key: cord- -u brl bi authors: annandale, ellen title: society, differentiation and globalisation date: - - journal: health, culture and society doi: . / - - - - _ sha: doc_id: cord_uid: u brl bi first, theories of globalisation and their implications for the analysis of health issues are discussed. emphasis is on: ( ) globalisation as embodied, something often overlooked by sociologists working outside of the field of health and ( ) health vulnerabilities that arise from the heightened mobility and connectivities that characterise globalisation, taking migration and health as an illustration. second, differentiation is considered by highlighting disparities in health vulnerability and the capacity of social groups to protect their health. this is illustrated by reference to the securitisation of health and the health consequences of violent conflict and the special vulnerabilities of children and of women. third, the influence of interconnectedness of various national healthcare systems and implications for the delivery of effective healthcare are considered. sociology was born of modernity and the conception of 'society' as a sovereign unit of analysis. since the turn of the present century this has been subject to considerable critical analysis as it has been argued, with increasing force, that the discipline has entered a 'post-societal phase' as a consequence of globalisation, challenging as a consequence sociology's basic units of analysis, namely, the nation-state (burawoy ). urry characterises this as 'a theoretical and empirical whirlpool where most of the tentative certainties that sociology has endeavoured to erect are being washed away ' ( : ) . the effects are several, including the search for new theoretical frameworks and associated conceptual tools which turn from the traditional emphasis on stasis, structure and social order in favour of mobility, contingency and complexity (see e.g. castells ; walby walby , . concurrently, theorists have re-examined the assumptions of modernity, or what it means to be modern, that shaped the discipline. as connell ( : ) expands, 'sociology developed in a specific location: among men of the metropolitan liberal bourgeoisie'. the so-called founding fathers of the nineteenth century, such as durkheim, marx and weber, were concerned principally with the social changes taking place as european societies modernised, processes such as socio-economic restructuring, loss of social cohesion and new forms of social inequality. consequently, the very meaning of modernity itself was eurocentric since the social was conceived as 'an internally coherent, bounded phenomenon that could be understood without any reference to external relations such as the colonial or imperial misadventures that were being undertaken at the time' (bhambra : ) . for example, durkheim's ( durkheim's ( [ ) analysis of the division of labour in society, especially his disquiet about excessive individualism and lack of social cohesion under organic solidarity, was approached overwhelmingly by reference to processes internal to a society. sociologists have questioned the constraints that this presents for an adequate understanding of social life in both the global north and the global south. but as bhambra ( : ) argues, while sociologists are now far more inclined to discuss modernities in the plural, these often refer back to european analysis such that 'the west is understood as the major clearing house of modernity' to the rest of the world, meaning that non-western peoples must now begin to engage their traditions with modernity in different forms of hybrid "modernities"'. as she continues, with globalisation these multiple modernities still tend to be seen as becoming global as they incorporate features of the west to local circumstances. thus, as she puts it, while there is recognition of difference, that difference does not necessarily make a difference to sociological ways of thinking. bhambra ( ) exemplifies this through the analogy of the spokes of a wheel where european modernity of the centre diffuses along the spokes of other parts of the world or countries in relation to their encounters with the west, with very little consideration given to how the spokes may relate to each other. perforce there is a tenacious northernness to sociological theory which can result in the erasure of the experience of peoples outside of the metropole-the majority of the people of world-from the foundations of social thought (connell ). this has sizeable implications for the analysis of society, differentiation and globalisation and health. the connections between 'global' and 'health' are very far from given, rather, as this chapter seeks to show, global health problems and responses are 'enabled, imagined, and performed via particular knowledges, rationalities, technologies, affects, and practices across a variety of sites, spaces, and relations' (brown et al. (brown et al. : . this means it is important not only to consider globalisation's processes and effects but also how they are theorised and the consequences that this might have for our understanding of health and healthcare in different parts of the world. this chapter is organised as follows. part addresses theories of globalisation and their implications for the analysis of health issues. in particular i emphasise that globalisation is embodied, something often overlooked by sociologists working outside of the field of health (turner ) . emphasis is given to the health vulnerabilities that arise from the heightened mobility, and connectivities that characterise globalisation, taking migration and health as an illustration. in part , i turn to consider differentiation by highlighting disparities in health vulnerability and the capacity of social groups to protect their health. this is illustrated first by reference to the securitisation of health and (elbe a) . a focus on the mental and physical health consequences of violent conflict then draws out the special vulnerabilities of children and of women. finally, in part , i reflect on neoliberalism as the dominant politico-economic policy framework driving health system change and on the increasing interconnectedness of various national health systems, and their implications for the delivery of effective healthcare. as turner emphasised over a decade ago, 'we can no longer study the treatment of disease in an exclusively national framework because the character of disease and its treatment are global ' ( : ) . the sociology of health needs to be global in scope and, crucially, the globalisation of health risks and of medical institutions should be added to globalisation theory as 'the first steps toward a globalisation of the body' (turner : ) . while turner underlines that the spread of global health risks and global health institutions can be thought of as a new phase of globalisation, attention in these terms is wanting in most globalisation theories. even so, they can provide a useful lens into the analysis of health in the global context. as already noted, since globalisation is envisaged as a new social order, a substantially new theoretical framework is necessary to analyse what is envisaged as a 'new unbounded social system' (connell : ) . while popular thinking tends to equate globalisation with linear diffusion of western values and ideas to the rest of the world and construe arrested globalisation as resistance to such a trend-such as in the interpretation of the rise of islamic fundamentalism as a direct response to the spread of western political and cultural values into the middle east-most social scientists maintain that globalisation has no one single logic. instead of moving in one direction, they stress that it is multi-dimensional and multi-causal. bauman ( : ) describes globalisation as uncontrolled, operating in what he depicts as a 'vast -foggy and slushy, impassable and untameable -"no man's land"'. similarly for beck ( ) , there is no over-riding logic or driver, such as the economic; rather globalisation is multi-causal and multi-dimensional. consequently it presents as a new form of radically uncertain modernity. according to walby, globalisation is best identified as 'a process of increased density and frequency of international interactions relative to local or national ones ' ( : ) . she argues that this can be grasped most effectively through the lens of complexity theory. this entails a reworking of the concept and theory of society to bring system to the fore but in a substantively different way to erstwhile approaches such as that of parsons ( ) , where social systems were construed as entities made up of parts. by contrast, walby ( ) proposes that sociology should be the study not of parts but of all of society as a set of relations. from this position, she maintains it is possible to 'address multiple regimes of inequality existing within the same territory without assuming that they must neatly map onto each other or be confined to the same borders' (walby : ) . this offers a new vocabulary with which to understand social change; that of co-emergence, non-linear processes and heterogeneity (walby ), which draws attention to features of globalisation such as heightened mobility and new forms of connectivity between people, all of which have health implications. in his theory of the networked society, castells ( ) advances that social structure is always in the making, connecting the local and the global. while mobility is crucial, of equal importance for castells is perpetual connectivity. mobility stratifies through movement and through the lack of it. for some, 'space has lost its constraining quality and is easily traversed in both its "real" and "virtual" renditions' (bauman : ) , increasingly making it possible to move around the world for employment, in search of personal health and well-being and, as discussed in part of the chapter, for healthcare. conversely, there are people, such as refugees, who, for reasons such as civil war and persecution, have no choice but to move and to keep on moving. globalisation also makes visible the world of the 'locally tied' and globally many people are tied to risky communities that are damaging to their physical and mental health. (see chap. .) in collateral damage, bauman argues that 'the inflammable mixture of growing social inequality and the rising volume of human suffering marginalised as "collateral" is one of the most cataclysmic problems of our time' ( ). 'collateral damage' is military in origin and refers to the unplanned effects of armed intrusions. applying it to global societies, bauman conveys how the poor become collateral damage in a profitdriven, consumer-oriented society. although he does not address health and illness, it may be instructive to conceptualise those increasingly vulnerable to health inequity as a form of collateral damage. we turn to look at this now through the example of recent migration and health. the term migrant encompasses multiple forms of mobility. in broad usage, it is often taken to refer to people who move 'voluntarily' to live in another country for a year or more, such as 'economic migrants' and also 'irregular migrants' (those entering a country without required documents). by turn, 'forced migrants' comprises refuges, defined under the united nations (un) refugee convention of as those forced to flee to save their life or preserve their freedom; asylum seekers, or people seeking international protection, awaiting a decision on whether they have refugee status; and internally displaced persons (idps) forced to leave their homes to avoid armed conflict, natural or human-made disasters, or violations of human rights, but who have not crossed an international border. the un convention protects refugees, but asylum seekers and idps have few rights and hence limited protection. the relationship between migration and health is complex for the reason that migrants are a heterogeneous group. nonetheless, it can be useful to draw a general distinction between 'voluntary' and 'forced' migrants. although we need to be wary of overgeneralising, where 'voluntary' movement is concerned, research points to health selection since migrants often are healthier compared to people in their country of origin, yet it is important to recognise that migration itself can carry risks such as those of transit and adjusting to life in a new country. from his in-depth consideration, gatrell ( ) concludes that although migrants tend to be in better health than those left behind as well as than those in the new host population, these relative health advantages attenuate as immigrants adapt their behaviours, particularly their dietary and exercise behaviour, to the norms of the new community. this is borne out by huijts and kraaykamp's ( ) large-scale analysis of immigrant health in europe. based on european social survey data for - , they analysed the health of over , immigrants from different countries who had moved to different european countries. basing self-assessed health on a five point scale (i.e. very bad, bad, fair, good, very good), they analysed foreign born and second generation migrants in europe with a focus on 'origin' and 'destination' effects on health. characteristics of origin were found to have a lasting influence. for example, high levels of political oppression were associated with poorer health in both first and second generation migrants. religion was found also to be influential. notably, first generation immigrants from islamic countries reported better health than those from countries where other religions predominate (all other factors being equal). the authors relate this to socialisation into positive health behaviours such as refraining from alcohol consumption and smoking, although, this did not apply to the second generation, something which they put down to the influence of culture in the destina-tion countries. overall then the health of immigrants shows a strong resemblance to the health of native inhabitants of the country of destination, but there are some lasting effects of origin countries (huijts and kraaykamp ) . the deregulation of wars is one of globalisation's most ominous effects. as discussed further below, most present-day war-like actions are carried out by non-state entities and consequently associated with the erosion of state sovereignty and the burgeoning frontier-land conditions of 'suprastate global space' (bauman : ) . populations who flee conflict in their homelands often find themselves as outcasts in camps where they are neither 'settled nor are they on the move; they are neither sedentary not nomadic', becoming 'undecidables' made flesh (bauman : ) . when analysing forced migration we need to think less in terms of individuals moving in a linear fashion from point a to point b and more of constructed group movement, where the journey from a to b is often protracted and involves periods of stasis in 'transit' locations such as idp and refugee camps, as well as interception stages, such as border controls. such journeys are risk-laden (zwi and alvarez-castillo ) . as gostin and roberts ( : ) relate, 'each stage of the forced migration journey…poses health risks. individuals face armed conflict, famine, or both in their home countries causing physical illness, severe mental distress, and lifelong trauma'. the body of a -year old syrian refugee, aylan al-kurdi, lying on a turkish beach in september is an enduring image of the present european 'migrant crisis'. in alone, people were reported dead or missing in the mediterranean sea as they sought to escape conflict in countries such as syria and afghanistan (unhcr ). other health risks include injury and disability in transit and infectious diseases, such as measles, polio, cholera, tuberculosis, dysentery, and typhoid which can be rife in camps and exacerbated by food insecurity and lack of clean water. a report from unhcr (hassan et al. ) on the mental health and psychosocial well-being of syrians affected by armed conflict draws attention to experiences of violence, exploitation, isolation and losses such as grief for loved ones, homes and possessions. this manifests in helplessness, loss of control and anxiety as well as social withdrawal (especially amongst women and young people), fatigue, sleep problems, loss of appetite, and unexplained physical symp-toms. the authors detail that often suffering is understood as a normal part of life, not in need of medical attention. most arabic and syrian idioms of distress do not separate physical experience and mental symptoms since body and soul are linked in explanations of illness. for example, 'habat qalb or houbout el qalb, literally "falling or crumbling of the heart", corresponds to the somatic reaction of sudden fear', and 'kamatni kalbi "my heart is squeezing"…generally refers to anticipated anxiety and worry' (hassan et al. : ) . the health consequences of forced migration are a powerful illustration of the 'social suffering [that] results from what political, economic, and institutional power does to people, and reciprocally, from how these forms of power themselves influence responses to social problems' (kleinman et al. : ix) . bauman ( ) argues that, from the stance of the more secure in the world, migrants embody ambient fears of precarity and of people whose lives are defined by precariousness and anxiety. the insecure are less able to evade their own vulnerabilities, including fears of loss such as of work, homes and loved ones, that are intensified by their scattered and unpinpointable nature (bauman ) . grove and zwi ( ) draw on 'othering theory' to account for the responses of people in destination countries of the global north to forced migrants. the process of othering marks migrants out as different to 'us' and in the process shores up feelings of normalcy. concurrently migrants are constructed as risky to 'us', as distant and strange others, as needy, as charity cases and as health services queue jumpers who create welfare overload. as grove and zwi ( ) discuss, the language used is that of burden to the neglect of the agency, resilience and skill of many migrants. the health of forced migrants is but one example of the negative health consequences of globalisation. it highlights differential health vulnerabilities and the (in)capacity of groups of people to protect their health, the focus of this section of the chapter. the concept of the 'other', referred to earlier, is a useful frame within which to approach the effects of the securitisation of health in global context. although there is a strong historical connection between health and the security of nations, such as in times of war, the notion of 'health security' is quite recent. the catalyst was the events of / in the year . this occasioned the setting up of the global health security initiative, an international partnership between several countries, including canada, france, germany, italy, japan, mexico, the uk and the us, intended to supplement and strengthen their preparedness to respond to threats to global health, not only in regard to terrorism, but also pandemic infection and bio-chemical warfare. by , 'health security' was high on the global agenda, as reflected in the world health organisation's annual report, a safer future (who ) . the report defines health security as 'the activities required, both proactive and reactive, to minimise vulnerability to acute public health events that endanger the collective health of populations living across geographical regions and international boundaries' (who : ix) . this signifies a two-way relationship between health and security. first, the health of populations is seen increasingly in security terms; that is, there is a felt need to secure population health against threats. concomitantly, the security of nations is viewed in medical terms. in security and global health, elbe ( a) proposes that the medicalisation of security has three dimensions. the first is that national security moves from being only about military capabilities and the hostile intentions of other states to the proliferation of lethal medical problems in the bodies of citizens. an instructive way to consider this, and also to track changes in ways of thinking over recent time, is to consider responses to infectious diseases such as hiv/aids and sars (severe acute respiratory syndrome). the aids epidemic (see also the discussions on aids in chaps. and ), which began over years ago in the s, was perhaps the first time that governments, notably the us as a superpower, began to link pandemics to national security and to worry about the possible effects of illness on us interests abroad (mcinnes and ruston ). several years on in , then us president clinton declared aids a national security threat to the country. first, and perhaps foremost, there was concern with high hiv prevalence in the armed forces in times of war and hence the capacity to protect the nation (elbe a) . with the sars epidemic of , security concerns shifted from armed conflict and the stability of national states to mortality burdens and economic repercussions (elbe a) . sars was traced to guangdong province in china, and thereafter it spread to hong kong, singapore and toronto. by , the who was warning against all but essential travel to these countries. in hong kong, over people were subject to isolation orders. when sars spread to the middle-class private housing complex of amoy gardens in kowloon, the department of health quarantined apartments (although by the time the police arrived most people had already fled). a headline in the singapore straits times of may that year emblazoned that 'sars is like singapore's / '. the security threat attended very much to the economic repercussions. with sars respiratory droplets are produced when an infected person coughs or sneezes; this is largely invisible and unpredictable and hence hard to avoid. during the outbreak people began to keep away from public spaces, to minimise time spent outside home, and to wear face masks. the economic effects were predictable; with the avoidance of travel, retail sales declined and there were less business exhibitions and meetings. it was estimated that the asian region as a whole lost the equivalent of - million us dollars. the canadian government evaluated that three million dollars were lost to the country's economy in the first two weeks alone of the outbreak in toronto (elbe a) . this prompted wider concern that any epidemic outbreak could wreak havoc on the world economy, further boosting the medicalisation of security. the second dimension of the medicalisation of security addressed by elbe ( a) is the expansion of medical power and accompanying influence. at the most general level this is evident in increased involvement of medically trained persons in national security circles, most notably in the us. a key turning point was when then president clinton brought physicians into politics in relation to aids with the objective of using them in helping to defend the us population from disease. of significance here is the shift in emphasis from physicians as not only treating disease in individuals but defending against disease in populations. presently, the us homeland security hosts an office of health affairs which has a division of health threats resilience. the third and final dimension of the medicalisation of security brought to the fore by elbe ( a) is measures to secure, or attempt to secure, population health. the main strategy of governments to protect citizens has been the stockpiling of medical countermeasures to major illness as a readiness or preparedness against future uncertainly highlighted by bauman ( ) as referred to earlier. this is exemplified by the stockpiling by several governments of the global north of the anti-viral tamiflu during the 'swine flu' (h n ) outbreak of . the differential consequences for populations of containment efforts can be illustrated by the race to secure antiviral medications and vaccines in the wake of the possible h ni (avian flu) pandemic in the mid- s. as recounted by elbe ( b) , the majority of cases and of deaths at the time were in indonesia (see also chap. regarding how rural poor women in indonesia are at great risk for maternal mortality, morbidity and infant death). in , the country's government stopped sharing its virus samples to who under the global influenza surveillance network because it discovered that they were being given to western pharmaceutical companies and novel vaccines offered back at unaffordable commercial rates. it is therefore important to underscore that the securitisation of health is practised through, and acts on, the bodies of populations; it is a fundamentally embodied phenomenon involving the surveillance and control of populations, their bodies and their health (see also chap. for a detailed discussion on embodiment). this is now pervasive for the reason that many of the health threats referred to are unpredictable-no one predicted the outbreaks of sars in and ebola virus in - , for example, and it is hard to know where future threats may come from and what they will mean. future health pandemics have rogue status, as depicted in the metaphor of the black swan. initially the notion of black swan was used to refer to unexpected events in financial markets, and then expanded to refer to any surprise event of major proportions. it has been evoked by the us national intelligence council ( : ), which advises that 'no one can predict which pathogen will be the next to start spreading to humans, or when or where such a development will occur. an easily transmissible novel respiratory pathogen that kills or incapacitates more than one percent of its victims is amongst the most disruptive events possible. such an outbreak could result in millions of people suffering or dying in every corner of the world'. uncertainly is associated with both vulnerability and the escalation of agencies of health security. while the securitisation of health might seem to the good for all individuals and all populations, it can also be divisive, highlighting our concern with differentiation. among the questions to be posed are: to what extent is the concern with 'national security' and to what extent with 'human security'? (delaet ) are differential health interests being served? it has been argued (davis ) that the securitisation of infectious disease prioritises the health concerns of western states. in this regard agencies such as who are not neutral actors; diseases come to be identified as a threat when western states feel threatened; after the threats wane so does the support (davis ) . securitisation is then state-centric and shaped by the interests of privileged populations. disease that is seen as containable within national boundaries, such as diarrheal disease and the more hidden burdens such as maternal mortality, infant mortality, hunger and traffic deaths, fails to reach the level of concern that securitised infectious diseases evoke. resources are directed away from public health actors and poverty-related health challenges in ways that do not accurately reflect the global burden of disease (delaet ). based on data reported at the end of , there were extremely violent conflicts going on in the world in (ocha ). as well as deaths, injuries and all the other effects of collective violence, there were . million forcibly displaced persons, including . million refugees, . million asylum seekers and . million idps (ocha ). most contemporary or 'new wars' involve a range of not only state but also nonstate combatants who use violence to pursue exclusionary goals, such as religious, ethnic and economic interests, as exemplified by the civil war in syria. frequently in such contexts, civilian casualty is not a side effect but an aim in itself. to give an illustration, unicef ( ) reports that two million children are living in areas largely cut off from any humanitarian assistance; saw over cases of killing and maiming of children, as well as attacks on schools and hospitals and denial of humanitarian aid to children. when considering the health effects of armed conflict analysts can be inclined to focus on fatalities from direct combat or death from fatal injuries sustained in combat, including the deliberate use of starvation as a direct weapon of war. but, there are other direct effects such as significant physical and mental health problems amongst both the armed forces and targeted and untargeted civilians-such as illness resulting from disabilities (e.g. loss of limbs) and from atrocities of war, such as rape and torture, and sexually transmitted infections. there are also indirect effects of conflict. for example, health facilities, which may not have been of the highest standard even before the onset of conflict, can be destroyed, cutting off access to essential care. moreover, disease spreads in insanitary conditions such as overcrowded refugee camps, and persons living in war-torn environments invariably suffer fear, insecurity and mental trauma (levy and sidel ) . the differentiation of peoples is fundamental here. in frames of war, butler ( ) counsels that wars seek to manage populations by distinguishing lives to be preserved from those that are dispensable. some lives become grievable and others not, since to be grievable a life has to matter rather than to be seen as imminently destructible. violent conflict is then one of the most radical inequalities imaginable as some deaths of some populations or groups are seen as necessary to protect the living of others. as will be discussed later, women and girls, and children in general are often differentially vulnerable. we will now take this further through two case illustrations: the health of former child soldiers and rape of women in war. the term 'former child soldier' refers to children abducted into armies and rebel forces and then returned home. there are an estimated , child soldiers in the world today, of whom, over percent are girls. the participation of children under the age of years in armed conflict is generally prohibited under international law, and the recruitment of children under into conflict is a war crime (amnesty international ). coerced, enticed or abducted, children serve as combatants, porters, spies, human mine detectors and sex slaves. their health and lives are endangered. many are forced to commit atrocities such as killing or maiming a family member in order to break ties with their community and to make it harder for them to return home. a high rate of mental health problems amongst returnees is inevitable, not the least because when they return home they can experience stigma due to perceptions that they are immoral or dangerous. it is unsurprising, therefore, that former child soldiers have high incidences of post-traumatic stress disorder (ptsd), which is associated not only with their experience during war, but its aftermath. betancourt et al. ( ) researched children in sierra leone who were recruited into the national army and civilian defence during the civil war of , most notably the revolutionary united front (ruf), which was responsible for brutal atrocities against civilian populations, including amputations to supress resistance, and large-scale abduction of children. the ruf forced children to commit atrocities including the murder of loved ones. many were subject to repeated rape and forced to take drugs to reduce inhibition against committing violent acts. after the war ended, programs were set up to reintegrate children into their former communities, yet this was very difficult as most faced fear and distrust and girls were seen as sexually promiscuous or defiled. betancourt et al. ( ) studied the role of stigma in mediating children's exposure to war-related events and mental health outcomes. a total of former ruf child soldiers aged between and years were interviewed at the end of the war in and again in with a focus on family and community acceptance and psychological adjustment, especially levels of depression, anxiety and hostility. the researchers found that the large majority of the respondents were involved with the rebels by force with an average age at abduction of years. in all, percent of the girls and percent of the boys reported being a victim of rape; percent of girls and percent of boys had wounded or killed either a loved one or a stranger. levels of depression were high and percent felt local people acted afraid of them, and percent that the local people