictions on non-essential surgical services were thought to have aggravated precipitous declines in surgical volume, with only small increases in surge capacity for the outbreak. postpandemic waiting lists for paediatric cancer are also expected to be sizeable. a recent modelling study from the 'covidsurg collaborative' paints a grim picture. twenty-eight million surgical operations are estimated to be cancelled and low-income and middle-income countries (lmics) such as africa will be hardest hit. the expectation that surgical volumes will bounce back rapidly is implausible, particularly in countries where there was already baseline fragility, and it may take longer than the weeks forecast to make up the backlog. current surgical rationing policies are based on a classification of the urgency of the patient's intervention, such as the national confidential enquiry into patient outcome and death system. effects on surgical practice paediatric surgical services in africa are characterised by significant delays in health-seeking and within the referral chain. the mobility restrictions imposed on patients by shelter-in-place measures, as well as reduced income during the pandemic, will presumably cause further delays in presentation that may adversely affect outcomes. the change to non-operative treatment in eligible patients for certain conditions, for example, appendicitis that is being contemplated, may find less success in africa, where a higher proportion of patients have complicated disease not amenable to non-operative treatment. it also has the potential to prolong hospital stay, which increases the chances of nosocomial transmission of the virus. preoperative screening and testing perinatal transmission of sars-cov- has not yet been demonstrated in recent small case series and a systematic review. [ ] [ ] [ ] this is consistent with findings during the sars-cov- and middle east respiratory syndrome (mers-cov) epidemics and should reassure surgeons working with neonates. however, neonates can still acquire infection from an infected mother's respiratory secretions. also, xu et al reported on eight infants who tested positive on rectal swabs even after having tested negative by nasopharyngeal swabs. this was thought to potentially represent faeco-oral viral transmission and has implications for surgeons of the gastrointestinal tract. sars-cov- has also been isolated in peritoneal fluid. larger studies are needed to determine the significance of these findings. airborne and contact precautions are indicated in all hcws working with children of all ages. experience from previous pandemics has demonstrated that hcws are the lynchpin of resilient surgical systems during an outbreak. during the ebola outbreak, the unfortunate death of % of the surgeons in one institution has led to a % reduction in surgical volumes, while trepidation on the part of hcws and lack of personal protective equipment have led to a reluctance to work during the sars-cov- , mers-cov and ebola outbreaks. this is particularly damaging in africa, where hcw morale is already low. hcw should be first in the minds of policy-makers because the axiom that there is no health without a workforce is as true during a pandemic as it is at any other time. children have been called 'the link in the transmission chain' because of their importance in facilitating and amplifying viral transmission. paediatric care in africa is typically characterised by significant involvement by guardians and other family members who support the child during hospital admission, assist the overburdened healthcare workforce and act as care advocates. they frequently live on the hospital grounds because of long distances from home and prohibitive transportation costs. a study from malawi showed that overcrowding in the hospital was a major issue due to the large population of guardians in the hospital. this is at odds with social distancing policies and has the potential to accelerate nosocomial transmission. guardians should be limited to the minimum practical number per patient (table ) . guardian policy should also take into account 'parental presence at induction of anaesthesia', a common practice that facilitates administration of anaesthesia but potentially places the parent at risk during an aerosolgenerating procedure. hospital visitors have been implicated as vectors in pathogen transmission during the sars-cov- outbreak of - , and hospital visitor policies were changed accordingly. the evidence linking restrictive visiting policies with prevention of nosocomial transmission during outbreaks is scant; however, it is a rational approach until better evidence comes to light. expert guidelines from the society for healthcare epidemiology of america give recommendations for guardian and visitor policy based on a systematic review of the literature and are incorporated in our recommendations (table ) . experiences from this and past epidemics show that in health emergencies children, the most vulnerable members of society suffer disproportionately. the 'agenda for action' recently announced by unicef is a timely intervention aimed at preventing the pandemic from becoming a child's-rights crisis. the incidence of family violence and accidental household trauma, for example, burn injuries, are anticipated to rise during the pandemic and is associated with shelter-in-place measures. paediatric surgeons have a unique role in management of the traumatic injuries, protection of children from a dangerous household and in tertiary prevention (minimising the effects of child physical abuse and preventing recurrence). churches, schools and shelters, which would otherwise be safe havens, may be closed and healthcare facilities may be the option of last report. bringing a child into a potentially hazardous hospital environment with the risks of nosocomial infection brings up difficult choices. impact on training surgical training programmes are an additional casualty of the social distancing measures and surgical rationing. the reduction in elective surgical cases and clinics, as well as contact between teachers and trainees, has brought challenges in the delivery of surgical education worldwide. [ ] [ ] [ ] academic training programmes have had to adapt rapidly to maintain the integrity of training programmes, ensure trainee welfare and comply with local laws. postgraduate qualifying examinations of the west and south african colleges of surgeons scheduled for april and july, respectively, have been postponed; however, the examination of the college of surgeons of east, central and southern africa (cosecsa) scheduled for november have not yet been impacted. a recent