felt threatend by them. as one child said, 'initially when i arrived [back home], people feared me. some said i was a killer. there were times when i wanted to touch or play with other kids, but their parents will shout at me. i felt bad during those early days' (quoted in betancourt et al. : ) . in conflict zones around the world, military forces use gender-based sexual violence (gbsv) to terrorise, humiliate and demoralise whole communities, including by the spread of a disease such as hiv and of sexually transmitted diseases-a clear illustration of illness as a tactic of war. here the association between the individual and the collective becomes paramount. there has been a tendency to explain rape and sexual violence as random and opportunistic acts of war, that is, outside of the wider structural context of the society concerned. yet gendered structural conditions are crucial. indeed, it is arguably because of the normalisation of women's inequality in a society where gbsv appears logical and instrumental (davis and true ) . though violent conflict and health is not their focus, scheper-hughes and lock's ( ) theorisation of the 'mindful body' is a valuable lens through which to evaluate gbsv. (see chap. for a discussion of 'the mindful body' in the context of embodiment theory.) they draw attention to the individually experienced body-self, and also to the social body and its symbolic and representational uses, and to the body politic, or the regulation and control of bodies, for example in families and in medical systems. research examples illustrate how the individual body, social body and body politics come together to help explain rape and sexual violence in war. in their research on gbsv in south kivu, democratic republic of the congo, kelly and colleagues ( ) found that, absolutely vital though this is, rape goes far beyond individual physical and psychological trauma and becomes a societal phenomenon where isolation and shame often become as important as the attack itself. analysis of focus group data revealed that many interpreted rape as a form of destruction to the community, associated with the spread of disease, the devaluation of women and the breakdown of families. as one respondent put it, 'if you are a girl [who has been raped], your parents will start mistreating you, they can't understand that you have been forced and that it was not your fault. you will never get married. they will throw you away because you are not worth anything; you will lose all value because nobody will marry you' (quoted in kelly et al. : ) . husbands may view their wives as 'contaminated', such as by sexually transmitted infections, and also as morally contaminating since the rape of a wife can result in loss of pride and a feeling of impotence in being unable to provide support (kelly et al. ) . a second illustration of the power of collective structural context on individual experience comes from the serbian occupation of croatia in the early s. olujic ( ) argues that to understand what happens in war we must take account of the pre-war gendered context, especially meanings of female sexuality and the codes of honour and virtue that women represent in the family, alongside the role of men in protecting this honour. as she puts it, 'women's honour reflects that of men's, which, in turn, reflects that of the nation' (olujic : ) . rape can then represent men's inability to protect women, an attack on their honour and a cause of their shame. thereby the individual bodies of women become metaphoric representations of the social body and the injury to their bodies maims the family and the community. based on fieldwork in hospitals in 'post-conflict' erbil, kurdistan, keller ( ) explored women's expression of illness through presenting symptoms such as limb paralysis, convulsions and muteness. in women's own accounts, symptoms such as these were linked to home life, to experiences that were too much to bear and to lack of support. keeler ( ) associated this with the imposition of global neoliberal agendas in the individual and social body: women's trauma narratives become (re)inscribed by their physicians as anti-modern, positioned as belonging to a 'bygone age'. thus 'hysterical women' become a counternarrative to the global prosperity trope and are medically silenced by the 'body politic' to 'expunge non-normative expressions of trauma' (keeler : ) in post-conflict modernity. this occurs by such procedures as 'pain stimulation', including saline injections, the bending back of fingers and the threat of sexual trauma as 'medical treatment'. this illustration directs our attention to the alliances between healthcare and political agendas. in the final part of the chapter, i reflect on the interconnections of healthcare systems and neoliberal political agendas. health systems can be defined as the assemblage of public and private sector institutions and actors concerned with the support of health and the amelioration of illness. even though globally many countries are grappling with common problems, such as increased health needs and demands for healthcare, alongside the rising costs of providing it, there is not one, simple international line of convergence towards a common form of health system. the reason is that health systems are shaped significantly by their centuries-old economic and political regimes. in addi-tion, they take their form from 'national logics', that is, how a society defines and deals with issues of health and illness. equally, cultural factors influence how populations respond to proposed changes to their health system as well as how those external to a country relate to it. even so, without undue risk of overgeneralisation, we can point towards a worldwide drive towards the commercialisation of health systems and, where public provision exists, such as in our case example of the uk, to the rollback of state or public provision in favour of the free market principles. thus, most health systems around the world have or are moving towards a mix of public/private provision. with this point in mind, it has been argued that health services are now as much about investor potential as access to care for patients. tritter and colleagues maintain that health systems are no longer important primarily because they ensure that people gain access to health services when in need and irrespective of their ability to pay, that epidemics are prevented or controlled [...] or that the social determinants of health are addressed as part of public policies. in the emerging context of the reform policies, health systems are important not only as providers of products and services for which people are willing to pay, but also as an investment opportunity within global financial markets. (tritter et al. : ) although they manifest in different ways across health systems, we can point to a set of three shared global influences: neoliberalism (see also the discussions on neoliberalism in chaps. and ) as the dominant politico-economic policy framework driving system change; macroeconomic policies and structural adjustment programmes (saps); and international trade agreements. as addressed elsewhere in this book, neoliberalism can be defined as a project of economic and social change based on the transfer of economic power and control from governments to private markets and the injection of market competition into areas such as education, housing and healthcare which, in many western countries at least, were once part of the welfare state (scott-samuel et al. ) . as discussed in chap. , neoliberalism is usually interpreted as a response to the period of structural crisis of the s when, from mid-decade, countries such as the us and uk witnessed lower rates of financial accumulation and growth, rises in unemployment and rising inflation. neoliberal economic policies encourage financial deregulation and the opening up of trade and investment by resource-rich countries in regions where social conditions afford high returns. up to the late s, the predominant approach to health improvement globally was to strengthen public health systems, especially access to primary health care. this was the position established by the who's influential alma-ata declaration of which brought about access to healthcare as a human right. the world bank (wb), the international monetary fund (imf), the world trade organisation (wto) and other agencies rebuffed this position in the s as they established monetarist policies prioritising the achievement of macroeconomic stability by putting constraints on the growth of money supply and public spending. supranational agencies, such as the imf, wto and the wb, have been key players in the spread of global neoliberalism in the health field. their influence is often indirect comprising the development of trade and investment agreements negotiated at bilateral and multilateral levels and the promotion of market-friendly structures and regulatory reforms. one of the most controversial of wb policies has been the pressure upon countries of the global south to adopt saps. as a condition of receipt of foreign aid and loans, structural adjustments comprise lowering trade barriers, the selling off of state-owned assets and cutting public sector budgets and public sector workforces (rowden ). the stance of the wb is that structural adjustment stabilises economies, promotes investment and generates long-term economic growth. but it has been argued to the contrary that this leads directly to chronic underfunding of local public sector services, collapsing domestic industries in the face of cheaper imports, rural-urban migration, reduced health budgets (and less money for health workers) and the reduction of access to services by local communities. for example, it might be argued that the unpreparedness of liberia, sierra leone and guinea to deal with the ebola virus outbreak of - in west africa was associated with a short-term focus on economic objectives and on profitable sectors, such as minerals (iron ore, gold, bauxite and rubber) at the expense of the public sector. stubbs et al. ( ) explored the effects of imf aid conditionalities on the provision of healthcare in west african countries including the gambia, liberia, nigeria and sierra leonne, between and . the number of conditions put on aid over the period amounted in total to in the region. imf targets, such as budget deficit reduction, were found to crowd out or to reduce the space for investment in the health sector and aid conditions which stipulated staff layoffs or caps on public sector wages limited much-needed staff expansion of doctors and nurses. in other words, conditionalities of aid negatively impacted the provision of healthcare in the countries concerned. the third significant influence on global health systems is international trade agreements, specifically the general agreement on trade in services (gats) and the associated proliferation of bilateral agreements. gats, which came into effect in , was the first set of multilateral rules governing international trade in services, such as education and healthcare, with the object of removing trade barriers. ultimately, since it aims to liberate all services, it is a potential challenge to the sovereignty of national governments over policy-making in relation to public health and the provision of health services. for example, at the time of writing in march , it is not clear whether the transatlantic trade and investment partnership (t-tip) between the eu and the usa, presently in an eighth round of discussions, will exclude the uk nhs (national health service). if it does not then it could give transnational corporations the right to enter the uk market and operate without limits on their activities. for the reasons referred to earlier concerning the different histories and cultural contexts, the organisation of health systems varies considerably in different countries. the us, for example, has always been a privately reimbursed system where citizens pay for care by insurance through employment or out of pocket. by contrast, in the uk health system since the inception of the nhs in most aspects of care have been provided free of charge through taxation. the same broadly applies to the nordic countries, as well as others such as italy. in between this many countries, such as germany, japan, taiwan and france, have social insurance models whereby patients and employers pay into sick funds which contract with a range of health providers. but, to varying degrees and in different ways, almost all are moving towards a blending of public/ private elements. the uk has in many ways been at the fore in this regard, beginning with reforms of the thatcher government in the s. but the approach has been espoused internationally by countries as varied as italy, singapore, india, taiwan, malaysia, the philippines and russia. fundamentally, the intent has been to introduce market mechanisms to control costs. globally, though to varying degrees, healthcare costs have been rising at significant rates. for example, healthcare expenditure as percentage of gdp rose from . percent in / to . percent in in the uk and, for the equivalent period, from . to . percent in the us, and from . to . percent in germany (world bank ). in the uk and most notably england, an internal market was introduced in the early s as a number of gp practices became fundholders who purchased care from hospitals and other providers on behalf of their patients (doh ) . the intention was that this would make them more cost conscious since they would be paying; that is, they would be deterred from referring patients too readily for tests and treatments, and that they would hold care providers, principally hospitals, to account for spending and quality of care for patients (hunter ) . the new labour government of broadly extended this policy, merging general practices into primary care trusts which jointly commissioned services for patients. the late s into the early s saw the further introduction of private providers into the nhs, for example, to run day surgery, pathology and diagnostic services (doh ). in , the new coalition government consolidated this by the setting up of clinical commissioning groups (ccgs) which hold approximately two-thirds of the nhs budget. ccgs currently purchase care on behalf of gps for their patients. moreover, under the new 'any qualified provider' provision, care could be commissioned not only from nhs providers but also from the for-profit and the not-for-profit third sector (charities and social enterprises) (doh ). this overall policy remains in place at the time of writing in with recent concern focusing less visibly on structural reform and more on incapacity to meet demand-for example, in january the british red cross said that the nhs was facing a humanitarian crisis in the face of escalating demand and rising waiting lists for treatment. health, culture and society endorses the enduring conceptual legacies that have shaped and continue to shape our thinking. it seeks to understand not only where we have come from but where we are going to. this has been the focus of the current chapter as we have explored sociology's disquiet with 'society', as its erstwhile unit of analysis. while theorists of globalisation have given relatively little direct attention to matters of health, it has been suggested that the attention to international connections, mobility and new emergent forms of differentiation and inequality can be a useful point of departure for the analysis of health and healthcare. in these terms we have addressed several critical health issues of our time, such as migration and health, the securitisation of health, the health devastation wrought on civilians caught up in violent conflicts around the world, and the commercialisation of health systems. amnesty international globalization: the human consequences collateral damage: social inequalities in a global age why the world fears refugees what is globalisation? cambridge: polity past horrors, present struggles: the role of stigma in the association between war experiences and psychosocial adjustment among former child soldiers in sierra leone rethinking modernity: postcolonialism and the sociological imagination critical interventions in global health: governmentality, risk and assemblage for public sociology fames of war: when is life grievable? london southern theory securitizing infectious disease reframing conflict-related sexual and genderbased violence: bringing gender analysis back in whose interests is the securitisation of health serving? working for patients. london: stationary office the new nhs: modern, dependable. london: stationary office equality and excellence: liberating the nhs. london: stationary office the division of labour in society security and global health haggling over viruses: the downside risks of securitizing infectious disease mobilities and health forced migration: the human face of a health crisis our health and theirs: forced migration, othering, and public health culture, context and the mental health and psychosocial wellbeing of syrians: a review for mental health and psychosocial support staff working with syrians affected by armed conflict immigrants' health in europe: a crossclassified multilevel approach to examine origin country, destination country, and community effects the health debate first do no harm? female hysteria, trauma, and the (bio)logic of violence in iraq if your husband doesn't humiliate you, other people won't': gendered attitudes towards sexual violence in eastern democratic republic of congo social suffering war and public health global trends : alternative worlds. a publication of the national intelligence council ocha (office for the national coordination of humanitarian affairs) embodiment of terror: gendered violence in peacetime and wartime in croatia and bosnia-herzegovina the social system the mindful body: a prolegomenon to future work in medical anthropology the impact of thatcherism on health and well-being in britain the impact of imf conditionality on government health expenditure: a crossnational analysis of west african nations globalisation, markets and healthcare policy the new medical sociology. london: w. w. norton company. unhcr bureau for europe no place for children -the impacts of five years of war on syrian children and their childhoods sociology beyond societies globalization and inequalities: complexity and contested modernities world development indicators: health systems the world health report -a safer future: global public health security in the twenty-first century forced migration, globalisation, and public health; getting the big picture into focus key: cord- -qzg jsz authors: royo, sebastián title: from boom to bust: the economic crisis in spain – date: - - journal: why banks fail doi: . / - - - - _ sha: doc_id: cord_uid: qzg jsz this chapter analyzes the overall economic crisis that started in in spain. it is impossible to disentangle the banking crisis from the overall economic crisis that affected the country at the same time. this chapter looks at the performance of the spanish economy throughout the s and the first decade of the twentieth century. it examines the reasons for the success of the spanish economy in the s and provides an overview of the main causes of the – crisis and the governments’ responses. the economic crisis that hit the country in cannot be separated from the subsequent financial crisis. in order to contextualize the banking games that inform the next chapters and to understand the overall consequences that the economic crisis had on spanish banks and cajas , this chapter examines the economic crisis and analyzes its causes and consequences. yet again, the performance of the spanish banking system was deeply connected to the performance of the spanish economy, and progress in the banking sector was marred by the performance of the spanish economy at large. the economic crisis that started in , part of the great recession that engulfed most countries, had profound consequences for the spanish banking system. this book will show that the financial crises were the result of a political bargain in which incentives and a lax regulatory framework favored developers, property owners, and bankers, thus confirming a central tenant: the crucial importance of domestic political institutions, the rules of the game, and the role of domestic players operating within those institutions. from: sebastián royo, "after austerity: lessons from the spanish experience," in towards a resilient eurozone: economic, monetary and fiscal policies, ed. john ryan (new york: peter lang, ) . the economic crisis, while not fully unexpected, came as a relative surprise given the strong performance of the spanish economy during the first years of the twentieth century. the overall pattern of spanish economic history has been described, crudely, as a graph shaped like an upside-down version of the letter 'v'. that is, the graph rises-bumpily at times, through years under the romans, years under or partly under the moors, and a century of empire-building-to the peak of spanish power in the sixteenth century. after that, the history of the nation goes downhill until the s. a vast empire was gradually lost, leaving spain poor and powerless. and there was much political instability: spain suffered forty-three coup d'états between and , a horrendous civil war between and , followed by thirty-six years of dictatorship under generalísimo franco. after franco's death in , the graph turned upward again. king juan carlos, franco's heir, oversaw the return of democracy to the country. a negotiated transition period, which has been labeled as a model for other countries, paved the way for the elaboration of a new constitution, followed by the first free elections in almost forty years. these developments were followed by the progressive return of spain to the international arena-where they have been relatively isolated during the dictatorship. the following decade also witnessed the socialist party being elected to actual power in , bringing a new aura of modernity to the country. the s also witnessed spain's integration into nato ( ) and the european community ( ). the following two and a half decades were a period of phenomenal growth and modernization. indeed, before the global crisis that hit spain in the spring of the country had become one of europe's most successful economies. while other european countries had been stuck in the mud, spain performed much better at reforming its welfare systems and labor markets, as well as improving flexibility and lowering unemployment. over the decade and a half that preceded the global financial crisis, the spanish economy seemed to had been able to break with the historical pattern of boom and bust, and the country's economic performance was nothing short of remarkable. yet all this came to a halt when the global financial crisis hit spain in . as a result, spain is suffering one of the worst crises since the s (royo ) . following the transition to democracy and the country's european integration, spain was, prior to the crisis, a model country. but then the (debt fueled) dream was shattered and the country's economy imploded after . how did this happen? policy choices and the structure of decision making; the role of organized interest; the structure of the state; and institutional degeneration all played an important role in explaining the severity of the economic crisis in spain; as did the country's membership under an incomplete monetary union. the country had to face a triple crisis: financial, fiscal, and competitiveness. this chapter seeks to provide an overview of the country's evolution since the transition to democracy, and to explain its economic collapse after (see royo royo , royo , . the first section of the chapter outlines the main features of the spanish growth model, and the challenges that it faced. section two describes the scale of the shock it underwent from onward and analyzes the triple crisis in financial, fiscal, and competitiveness performance. the chapter concludes with brief lessons from the spanish experience. european integration was instrumental in the modernization of the country. indeed, before the global crisis that hit spain in the spring of the country had become one of europe's most successful economies (see table . ). propped up by low interest rates and immigration, spain was (in ) in its fourteenth year of uninterrupted growth and it was benefiting from the longest cycle of continuing expansion of the spanish economy in modern history (only ireland in the euro zone has a better record), which contributed to the narrowing of per capita gdp with the eu. indeed, in years per capita income grew points, one point per year, to reach close to % of the eu average. with the eu , spain already reached the average in . the country grew on average . percentage points more than the eu since . unemployment fell from % in the mid- s to . % in the first half of (the lowest level since ), as spain became the second country in the eu (after germany with a much larger economy) creating the most jobs (an average of , per year over that decade). in , the spanish economy grew a spectacular . %, and . % in . as we have seen, economic growth contributed to per capita income growth and employment. indeed, the performance of the labor market was spectacular: between and , % of all the total employment created in the eu- was created in spain. in , the active population increased by . %, the highest in the eu (led by new immigrants and the incorporation of women in the labor market, which increased from % in to % in ); and , new jobs were created. the economic success extended to spanish companies, which expanded beyond their traditional frontiers (guillén ) . in , they spent a total of e billion on domestic and overseas acquisitions, putting the country third behind the uk and france in the eu. of this, e billion were to buy companies abroad (compared with the e billion spent by german companies). in , spanish foreign direct investment (fdi) abroad increased %, reaching e . billion (or the equivalent of . % of gdp, compared with . % in ). in iberdrola, an electricity supplier purchased scottish power for $ . billion to create europe's third largest utility; banco santander, spain's largest bank, purchased britain's abbey national bank for $ billion, ferrovial, a family construction group, concluded a takeover of the british baa (which operates the three main airports of the uk) for £ billion; and telefonica bought o , the uk mobile phone company. indeed, was a banner year for spanish firms: % of them increased their production and . % their profits, . % hired new employees, and . % increased their investments. the country's transformation was not only economic but also social. the spanish became more optimistic and self-confident (i.e., a harris poll showed that spaniards were more confident of their economic future than their european and american counterparts, and a poll by the center for sociological analysis showed that % were satisfied or very satisfied with their economic situation). spain became 'different' again and according to public opinion polls it had become the most popular country to work for europeans. between and , some million immigrants ( , in and , in ) settled in spain ( . % of the population compared with . % in the eu ), making the country the biggest recipient of immigrants in the eu (they represented % of the contributors to the social security system). this was a radical departure for a country that used to be a net exporter of people, and more so because it was able to absorb these immigrants without falling prey (at least so far) to the social tensions that have plagued other european countries (although there have been isolated incidents of racial violence) (see calavita ) . these immigrants contributed significantly to the economic success of the country in that decade because they boosted the aggregate performance of the economy: they raised the supply of labor, increased demand as they spent money, moderated wages, and put downward pressure on inflation, boosted output, allowed the labor market to avoid labor shortages, contributed to consumption, and increased more flexibility in the economy with their mobility and willingness to take on low-paid jobs in sectors such as construction and agriculture, in which the spanish were no longer interested. indeed, an important factor in the per capita convergence surge with the eu after was the substantive revision of the spanish gdp data as a result of changes in the national accounts from to . these changes represented an increase in gpd per capita of % in real terms (the equivalent of slovakia's gdp). this dramatic change was the result of the significant growth of the spanish population since as a result of the surge in immigration (for instance in population grew . %). the key factor in this acceleration of convergence, given the negative behavior of productivity (if productivity had grown at the eu according to the financial times, % of those polled selected spain as the country where they would prefer to work ahead of the uk ( %) and france ( %). see "españa vuelve a ser diferente," el país, february , , and financial times, february , . calativa provides a detailed analysis of the immigration experience in spain and exposes the tensions associated with this development. she also highlights the shortcomings of governments' actions in regard to integration, and the impact of lack of integration on exclusion, criminalization, and radicalization. see . "immigrants boost british and spanish economies," financial times, tuesday, february , , p. . average spain would have surpassed in the eu per capita average by points), was the important increase in the participation rate, which was the result of the reduction in unemployment, and the increase in the activity rate (the proportion of people of working age who have a job or are actively seeking one) that followed the incorporation of female workers into the labor market and immigration growth. indeed between and , the immigrant population has multiplied by threefold. as a matter of fact, most of the , new jobs created in spain in went to immigrants (about %). their motivation to work hard also opened the way for productivity improvements (which in experienced the largest increase since , with a . % raise). it is estimated that the contribution of immigrants to gdp had been of . percentage points in the four years to . immigration represented more than % of employment growth, and . % of the demographic growth (as a result spain led the demographic growth of the european countries between and with a demographic advance of . % compared with the eu average of . %). they also contributed to the huge increase in employment, which was one of the key reasons for the impressive economic expansion. indeed, between and , employment contributed percentage points to the . % annual rise in spain's potential gdp (see table . ). what made this transformation possible? the modernization of the spanish economy in the two and half decades prior to had been intimately connected to the country's integration in the european union. indeed, european integration was a catalyst for the final conversion of the spanish economy into a modern western-type economy. yet, membership was not the only reason for this development. the economic liberalization, trade integration, and modernization of the spanish economy started in the s and s and spain became increasingly prosperous over the two decades prior to eu accession. however, one of the key consequences of its entry into europe was that it consolidated and deepened that development processes, and it accelerated the modernization of the country's economy. indeed, eu membership facilitated the micro-and macroeconomic reforms that successive spanish governments undertook throughout the s and s. spain also benefited extensively from european funds those two decades: approximately billion euros from agricultural, regional development, training, and cohesion programs. moreover, european monetary union (emu) membership was also very positive for the country: it contributed to macroeconomic stability, it imposed fiscal discipline and central bank independence, and it lowered dramatically the cost of capital. one of the key benefits was the dramatic reduction in short-term and long-term nominal interest rates: from . % and . % in , to . % and . % in , and . % and . % in . the lower costs of capital led to an important surge in investment from families (in housing and consumer goods) and businesses (in employment and capital goods). indeed, emu membership (and the stability pact) provided the country with unprecedented stability because it forced successive governments to implement responsible economic policies, which led to greater credibility and the improvement of the ratings of spain's public debt (and consequently to lower financing costs). another important factor to account for the country's economic success was the remarkable economic policy stability that followed the economic crisis of - . indeed, there were few economic policy shifts throughout the s and early s, and this despite changes in government. between and , there were only two ministers of finance, pedro solbes (from to , and from to ) and rodrigo rato (from to ; and the country only had three prime ministers (felipe gonzález, josé maría aznar, and josé luís rodríguez zapatero). this pattern was further reinforced by the ideological cohesiveness of the political parties in government and the strong control that party leaders exercise over the members of the cabinet and the parliament deputies. in addition, this stability was reinforced by the shared (and rare) agreement among conservative and socialist leaders regarding fiscal consolidation (the balance budget objective was established by law by the popular party), as well as the need to hold firm in the application of restrictive fiscal policies and the achievement of budgetary surpluses: as a result, a % budget deficit in became a . % surplus in , and public debt decreased from % of gdp in to . % in . finally, other factors that contributed to this success included the limited corruption and the fact that politics were fairly clean and relatively open; that spain had a flexible economy; and the success of spanish multinationals: there were eight firms in the financial times list of the world's largest multinationals in , and in . the challenges however, this economic success was marred by some glaring deficiencies that came to the fore in when the global financial crisis hit the country, because it was largely a "miracle" based on bricks and mortar. the foundations of economic growth were fragile because the country had low productivity growth (productivity contributed only . percentage points to potential gdp between and ) and deteriorating external competitiveness. over the decade that preceded the crisis spain did not address its fundamental challenge, its declining productivity, which only grew an average of . % during that decade ( . % in ), one whole point below the eu average, placing spain at the bottom of the eu and ahead of only italy and greece (the productivity of a spanish worker was the equivalent of % of a us one). the most productive activities (energy, industry, and financial services) contributed only % of gdp growth. according to data from the world bank governance indicators (http://info. worldbank.org/governance/wgi/sc_chart.asp), spain was ranked in the - th country's percentile ranks in control of corruption, government effectiveness, regulatory quality, rule of law, and voice and accountability. according to martinez-mongay and maza lasierra, "the outstanding economic performance of spain in emu would be the result of a series of lucky shocks, including a large and persistent credit impulse and strong immigration, underpinned by some right policy choices. in the absence of new positive shocks, the resilience of the spanish economy to the financial crisis might be weaker than that exhibited in the early s. the credit impulse has ended, fiscal consolidation has stopped, and the competitiveness gains of the nineties have gone long ago." see martinez-mongay and maza lasierra ( moreover, growth was largely based on low-intensity economic sectors, such as services and construction, which were not exposed to international competition. in , most of the new jobs were created in low-productivity sectors such as construction ( %), services associated with housing such as sales and rentals ( %), and tourism and domestic service ( %). these sectors represented % of all the new jobs created in spain in (new manufacturing jobs, in contrast, represented only %). furthermore, the labor temporary rate reached . % in , and inflation was a recurrent problem (it closed with a . % increase, but the average for that year was . %), thus the inflation differential with the eu (almost point) had not decreased, which reduced the competitiveness of spanish products abroad (and consequently spanish companies were losing market share abroad). competitiveness was further hindered by a deep process of economic deindustrialization, low value added and complexity of exports, and low insertion in global value chains. in addition, family indebtedness reached a record % of disposable income in , and the construction and housing sectors accounted for . % of gdp (twice the eurozone average). house prices rose by % since , and the average price of a square meter of residential property went up from euros in to at the end of , even though the housing stock had doubled. many wondered whether this bubble was sustainable. the crisis that started in confirmed the worst fears, and the implosion of the housing bubble fueled corruption and bad practices in the cajas sector of the financial system. moreover, between and % of the benefits of the largest spanish companies came from abroad. yet, in the years prior to the crisis this figure had decreased by approximately percentage points, and there had been a decline in direct foreign investment of all types in the country, falling from a peak of . billion euros in to . billion euros in . states; imports were % higher than exports and spanish companies were losing market share in the world. hence, the trade deficit reached . % in . while there was overall consensus that the country needed to improve its education system and invest in research and development to lift productivity, as well as modernize the public sector, and make the labor market more stable (i.e., reduce the temporary rate) and flexible, the government did not take the necessary actions to address these problems. spain spent only half of what the organization of european co-operation and development (oecd) countries spent on average on education; it lagged most of europe on investment in research and development (r&d); and it was ranked th by the unctad as an attractive location for research and development. finally, other observers noted that spain was failing to do more to integrate its immigrant population, and social divisions were beginning to emerge. by the summer of , the effects of the global crisis were evident in spain, and between and the country suffered one of the worst recession in modern history. this collapse was not wholly unexpected. the global liquidity freeze and the surge in commodities, food, and energy prices brought to the fore the unbalances in the spanish economy: the record current account deficit, persisting inflation, low productivity growth, dwindling competitiveness, increasing unitary labor costs, excess consumption, and low savings, had all set the ground for the current devastating economic crisis (see royo ) . as we have seen, the imbalances in the spanish economy came to the fore in - when the real estate market bubble burst and the international financial crisis hit spain (see table . ). in just a few months the 'debt-fired dream of endless consumption' turned into a nightmare. by the summer of , spain faced the worst economic recession in half a century. according to government statistics, was the worst year since there has been reliable data: gdp fell . %, unemployment reached over four million people (eventually reaching over % in , with more than million people unemployed), and the public deficit reached a record . % of gdp (up from . % in ). consumer confidence was shattered, the implosion of the housing sector reached historic proportions, and the manufacturing sector was also suffering. initially, the zapatero government was reluctant to recognize the crisis, which was becoming evident as early as the summer of , because of electoral considerations: the country had a general election in march . and after the election, the zapatero government was afraid to admit that it had not been entirely truthful during the campaign. by , there was increasing evidence that the model based on construction was already showing symptoms of exhaustion. yet, the spanish government not only refused to recognize that the international crisis was affecting the country, but also that in spain the crises would be aggravated by the very high levels of private indebtedness. as late as august , , finance minister solbes predicted that 'the crisis would have a relative small effect' in the spanish economy. when it became impossible to deny what was evident, the government's initial reluctance to recognize and address the crisis was replaced by frenetic activism. the zapatero government introduced a succession of plans and measures to try to confront the economic crisis, and specifically to address the surge of unemployment (royo ) (see fig. . ) . the sharp deterioration of the labor market was caused by the economic crisis and the collapse of the real estate sector, and it was aggravated by a demographic growth pattern based on migratory inflows of labor: in , there were . million immigrants in the country, of which . million were employed and , unemployed. in , the number of immigrants increased by almost , - . million (representing % of the growth in the active population), but , of them were unemployed (and . million employed), an increase of , . in the construction sector alone, unemployment increased % between the summer of and . meanwhile, the manufacturing and service sectors (also battered by the global crisis, lower consumption, and lack of international competitiveness) proved unable to incorporate these workers. the pace of deterioration caught policy-makers by surprise. the zapatero government prepared budgets for and that were utterly unrealistic in the face of rapidly changing economic circumstances (as did all other advanced countries, the g- agreed on a plan for fiscal stimulus that would later prove relatively ineffective and dangerous for spain as it increased the country's debt). as a result, things continued to worsen over the new four years. the most significant decline was in consumer confidence, which was hammered by the financial convulsions, the dramatic increase in unemployment, and the scarcity of credit. as a result, household consumption, which represented % of gdp, fell % in the last quarter of for the first time in the last years. according to the bank of spain, this decline in household consumption was even more important in contributing to the recession than the deceleration of residential investment, which had fallen %, driven down by worsening financial conditions, uncertainties, and the drop in residential prices. the government actions had limited effect stemming this hemorrhage, and their efficacy was inadequate. finally, the impact of the global economic crisis was felt well beyond the economic and financial realms. the crisis also had severe political consequences. spain followed in the path of many other european countries (including ireland, portugal, greece, and france) that saw their governments suffer the wrath of their voters and have been voted out of office. the socialist party (psoe) was re-elected in a general election on march , . soon thereafter, economic conditions deteriorated sharply and the government's popularity declined rapidly. between march and march , there were a number of electoral contests in spain at the local, regional, national, and european levels. at the national and european levels, the one common pattern was the outcome: the defeat of the socialist party and the victory of the popular party (pp). and at the regional and local levels the socialists suffered historical losses, losing control of regional government that they ruled for decades (notably, castilla-la mancha and extremadura), and even losing the election for the first time in one of its historical strongholds, andalusia (although they were able to reach a coalition with a smaller leftist party to stay in power). in the end, the economic crisis ignited a pattern of political polarization, instability, and fragmentation of the party system that crystallized in (following the pp's absolute majority) and lasts through today: as of fall of , spain has had general elections in years. one of the most common misinterpretations regarding the crisis in southern europe was attributing it to mismanaged public finances. many policy-makers across europe, especially in the creditor countries (crucially germany), still insist today ( ) that the crisis was caused by irresponsible public borrowing, and this, in turn, led to misguided solutions. in fact, with very few exceptions, notably greece, that interpretation is incorrect. in spain, the crisis did not originate with mismanaged public finances. on the contrary, as late as , spain's debt ratio was still well below the average for countries that adopted the euro as a common currency: while spain stood at less than % of gdp, greece stood at . %, italy at %, portugal at . %, ireland at %, belgium at . %, and france at %. on the contrary, prior to , spain seemed to be in an enviable fiscal position, even when compared with germany. spain ran a budget surplus in , , and . it was only when the crisis hit the country and the real estate market collapsed that the fiscal position deteriorated markedly and the country experienced huge deficits. the problem in spain was the giant inflow of capital from the rest of europe; the consequence was rapid growth and significant inflation. in fact, the fiscal deficit was a result, not a cause, of spain's problems: when the global financial crisis hit spain and the real estate bubble burst, unemployment soared, and the budget went into deep deficit, caused partly by depressed revenues and partly by emergency spending to limit human costs. the government responded to the crisis with a massive e billion public works stimulus. this decision, combined with a dramatic fall in revenue, blew a hole in government accounts resulting in a large deficit. furthermore, the conditions for the crisis in spain were created by the excessive lending and borrowing of the private sector rather than the government. in other words, the problem was private debt and not public debt. spain experienced a problem of ever-growing private sector indebtedness, which was compounded by the reckless investments and loans of banks (including the overleveraged ones), both integral components of the bank bargains that we examine later in the book, that were aggravated by competitiveness and current account imbalances. in spain, the private sector debt (households and nonfinancial corporations) was . % of gdp at the end of ; total debt increased from % of gdp in to % in mid- . yet, although spain entered the crisis in a relatively sound fiscal position, that position was not solid enough to withstand the effects of the crisis, especially being a member of a dysfunctional monetary union with no lender of last resort. the country's fiscal position deteriorated sharply-collapsing by more than % of gdp in just two years. looking at the deficit figures with the benefit of hindsight, it could be argued that spain's structural or cyclically adjusted deficit was much higher than its actual deficit. the fast pace of economic growth before the crisis inflated government revenues and lowered social expenditures in a way that masked the vulnerability hidden in spanish fiscal accounts. the problem is that it is very difficult to know the structural position of a country. the only way in which spain could have prevented the deficit disaster that followed would have been to run massive fiscal surpluses of % or higher during the years prior to the crisis in order to generate a positive net asset position of at least % of gdp. this, for obvious reasons, would not have been politically feasible. there is another way to look at the crisis. many economists argue that the underlying problem in the euro area was the exchange rate system itself, namely, the fact that european countries locked themselves into an initial exchange rate. this decision meant, in fact, that they believed that their economies would converge in productivity (which would mean that the spaniards would, in effect, become more like the germans). if convergence was not possible, the alternative would be for people to move to higher productivity countries, thereby increasing their productivity levels by working in factories and companies there (or to create a full fiscal union to provide for permanent transfers, as argued by oca theory). time has shown that both expectations were unrealistic and, in fact, the opposite happened. the gap between german and spanish (including other peripheral country) productivity increased, rather than decreased, over the past decade and, as a result, germany developed a large surplus on its current account; while spain and the other periphery countries had large current account deficits that were financed by capital inflows. in this regard, one could argue that the incentives introduced by emu worked exactly in the wrong way. capital inflows in the south made the structural reforms that would have been required to promote convergence less necessary, thus increasing divergence in productivity levels. in addition, adoption of the euro as a common currency fostered a false sense of security among private investors. during the years of euphoria following the launching of europe's economic and monetary union and prior to the onset of the financial crisis, private capital flowed freely into spain and, as a result as we have seen, the country ran current account deficits of close to % of gdp. in turn, these deficits helped finance large excesses of spending over income in the private sector. the result did not have to be negative. these capital inflows could have helped spain (and the other peripheral countries) invest, become more productive, and "catch up" with germany. unfortunately, in the case of spain, they largely led to a massive bubble in the real estate market, consumption, and unsustainable levels of borrowing. the bursting of that bubble contracted the country's real economy and it brought down the banks that gambled on loans to real estate developers and construction companies. at the same time, as noted above, the economic boom also generated large losses in external competitiveness that spain failed to address. successive spanish governments also missed the opportunity to reform institutions in their labor and product markets. as a result, costs and prices increased, which in turn led to a loss of competitiveness and large trade deficits. this unsustainable situation came to the fore when the financial shocks that followed the collapse of lehman brothers in the fall of brought "sudden stops" in lending across the world, leading to a collapse in private borrowing and spending, and a wave of fiscal crisis. a third problem had to do with the banks. as we will see in much greater detail later in the book, this problem was slow to develop. between and , the spanish financial system, despite all its problems, was still one of the least affected by the crisis in europe. during that period, of the financial institutions that received direct assistance from brussels, none was from spain. in december , moody's ranked the spanish banking system as the third strongest of the eurozone, only behind finland and france, above the netherlands and germany, and well ahead of portugal, ireland, and greece. finally, santander and bbva had shown new strength with profits of e . billion and e . billion, respectively, during the first half of . spanish regulators had put in place regulatory and supervisory frameworks, which initially shielded the spanish financial system from the direct effects of the global financial crisis. indeed, the bank of spain had imposed a regulatory framework that required higher provisioning, which provided cushions to spanish banks to initially absorb the losses caused by the onset of the global financial crisis. and there were no toxic assets in bank´s balance sheets. nevertheless, this success proved short-lived. in the summer of , spanish financial institutions seemed to be on the brink of collapse and the crisis of the sector forced the european union in june ( ) to devise an emergency e billion rescue plan for the spanish banking sector (see chapter ). when the crisis intensified, the financial system was not able to escape its dramatic effects. by september , the problem with toxic real estate assets forced the government to intervene and nationalize eight financial institutions. altogether, by may , , the reorganization of the banking sector involved e billion in public resources, including guarantees. as we will examine later in the book, there are a number of factors that help account for the deteriorating performance of the spanish banks after . the first was the direct effect of the economic crisis. the deterioration in economic conditions had a severe impact on the bank balance sheets. the deep recession and record-high unemployment triggered successive waves of loan losses in the spanish mortgage market coupled with a rising share of nonperforming loans. like many other countries such as the united states, spain had a huge property bubble that burst. land prices increased % in spain between and , the largest increase among the oecd countries. as a result of the collapse of the real estate sector had a profound effect in banks: five years after the crisis started, the quality of spanish banking assets continued to plummet. the bank of spain classified e billion euros as troubled assets at the end of , and banks were sitting on e billion of mortgages of which . % were classified as nonperforming. a second factor was concern over the country's sovereign debt. as mentioned before, the crisis in spain did not originate with mismanaged public finances. the crisis has largely been a problem of ever-growing private sector debt, compounded by reckless bank investments and loans, particularly from the cajas , as well as aggravated by competitiveness and current account imbalances. to place the problem in perspective, the gross debt of household increased dramatically in the decade prior to the crisis, and by it was percentage points higher than the eurozone average ( % of gdp versus %). but the austerity policies implemented since may aggravated the fiscal position of the country. the ratio of spain's debt to its economy was % before the crisis and reached % in . in sum, spain fell into the "doom loop" that had already afflicted greece or portugal and led to their bailout. the sustainability of the spanish government debt was affecting spanish banks (including bbva and santander) because they had been some of the biggest buyers of government debt in the wake of the ecb long-term refinancing operation liquidity infusions (the percentage of government bond owned by domestic banks reached % in mid- ). again, the doom loop was a result of emu weakness, namely the lack of a banking union with a centralized eu funded mechanism to bail out banks. spanish banks were also suffering the consequences of their dependence on wholesale funding for liquidity since the crisis started, and, in particular, their dependence on international wholesale financing, as % of their balance depends on funding from international markets, particularly from the ecb. borrowing from the ecb reached e billion in , and spanish banks had increased their ecb borrowings by more than six times since june , to the highest level in absolute terms among euro area banking systems as of april . the crisis also exposed weaknesses in the policy and regulatory framework, part of the banking bargains that we will examine later in the book. the most evident sign of failure was the fact that the country had already adopted five financial reforms in three years and had implemented three rounds of bank mergers. the results of these reforms were questionable at best. the fact that spain had five reforms in less than three years, instead of one that really fixed the problem, says it all. they had been perceived largely as "too little and too late," and they failed to sway investors' confidence in the spanish financial sector. finally, the financial crisis can also be blamed on the actions (and inactions) of the bank of spain, one of the key actors involved in the bank bargains. at the beginning of the crisis, the bank of spain's policies were all praised and were taken as model by other countries. time, however, tempered that praise and the bank of spain was criticized for its actions and decisions (or lack thereof) during the crisis. spanish central bankers chose the path of least resistance: alerting about the risks but failing to act decisively. the economic crisis that started in spain was largely a problem of ever-growing private sector debt, aggravated by competitiveness and current account imbalances, and compounded by reckless bank investments and loans, particularly from the cajas , which by over-lending freely to property developers and mortgages contributed to a real estate property bubble. this outcome was a result of the political bargains at the heart of the game of bank bargains focus of this book. the bubble contributed to hide the fundamental structural problems of the spanish economy outlined in the previous sections and had an effect in policy choices because no government was willing to burst the bubble and risk suffering the wreath of voters. furthermore, cheap credit also had inflationary effects that contributed to competitiveness losses and record balance of payment deficits. therefore, three dimensions of the crisis (financial, fiscal, and competitiveness) are interlinked in their origins. the crisis exposed the underbelly of the financial sector and showed that many banks (particularly the cajas ) were not just suffering liquidity problems but risked insolvency, which led to the eu financial bailout of june . the bailout had onerous conditions attached and it limited national economic autonomy (see dellepiane and hardiman ) . finally, the financial and fiscal crises were made worse by the incomplete institutional structure of emu and by bad policy choices at the eu level (excess austerity and refusal to act as a lender of last resort for sovereigns by the ecb) (royo ) . in the end, the crisis exposed the weaknesses of the country's economic model. indeed, despite the previous two decades' significant progress and achievements, the spanish economy still faced serious competitive and fiscal challenges. unfortunately, the economic success the country prior to the crisis fostered a sense of complacency, which allowed for a delay in the adoption of the necessary structural reforms. and this was not a surprise as the spanish economy was living on borrowed time, despite all the significant progress, and the country still had considerable ground to cover, given the existing income and productivity differentials, to catch up with the richer eu countries and to improve the competitiveness of its economy (see royo ) . the sudden collapse of the spanish economy came as a shock. yet, in retrospect it should not have been such a surprise. the policies choices and political bargains taken during the previous decades led to an unsustainable bubble in private sector borrowing that was bound to burst. moreover, as we will examine on chapter , the institutional degeneration that led to systemic corruption and contributed to the implosion of parts of the financial sector made the crisis almost unavoidable. as we have seen, much of spain growth during the s was based on the domestic sector and particularly on an unsustainable reliance on construction. as we will later in the book, this outcome was part of a political bargain in which tax incentives and a lax regulatory framework favored developers, property owners, and bankers (particularly cajas ). the particular regulation of the cajas proved fatally flawed, as it provided incentives that favored local and regional government actors' access to finance at the expense of an environment that would have provided a stable and efficient banking system. on the contrary, it led to a form of crony capitalism spanish style, in which they invested massively in the construction sector in search of rapid growth and larger market share. these decisions proved fatal once the real estate bubble burst, and they led to the nationalization of several cajas , including bankia, and the financial bailout from the european union. membership in the european single currency was not the panacea that everyone expected to be, thus confirming the crucial importance of domestic political institutions and how domestic players operate within those institutions. in spain, the adoption of the euro led to a sharp reduction in real interest rates that contributed to the credit boom and the real estate bubble. however, it also altered economic governance decisions. successive spanish governments largely ignored the implications of emu membership and failed to implement the necessary structural reforms to ensure the sustainability of fiscal policies and to control unitary labor costs. these decisions led to a continuing erosion of competitiveness (and a record current account deficit), and a huge fiscal deficit when the country was hit by the global financial crisis. indeed, the experience of the country shows that eu and emu membership had not led to the implementation of the structural reforms necessary to address these challenges. on the contrary, emu contributed to the economic boom, thus facilitating the postponement of necessary economic reforms. this challenge however is not a problem of european institutions, but of national policies. the process of economic reforms has to be a domestic process led by domestic actors willing to carry them out. the spanish case serves as an important reminder that in the context of a monetary union, countries only control fiscal policies and relative labor costs. spain proved to be weak at both. it failed to develop an appropriate adjustment strategy to succeed within the single currency, and it ignored the imperative that domestic policy choices have to be consistent with the international constraints imposed by euro membership. on the contrary, in spain domestic policies and the imperatives of participating in a multinational currency union stood in uneasy relationship to one another. the crisis was the tipping point that brought this inconsistency to the fore, which led to the worst economic crisis in spanish modern history (before covid- ). next we turn to the elements of domestic bargains that underline the financial crisis. immigrants at the margins ucd geary institute discussion series chapters the rise of spanish multinationals competitiveness and growth in emu: the role of the external sector in the adjustment of the spanish economy from social democracy to neoliberalism royo, sebastián. lessons from the economic crises in spain after austerity: lessons from the spanish experience key: cord- -t dn bc authors: spring, Úrsula oswald title: food as a new human and livelihood security challenge date: journal: facing global environmental change doi: . / - - - - _ sha: doc_id: cord_uid: t dn bc as a result of a process of “regressive globalization” (kaldor/anheier/glasius ; oswald b) and of an increasing concentration of wealth in few hands, the economic gap has widened between north and south and within the countries between rich and poor, which has often affected the survival of social groups. as a result of a process of "regressive globalization" (kaldor/anheier/glasius ; oswald b) and of an increasing concentration of wealth in few hands, the economic gap has widened between north and south and within the countries between rich and poor, which has often affected the survival of social groups. this inequality is one of the core elements of failure in the eradication of hunger and poverty. therefore, many multilateral organizations, such as the world bank (wb), the international monetary fund (imf), and regional associations like the economic commission for latin america and the caribbean (cepal), the inter-american development bank (idb), the asian development bank (adb), and the african development bank (afdb) and the east african development bank (eadb), have recommended to the governments to reduce the internal gap and to dedicate more resources for human development. they should address basic food production systems with job creation, increase low salaries and subsidies for the marginalized and promote cheap prices of basic food for the urban poor. these recommendations have directly linked 'food security' to the wider concept of 'human security' (brauch ; oswald b, d; brauch/oswald/ mesjasz/grin/dunay/behera/chourou/kameri-mbote/ liotta ). 