global review of paediatric surgical workforce density showed that a minimum of four paediatric surgeons per million children under years of age would be required to achieve a survival of > % for a group of four bellwether paediatric surgical conditions. this translates to a deficit of additional paediatric surgeons in lmics required to attend to the almost billion children living there. the paediatric surgical workforce deficit in africa is particularly large, and disruption of training programmes is likely to significantly affect achievement of workforce goals. the pandemic has also presented opportunities for surgical education. virtual didactics are poised to increase the size of the classroom and to allow easier collaborative learning between teams in different hospitals or countries. this is occurring all over the continent and the practice may persist long after the pandemic is over. the inexorable spread of covid- around the world continues unabated and threatens to affect every clinical specialty. children have unique needs and suffer disproportionately during health emergencies and therefore require enhanced protection. paediatric surgeons in africa have an important role during times such as these and should use tailor-made, context-appropriate strategies to minimise the impact on our patients and hcws. protection for hcws should be the foremost in the minds of policy-makers as they are a precious and irreplaceable resource. covid- pandemic in west africa early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia looming threat of covid- infection in africa: act collectively, and fast preparedness for covid- in the oncology community in africa critical care capacity during the covid- pandemic: global availability of intensive care beds covid- : africa records over cases as lockdowns take hold outbreak brief # : coronavirus disease pay attention to sars-cov- infection in children characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention severe acute respiratory syndrome coronavirus (sars-cov- ) infection in children and adolescents: a systematic review epidemiology of covid- among children in china world population prospects : highlights. new york: united nations, department of economic and social affairs, population division covid- preparedness within the surgical, obstetric and anesthetic ecosystem in sub saharan africa correspondence from northern italy about our experience with covid- from the editors: the covid- crisis and its implications for pediatric surgeons global guidance for surgical care during the covid- pandemic global surgery : evidence and solutions for achieving health, welfare, and economic development letter to the editor: cancellation of elective surgery during the covid- pandemic ssz covid- subcommittee. statement on the conduct of surgical services during the covid- outbreak association of surgeons of south africa's statement on covid- covid- : ssk statement on recommendations for surgical procedures and outpatient clinics effect of widespread restrictions on the use of hospital services during an outbreak of severe acute respiratory syndrome elective surgery cancellations due to the covid- pandemic: global predictive modelling to inform surgical recovery plans the ncepod method' -how the national confidential enquiry into patient outcome and death designs and delivers national clinical outcome review programmes quantifying delays and self-identified barriers to timely access to pediatric surgery at mbarara regional referral hospital, uganda acute appendicitis in the developing world is a morbid disease clinical recovery in children with uncomplicated appendicitis undergoing non-operative treatment: secondary analysis of a prospective cohort study infants born to mothers with a new coronavirus (covid- ) perinatal transmission of covid- associated sars-cov- : should we worry? vertical transmission of coronavirus disease (covid- ) from infected pregnant mothers to neonates: a review infants born to mothers with severe acute respiratory syndrome mers-cov infection in a pregnant woman in korea a case report of neonatal coronavirus disease in china characteristics of pediatric sars-cov- infection and potential evidence for persistent fecal viral shedding sars-cov- is present in peritoneal fluid in covid- patients surgery in the time of ebola: how events impacted on a single surgical institution in sierra leone fear of severe acute respiratory syndrome (sars) among health care workers an assessment of the level of concern among hospital-based health-care workers regarding mers outbreaks in saudi arabia the health impact of the - ebola outbreak job satisfaction and morale in the ugandan health workforce a universal truth: no health without a workforce. geneva: global health workforce alliance and world health organization covid- in children: the link in the transmission chain patient guardians as an instrument for person centered care parental involvement in the management of hospitalised children in kenya: policy and practice utilization of family members to provide hospital care in malawi: the role of hospital guardians sars in a hospital visitor and her intensivist sars transmission and hospital containment how severe acute respiratory syndrome (sars) affected the department of anaesthesia at singapore general hospital isolation precautions for visitors impacts of covid- on vulnerable children in temporary accommodation in the uk feeding lowincome children during the covid- pandemic should children with suspected nonaccidental injury be admitted to a surgical service an increasing risk of family violence during the covid- pandemic: strengthening community collaborations to save lives burn center function during the covid- pandemic: an international multi-center report of strategy and experience child abuse and the pediatric surgeon: a position statement from the trauma committee, the board of governors and the membership of the american pediatric surgical association public health models for preventing child maltreatment: applications from the field of injury prevention practical techniques to adapt surgical resident education to the covid- era together: a training program's response to the covid- pandemic the impact of covid- on medical student surgical education: implementing extreme pandemic response measures in a widely distributed surgical clerkship experience notice of postponement of west african college of surgeons (wacs) announcement to cmsa candidates defining the critical pediatric surgical workforce density for improving surgical outcomes: a global study the pediatric surgery workforce in low-and middle-income countries: problems and priorities