'freedom from want' requires sufficient food ('food security') and water ('water security'), and both are key demands of any human security concept as a necessity for survival, and thus it has become a basic human right. human security requires not only a quality of life and a decent livelihood, but also health and stable productive conditions for almost half of the world population living in marginal rural and urban areas (see part ix and chap. to ). in the early st century, more than billion persons depend on food self-sufficiency and another billion peasants suffer from eroded and polluted land, are unable to satisfy basic human needs, and are often forced to migrate to shanty towns or to cross illegally the borders to industrialized countries in search of jobs and quality of life (schteingart ; oswald a). thus, in this author's understanding 'food sovereignty' goes beyond the physical conditions of production and market, and involves social (campos ; strahm/oswald ), cultural (arizpe ), economic (calva /a; martínez ; cadena this article has been substantially improved as a result of an international cooperation. i want to thank two anonymous reviewers for helpful comments and hans günter brauch for his critical input to the first draft. he also compiled box . and systematized important parts of box . . i am immensely grateful for his careful editing and style correction and to ronnie lappin for his language editing. regressive globalization is understood in this context as a doctrine, rooted in the confidence of the efficacy, institutional building and moral authority of us power, allied with transnational capital in the sphere of communication, military, commerce, finance, and productive system. using the term democracy and progress it is promoting a liberal global world order, favouring international capital and transnational productive systems. in the poor countries this process creates greater poverty, technological dependency, debts, massive rural migration and often loss of food sovereignty, while a small elite benefits from this alliance. for the definition of and the scientific debate on the term 'security' in english and spanish see albrecht/ brauch ( , a ; brauch ( a brauch ( , brauch ( , brauch ( , a brauch ( , b brauch ( , c ; and oswald/ brauch ( , c) . the author will not use the term 'food security' developed during the past four decades (see part . , where the debate in the fao and world bank has been briefly documented and criticized as a too technological and top-down approach), but will developed a wider concept of 'food sovereignty'. the author has developed in chap. her proposal for a new and wider policy-relevant security concept that combines human, gender and environmental security (huge) dangers and concerns. on this dual political and conceptual background, this chapter addresses the following research problem: food represents not only a security issue of intake of nutrients, but it forms part of a holistic understanding of life and a constituting element of any civilization. thus it includes networks of connectedness (vertical: patron-client, and horizontal: social groups), belonging, relationship of trust, reciprocity, cooperation and exchange. it creates social benefits and risk reduction, but also innovative activities through a wider access to information and learning. it is a process of anchoring of personal and group identity (see chap. by oswald on huge), where social relations reaffirm the integration of a person inside a community with clear rights and obligations, such as access to land, credit, technology, training, market, life quality and rituals. besides guaranteeing the physical and cultural survival, food also creates new opportunities for people-centred poverty alleviation and new understanding of 'rurality'. it represents a critical response to the past development and modernization paradigms and opens ways for diverse rural life processes, where agricultural activities and environmental services coexist with services, technology, and industries. in addressing this research question, this chapter links the concept of food security with food sovereignty, a term developed by peasant movements, especially via campesina that was later also taken up by fao. it first reviews basic concepts such as food security, food sovereignty, survival strategies, self-sufficiency, and livelihood ( . ). then it scrutinizes the contradiction that in a world with increasing production and a diverse offer of food, hunger is still one of the most important causes of illness and death, because an important part of food is used for livestock and for industrial purposes. recently, biofuels have aggravated the scarcity of food worldwide and regionally, affecting above all vulnerable groups such as poor peasants and marginalized urban people in the south and north. this part reviews the internal food intake not only globally, but also for latin america and in a case study of mexico that focuses on the remote indigenous regions of chiapas, oaxaca, and guerrero where undernourishment is still high and one of the causes of child mortality ( . ) . part explores three global models of food production: a) the productive paradigm, represented by the 'green revolution' that emerged in mexico; b) the new paradigm of the 'life sciences', where transnational enterprises (tne) have converted food not only into a commodity, but also into health and medical items; c) the third paradigm refers to 'organic agriculture' that cannot be globalized. it uses traditional agricultural methods developed in each region; recycles organic waste, produces soil enrichment with compost and uses biopesticides and natural seeds. the transformation of food uses long-established techniques and avoids the use of chemicals for conservation. this production system not only conserves the natural nutritional values of food and soils, but it is also an alternative for the self-sufficiency of poor peasants worldwide ( . ). in the concluding part these three models are compared and related to its repercussion on environmental, gender, and human security (oswald , a and chap. below on huge). it links 'food security' with some traditional models of self-sufficiency that were proposed by julius nyerere in his 'ujamaa' philosophy and by ecofeminists (mies ; shiva/mies ; d'eaubonne ). it was taken up by via campesina, the most important world peasant movement and developed into a 'food sovereignty' paradigm. this approach is able to link up small producers from south and north, east and west, and to produce enough food for a livelihood with dignity. this approach integrates democratic land reforms, local market structures, green agriculture, and natural seeds as the patrimony of peasants and communities, with a culturally diverse livelihood (shiva , see preface essay in this vol.). why is food important for humans? food, water, and air are the crucial elements of survival for humans. food creates energy required for growth, sustenance, and biological and physical activities; it acts within the cells and it purveys the structural and catalytic components to build anabolism. whenever one of these vía campesina is a world organization of peasants and small producers and fishermen from the south and north with sub regional association such as latin american peasant organizations (cloc in spanish), in latin america, north america, europe, asia and africa. their goal is to defend an integral process of rural livelihood including agriculture, livestock, orchards, fishing, hunting and recollection, including direct producers, rural workers, women, elders and the young. their executive committee is democratically elected and regionally representative, caring about gender and youth equity. functions fails, organisms substitute it with another process (oswald : - ). food is the generic term used for vegetal and animal nourishment as a whole, in parts or its different versions (flowers, fruits, leaves, roots, milk, eggs, muscles, kidney, blood, etc.). it can be distinguished from nutrition, which is the process through which food is absorbed and transformed. food intake is a biological necessity, determining the quality of life and health of a human being, and its nutritional requirements vary according to age, sex, physical activities, climatic factors, and health conditions. nutrition refers to the process of absorption of food by living organisms'. it starts with ingestion, continues with digestion, where the proteins are transformed into amino acids and keeps on with the absorption of nutrients in the intestine. once integrated into the blood, they are assimilated by the body and transformed metabolically in each cell. the last phase is the excreta of faecal material and urine, where also toxins are eliminated from the body. nevertheless, food cannot be reduced only to this physiological process. it is a holistic experience where different senses intervene (smell, flavour, touch, view). each civilization has developed a culture of tra-ditional, ritual and food specialties linked to religious and civil events. different diets and food preparation, but also taboos, ceremonies and rituals, are able to reinforce the cultural and territorial identity of people. maxwell and smith ( ) had counted more than definitions of 'food security' (fao a (fao , c . within the food and agricultural organization (fao) the food security concept has gradually been developed as a guiding concept for fao's evolving food policy (box . ). the general definition of 'food security' that was inspired by fao is related to the personal right to sufficient food for a person and a nation, discounting nofood uses. the us department of agriculture (usda) evaluates national food security by measuring the gaps between actual food consumption, domestic production, plus commercial imports, minus unused food and consumption targets. sometimes, nutrition gaps are also measured by the minimal daily nutritional requirements in relation to age, sex, and activities. thus, food security is assuring the physical availability and the economic accessibility to enough food in an environmentally and socially sustainable manner, where adequate quantity and quality, but also culturally acceptable food for everybody at any time is able to guarantee a healthy and active life. quantity refers to amount, distribution, calories and proteins, and quality to safe, innocuous, nutritious balanced, good and culturally accepted food. among the many anabolism is the process which builds up complex molecules from smaller units, able to give the body the required energy that is coming from glucose and fatty acids. therefore, it refers to chemical reactions that produce a combination of different molecules. the result of anabolism is the creation of new cellular material (enzymes, proteins, cells and its membrane, organs and tissues). thus, anabolism is crucial for growth, maintainance, and reparation of tissue. an optimal functioning of an organism or of its cells requires about a hundred different substances located in the environment. their function is to maintain the structure and to control the metabolism. metabolism means the sum of chemical changes taking place inside an organism by which food is transformed and utilized by the organisms, and water products are eliminated. according to fao ( a) the food security concept gradually emerged in the mid- 's when the initial focus was on: food supply problems -of assuring the availability and to some degree the price stability of basic foodstuffs at the international and national level. that supply-side, international and institutional set of concerns reflected the changing organization of the global food economy that had precipitated the crisis. a process of international negotiation followed, leading to the world food conference of , and a new set of institutional arrangements covering information, resources for promoting food security and forums for dialogue on policy issues (odi ). focus was put on productivity, within a frame of green revolution, independent of social, environmental, and political costs. the problems of famine, hunger, and food crises were analysed in detail, resulting in a "redefinition of food security, which recognized that the behaviour of potentially vulnerable and affected people was a critical aspect" (fao a). the insight that the green revolution "did not automatically and rapidly lead to dramatic reductions in poverty and levels of malnutrition ... were recognized as the result of lack of effective demand" (fao a). food security was defined in as: 'availability at all times of adequate world food supplies of basic foodstuffs to sustain a steady expansion of food consumption and to offset fluctuations in production and prices' (un ) . in , fao expanded its concept to include securing access by vulnerable people to available supplies, implying that attention should be balanced between the demand and supply side of the food security equation: 'ensuring that all people at all times have both physical and economic access to the basic food that they need' (fao a) . the commoditization of inputs and food markets widened the existing social gap, giving support to large-scale industrial agriculture and expelling millions of peasants from their land. an influential world bank ( ) report on poverty and hunger addressed the temporal dynamics of food insecurity and introduced the "distinction between chronic food insecurity, associated with problems of continuing or structural poverty and low incomes, and transitory food insecurity, which involved periods of intensified pressure caused by natural disasters, economic collapse or conflict" (fao a). the food security concept evolved to: "access of all people at all times to enough food for an active, healthy life" (world bank : chap. ). in the mid- 's, this definition was widened: to incorporate food safety and also nutritional balance, reflecting concerns about food composition and minor nutrient requirements for an active and healthy life. food preferences, socially or culturally determined, now became a consideration. the poten-tially high degree of context specificity implies that the concept had both lost its simplicity and was not itself a goal, but an intermediating set of actions that contribute to an active and healthy life. in undp's ( ) human security concept, food security was one of its seven aspects. in , the world food summit adopted an even more complex definition: food security, at the individual, household, national, regional and global levels [is achieved] when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life (fao b food security … as a phenomenon relating to individuals. it is the nutritional status of the individual household member that is the ultimate focus, and the risk of that adequate status not being achieved or becoming undermined. the latter risk describes the vulnerability of individuals in this context. … useful working definitions are described below. food security exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food which meets their dietary needs and food preferences for an active and healthy life. household food security is the application of this concept to the family level, with individuals within households as the focus of concern. confronted with new models of fast food, people began to suffer more from obesity, cardio-vascular accidents, diabetes and cancer. thus the concept of food security shifted again, now to healthy and innocuous food, able to maintain a person vigorous and active by reducing the intake of animal fat, sweet beverages, and junk food. but when confronted still with million hungry people, food insecurity was addressed, together with the fact that per cent of the poor live in rural areas and agriculture employs almost per cent of them: rural development is critical for improving food security. the traditional agriculture sector has low productivity due to the lack of investment, inadequate water supply and scarce arable land. rapid depletion of groundwater resources may be the most serious problem facing the countries (fao : ) . definitions of 'food security' used in the scientific and policy oriented food discourse those selected here indicate its scope: • "when people do not need to live with hunger or fear starvation" ; • "physical and economic access, at all times, to sufficient, safe and nutritious food to meet dietary needs and food preferences for an active and healthy life" ; • "the ability of individuals to obtain sufficient food on a day-to-day basis" ; • "the notion that all people, especially the most vulnerable, have dignified and unthreatened access to the quality and quantity of culturally appropriate food" that will fully support their physical, emotional, and spiritual health (wolfe/frongillo/valois ); • "state in which all persons obtain a nutritionally adequate, culturally acceptable diet at all times through local non-emergency sources" (riely/ mock/cogill/bailey/kenefick ); • "condition of having enough food to provide adequate nutrition for a healthy and productive life" (usaid, bureau for africa a). usaid defined 'food security' as: all people at all times have both physical and economic access to sufficient food to meet their dietary needs for a productive and healthy life. achieving food security requires that the aggregate availability of physical supplies of food is sufficient, that households have adequate access to those food supplies through their own production, through the market or through other sources, and that the utilization of those food supplies is appropriate to meet the specific dietary needs of individuals. achieving food security requires that the aggregate availability of physical supplies of food is sufficient, that household have adequate access to those food supplies through their own production, through the market or through other sources, and that the utilization of those food supplies is appropriate to meet the specific dietary needs of individuals (riely/mock/cogill/bailey/kenefick : - ). the us food and drug administration (fda ) defined 'food security' as the daily balanced intake of proteins, carbohydrates, vitamins and minerals re-quired for a healthy life. the disequilibrium in quantity and polluted food, or with toxins, could generate illnesses and limit the physical and mental development of children. finally, food security is also related to food safety such as hygiene and prevention of illnesses caused by food in bad conditions or foodborne sicknesses. according to who, bacteria are the main threat for innocuous food that are present in the domestic and professional food chain. food security, as defined by fao, does not include social and cultural factors of food and nutrition, nor land rights, seeds, credits, family ties, social relations of productive and consumption pattern together with communitarian cohesion. therefore, via campesina understood 'food sovereignty' as "the right of peoples, communities, and countries to define their own agricultural, labour, fishing, food and land policies, which are ecologically, socially, economically and culturally appropriate to their unique circumstances. it includes the true right to food and to produce food, which means that all people have the right to safe, nutritious and culturally appropriate food and to food producing resources and the ability to sustain themselves and their societies" (food sovereignty: a right for all, political statement of the ngo/cso forum for food sovereignty, rome, june ). thus important elements of food as a cultural and not only as a technical process are lacking in the fao definitions. the concept of "food sovereignty represents both a social and a personal right of individuals and communities to healthy, culturally appropriate and permanent food" (oswald : ), but includes also the process of production, land tenure, local native seeds, access to water and to other natural resources, storage processes, transformation of food, eating, fiestas and rituals in which women play a key role. social movements such as via campesina have used in their daily struggle the concept of food sovereignty, including geopolitical, socio-economic, identity and cultural aspects (box . ). this new concept of 'food sovereignty' that differs significantly from the concept of 'food security' (box . ) that is being used by fao and the food aid community has been taken up by the un forum for indigenous peoples during its sixth session, - may that defined food sovereignty as: the right of peoples to define their own policies and strategies for the sustainable production, distribution, and consumption of food, with respect for their own cultures and their own systems of managing natural resources and rural areas, and is considered to be a precondition for food security. this concept has also been discussed by several ngos, such as the africa europe faith and justice network (aefjn) that adopted a food sovereignty document in september that points to many shortcomings of the food security concept (box . ). these definitions on food sovereignty by social movements representing the interest of farmers in the south (via campesina, box . ) and of an african-european catholic group (box . ) are just two exemplary snapshots that point to major shortcomings of the debate on food security during the past three decades. they are also responsible for the lack of progress against hunger since until today , people, above all small children, die daily of hunger. the next two concepts of 'survival strategies' and 'livelihood' that have been developed in the south address different means for the marginalized poor to achieve 'food security' with 'food sovereignty'. vía campesina, social movements, ecofeminists and indigenous organizations define food sovereignty as an integral process of production, commercialization, transformation and intake related to the family and community culture of food, proper of any region, social class and nations. their understanding of food sovereignty includes: a.) local production and trade of agricultural products with access to land, water, native seeds, credits, technical support and financial facilities for all participants; b.) women are the main food producers worldwide ) and they are often in charge of transformation and local trade; c.) therefore, access to land, credit and basic production means for women and girls at home and in the community is a guarantee of food security, but it is also able to overcome the violent and unjust patriarchal structures within families, communities, social organizations, countries, and global economic systems; d.) inclusion of the indigenous, women, and peasants in regional and national rural policy and decision-making processes related to agriculture and food sovereignty; e.) the basic right to consume safe, sufficient, and culturally accepted non-toxic food, locally produced, transformed and sold, since food is more than intake of proteins and calories: it is a cultural act of life; f.) the rights of regions and nations to establish compensations and subsidies to get protection from dumping and artificial low prices as a result of subsidies in industrialized countries; g.) the obligation of national and local governments to improve the food disposal of its citizens through stimulus of production and transformation of food, subsidies, and economic programmes to achieve food sovereignty in basic crops; discounts in urban poor regions, able to guarantee the basic food basket; popular kitchens; breakfast in schools, and special food for undernourished babies and pregnant mothers; h.) governments should guarantee an adequate nutrition above all for babies, infants, and pregnant women, offering food supply for poor people; i.) during bad harvests the importation of basic crops from the world market, and when countries are threatened by famine, with the advice and support from the world food programme; j.) clean water and sewage facilities to eliminate parasites, viruses, helminth and protozoa ) ; k.) links among environmental services, agriculture, territorial planning and democratic participation in the decision-making process to guarantee the livelihood and dignity of the most vulnerable in rural areas. they create opportunities for rural population to stay on their field without pressure for migration. the sum of these processes reinforce for each citizen the basic rights of life, but also the right of non-migration, thanks to sustainable life with dignity in its own communities and countries. on july some representatives of aefjn met … to discuss the principles of food sovereignty as a possible framework for the work of aefjn. the discussion stimulated interesting reflections about the definition of the term, the difference with other mainstream concepts such as the right to food and food security, weaknesses and strengths of this paradigm, and the specific aspects that can relate food sovereignty to catholic social teaching, human rights and policymaking. we would like to summarize here some of our findings. life is the most precious gift. the right to life is therefore the most fundamental right for any human being. an essential condition to sustain life is food. access to food is recognized as a basic human right. the right to food was recognized in the universal declaration of human rights in . it is also included in the international covenant on economic, social and cultural rights of : "everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food…" (universal declaration of human rights, art. . ) therefore the right to food is an integral component of human rights, based on existing international law and protected by a legally binding framework in international law. also important are the fao "voluntary guidelines " (november ) formally accepted by fao members states as a useful tool to challenge unwilling governments to take their internal and external responsibilities serious. the concept of food security has long dominated the discussion about the question how to diminish and eliminate poverty and hunger. coined in the context of the un specialized agencies, such as fao, the term has been used since the 's. although there is a definition agreed by all, the world food summit defined food security as 'the situation in which all people, at all times, have physical and economic access to safe and nutritious food that meets their dietary needs and food preferences for a healthy life'. though it refers to having enough food to eat, it doesn't talk about where the food comes from, who produces it, how and under which conditions it has been grown. food sovereignty is a global or national vision oriented towards production, rather than access to food by deprived persons and groups. the way to have access to food can be different: to grow food, to have paid work to buy food, or to receive welfare in case of inability. this allows the big food producers both in the north and south to argue that the best way for poor countries to achieve food security for their people is to import cheap food from abroad rather than trying to produce it themselves. it does not question the existing relations of inequality and processes that increase these social gaps, within a country by landlords and outside by tne. in spite of the green revolution, improved productivity and tremendous efforts to provide food security, the number of hungry people in the world has been growing. surprisingly, the very people who grow food, the small peasant farmers, particularly women, are afflicted by hunger and can no longer make a living on their land. to speak only of food security is no longer enough. we have to look at the question of what kind of food is produced, how it is produced, for whom it is produced. food security is a definition of a goal rather than a programme with specific policies that aim at the eradication of the causes of hunger and malnutrition. therefore a more comprehensive notion is under discussion today to ensure the daily food for all through food sovereignty. there are several definitions of 'food sovereignty': food sovereignty is the right of people, communities, and countries to define their own agricultural, pastoral, labour, fishing, food and land policies which are ecologically, socially, economically, and culturally appropriate to their unique circumstances. it includes the right to food and to produce food, which means that all people have the right to safe, nutritious, and culturally appropriate food, and to food-producing resources and the ability to sustain themselves and their societies. food sovereignty also refers to the right of states to protect their population by restricting the dumping of products in their markets and through the control of the domestic market. the notion of food sovereignty has not been invented by intellectuals. it comes from the grassroots, from peasant farmers and indigenous people in latin america who started to reflect on the root causes of their misery and to look for a way to live a dignified life. farmers associations in asia took up the concept. today farmers in europe are threatened as well in their existence by the effects of globalization. they, too, begin to accept food sovereignty as a revolutionary alternative to the dominant neo-liberal model, which tends to look at reality exclusively from an economic and a commercial angle. more important, the concept of 'food sovereignty' wants to integrate the welfare of people/human beings as well as/and to integrate the notions of the common good of society and ecological sustainability into concepts of the market economy. the concept of food sovereignty is not necessarily opposed to that of food security, but it goes beyond it. food sovereignty actually expands the focus by looking at the causes of hunger rather than concentrating only on the effects. food sovereignty can be an alternative to the current mainstream thinking on food production. it is people-centred as it looks at people not only as consumers of food, but at active agents in the production of food. there are various definitions of food sovereignty. we want to look at the definition accepted by the forum for food sovereignty in rome in . food sovereignty is the right of people, communities, and countries to define their own agricultural, pastoral, labour, fishing, food and land policies which are ecologically, socially, economically, and culturally appropriate to their unique circumstances. it includes the right to food and to produce food, which means that all people have the right to safe, nutritious and culturally appropriate food and to food-producing resources and the ability to sustain themselves and their societies." let us analyse the most important elements: the democratic principle (who decides what we grow and eat?): at present the decision concerning what is grown on farms and sold in supermarkets is taken by a few powerful transnational companies, which control much of the food production and distribution. their principle aim is to produce and sell as cheaply and as profitably as possible. the concept of food sovereignty wants to give back to states or groups of states and agricultural communities and farmers the possibility to decide what kinds of food they want to grow and how to grow it. states are to remain "sovereign" and need to have a political space in order to implement their own agricultural policies. the question of ownership (who controls the means of production?): with the advance of industrialized farming the means of production (land, water, and seed) are taken over by companies, turning farmers into underpaid slave labour or slum dwellers. in an economy of food sovereignty the state will provide small farmers with the resources needed to grow their own food. agrarian reform and redistribution of land is the most appropriate means to achieve that. in contrast to the social-ist model (state ownership of the means of production) and the capitalist model (the capital is owner) food sovereignty demands that it is the producers who remain in control of their resources. food is a social and personal right. the right to protection: today the political choices made by the multilateral institutions, like imf and wto tend to protect the agribusiness industry both in the north and the south, and to destroy the livelihood of millions of subsistence and family farmers by controlling the food cycle all the way from agricultural inputs and the growing of the crops to the distribution, processing, and selling of food. the dumping of heavily subsidized agricultural products onto the world market thus drives local farmers into bankruptcy. this is the very vision of agriculture that the concept of food sovereignty challenges. not only does this practice constitute a grave injustice, it contributes to the decline in food production and to the increase of hunger, and at the same time creates mass unemployment for millions of people. food sovereignty stipulates the right of peoples to protect themselves against dumping through protective tariffs, to retain the capacity of receiving remunerative prices for their products and so remain masters of their own way of life. the principle of ecological sustainability (who can best produce healthy food without destroying the environment?): the present system of industrial monocultures is economically efficient and profitable. yet, for the environment it is a disaster. biodiversity and the nutritional value of the food are reduced. the destruction of the environment for the sake of profits destroys the irreplaceable richness of animal and plant life for future generations, and is thus a crime against them. food sovereignty favours food production through family units who produce healthy food in respect of natural processes. economic models are based on ideas and a vision of human nature, of the role of society, and of the purpose of creation. the present economic philosophy sees human beings mainly as producers and consumers. the social dimension which used to be part of the 'social market-economy' is gradually eliminated. the long-term ecological cost of our way of producing, transporting, and selling our goods is completely neglected. food sovereignty wants to come back to a holistic view of the world and integrate the different dimensions that make up our reality. economic activities have consequences for social relations and the environment that have to be considered. the scientific modernization theories , the economic recipes of the neoliberal 'chicago school' , and the 'washington consensus' offered by northern theoreticians that have been implemented by many development agencies and international financial institutions (ifis), especially by the bretton woods organizations (wb, imf, ifc), have failed to achieve thier goals in many parts of africa, asia, and latin america. the implementation of these theories by governments in latin america is reflected in three lost decades of development, while the policies have failed to eradicate poverty and to overcome hunger. in many cases these neoliberal concepts have worsened the situation of the rural and urban poor who still experience undernourishment with all the negative human, social, economic, and cultural effects. due to the low income of the marginalized poor as a result of underdevelopment, economic crises, the increase of productive costs and chemical inputs, the rise of prices for basic products when crop prices collapsed, erosion of soils and scarcity as well as pollution of water, the peasants started in latin america in the 's to migrate massively to big towns. in marginal slums, they have lived with survival strategies (box . ) that are defined by diego palma as "a sum of initiatives able to complement the salary in terms of the reproduction of their labour force" (palma : ). nevertheless, the origin of the concept started with duque and pastrana ( ) when they described the situation of rural migrants invading urban marginal land in chile, and started to create their new livelihood. susana torado included in the concept "the procreation of family life cycle and labour migrations" and named them "strategies of family life" (nd: ), a term that was amplified by the group of quito as "strategies of existence" (pispal ). thus, 'survival strategies' were consolidated in the socio-economic crises of latin america, when in the 's the models of capital accumulation and of import substitution as post-war strategies were exhausted and the neoliberal globalization process was reinforced. on september , chile experienced first with the military coup the neoliberal imposition of the chicago school. argentina followed with a military coup in , and many other countries in south and central america experienced this regressive globalization combined with repression and empoverishment of large social groups. mexico (like venezuela and ecuador) seemed to be exempted from these repressive coups due to its richness in hydrocarbons, however, with the fall in oil prices, and a corrupt financial management of the governments (oil rent), elites were unable to consolidate and distribute profits, and thus crashed the 'mexican wonder'. confronted with the incapacity to pay the debt service, the imf imposed its structural adjustment policies (sap, see figure . ). from mexico the crisis spread all over la, africa, and to several asian countries. the affected nations were obliged though draconic policies to pay back at any cost their debts, and as a consequence public support and subsidies were drastically reduced. the adjustment costs of this failed policy were transferred to the workers and peasants, and later to the middle classes, which resulted in massive unemployment, loss of purchase power, increasing prices of the basic food basket, the elimination of controlled prices in basic products, a growing monopoly in the trade system, and a reduced purchase power parity (ppp) ( members, neighbours, and from the corner shop. soon, these possibilities disappeared due to the persistence of economic crisis, and food became scarce. then, e.g. in mexico city (oswald ), women organized themselves, picking up half-perished products from the garbage of the central market and transformed these products into food in collective popular kitchens collective community work (kitchen, child rearing, pressure on public functionaries) was organized through a system of rotation. united, they fought for basic services (electricity, water, roads, security, health and community centres; rosiques ) and the legalization of land and services. due to lacking cash and jobs, they struggled also for public subsidies and poverty alleviation programmes (ramírez ). besides all these activities, women still found time for some temporary paid work as domestics, washing or ironing; others generated services, handicrafts, food selling, etc. to be able to maintain their families. children, grandparents, and sometimes husbands supported these complex strategies, where poverty of time was the highest cost paid by women (damian ) . furthermore, these popular colonies have not only been hazard-prone but also exposed to organized crime and gangs. thus, only a strong social organization permitted them to fight against public insecurity, where often the police was involved in illegal activities. the sum of these complex actions empowered women, and therefore they were also able to fight against interfamilial violence. as a result these women were often abandoned by their partner, and as heads of household they had to struggle for the future of their children (inegi ) . after a decade of intensive mobilization and organization, most of these quarters achieved some social and economic consolidation (oswald (oswald , b , and their living conditions and livelihood improved. when they have been confronted with chronic unemployment, they integrated their microbusinesses vertically and horizontally (cadena ) with popular savings banks, collective childhood, pre- these are some of the alternatives to avoid perverse poverty and to improve their quality of life. . in india, bangladesh and africa similar processes of survival strategies took place, all of them replete with criticism of the imposed liberal modernization and globalization process. "over the past two decades every issue … what the industrial economy calls 'growth' is really a form of theft from nature and people" (shiva : ) . after the slogan in seattle "no new round, turnaround", she added that the real challenge is to "turn the rules of globalization and free trade around, and make trade subservient to higher values of the protection of the earth and people's livelihood" (shiva : ) . the future of the three billion impoverished people in the world lies on small farms, peasant and marginal urban livelihood, able to produce safe and culturally accepted food. this productive process is neither marginalized nor criminalized, and food sovereignty is a secure basis for regional sovereignty. the there exists a vicious circle linking hunger and undernourishment with poverty and ignorance ( figure . ) . these authors analysed the food transition in the mexican diet from traditional corn and bean intake to a modern food pattern that is rich in carbohydrates, fat and sugar, thus inducing illnesses, excess of weight, and hypertension which starts in the womb of mothers, creating chronic malnutrition and later obesity and associated epidemics. this phenomenon exists worldwide and has contributed to a deterioration of food, livelihood, and health security. thus, hunger is a complex interrelation where poverty is reinforced by ignorance and propaganda in the mass media, inducing people to buy junk food with their scarce money. unhealthy food creates further health problems above all for children, limiting their brain and bone development and adversely creating modern illnesses and degenerative processes from childhood on. the world the fao ( a) estimated that there are still million people suffering from hunger in poor countries, implying a loss of gdp of billion dollars/ year. chronic infant undernourishment linked to a lack of iron and iodine reduces the intellectual capacity of infants by to per cent. combining proteincalorie insufficiency with missing micro elements, the economic loss in poor countries affects to per cent of their gdp, equivalent to bd/year. regions threatened by war and internal conflicts are responsible for per cent of deaths limited by famine. nevertheless, malnutrition is basically concentrated in rural areas of poor countries and increasingly chronic undernourishment is present in urban slums, affecting also industrialized countries . the global demand of food is estimated to increase between to per cent between and , and simultaneously an increase of irrigation water of to per cent is estimated, due to an unsustainable management of aquifers. water withdrawal is regionally limited and it will affect regions that have already today overexploited its reserves. this refers also to areas with high population growth and countries such as india, the south of the usa, and northern mexico, peru, to the south-east of australia, to north africa, spain, the sahel region, the nile basin, east africa, south africa, central asia, the south of china, pakistan and mongolia (millennium ecosystem assessment ). thus, the future of food production increase is limited due to the availability of water, desertification processes, and loss of soil fertility, but also due to growing food prices since because of the promotion of biofuels. the trend towards an increasing undernourishment may grow when natural, population, and economic factors together become more urgent ( figure . ) .. in , in countries with a high human development index (hdi) the intake was , calories ( . per cent more than in ) and . g of proteins (a per cent increase); in countries with a medium hdi the intake was , calories ( . per cent increase) and . g of proteins ( . per cent increase) and in countries with low hdi the intake was , calories ( per cent less) and . g of proteins ( . per cent less). another indicator of life quality is the birth weight. in industrialized countries in seven per cent of babies had low weight, per cent in countries with medium development and per cent with low hdi (undp : - ) . according to undp . this process reduced the workers' capacity to negotiate labour conditions and salaries, and the survival problems pulverized the labour struggles of a whole favor of capital. in , when on june the rally against hunger started in the us, million us citizens ( million children) were exposed to food insecurity, meaning, they suffered from hunger or did not know how to get their next food. hunger increased in african countries affected by war, but also in east and south asia, and an increase of million in latin america. furthermore, regional and social differences exist ( figure . ) . food production has augmented, but at the same time poverty, hunger, and preventive illnesses (hiv/aids) increased in several countries, above all in sub-saharan africa (ssa). this region has at its disposal today per cent less food than years ago, despite the population increase (undp (undp , (undp , (undp , . the ssa countries produced between and about . million tons of cereals; a small increase compared with the . mt of the previous year. this production is insufficient to feed the population and . million people are threatened by famine or require international food support (figure . ). causes are complex: in the former grain reserve of the region in zimbabwe a corrupt government rules; in congo a civil war is ongoing; and namibia is confronted with a severe desertification process. in general, severe droughts and disasters have affected food production in many countries, but also the international trade rules are unequal for africa (turner ). in ssa the fifth poorest segment of the population obtained only per cent of nutritional requirements, in latin america per cent, and in the recent independent countries of the former ussr, per cent. the gap among and within countries in africa and asia is increasing, and only the fifth wealthiest will get their nutritional requirements in the near future. these negative results are reinforced by the present policy of cash crops, the food production, and the policy of biofuel controlled by multinational enterprises (mne). tajikistan and probably azerbaijan will lose their food security without armed conflicts, but the food situation can get worse in the event of political destabilization (chap. by salih). in sum, with the estimated population growth in poor countries and the present policy of food as a commodity, poor countries will be highly affected by the change of food patterns, and therefore more exposed to hunger and famine. these processes are reinforced by propaganda, where occidental introduced values of food patterns are taking away the few resources able to offer healthy food to poor people. with a global population of more than . billion inhabitants, more than one sixth in countries are suffering from hunger (usda ). natural factors such as loss of fertile soils, salinization of coastal areas and deltas, intrusion of salty water into coastal aquifers, and greater droughts will increase food vulnerability in countries that are today food insecure. these processes will be aggravated by climate change and more frequent hazards. the export of primary commodities from the poor countries to the world market equals that of , representing per cent of the global trade. nevertheless, the imports grew from per cent in to per cent in . the net food imports in the poorest countries have increased by about per cent between and (a rise from us$ . to us$ billion). the increase in medium income countries was per cent (from us$ . to us$ ; see: kwa : ). food distribution is another unequal issue (sen ). globally, one fifth of the world population has access to per cent of world consumption, compared with the poorest per cent that obtain . per cent, and consumption in rich countries is still rising. these data show the concentration of food in industrialized countries and a situation of increasing hunger in the poorest nations as a result of missing money, unemployment, low prices for prime material, unjust terms of trade and trade system, low salaries, population growth and corrupt governments, but also missing land and production means for the poorest. especially women and girls belong to the group of highly vulnerable persons, and are affected by this perverse poverty. the sum of these factors prevents rural people from getting sufficient food to overcome hunger, and thus many are forced to migrate to slums in cities where environmental, social, and economic deterioration affects again the most vulnerable (villareal ; schteingart ). during / , low income countries required . million tons (mt) of grain from food aid, and in it increased to mt. the usda estimated that this aid covered per cent of the projected needs, and the minimal nutritional requirements are . mt. the fao ( b) calculated that the food deficit will grow in , and with the same minimal ingestions, per capita insufficiency will increase by per cent to . mt, while nutritional deficiency will rise by per cent to . mt. as a result, poor countries will experience food shortage and countries more must reduce food intake. this implies new subsidies for food surpluses and a greater food power for exporting countries (usa, canada, eu, australia). this power is based on highly subsidized prices affecting poor countries and their rural people. tne obtain a wide with global horizons sufficient, regional horizons limited or missing local horizons gas, gasoline, kerosene gasoline, gas wood, excrement, organic waste high considerable low extreme poverty is better characterized as 'perverse poverty' (oswald ). the perversity lies in the fact that a child before being born, is condemned already to becoming a second class citizen due to brain damage, caused by chronic undernourishment and having an anaemic mother. later, the child enters into the 'valley of death' between and ½ years of age, because of its fragile immune system. if they survive despite chronic hunger, often the growth, intellectual improvement, and motricity of the child is seriously damaged. during the first year of life a child requires per cent of the nutrients for brain development and growth. malnutrition causes irreversible intellectual and physical damage. besides the small size, there are problems for logical learning, altercated micro-motricity, and slow reactions. major part of these subsidies, and gorelick ( ) estimated that profits obtained by big companies in the usa in form of subsidies and external support amount to us$ . billon dollars, without including environmental costs or health damages. vandana shiva ( ) calculated that each kilogramme of food consumed in the usa travels , miles, generating kg of co , thus contributing to global warming. these structural inequalities create worldwide prototypes of food consumption, depending on economic possibilities (see table . ). it represents a kind of schizophrenic behaviour of upper classes that are damaging to the global environment (see chap. by dalby/brauch/oswald) and their personal health, with their inadequate food intake (murray/lópez ). middle classes are becoming aware of their health and consume more locally produced organic food, but they also buy fruit and vegetables from outside. the lower classes struggle not only for their food survival, but also for drinking water and other basic services. these social groups create the lowest environmental impact. this global food pattern is the result of complex and multicausal processes, where local and global activities get negatively reinforced, and where free trade agreements (fta), indiscriminate openness of agricultural markets in the south, sap imposed by imf (strahm/oswald ; stiglitz ), failed policies by the world bank (mega-projects of dams and irrigations districts, and modernization of agriculture in hands of agribusiness) have created hunger. this critical situation worsened due to subsidies for agricultural products by industrialized countries, corrupt national governments, and local elites , financial monopolies, exports of prime materials at international prices below production costs, debt payments, bank rescues, patriarchal structure inside families and society, lack of peasant support also for organic agriculture, and low agricultural wages. with deteriorated and marginal land, polluted resources and high prices ( ) referred to one billion environmental refugees due to desertification, water scarcity, and soil depletion. the repercussions of the failed development policies in latin america are affecting vulnerable groups, especially indigenous and rural children, the elderly, and women. the causes of chronic hunger in the most biodiverse countries of the world are complex and are directly related to the unequal income distribution, (undp (undp - . most affected by these developments were peasants and indigenous people during these crises years, which were often pushed from their land and natural resources by tne that imposed a model of capital intensive production when the country had enough human power. as a model of this unsustainable agribusiness a modern chicken farm must produce yearly about , birds. after paying credit and inputs to the tne "this prodigious (and inhuman) production left the farmer only us$ , , or five cents/ bird" (gorelick : ) . mexico is one of the most unequal countries, with the richest man in the world (forbes, august ). during the 's its model of import substitution and stable development was replaced by a neoliberal globalization process (klein/fontan/tremblay ). after joining nafta in , the effects in rural areas and for the peasant economy were disastrous. the wealth has been even more concentrated (table . ). the effects of free trade, promoted by business monopolies, and the rapid openness by government without compensatory processes permitted an evaluation a decade later. the results are complex: economic growth was below one per cent; the employment policy was unable to offer to more than one million young people a job and the new employments are precarious, without social protection, and with 'white' trade union leaderships that are favouring enterprises. about half of the labour force is (self-) employed in the informal, often illegal sector, salaries declined by ures . and . ) . the severe undernourishment hardly declined since due to inflation and economic crises, while the concentration of wealth owned by a tiny elite has increased dramatically. women have developed survival strategies for their children and elders, and often they have to pay the debt for the illegal crossing of their husbands. also feminization of agriculture rose to per cent (inegi ) . food imports affect both countries: the usa due to pollution of agrochemicals to raise yield productivity, and mexico due to payment of us$ billion for food imporation and job creation in a foreign country (inegi ) . only a small elite representing . per cent of the population benefits from this type of modern rape capitalism, owning . per cent of national wealth and per cent of financial savings (table . ) . nevertheless, these global data do not reflect the existing regional disparities. the food perspectives for the future are uncertain, and will most likely get worse due to the massive use of corn and oil seeds for biofuel. furthermore, confronted with climate change, disasters and greater drought, mexico must take its food security problem seriously, especially if the usa and canada that presently provide more than million tons of basic grain should become food insecure. therefore, the term of 'food power', created in by henry kissinger, may generate structural instability, migration, and social riots (figure . ). (innsz (innsz , (innsz , (innsz , based on global and regional scenarios on temperature rise, precipitation, decline in groundwater, and hydro-meteorological disasters, together with biofuel from cereals, the worldwide supply of basic grain will be reduced drastically. in , still half of the people live in regions with a low level of underground water, including the three large grain producers: china, india, and the usa. countries such as mexico, iran, israel, pakistan, saudi arabia, jordan, and yemen are overexploiting their aquifers and limiting alternatives for the future. due to projected water scarcity in the next years, cheap grain will disappear from the world market and only very few countries will be able to improve their agricultural production due to climate change. in , the world market price of rice, highly vulnerable to water, increased by per cent reaching us$ /t (usda ). the corn price in mexico rose between september and december from , to , pesos/ton, as a result of the demand for biofuel for corn in the usa, but also due to speculative practices. therefore, the future of the world food system is complex and uncertain, and a new policy of food sovereignty will play an important role in the political stability of many countries. related to the conceptualization of food security and food sovereignty (see . ), three models of food production and commercialization have evolved: a) the productivity model based on the green revolution; b) the life science model that relies on modern biotechnology and genetics; and c) the traditional organic or green model. throughout the th century the productivity model tried to homogenize food crops similar to industry, and during the last two centuries the supply of food and agricultural inputs was in the centre. the green revolution promoted monocultures, intensive use of chemicals, veterinarian drugs, improved seeds, machines, fossil energy, and irrigation systems. politically, this system relied on high government subsidies (usa, eu, ocde, japan), offering the consumers cheap products. the production was controlled by agronomists, veterinarians, and the chemical industry. health and environment concerns were marginal. the ministry of agriculture managed natural resources such as soils, water, forests, flora, fauna, and fish. internationally, this model should have eradicated hunger and given the whole world food security. until today it remains the basic tool against hunger (fao a, a, , b, c) . high crop yields and 'free markets' were at the centre of the concern and therefore hunger could not be eradicated, owing to the maximization of profit of agribusiness and governmental subsidies in developed countries. hunger and poverty were considered undesirable side effects for southern countries and for people with a low capacity to modernize. social, environmental, and cultural factors of diverse food production are only marginally considered. food is not treated as a cultural good or as a patrimony of thousands of years of human effort. the limits of this model are imposed by negative effects on health (gallaher ) and on the environment (scarcity in water and oil resources). in the st century a new model is emerging that establishes links among health, food production, and dietetic habits. it represents the new health safety and food security concerns where individuals with purchasing power are at the centre of attention. concrete genes were linked to specific illnesses (nestlé ), creating a scientific basis for life or a 'life science' paradigm (lang/heaseman ). this model is demand-oriented and takes into account the consumers and their needs. productivity is still important. it refers to the balanced daily intake of proteins, carbohydrates, vitamins and minerals, all of them necesary for a healthy life. this life science model integrates the food chain in the form of clusters and relates it to production, transformation, and trade of food. it combines genetic research with field experiments, including biology, engineering, nutrition, pharmacology, health, and mobile field labs. the industries are controlled by multinational food chains. they offer clean, safe, and homogenous products that can stay for weeks on the shelves of supermarkets, thanks to genetically modified genes and organisms (gmo). food is not only modified but also enriched artificially with nutrients to prevent illness, such as enzymes, proteins, minerals, etc. at the centre of concerns is the individual health, improved by technological proceedings in bio-labs, where specialists are in charge of human lives (nestle ). these processes of 'healthy' food can only be controlled through sophisticated scientific procedures in well-equipped laboratories in universities or research institutes of mne. the experts are paid by the food mne, which are simultaneously producers, sellers, and supervisors. when nonconformities arise, due to the complexity of the process, governments rely on these institutions, where those who are interested and involved are both judge and arbiter (beck ; ) . independently of an intensive propaganda in mass media, some undesired effects can not be denied, and ngos are trying worldwide to carefully educate people on these negative effects. most evident are genetic modified crops (gmo), which started commercially in . in more than million hectares were produced in the usa ( per cent), per cent in argentina, per cent in canada, and per cent in china. south africa, chile, india, and brazil are joining this production process. on gmo seeds there exists an oligopoly of four main multinational enterprises. one sole holding (monsanto) controls per cent of all seeds with two genetic modified proprieties: a herbicide (roundup) and an insecticide (bt). conclusive results are still lacking whether these seeds are innocuous, but there are risks that the recombinant process could produce unknown effects in human and animal health and environment. unwanted pollution occurred in canada where wind, water, insects, and other animals have polluted natural crops of canola with gmo ties, destroying the great biodiversity and the natural production of this crop (schmeiser ). another threat is related to new toxics, new plagues, and insects resistant to gmo and other insecticides. paediatricians have found a high level of food allergy in babies and therefore baby food is produced without gmo seeds. in socio-economic terms, eight mne merged in into four, able to produce per cent of biotechnological research in the world. this is a threat for the freedom of science and technology in favour of humankind. there is another danger that small farmers may be forced to stop farming due to the expensive productive processes of gmo seeds ( per cent of cotton production in ), what is reinforced through subsidies that are highly concentrated in big enterprises. finally, these gmo seeds are controlled by patents and the wto is the arbiter through trips (heineke ; schmid ; oswald ; ) . the study of fao ( a) in different countries has shown that the income of producers in mexico in-creased by per cent using cotton gm-seeds from monsanto, but the benefits were more than three times as high in china where a national research institute produced their own gm-seeds. the 'life science' paradigm continues with the same model of productivity, but it oriented at the consumers and their health needs. the integration into the food chain is through clusters. this model of production has generated new illnesses (bse ) and could promote new epidemics such as avian flu, since genetically modified organisms work with virus and bacteria that could have their own dynamism when they are modified and inserted into different plants or animals. therefore, the cornucopian vision to resolve by mne environmental, social, and health problems through science and technology shows its limits, but above all poor people have to pay for the mistakes, and biodiversity can get lost for ever. it is horrific that thousands of peasants have committed suicide when gmo harvests failed and credits could not be paid back (shiva , , ). with regard to food sovereignty there is no doubt. this model of production has enormously increased the costs of production (gm-seeds), and created a monopoly of agrochemicals and the transformation of basic food in the hands of tnes. these processes are able to concentrate wealth within few hands, increasing poverty not only due to more expensive food, but also due to associated health problems. the green model generates symbiotic relations and mutual dependence between nature and food production, and therefore uses soft methods of agriculture. they are regionally diverse and utilize policultivation, association of crops, rotation, mixed agriculture, fixation of nitrogen from air to soil, biopesticides, traditional methods of soil conservation and food, integral management of water, plagues, and environmental services. the combination of traditional and modern knowledge is consolidating food sovereignty in any region. a biodiverse and regionally adapted use of seeds is conserving diversity of species, and therefore is agro-ecological. this mode of production cannot be globalized. the surplus of production is sold in the local markets and thus reduces environmental pollution and global warming linked to transnational agribusiness and global markets. local agricultural production and trade, with access for peasants to water, seeds, credits, as well as technical and financial support could promote this model of agriculture. this green model takes women and peasants as key elements for food issues and agricultural consolidation. it encourages the participation of indigenous, women, and peasants in the national and regional definition of rural policies. it can guarantee women access to land for production and livelihood, and through empowerment they can overcome the violent and patriarchal structures inside families, regions, countries, and the global economic system. it includes the right that peasant organizations have developed their own model of food sovereignty and are now struggling for their right to produce and consume healthy, permanent, and culturally accepted food which is locally produced, sold, cooked, and consumed. governments have the obligation of protecting their economy from subsidized food imports. they have to establish agricultural prices which are able to cover the production costs and to protect the environment. by linking environmental services with farming, land planning, and participative democracy, this paradigm supports a stable rural development and therefore respects the human right for non-migration. when livelihood in villages and countries is guaranteed with public resources for poverty and hunger alleviation, bottom-up efforts can be reinforced. in the medium term, safe ecosystems and stable social relations create synergies and cooperation where safe food and the environment improve public health and cultural diversity at the local level. this third model reflects the food sovereignty debate. it understands food in a holistic way, where livelihood, sustainability, and culture are the driving elements to maintain the genetic diversity for future generations, offering healthy nutrition and establish- bse is a result of feeding cows with waste from animals instead of grass. after years research of more than drugs, it was proven that bovine somatropina, an amino acid able to stimulate growth in cows, is responsible for an increase of per cent of breast cancer in pre-menopausal women and the same number of prostate cancer in men (world cancer research fund ). confronted with avian flu threats, the same mnes are producing expensive medicaments with dubious results to combat a potential epidemic. foreign food aid from outside has to be targeted to avoid a distortion of non-market items such as equity, corruption, electoral use, etc., but above all it can destroy the local productive systems. thus, it must always be an emergency support, limited in time and for specific events. ing a direct relation among productive, commercialization, and consumption cycles. it represents also an alternative for more than . billion peasants and small farmers who still depend on their ancient technology. they carefully selected the seeds from the former year that were and are able to guarantee the next harvest. it consolidates the basic right to consume safe, sufficient, and culturally accepted toxicfree food that is locally produced, transformed, and sold. thus, in the green agricultural paradigm food is a cultural act of life and more than the intake of proteins and calories. it is until today the only real possibility to overcome existing famine and hunger and offer humankind an opportunity to create justice and well-being all over the world by fulfilling the universal declaration of human rights in its art. . . food sovereignty within the green paradigm represents the rights of people, communities, and countries to define their own ecological, social, economical, and cultural project of the future. besides maintaining food as a pleasure of life, and not a threat to health and survival, it consolidates the world food culture and consumption for the future. food perspectives: models of production, population growth, climate change, and environmental deterioration 'food security' in the context of the model of agribusiness production or life science has failed to improve the world food situation. it is not a problem of the amount of food and of the knowledge how to produce more, but it is basically a problem of poverty (fao ) . therefore the evidence is that in most poor countries the total number of hungry people has not been reduced, except for china and india and the former countries of ussr. rather, new threats of food insecurity are rising. this requires the reformulation of the basic assumption of how to reduce hunger and how to achieve the mdgs. the globalization process in its regressive phase has reversed some advances, but in countries with high population growth that are threatened by severe impacts of climate change and disasters, the eradication of hunger is further limited. both the 'productivity' and the 'life science' paradigms have also led to higher emissions. aquifers have collapsed in india and mexico. through genetic pollution both models have been destroying the biodiversity of southern countries. thus, with regard to food security, but also for the survival of humanity and nature, the present understanding of food security has failed to combat hunger. it has rather increased the threats and risks of more serious famine not only in africa, but worldwide. imposing food security instead of food sovereignty, and destroying the traditional green production, could become a boomerang also for northern and developed countries. from to organic food production has grown by to per cent. in germany organic food products grew annually by per cent. a major increase has also occurred in the us where the national organic programme (nop) supports small farmers and promotes the certification of green agriculture where organic products grew from us$ to billion from to . in about million hectares of land were certified and , farmers were affiliated. in most countries, due to the productive model of the political elites, the support for organic agriculture is still limited. nevertheless, the tnes have discovered this green option for supermarkets. they are now charging higher prices for naturally grown products. consumers, confronted with doubts about gmo, are demanding comprehensive labelling, but tnes have tried to influence national laws to avoid or restrict this. propaganda on different products is confusing the consumers even more by letting them believe that they determine their own model of life. via campesina has challenged this tne and has campaigned against gene modified seeds and promoted laws favouring its alternative agricultural model. they insisted that environmental, cultural, and social factors are as important as the economy. further, economic crises and increasing poverty in rural areas have created among peasants, the indigenous, and women a sense of security that they can manage their own food supply with regional resources and local seeds. at the international level, fao has argued that food needs could be linked with a protection of the natural heritage by: promoting market-based incentives that compensate farmers for their stewardship efforts, thus maintaining their economic viability; replacing polluting agricultural practices with approaches that can reverse the dramatic trends in biodiversity loss; thriving on community par- ticipation in land conservation. meeting food needs while protecting the natural heritage is a challenge shared by all countries of the planet. organic agriculture can meet this challenge head-on by: promoting marketbased incentives that compensate farmers for their stewardship efforts, thus maintaining their economic viability; replacing polluting agricultural practices with approaches that can reverse the dramatic trends in biodiversity loss; thriving on community participation in land conservation (el-hage scialabba : ). simultaneously, fao has also promoted gmo seeds in diverse poor countries, and continues to support the 'green revolution' model. many existing contradictions are inherent in the three productive models, and reflect the struggle for hegemony. they can be synthetized as follow: the 'productive' model is unsustainable due to the scarcity and pollution of natural resources (water, soil, seeds, and loss of biodiversity). ministers of agriculture have shifted slowly to the 'life science' model that is supported by ministers of trade who promote free trade and bilateral agreements. health ministers have supported nutria-genomic research, biosecurity protocols and vaccines that are often produced from genetically modified plants. productivity concerns dominate over inherent risks and threats for biodiversity and humankind, due to the uncertainty and insecurity of genetic manipulation and nanotechnology. both could affect the essence of human beings and the future of life (habermas ). these two models induce a scenario of a 'food war' (lang/heasman ), when multiple factors of aggravation of conflicts intervene: the quality and innocuous food demand, international commerce, governmental regulations, nutritional requirements, control of tnes, anti-monopoly laws in transportation, financial monopsony, security in food chains, supply of safe food products, coexistence of over-and undernourished people, environmental damages, science and technology (s&t). arbitration among these many contradictions are often handled by experts associated with tnes. but despite the unimaginable advances in s&t; hunger is still increasing and far from being eradicated. why is this so? there is a second related factor. the model of transnational agribusiness is oriented at the individual, considering his or her consumption and ppp. as with the modern health system, the individuals become victims and objects of persuasion for food recipes to strengthen their health that are often counterproductive. these two realities have opened for social movements, ngos, and critical scientists a space for struggle. confronted with the nutritional and health deterioration, they have denounced these tnes and often corrupt government allies which try through early alerts and catastrophic predictions about epidemics to push the errors and possible consequences of this erroneous productive system to various 'natural' causes. the global deterioration of life quality and limited progress in hunger alleviation in most developing countries, as well as high levels of obesity and cancer in industrialized countries, offer organic agriculture an option for the future. social movements understood these opportunities and are promoting food sovereignty with native seeds and organic input as a real alternative against hunger and malnutrition. table . summarizes, contrasts, and compares the many advantages and disadvantages of the 'life science' model with those of the 'sustainable organic agricultural' model. in synthesis, the paradigm of 'science of life' relies on governmental financial resources; however, the consolidation of this model depends on the acceptance by consumers who are induced through advertisements to buy these products. therefore, the competition among some tnes could leak information about damages in health through this model of food intake, and strict governmental control can avoid a manipulation of consumers. but often the same pharmaceutical holdings are also selling medicaments, control hospitals through the stock market, and often repel demands to pay compensation for damages caused by unhealthy food. their treatment (chemo- value of change, with maximization of profits and socialization of losses value of use with maximization of social relations and collective livelihood therapy and radiotherapy) creates further collateral effects compensated with other expensive drugs. their goal is only the maximization of profits by taking away the surplus created by society. these contradictions in the health, education, and food system were exposed by ivan illich ( ). on the other side, there is the small green production for poor people, peasants, women and minorities. organizing production and transformation, food diversity, and local markets increase local food security. more governmental support is still lacking, and also scientific and technological efforts to combine traditional and modern knowledge has to be developed, e.g. in new zealand. there are enough universities that could support green models of production able to facilitate the creation of local jobs and offer young people an opportunity for employment and a decent life. however, the political and economic elites that benefit from the other two productive models are preventing an enhanced 'food security' combined with 'food sovereignty' and a dignified livelihood (nord/andrews/carlson ). conclusions: food security with self-sufficiency, food on this dual political and conceptual background, this chapter addressed the following research question: food represents not only a security issue of intake of nutrients, but it forms part of a holistic understanding of life and a constituting element of any civilization. thus, food includes networks of connectedness, belonging, and relationship of trust, reciprocity, cooperation, solidarity, care, and exchange. it creates social benefits and risk reduction, but also innovative activities through the wider access to infor- artificial international prices due to subsidies, generating dumping in the world market local, interchange of products and services fixed by the economy of solidarity and support for the vulnerable monopolies, oligopolies and monopsonies local chains of integrated micro-business monopsonies integrated in fta, wto controls through gats, trips and international arbitration family unity and local market with incipient household transformation, local non-violent conflict resolution food disposal world supply-demand, depending on available capital and prices, speculation with crops, increase of hunger proper system of production for local food, family and regional storage the case of old people is often dramatic. they loose their savings for medical treatment and hospitalization. once without resources they are abandoned and in the best case they go back to the traditional medical sector. however, governmental controls can further limit this alternative. mation and learning. it is a process of anchoring of personal and group identities (see chap, by oswald on huge; oswald a), where social relations reaffirm the integration of a person inside a community establishing rights and obligations, such as access to land, credit, technology, training, market, life quality, and rituals. besides guaranteeing physical and cultural survival, 'food sovereignty' creates also new opportunities for people-centred poverty alleviation and new understanding of rurality as a complex social network. it represents a critical response to the accepted development and modernization paradigms, and opens ways for diverse rural life processes where agricultural activities and environmental services coexist with services and industries. thus, food is part of a holistic model of life and a constituting element of any civilization. networks of interrelationships, and processes of identity and social belonging, create relationships of trust, reciprocity, cooperation and exchange. they are at the basis for 'food security' which could evolve into an integral 'food sovereignty'. confronted with new threats of global environmental change, 'food sovereignty' represents social benefits and contributes to risk reduction through innovative creativity where instant world communication helps to establish new learning processes. during this process of achieving 'food sovereignty', personal and group identity is anchored and social relations may overcome stereotypes by reaffirming the integration of a person or a group within a community. such a wider understanding of rurality that includes non-agricultural activities facilitates critical responses to historical injustice, abuse and environmental changes, and opens ways for diverse ruralurban life processes, where agricultural activities and environmental services coexist with other services and non-contaminating industries and transportation systems. the future is getting complex and the world is confronted with unexpected climatic events, generating massive migrations, chaotic urbanization, pollution of natural resources, and loss of biodiversity. the ecological footprint and the size of the 'food footprint' is converted from food consumption by this equation: where crop yields are taken from the fao database (friends of the earth ). population growth creates new challenges when billions of young people ask for dignified employment. on the contrary, the lack of jobs could create complex emergencies. in this multifaceted panorama new agreements among governments at all levels with business and organized civil society should be negotiated where public well-being has to prevail over private interests. this implies to transform through creative activities related to food production, transformation and consumption, the existing monopolies into local chains of micro-enterprises that are able to offer cheap, healthy and, culturally accepted food in a framework of an economy of solidarity. but market forces are pushing in a contrary direction. the future food sector will experience a competition between the 'life science' and 'sustainable small production' model. new food-related illnesses (e.g. bse) have created a greater awareness among people, what they are eating. in europe, some per cent of the population is familiar with the associated risks of agribusiness by tnes and per cent reject gmo food. increasing degenerative illnesses and obesity have forced the tnes to focus on new products, and the culture of 'light' food has been their response. however, only a comprehensive approach with preventive health, vitamins, proteins, iodine, flour, and other microelements for the undernourished will be able to alleviate hunger and create livelihood for all with a distribution of profits. the future will show if the public relations activities by tnes will be able to counter a wider public awareness on the risks associated with the life science approach or whether small green food production will slowly replace big food monopolies. however, there are some global decision-making processes that may contribute to and speed up a strategic shift aiming at 'food sovereignty' (cloc ): tries women produce most of the local food (fao ; b) . . regional food sovereignty: via campesina, cloc ( ) , mst ( ) , and the peasant university of the south (unicam) are promoting an integral model of food with democratic landreform, credits and local savings, green agriculture, chains of integrated local micro-businesses, an economy of solidarity, and traditional medicine. . food policy to alleviate hunger: brazil proposed a model of food support for popular sectors linking the small production system with an offer of healthy food, increase of minimal salary of workers, and an urban offer of cheap food for the poor (figure . ). . a well developed system of periodic measurement of basic indicators of undernourishment is needed, above all for children below five years, including anthropometric measurements of weight and size related to their age. unicef, who, and innsz have proposed six steps with minimal costs to avoid premature deaths, slow development, and brain damage in infants: vitamin a complements; a complete scheme of vaccines; nutritional supplements to overcome severe undernourishment; periodic elimination of parasites, complements of iron, iodine, and other minerals (such as flour against caries) depending on the water composition, floors covered with cement, latrines, clean water access, and nutritional education and care (Álvarez/oswald ). furthermore, the metabolic syndrome of undernourished children with small size should be addressed. they of- . improvement of local food through a mixed agriculture of fruit trees, plants able to fix nitrogen from the air to the soil, rotation of crops, organic composting, and bio-pesticides; . community health centres able to treat the most common gastro-intestinal illnesses, malaria, dengue, reproductive health and campaign for vaccination, undesired pregnancy, and sexually transmitted illnesses; . basic education: training in simple technologies for production, and conservation of safe food at the community level, especially for women; . renewable energies: solar systems, biogas, oil and other energies able to give children light for studying, energy for water pumps, machines for grain mills, and refrigeration of medicaments and food; . clean water, building of latrines, water harvesting, protection of wells, and other simple techniques to conserve safe water and to avoid water-borne illnesses. ten rely on a diet that is rich in carbohydrates and fat, and are subsequently frequent victims of obesity, later on diabetes and coronary illnesses. . education, training, and the rescue of traditional elements of food culture are basic requirements to improve the nutritional situation in poor countries. education and training, especially of women, reduces not only the illnesses in families and premature death, but it opens the cooperation in reproductive health and creates stable livelihood conditions in villages, and colonies, and slums of the urban poor. ) enabling women, indigenous, and peasants to handle food and nutrition for their families in an integral way, improving their quality of life, and reducing premature death and preventing diseases. such a new comprehensive security process that combines 'food security' with 'food sovereignty', and also with 'water' and 'health security', may be better able to resolve the food problems of the other half of the world population for whom food security has been an issue of daily survival of their families that avoids the overconsump-tion and loss of life quality with which the food security problems of the oecd world and the elites in the global south are struggling (see chap. by salih). the discussion has shown that the evolution of the concept of 'food security' within multilateral organizations has failed due to a top-down approach that is neither questioning the demands of the people, nor the interests behind the driving forces of world business. the continuous adaptation of the 'food security' concept and model by fao reflects its basically technocratic approach that is far away from the real problems of hunger and of agribusiness. the fao has tried to resolve a complex health problem with aspirin (preker/feachem/de ferranti ). confronted with serious environmental deteriorations and adverse economic conditions resulting from the neoliberal approach, the directly affected people started first with a critical analysis of agricultural and food aid policies from industrialized countries. greater environmental destruction, new threats due to climate change, and deeper ecological footprints forced organization of civil society to create the new paradigm of 'food sovereignty' as a holistic life concept. that there "are no secrets how to eradicate hunger. there are no new technologies necessary. simple political will is required to change the existing policies which make the rich richer and the poor poorer or ) linked the multidimensional roots of hunger to poverty. in the kenyan village of sauri he tried 'the big five' with us$ per person and year women are not only more affected by modernization, they represent also an alternative for self-sufficiency and to the food supplies by tnes this understanding could overcome the limited productive approach, but also the behaviour of converting poor people into victims of their circumstances, when the real causes of their situation of marginalization are precisely the forces of the free market, the political domination and the exploitation of humans and nature for profit. the future is complex and the situation will probably get worse. then biodiverse and culturally determined approaches to food sovereignty could foster solidarity among human beings and protect their remaining common natural and cultural capital. key: cord- - glgeft authors: possas, cristina; antunes, adelaide maria de souza; de magalhães, jorge lima; mendes, flavia maria lins; ramos, mateus pinheiro; de simone morais, juliana; homma, akira title: vaccines: biotechnology market, coverage, and regulatory challenges for achieving sustainable development goals date: - - journal: bioeconomy for sustainable development doi: . / - - - - _ sha: doc_id: cord_uid: glgeft this chapter provides an overview, from bioeconomic and global sustainability perspectives, of the main constraints to the current global vaccine innovation system for achieving sustainable development goals – sdgs. biotechnology market trends, gaps in vaccine coverage against emerging and neglected diseases, and patent protection and regulation are discussed. a structured long-term “public-return-driven” innovation model to overcome vaccine market failure is proposed. innovative preventive vaccines against emerging and neglected infectious diseases, such as zika, dengue, chikungunya, influenza, and hiv/aids, are examined here from bioeconomics and global sustainability perspectives, aiming to integrate public health and biotechnology market approaches. novel vaccines with reduced adverse effects can have an enormous impact on life expectancy and on the quality of life of the global population, significantly reducing government, individual, and business costs . nevertheless, there are significant production, technological development, market, coverage, regulatory, and governance constraints to achieving sustainable development goals (sdgs) . in this chapter we examine vaccine biotechnology market and the factors contributing to market failure, discussing policy strategies to optimize science, technology, and innovation (sti) and drastically reduce current constraints to vaccine development (singh et al. a (singh et al. , b, . for achieving sdg, it should be noted that only one of these goals, sdg , refers specifically to vaccines ( .b. ). however, in addition, we have also identified other sdg goals strongly related to vaccines and sdg goals related to vaccine, in a total of vaccine-related goals in sdgs. two of these goals are related to innovation and technological development of vaccines (sdg and sd ). we discuss the main vaccine development challenges for achieving sdg and current technological and regulatory obstacles particularly affecting developing countries. from this perspective, we propose sti governance strategies to overcome these gaps and increase global access to vaccines, focusing on institutional and regulatory perspectives, including intellectual property and ethics. policy recommendations for vaccine funding and incentives for innovation, development, and production are made. finally, we emphasize the enormous potential role that access to innovative vaccines can play on global sustainability (milstien et al. ; possas et al. ) , benefiting particularly the poorest countries in a global context permeated by sharp social inequalities. the global market for human vaccines is projected to reach usd . billion by from . billion in at a cgar of . % (markets and markets ) driven by the growing importance of vaccines in public health, reducing healthcare costs and contributing through prevention of diseases toward a more sustainable healthcare system. drastic changes in the dynamics of the global vaccine market occurred between and , with a sharp growth from usd billion in to usd billion in (access to vaccines index ) and to usd . billion in (markets and markets ) , with sales to high-income countries representing about % of the total value of this market (access to vaccines index ). in fig. . we indicate the evolution of the global human vaccine market from to and the forecast for . recently, other reports have been released anticipating an even more favorable scenario for the global human vaccines market. a recent study estimated that this market would grow from . billion in to . billion by (grand view research ) . these market forecasts also anticipate rising r&d investments in vaccine development projects by the main global players in the vaccine market. table . indicates the top pharmaceutical players according to global revenue share in . pfizer is expected to increase its participation in the market in the next decade due to the success of its pneumococcal vaccine prevnar and increasing investments in vaccine development. other important vaccine players include emergent biosolutions, csl, inovio pharmaceuticals, bavarian nordic, mitsubishi tanabe, serum institute of india pvt. ltd., alk-abelló a/s, altimmune, inc., bharat biotech international, and medimmune. the world vaccine market consists of four segments: gavi (the global alliance for vaccine and immunizations), unicef, paho revolving fund (rf), and rest of the world (row). about of the lowest-income countries in the world rely on gavi for funding of some key vaccines (who ) . unicef supply division (sd) is the procurement agent for most of these countries and for an additional approximately middle-income countries (mics) (totaling about countries). the paho rf provides financial and procurement support to about countries and territories in the americas. the row consists of self-funding and self-procuring countries spanning all income levels and receiving only marginal, mostly indirect, financial, procurement, market shaping, or other related support. these increasing investments in vaccine innovation, development, and production are guided by the growing global need for preventive vaccines and immunotherapy strategies against cancer, zika, hpv, hsv, hiv, and a broad range of infectious diseases that currently burden the healthcare system and societies worldwide (who (who , . this scenario of increasing global demand for vaccines in the next decade is supported by epidemiological indicators: annual burden of new hpv-related cancers worldwide to the tune of , ; rise of zika into a public health emergency with over countries reporting , cumulative confirmed cases of infection between and ; very high prevalence of hsv which infects approximately % of the world population under years of age; continued prevalence of tuberculosis which infects million and takes . million lives each year despite the progress made toward eliminating the disease; and rise in hiv infections worldwide over . million (who ; global industry analysts ). developments in reverse vaccinology and synthetic vaccinology are expected to help increase the rate of successful vaccine design and development (sette and rappuoli ) . emerging countries with mandatory immunization programs represent large markets with enormous potential for future growth and expansion. with large population base and relatively high proportion of young children and teen population, emerging markets including china and india represent the fastest growing markets in asia-pacific, with this region expected to grow at the fastest rate of . % in the next decade. the pharma industry is rapidly becoming a competitive player in the bioeconomy market, a new global paradigm that will introduce novel technologies such as genomics and proteomics across multiple economic sectors and industries. immunome, resulting from advances in sequencing technology and a bioinformatics resource, is also contributing to vaccine innovation and development. these advances in genomics, proteomics, immunome, bioinformatics and new information technologies and their increasing convergence are driving these new market trends. this accelerated innovation scenario is revolutionizing healthcare with new preventive and therapeutic technologies, expected to provide longer, healthier lives to the global population. physicians will eventually be able to predict a person's predisposition to a broad range of diseases and intervene appropriately, insert new genes to replace faulty ones, and tailor therapies to an individual's needs and profile. the immune system is a highly complex system, based on a coordinated expression of a wide array of genes and proteins. one of the major gaps in vaccine innovation, particularly affecting the development of new vaccines against emerging and neglected diseases, is related to the inability of scientists to explain the diversity of individual immune responses and clinical outcomes to the same vaccine and how this diversity relates to innate and acquired immunity. the human immunome, a specific set of genes and molecular structures underlying the response of the immune system to fight disease, is vast and estimated at billion times larger than the human genome project in terms of data output. because of this scale, scientists have never been able to characterize the core parts by which the immune system responds to pathogens and develops a disease. only recently, with the dramatic advances in sequencing technologies and bioinformatics, exponentially extending their informational scale, it became possible for the first time for scientists to uncover the complexity of the human immunome (soto et al. ; briney et al. ) . immunome, a bioinformatics resource, has been conceived for the characterization of the human immune system. it contains information about immunity-related proteins, their domain structure, and the related ontology terms and contains also information about the localization and mechanisms involved in the coding genes. determining the core parts of the immune system in the human immunome could drastically transform how we diagnose, prevent, and treat disease through the identification of new biomarkers while enabling highly targeted, computationally designed vaccines and therapies that reduce time and risk of product development. the immunome program of the human vaccines project is sequencing, in a global collaborative -year effort, receptors from a group of genetically diverse individuals in several continents and determines the structure and function of a key subset of receptors. through an open-source procedure, data will be made available to researchers across the world. in this program, laboratory analyses of biospecimens will be combined with an array of other genetic, lifestyle, and health information provided by volunteers to help researchers to identify individual genetic differences that contribute to diverse immune responses. the initial study will assess immune responses of ten healthy adults (ages - ) to a licensed hepatitis b vaccine (considered an ideal model to study human immunological protection), and it is expected that this study will expand to include several hundred people from neonates to the elderly in middleand low-income countries. the immunome program can thus bring crucial information to the development of more effective vaccines against emerging and neglected infectious diseases. vaccine manufacturers in developing countries, particularly affected by these diseases, should be actively involved in its international scientific and technological collaborations. in the near future, sophisticated technology will allow patients to search and manage their medical records, comparing them to current public health information based on individual genomic profiles. intelligent marketing agents will aggregate patient information from a variety of sources to provide timely and relevant responses. networks of distributed processing systems will offer new insights into data by mining all enterprise and public data sources. and supercomputing platforms and information management will enable the rigorous manipulation of genomic data. advances in remote sensing and artificial intelligence technologies have already created intelligent operating rooms with sensory control mechanisms and devices that transmit health information via telephones and personal digital assistants. the industry can now develop programmable microchips for the subcutaneous delivery of precisely timed doses of drugs and vaccines. interactive chips with built-in sensors may mimic the body's own regulatory ability. as the bioeconomy evolves, the industry faces an unprecedented era of opportunity and challenge. companies recognize that alliances are critical to their future and are now making them a major component of their strategy. virtual research organizations are now conceived searching to provide discovery technologies to scientists in pharmaceutical enterprises; providing them links to gene database, proteomics database, or high-throughput screening capabilities; and enabling fast and efficient access to vaccine and immunotherapy information. the world is facing multiple public health challenges, such as outbreaks of vaccinepreventable diseases, increasing reports of drug-resistant pathogens, climate change, and multiple humanitarian crises. the world health organization (who) included several emerging and neglected diseases among the ten global threats for (who ): influenza, dengue, hiv, and also high-threat pathogens, such as ebola, several other hemorrhagic fevers, zika, nipah, middle east respiratory syndrome coronavirus (mers-cov), and severe acute respiratory syndrome (sars) and disease x, which represents the need to prepare for an unknown pathogen that could cause a serious epidemic. to address these and other threats, started its new -year strategic plan: the th general programme of work. this plan focuses on a triple billion target: ensuring billion more people benefit from access to universal health coverage, billion more people protected from health emergencies, and billion more people in better health and well-being. reaching this goal will require addressing these threats to health from a variety of angles. the world will face another influenza pandemic; the only thing we don't know is when it will hit and how severe it will be. global defenses are only as effective as the weakest link in any country's health emergency preparedness and response system. who is constantly monitoring the circulation of influenza viruses to detect potential pandemic strains: institutions in countries are involved in global surveillance and response. every year, who recommends which strains should be included in the flu vaccine to protect people from seasonal flu. in the event that a new flu strain develops pandemic potential, who has set up a unique partnership with all the major players to ensure effective and equitable access to diagnostics, vaccines, and antivirals (treatments), especially in developing countries, in order to make possible the supply of required vaccines as soon as possible. dengue, a mosquito-borne disease that causes flu-like symptoms and can be lethal and kill up to % of those with severe dengue, has been a growing threat for decades. a high number of cases occur in the rainy seasons of countries such as bangladesh and india. now, its season in these countries is lengthening significantly (in , bangladesh saw the highest number of deaths in almost two decades), and the disease is spreading to less tropical and more temperate countries such as nepal that have not traditionally seen the disease. an estimated % of the world is at risk of dengue fever, and there are around million infections a year. who's dengue control strategy aims to reduce deaths from the disease by % by . hiv infections in sub-saharan africa despite being only % of the population. this year, who will work with countries to support the introduction of self-testing so that more people living with hiv know their status and can receive treatment (or preventive measures in the case of a negative test result). who has included in these ten global threats for diseases and pathogens that have potential to cause a public health emergency but lack effective treatments and vaccines. this list for priority research and development includes ebola, several other hemorrhagic fevers, zika, nipah, middle east respiratory syndrome coronavirus (mers-cov), and severe acute respiratory syndrome (sars) and disease x, which represents the need to prepare for an unknown pathogen that could cause a serious epidemic. international recognition of vaccines' impact and increased global demand for vaccines have stressed the need for global strategies to assure timely provision of lowprice vaccines (meissner ) through policies supporting free and universal access. in this scenario, the decade of vaccines (dov) initiative was launched at the world economic forum in davos in , signed by international agencies, such as the world health organization (who), unicef, the us national institute of allergy and infectious diseases (niaid), and the bill & melinda gates foundation, with the mission: "to extend, by and beyond, the full benefits of immunization to all people, regardless of where they are born, who they are, or where they live." this declaration was supported by a commitment by the bill & melinda gates foundation to donate usd billion to research and development and to delivering vaccines for the poorest countries. the dov initiative gained significant international support and visibility. two years later, after consultations with dov stakeholders, including industry groups, a global vaccine action plan (gvap) was launched by the member states of the th world health assembly in may , aiming to deliver universal access to immunization by . following the collaborative dov strategies, the gvap brought together multiple stakeholders to achieve the ambitious goals of the plan: the leadership of the bill & melinda gates foundation, gavi alliance, unicef, us national institute of allergies and infectious diseases (niaid), and who, mobilizing many partners (governments, health professionals, academia, manufacturers, funding agencies, development partners, civil society, media, and the private sector). if the gvap is translated into action and resources are mobilized, it is expected that between . and . million deaths could be averted by the end of the decade, with gains in billions of dollars in productivity. nevertheless, it is important to note that actions and resources will not be sufficient for the success of gvap if the plan does not conceive a global strategy to support manufacturers in the developing world to overcome the main ipr and regulatory barriers that delay and hinder vaccine development and production. the millennium development goals (mdgs) for - were incorporated by governments worldwide and had a strong global mobilization power on promoting development and social initiatives, engaging national leaders in elaborating and monitoring these goals (un ) . this mobilization was facilitated since the targets were quantifiable and could potentially be attained. although the two healthrelated goals, mdg (reduce under- mortality from to by two-thirds) and mdg (reduce maternal mortality from to by three-quarters), had not been met by and it is estimated by who that . million infants worldwide are still missing out on basic vaccines, significant progress has been made, with child and maternal mortality approximately halved, with significant global progress. in sequence to mdgs, the united nations promoted an in-depth revision of this strategy (un (un , and formulated a new global strategy, sustainable development goals (sdgs) for - with goals, with one of them (sdg ) directly related to health (un ). the target of sdg is to "ensure healthy lives and promote well-being for all at all ages." its sub-targets include ones that could be met: two-thirds less maternal mortality and a third less noncommunicable disease (ncd) mortality. they also include ending preventable newborn and under- deaths and ending hiv/aids, tuberculosis, malaria, and neglected tropical diseases, besides other non-vaccine related sub-targets. in this chapter, we argue that a major component of sdgs is crucial for attaining sdg goals and should not be minimized: innovation and technological development of vaccines. we discuss how this component should be incorporated into monitoring the sub-targets of this goal, and we emphasize the need for a new vaccine innovation model based on an expanded role of the state and incentive mechanisms to pharmaceutical companies and public manufactures to correct the current scenario of "market failure" constraining access to vaccines. it is certainly unacceptable, from ethical and sustainable development perspectives, to simply recognize this "market failure" as a detrimental and inevitable consequence of the rationale of a global market economy. on the contrary, it should be seen as a massive public health failure and a global failure to direct economic development for the benefit of societies (trouiller et al. ). the "valley of death" although vaccine candidates are in the development pipeline for neglected and emerging infectious diseases mainly affecting the poorest countries such as malaria, dengue, hiv, tuberculosis, and pneumonia, only of them have made it through the pipeline recently and are widely used in these countries: a conjugate vaccine for meningitis serogroup a diseases and a vaccine against japanese encephalitis virus (kaslo et al. ; who ) . it has been estimated by these authors that unfortunately much of this promising pipeline could go to waste and fall into the so-called valley of death, failing to move from proof-of-concept to second-phase trial due to lack of market interest in vaccines against these emerging and neglected diseases affecting only the poorest populations in developing countries. no single organization or group is interested in supporting the costly and more complex late-stage clinical trials for neglected diseases that mainly affect the poor nations. this scenario raises great concern for two reasons. first, around % of these vaccine candidates in the development pipeline target the mentioned neglected and emerging infectious diseases, a much higher problem in lower-and middle-income countries (kaslow et al. ). second, this means a significant waste of global resources in a crucial area for sustainable development, considering that these vaccine candidates received billions of dollars for the first phase of vaccine development from prestigious donors, such as the us national institutes of health (nih), the european union, the welcome trust, and the bill and melinda gates foundation. taking a vaccine candidate from a discovery at the laboratory bench to widespread deployment is a complex, lengthy, and expensive endeavor, with many financial, licensing, and regulatory barriers. no organization or group plans to support the emerging and neglected diseases vaccines from the beginning to end. therefore, it could take many decades to incorporate these vaccines into the national immunization programs in these poorest countries (kaslow et al. ) . in table . we provided a selection of promising projects for vaccines for emerging and neglected infectious diseases affecting the poorest developing countries that could significantly impact on achieving sdg targets. science and technology have made enormous progress and are now prepared to provide the innovative-intensive vaccines that the poorest populations in the world urgently need. but innovation and discovery are not the major bottleneck, which reside in technological development, production, and timely provision of vaccines to people (homma et al. ). r&d-based pharmaceutical major industry players are reluctant, due to freemarket rationale, to invest in the development of vaccines to treat the major neglected and emerging diseases affecting mainly the poorest nations, since return on their investments cannot be guaranteed. national and international policies currently support a free-market-based global order, with economic opportunities, rather than global public health needs guiding the direction and rationale of vaccines development. it is certainly unacceptable, from ethical and sustainable development perspectives, to simply recognize this "market failure" as a detrimental and inevitable consequence of the rationale of a global market economy. on the contrary, it should be seen as a massive public health failure and a global failure to direct economic development for the benefit of societies (trouiller et al. ). an urgent redefinition of priorities in vaccine development is needed. this strategy cannot rely only on fragmented contributions of researchers, funding agencies, and the pharmaceutical industry. effective national and international policies need to be urgently conceived to redirect the global economy to address the true public health needs of society (homma et al. ; røttingen et al. ) . "political will," identified as the need for a strong commitment to prioritize health considerations over economic interests, has been frequently emphasized by policy-makers as a major issue to ensure access to vaccines but is not sufficient. it is necessary to go beyond "political will," with a clear goal in mind and a realistic plan to achieve it. from this perspective, it will be necessary to promote effective global implementation of strategies to accelerate innovation, technological development, and production of new vaccines and to ensure timely global access to them. moreover, a global vaccine policy strategy should be conceived to promote the necessary enforcement of regulations and other mechanisms to stimulate vaccine development, production, and global access to these products. novel, creative, and effective strategies involving both the public and the private sector are needed to ensure low-price vaccines, accelerating innovation and technological of vaccines against emerging and neglected diseases. priority action areas should include: . advocating a preventive vaccines r&d agenda . conceiving capacity-building programs adequate to the conditions of developing countries' manufacturers . promoting technology transfer to public and private manufacturers in emerging countries . elaborating an adapted legal and regulatory framework to increase flexibility and "fast-track" procedures . prioritizing funding for vaccine development . securing availability, accessibility, and distribution of these vaccines consensus is building among the main stakeholders in the global vaccine community that the spiraling costs of risks associated with vaccine r&d are detrimental to global access to these products, particularly in the poorest developing countries. most of them agree that these vaccine r&d costs should be instead rewarded by means other than financial returns in the market from charging high product prices. novel mechanisms such as incentives, prizes, and "patent pools" for drugs and vaccine innovation and development have been proposed in the last two decades. there is now vast literature on the subject, claiming for alternative models that should be urgently implemented to meet the increasing global demand for vaccines, particularly in the poorest developing countries. the main question is: how to conceive a feasible long-term mechanism to minimize these risks faced by pharma companies? which global organizations should be responsible for this alternative model? we recommend this new vaccine incentive model should be coordinated by three international organizations: who, gavi, and unicef. these organizations would, in collaboration with the main stakeholders, identify from the list of candidates the priority vaccine candidates, identify the funding mechanisms necessary to these candidates to enter the second-phase clinical trials, and specify which organization, or alliance, would be responsible for these selected vaccine candidates from beginning to end. in this innovative global collaboration strategy, these three leading international organizations should bring together the main players and stakeholders in the vaccine market, with funding agencies such as the bill & melinda gates foundation, nih, welcome trust, and other organizations as path, iavi, and the international vaccine institute in seoul and vaccine manufacturers, in collaboration with other nongovernmental organizations in order to conceive and implement this alternative long-term model for sustainable development and provision of vaccines which are uncertain business products or require a great amount of public funding to go beyond the initial proof-of-concept phase. a novel global priority-setting strategy, driving adequate implementation, will be necessary to assess the vaccine candidates in the pipeline, trying to identify the most favorable candidates which are uncertain business cases that will require significant public funding to move into second-phase clinical trials. funding mechanisms supported by subsidies from governments, such as those of the g countries, and philanthropic organizations, such as the bill & melinda gates foundation, could remedy the market failure threatening vaccine development for lmics. gavi already provides one form of subsidy (gavi a, b). support to develop vaccines or to make them available during epidemics is also provided by public organizations, such as the coalition for epidemic preparedness innovations in oslo and the biomedical advanced research and development authority, part of the us department of health and human services. such schemes need to be expanded and rethought to give vaccine developers more certainty and upfront financial backing (kaddar et al. ) . for instance, gavi could commit to purchasing a vaccine before it has been developed, on the condition that the developers meet certain regulatory milestones. at present, the alliance buys vaccines to distribute to lmics after they have been licensed or recommended by the who for general use (gavi (gavi , b . only with this kind of leadership will the global community secure vaccines for some of the world's most debilitating diseases. there is an urgent need for a paradigm shift in global governance of health innovation systems to achieve sustainable development goals (buse and hawkes ; possas et al. ; seib et al. ; mazzucato ) . "mission-oriented" approaches have been proposed to overcome current constraints in innovation systems (mazzucato and penna ) . recently, in a new report, "the people's prescription: re-imagining health innovation to deliver public value" (mazzucato ) , the authors call for restructuring research and development innovation systems in order to create, rather than extract, value. it also calls for long-term "missionoriented" public investment and a public return on this investment. in this report the authors argue that health innovation is about making new treatments and cures available to the people that need them. profits might be earned but not at the cost of doing what the health system is meant to do: heal. this report is the outcome of result of collaboration between the ucl institute for innovation and public purpose, stopaids, and global justice now and just treatment. the report identifies gaps of the current health innovation system and sets principles for a new model. it proposes concrete policy actions that can be taken in the long term to actively shape and co-create a health system that delivers real public value. the report is structured into two sections. the first is "diagnosis" with chapters on "problems with the current health innovation system" and "principles for a health innovation model that delivers public value." the second section, "remedies," includes chapters on "immediate policy actions: getting better prices today" and "transformative proposals: re-imagining our health innovation system to deliver public value." the report focuses on the unethical and unacceptable current global scenario for health innovation, highly inefficient, with a pharmaceutical industry that makes billions in profits without providing the affordable products that people need. the report examines all those problems, and then it sets out some key principles of how a "healthy" innovation model for health would work, based on an analysis of case studies from different countries and different contexts, looking at where innovation has been done well. in vaccine development, as in drugs development, there is a tremendous waste of resources because public health is not driving the r&d agenda. we have all the money going into proof-of-concept studies instead of developing public accountability. track" the need to provide more flexible and expedite new vaccine products and processes resulting from biotechnology is challenging both developed and developing countries to accelerate the implementation of adequate regulations and intellectual property rights (crager ; possas et al. ) . ipr are granted by the state to individuals, enterprises, or organizations under temporary monopolistic conditions (patents) in order to compensate them for the investments made in their creations/innovations. in industry, a patent is clearly an instrument to guarantee the returns of the investments on r&d through the commercialization of the patented products and through the payment of property rights. patents are viewed as a crucial incentive to innovation. nevertheless, arrow ( ) recognized in his pioneer theory that in spite of its advantages, the patent system creates a suboptimal situation in economic terms: patents create a monopoly that restricts the diffusion and dissemination of innovation. the argument is that this restriction is temporary (after years the patent protection "falls" to public domain) and is compensated by the fact that the knowledge related to the patent is necessarily published in the moment that the patent is granted. nevertheless, several authors have noted the detrimental impacts of the monopoly created by the patent system on health products' innovation, particularly on the development and accessibility to new drugs for neglected and emerging diseases and proposed incentive mechanisms, such as prizes, "patent pools," and awards to compensate this "market failure." although in the vaccine sector many intellectual property and market issues affecting price remain unclear, in the current regulatory scenario, the access to new technologies in multipatented vaccines, such as adjuvants for vaccine compositions, remains a main challenge (possas et al. ) . for vaccine manufacturers in emerging countries, access to patent information on vaccine adjuvants is a crucial issue, detrimental to vaccine development. the incorporation of new adjuvants for vaccines which boost the immune response has become crucial to the development of innovative vaccines, as new antigens, with purer and smaller molecules, may have less then optimal immune responses, necessary to vaccine protection for a lengthy period of time. the malaria vaccine candidate rts provides a good example of the crucial role new adjuvants can play: this vaccine, based on the plasmodium falciparum sporozoite antigen circumsporozoite protein (csp), was successful in providing protection against clinical malaria only when combined with a powerful adjuvant (as or as ). another example are the tests using hybrid flagelins also in malaria vaccines. adjuvants have emerged thus as an alternative route for vaccine development with enormous potential in the global market (mbow et al. ) . the development of new, powerful, and safe adjuvants is therefore a key component of vaccine research. we present in table . some of licensed vaccine adjuvants, with company and class. figure . indicates the countries concentrating patent deposits for adjuvants to vaccine compositions and the diseases related to them (zika, dengue, hiv/aids, influenza), china ( %), the usa ( %), south korea ( %), and the uk ( %), with these three countries accounting for nearly % of all patent deposits. it is also observed that chikungunya had no deposit in the period from to , as indicated the espacenet base. it should be stressed that very few deposits are related to zika and dengue vaccine, only in china and the usa. it also indicates that most of these adjuvant deposits are concentrated in vaccine compositions related to just two diseases, influenza ( %) and hiv/aids ( . %), while zika, followed by dengue, is more neglected. the increasing risk of a pandemic of influenza, rapidly affecting all continents, might explain the concentration of r&d efforts on vaccine compositions and adjuvants for this disease. table . provides an overview of the patent holders of deposits for vaccine adjuvants against zika, dengue, and hiv in the - period, listed by country, number of deposits, and deposits with partnerships and partners. this table indicates that the number of partnerships is very low and should be stimulated. figure . shows the temporal evolution of patent deposits in the period - of the three largest patent depositors of adjuvants and formulation of vaccines with adjuvants for the diseases studied, showing that only in the last decade there has been a greater r&d effort. this figure also indicates the leadership of china and the increasing role played by this country in the development of adjuvants for vaccine compositions. finally, it should be noted that in addition to these intellectual property barriers to access to vaccine formulations and vaccine adjuvants, such as confidentiality and constraints to patent information sharing (possas ; possas et al. ) , other regulatory obstacles remain also a challenge to vaccine development and access to timely immunization: virtual inexistence in many countries, particularly the developing ones, of expedite and "fast-track" review processes (fda ; u.s. dept. of hhs et al. ) for evaluating priority and emergency projects; lack of flexible regulatory procedures for sharing biospecimens and samples; legal constraints in access to biorepositories and to biobank information; and the difficulties in defining the standard of care to be provided during clinical trials. we examined here, from bioeconomics and global sustainability perspectives, the current innovation system for vaccine development, providing considerations on how this system should be better designed and implemented to address sdgs' vaccine coverage targets. public investment plays a crucial role in biomedical r&d worldwide, but research and development activities supported by governments with public resources are in most cases not directed into targets that have the most public health value, such as vaccines. for this reason, there is increasing awareness and concern in the global vaccine community on the fact that public-supported vaccine products should be shared by the public and not just privately appropriated by pharmaceutical companies. this scenario evidences a need for conceiving a new innovation governance paradigm for vaccine development compatible with the market rationale, aiming profitable products with social return: an expanded role of the state, with clear procedures for planning, development, regulation, and forecast; a redefinition of the patterns of relationship between private and public players; and finally, a political agreement between the main players and stakeholders on the more adequate mechanisms to balance the risks and the rewards between those players. moreover, there is a need to conceive a more flexible intellectual property regime for emerging and neglected diseases mainly affecting the poorest populations in developing countries. the monopoly created by patent protection must be compensated by new incentive mechanisms such as awards, prizes, and "patent pools" to accelerate global access to vaccines. it is also crucial to strengthen the local capacity of vaccine r&d institutes and manufacturers in emerging developing countries in order to accelerate the incorporation of new technologies for production of innovative vaccine products. the multinational companies have the intellectual property of these new technologies, such as adjuvants for vaccine compositions, but they do not have sufficient production capacity to meet the global demand for these products, a gap that should be overcome with expanded global collaboration with developing countries' manufacturers. in addition, these players should identify gaps and priorities in infrastructure and capacity building in developing countries' manufacturers in order to facilitate technology transfer agreements with leading pharmaceutical companies and ensure a sustainable long-term supply of vaccines to the poorest populations. finally, clear expedite and "fast-track" regulatory procedures and pathways should be conceived and implemented. in other words, it will be necessary for international organizations and pharmaceutical companies to move from a short-term "shareholder-driven innovation model" to a long-term "public-return-driven innovation model", aiming global sustainability and social welfare for meeting the needs of low-income populations while searching for innovative and profitable vaccine products. access to vaccines index ( ) how vaccines companies are responding to 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medicine and industry: an overview intellectual property issues in microbiology high frequency of shared clonotypes in human b cell receptor repertoires drugs for neglected diseases: a failure of the market and a public health failure guidance for industry: expedited programs for serious conditions -drugs and biologics secretary general. the road to dignity by : ending poverty, transforming all lives and protecting the planet. synthesis report of secretary-general on the post- sustainable development agenda the millennium development goals report united nations development programme ( ) sustainable development goals who's vision and mission in immunization and vaccines - . who, geneva world health organization ( ) fact sheet v p pricing report world health organization ( ) ten threats to global health in key: cord- -yvx gyp authors: martin, susan f. title: forced migration and refugee policy date: - - journal: demography of refugee and forced migration doi: . / - - - - _ sha: doc_id: cord_uid: yvx gyp this chapter focuses on international, regional and national legal norms, policies, organizational roles and relations and good practices that are applicable to a broad range of humanitarian crises that have migration consequences. these crises and the resulting displacement differ by their causes, intensity, geography, phases and affected populations. the chapter examines movements stemming directly and indirectly from: persecution, armed conflict, extreme natural hazards that cause extensive destruction of lives and infrastructure; slower onset environmental degradation, such as drought and desertification, which undermine livelihoods; manmade environmental disasters, such as nuclear accidents, which destroy habitat and livelihoods; communal violence, civil strife and political instability; and global pandemics that cause high levels of mortality and morbidity. demographic trends are themselves drivers of displacement in conjunction with other factors. this can play out in two ways—demography as a macro-level factor and demographic composition as a micro-level driver of movement. the chapter compares the paucity of legal, policy and institutional frameworks for addressing crisis-related movements with the more abundant frameworks for addressing the consequences of refugee movements. the chapter discusses the policy implications of the findings, positing that state-led initiatives such as the nansen and migrants in countries in crisis initiatives are useful mechanisms to fill protection gaps in the absence of political will to adopt and implement more binding legal frameworks. it also argues that, in the context of slow onset climate change, in particular, there is a need for better understanding of how population density, distribution and growth as well as household composition affect vulnerability and resilience to the drivers of displacement. since , the international refugee regime has faced dozens of both traditional and non-traditional challenges in identifying and implementing policies for the protection of refugees and displaced persons. the massive displacement in and from syria has garnished the most attention but large scale movements in the context of conflicts in south sudan, central african republic, ukraine and elsewhere merit consideration as well. earlier in the decade, the famine and long-term conflict in somalia sent hundreds of thousands across the border into kenya and ethiopia while the crisis in libya and political instability throughout north africa caused more than one million to flee across international borders, some seeking asylum while others (mostly contract workers) tried to get to their own home countries as violence erupted in their destination countries. typhoon haiyan in the philippines displaced millions in , leaving many in a situation of protracted upheaval. migration resulting from these natural and man-made events may correspond to current international, regional and national frameworks that are designed to protect and assist refugees-that is, persons who flee across an international boundary because of a well-founded fear of persecution-but often, these movements fall outside of the more traditional legal norms and policies. yet, they have many characteristics in common with refugee movements. for example, they often take place in the context of political instability, countries of origin may not have the capacity or political will to protect their citizens from harm, an international response may be needed because of the scale of the migration, and the need for humanitarian assistance will likely overwhelm local capacities. s.f. martin (*) school of foreign service, georgetown university, washington, th and o streets, n.w, washington, dc , usa e-mail: susan. martin.isim@georgetown.edu this chapter focuses on international, regional and national legal norms, policies, organizational roles and relations and good practices that are applicable to the broader range of humanitarian crises that have migration consequences. the chapter examines movements stemming directly and indirectly from: persecution, armed conflict, extreme natural hazards that cause extensive destruction of lives and infrastructure; slower onset environmental degradation, such as drought and desertification, which undermine livelihoods; manmade environmental disasters, such as nuclear accidents, which destroy habitat and livelihoods; communal violence, civil strife and political instability; and global pandemics that cause high levels of mortality and morbidity. these crises lead to many different forms of displacement, including internal and cross border movements of nationals, evacuation of migrant workers, sea-borne departures that often involve unseaworthy vessels, and trafficking of persons. while the majority of those displaced from humanitarian crises move internally, a significant portion migrates cross borders to other countries. the chapter will compare the paucity of legal, policy and institutional frameworks for addressing these other crises with the more abundant frameworks for addressing the consequences of refugee movements. part introduces the concepts of the chapter, defining the types of humanitarian crises that have migration consequences. it will have subsections discussing briefly the range of crises referenced above, describing the types of forced migration that occur as a result of each category of crisis. part focuses on the legal frameworks and policies available at the international, regional and national levels for addressing the migration consequences of these crises. part will discuss institutional arrangements for addressing the types of migration under review. part will present the conclusions of the chapter and discuss the policy implications of the findings. it also discusses the important role that demography can play in helping to improve responses to forced migration in the context of humanitarian crises. this section presents a typology for analyzing the nature of forced migration. the migration consequences-and the resulting policy frameworks-will differ along five principal dimensions: the precipitating drivers or causes of forced migration, the intensity of these drivers, the geography of the displacement, the phase of displacement, and the affected populations ( fig. . ) . first, forced migration-producing events differ by their causes. some are primarily generated by natural causes whereas others are human made. in most cases, however, a governance failure is at the heart of the crisis whether the trigger is natural or human. among examples of the drivers of displacement are: • persecution, torture and other serious human rights violations. the precipitator of forced migration that, as we will see, fits best into current legal and policy norms involves persecution of individuals or groups on the basis of such factors as race, religion, nationality, membership in a particular social group (often used to address gender), and political opinion. persecution can affect individuals or it can affect groups of people as defined by what are often referred to as immutable characteristics shared by large numbers of people. it often occurs in contexts in which there are no safeguards to protect racial, ethnic, religious, and other minorities who may be targeted by other groups. persecution can involve serious physical or psychological harm (e.g., rape or torture), deprivation of one's liberty (e.g., imprisonment), forced removal or ethnic cleansing, severe economic deprivation, and other mechanisms that result in serious harm to the individual. • armed conflict. one of the principal drivers of forced migration is armed conflict. although most displacement today occurs in the context of internal armed conflict, significant levels of forced migration accompany international armed conflict as well. displacement may be a form of collateral damage as civilian populations get out of harm's way but in many conflicts forcing the relocation of civilians is an overt aim of one or another of the warring parties. • political instability and violence. the recent events in north africa and the middle east fit into this category, with millions fleeing violence perpetrated by the islamic state (isis) and other terrorist and insurgent groups. violence following contested elections in kenya ( ) , zimbabwe ( ) and cote d'ivoire ( ) is another example of political instability that has generated violence that has resulted in large-scale displacement. communal violence that does not rise to the situation of armed conflict, but nevertheless displaced large numbers, has occurred in and from the karamoja region of uganda, bangladesh, ethiopia and elsewhere. the violence can be between clans, ethnic groups, economic fig. . typology of forced migration competitors, religious groups or pastoralists claiming the same land. violence can also be the product of drug cartels and gangs that fight each other or government authorities. • natural hazards. recent examples of crises resulting from extreme natural hazards that have had migration impacts include hurricanes/cyclones (e.g., hurricanes mitch and stan in central america and cyclone nargis in burma/ myanmar), tsunamis (e.g., indonesia, sri lanka and somalia in and japan in ), flooding (e.g., pakistan in ), earthquakes (e.g., haiti in ); and prolonged droughts (somalia in ). generally, the hazard itself does not cause the crisis; a lack of national and local governance, lack of emergency preparedness, lack of adequate building codes, high levels of poverty and similar weaknesses in local and national capacity lead to crisis conditions. experiences with mass displacement after hurricane katrina show that even very wealthy countries are not immune to such disasters, but stable, more economically advanced countries generally have greater capacity to assist their citizens. the differences in deaths and displacement from earthquakes in haiti and chile in are indicative. although the seismic level of the chilean earthquake was much greater than that in haiti, the level of destruction was much greater in haiti, which is one of the poorest countries in the world and suffered from decades of political instability. the earthquake in mexico is another case in point. an albeit more intense earthquake in led to tens of thousands of deaths, but the recent experience demonstrated that new building codes, emergency preparations and timely response could reduce casualties to a handful. • man-made environmental crises. man-made crises include nuclear/chemical/ biological accidents and attacks, accidental or deliberate setting of fires, and similar situations that make large areas uninhabitable and cause displacement. the accident at the chernobyl nuclear plant in , for example, resulted in the evacuation of more than , people within days. the earthquake and tsunami in japan led to further crisis when nuclear power plants lost their capacity to cool reactors, forcing the evacuation of thousands. this classification system, though useful in understanding the causes of crises with migration impacts, is not composed of pure types because there are often overlaps among the factors that create disasters. for example, an acute natural hazard and political instability may intersect to drive people from their homes. in fact, as stated above, an absence of good governance is almost always one of the factors that is present when forced displacement occurs. demographic trends, while not usually directly linked to displacement, also intersect with each of these causes to increase or decrease a population's vulnerability or resilience. the demographic composition of the affected population also helps determine whether specific households or individuals will need to migrate. these may differ, however, depending on the causation. for example, adolescent and young men may be at particular risk of forced recruitment in conflict situations, necessitating flight if they do not wish to participate in the fighting. on the other hand, the elderly and young children may be at higher risk of starvation in the case of protracted drought, as discussed below. a second dimension of the typology is the intensity of the driving factors. the division is broadly between acute crises and slow-onset emergencies. the former often lead to emergency displacements that are readily defined as "forced migration" because conditions in home countries or communities are seen as the primary reasons that people leave. by contrast, the displacement generated by slow-onset situations is often seen as voluntary and often anticipatory migration and may have elements of labor migration. slower-onset crises arise in a number of different contexts. prolonged drought is a principal cause of displacement for millions who are reliant on subsistence agriculture and pastoralist activities. recurrent droughts undermine livelihoods when crops fail and livestock are sold or die because of inadequate rain and depletion of other water sources. when markets do not function in a manner that allows a redistribution of food to drought-affected populations, migration becomes one of the principal ways to cope with losses caused by the environmental change. since many of the affected populations resemble others who migrate to obtain better economic opportunities, it may be difficult to distinguish those whose loss of livelihood is environmentally-related. in worse case examples, when (for example) drought combines with conflict or other political factors to preclude food distribution in communities of origin, famine may be in the offing. when affected populations have exhausted all of their other coping capacities, they may be forced to migrate or suffer starvation. often, children, the elderly and those with pre-existing illnesses are among the first to succumb to famine in the absence of alternatives. they are also the least likely to be able to migrate without assistance. the third dimension is geography-where and how the displacement takes place. in almost all of the situations that are discussed above, most migration is internal or into neighboring countries that share a contiguous border. a smaller proportion of the movements are to countries outside of the immediate region of the crisis. currently, those who cross international borders are designated as 'refugees ' or 'international migrants' whereas those who remain within their national borders are 'internally displaced persons' or 'internal migrants. ' how migrants leave their own countries, pass through transit countries, and enter destination countries also affect designations. some migrants may have received permission to enter another country while others travel without documentation or otherwise on an "irregular" basis. sea-borne migrants, particularly those in small, unseaworthy boats, face dangers not only from variability in the weather but also from pirates and others who prey on them. migrants using smugglers may be routed through multiple countries before reaching their final destination. those crossing difficult land terrains may find themselves endangered as they attempt irregular entry across deserts and mountains. while these irregular means of transit may be common when there is political instability or natural disasters, pandemics present another geographic challenge. airports and seaports often become the focal point for action, especially when governments establish policies to quarantine those who may be carrying the disease. the fourth dimension relates to timing. the migration consequences of crises take different forms and must be addressed through different mechanisms depending on the phase of displacement or movement and its duration. some of the causes discussed above produce protracted crises whereas others lead to more temporary dislocations. for example, some cases of political instability are quickly resolved and new governments put in place but others drag on for years with no resolution in sight. similarly, reconstruction after some extreme natural hazards moves ahead quickly and people are able to return to their homes with little loss of livelihoods, but in other cases, return is delayed or impossible because governments have too little capacity to implement reconstruction programs, there is such great likelihood of recurrence of the same type of natural hazard, and/or the home community has been damaged beyond repair. in extreme cases, an entire country may become uninhabitable (for example, montserrat after the volcano and potentially, small island states as a result of climate change). in these cases, return may be impossible. these phases may play out differently for different populations affected by the same triggering event depending on their personal or household circumstances. they are also not necessarily linear; for example, those who return may find themselves engulfed in new crises and experience new displacements. needs and frameworks differ depending on the stage of the crisis. the first stage is pre-crisis, when actions to prevent, mitigate and help individuals adapt to the causes that may force them to move take place. of particular importance is disaster risk reduction, which involves "systematic efforts to analyse and manage the causal factors of disasters, including through reduced exposure to hazards, lessened vulnerability of people and property, wise management of land and the environment, and improved preparedness for adverse events" (unisdr ). disaster risk reduction does not prevent the extreme natural hazard from occurring but it helps communities to cope with their damaging effects. in some worse case examples, the only option to reduce the risk of disaster may be relocation from fragile areas. identifying and addressing demographic and socio-economic vulnerabilities is essential since the "characteristics and circumstances of a community, system or asset … make it susceptible to the damaging effects of a hazard" (unisdr ). meeting the sustainable development goals would have positive impact in enhancing the ability of people to cope with crises in situ. more broadly, economic, social and human development-with the aims of reducing poverty, increasing access to livelihoods, education and literacy, improving health outcomes, maintaining sustainable environments, etc.-will reduce long-term emigration pressures while giving people increased human security. appropriate interventions will depend on the demographics of the affected populations. equally important, given the highly political nature of many of these emergencies, are efforts to improve governance in countries that are prone to crises. effective governance not only helps mitigate the risks associated with natural and human made hazards (through such preventive actions as earthquake-resistant building codes or public health measures to lessen pandemic risks) but it also helps reduce tensions that can escalate into conflict. early warning mechanisms can help trigger conflict resolution and mediation processes to reduce the potential for communal or political violence. the second stage is the migration itself, with rights and needs differing depending on the form and stage of migration as well as the demographic and socioeconomic composition of those who move. those who have recently migrated will generally have greatest need for such basics as housing, employment, orientation to the social, cultural and political norms of the destination, and some knowledge of the host country's language. over time, those who remain in the destination may have need for assistance to integrate more fully into the host community-for example, skills training to move up the economic ladder, language training and civics education if required for citizenship, services for their children, etc. those who return to their home countries or communities may have needs very similar to what they had at the early stages of their movement. the decision as to whether return is possible involves a range of variables, including the extent, for example, to which the causes-either direct or through other channels-are likely to persist. policies in the receiving communities and countries, depending on whether the migration is internal or international, will also affect the likelihood for return or settlement in the new location. in addition to immigration policies, the policies affecting return and settlement include land use and property rights, social welfare, housing, employment and other frameworks that determine whether individuals, households and communities are able to find decent living conditions and pursue adequate livelihoods (brookings institution ) . the final stage of the life cycle involves (re)integration into the home community or new location. the issues outlined above regarding the potential for solutions will be key determinants of integration, influencing the access of displaced populations to housing, livelihoods, safety and security. these needs will vary depending on the demographic and socio-economic composition of the groups returning home or settling in new locations. integration is also affected by plans and programs to mitigate future dislocations from the hazards that caused the movements, coming full circle on the life cycle to a focus on prevention, adaptation and risk reduction. the fifth dimension of this typology refers to the affected populations. responses may differ in terms of scale-that is, how many people are affected by the crisis. they also differ by the demographic and socio-economic characteristics of the affected populations. generally, those most vulnerable to the harms associated with crises of the type described are already in difficult economic situations, with few financial resources to get them through the crisis. unaccompanied and separated children, women at risk of gender and sexual based violence, adolescents at risk of forced recruitment into gangs and insurgencies, ill and disabled persons, the elderly and other vulnerable groups may require specific approaches to ensure their safety. trafficking in persons is often associated with crises, with criminal elements preying on the desperation of people who have lost their homes and livelihoods. this section focuses on laws and policies for addressing the migration consequences of the types of crises discussed previously. the section focuses on frameworks governing migration across borders, including general human rights instruments as well as migration-specific instruments. it also discusses legal frameworks for protection and assistance of internally displaced persons as they provide useful guidance for issues related to protection and assistance for those who move across international borders (fig. . ). states possess broad authority to regulate the movement of foreign nationals across their borders. although these authorities are not absolute, states exercise their sovereign powers to determine who will be admitted and for what period. the authority of states is limited by certain rights accorded foreign nationals in international law. the principal constraints on state authority are the non-refoulement provisions of the un convention relating to the status of refugees and its protocol and the convention against torture. some migrants in the scenarios described above may be covered under these instruments. the refugee convention defines refugees as persons who were unable or unwilling to avail themselves of the protection of their home countries because of a "well-founded fear of persecution based on their race, religion, nationality, political opinion or membership in a particular social group." states have no obligation to admit refugees, but they do have an obligation not to refoule (return) a refugee to "frontiers of territories where his life or freedom would be threatened on account of his race, religion, nationality, membership of a particular social group or political opinion." in each of the crises discussed above, a subset of migrants may meet the refugee definition although the majority are unlikely to be able to demonstrate that they fear persecution on account of a protected characteristic (that is, race, religion, nationality, membership of a particular social group or political opinion), rather than a more generalized harm. the refoulement provision of the convention against torture applies to persons who face "any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acqui-escence of a public official or other person acting in an official capacity." particularly in the situations in which political instability and violence precipitate displacement, a subset of migrants may well meet this definition even if the majority does not have a well founded reason to fear torture upon return. in africa, the scope of coverage for refugees is greater because the oau (now au) refugee convention includes those who, "owing to external aggression, occupation, foreign domination or events seriously disturbing public order in either part or the whole of his country of origin or nationality (emphasis added), is compelled to leave his place of habitual residence in order to seek refuge in another place outside his country of origin or nationality." the cartagena declaration (a non-binding agreement) offers a similar expanded definition of refugees in latin america: "persons who have fled their country because their lives, safety or freedom have been threatened by generalized violence, foreign aggression, internal conflicts, massive violation of human rights or other circumstances which have seriously disturbed public order." to the extent that a crisis involves generalized violence, massive violations of human rights or seriously disturbs public order, persons forced to leave their homes because of the crises described above may be covered under the au and cartagena instruments, while they would not be under the convention. the new au convention on internally displaced persons goes even further in specifying that those displaced by natural and human made disasters are covered. those who are forced to migrate, but who are not considered to be refugees or potential torture victims, have certain basic rights even if they are not covered under these specific instruments. the universal declaration of human rights, the international covenant on civil and political rights and the international covenant on economic and social rights, for example, define certain rights that accrue to all persons, not just citizens. importantly, the universal declaration article , which is enshrined in article of the international covenant on civil and political rights, declares that "everyone has the right to leave any country, including one's own, and to return to one's own country." the universal declaration article states that "everyone has the right to seek and to enjoy in other countries asylum from persecution." in neither situation, however, is there a corresponding obligation on the part of states to admit those who exercise their right to leave or to seek asylum. other applicable human rights conventions include the international covenant on social, economic and cultural rights, the convention on the rights of the child, the convention on the elimination of all forms of discrimination against women, the convention on the elimination of all forms of racial discrimination, and the convention on the rights of persons with disabilities. these instruments and relevant articles of the geneva conventions on armed conflict form the basis for the guiding principles on internal displacement. although not legally binding, the guiding principles provide a critical framework for defining and promoting idp protection. under the guiding principles, idps are described as: persons or groups of persons who have been forced or obliged to flee or to leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognized stated border. the guiding principles identify the rights and guarantees relevant to the protection of idps in all phases of displacement. they provide protection against arbitrary displacement, offer a basis for protection and assistance during displacement, and set forth guarantees for safe return, resettlement and reintegration. they also establish the right of idps to request and receive protection from national authorities, and the duty of these authorities to provide protection. african leaders adopted the au convention for the protection and assistance of internally displaced persons (idps) in africa at a summit in . it went into force in . forced migrants who use irregular means of exit or entry may be covered under the protocol to prevent, suppress and punish trafficking in persons, especially women and children and the protocol against the smuggling of migrants by land, sea and air, both of which supplement the united nations convention against transnational organized crime and went into force in december and january , respectively. within a few years of their adoption, the trafficking and smuggling protocols have garnered considerable support, with more than signatories and and parties, respectively. these instruments apply respectively to "the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation" and "the procurement, in order to obtain, directly or indirectly, a financial or other material benefit, of the illegal entry of a person into a state party of which the person is not a national or a permanent resident." trafficking requires coercion or deception as well as exploitation of the labour of the trafficked person, whereas smuggling is usually a voluntary agreement between the migrant and the smuggler in which the migrant gains irregular entry and the smuggler gains a financial benefit. under certain conditions-for example, when the smuggled migrants is placed in bondage to pay off his or her smuggling fees-smuggling may turn into trafficking. those affected by crises are often more vulnerable to exploitation by both smugglers and traffickers, particularly if they are desperate to leave dangerous places with few options to support themselves and their families. the un convention on the law of the sea has provisions applicable to persons in distress at sea, which can include sea-borne migrants. under the convention, "state shall require the master of a ship flying its flag, in so far as he can do so without serious danger to the ship, the crew or the passengers: (a) to render assistance to any person found at sea in danger of being lost; (b) to proceed with all possible speed to the rescue of persons in distress, if informed of their need of assistance, in so far as such action may reasonably be expected of him; (c) after a collision, to render assistance to the other ship, its crew and its passengers and, where possible, to inform the other ship of the name of his own ship, its port of registry and the nearest port at which it will call." the convention also has provisions that outlaw piracy, defined as "any illegal acts of violence or detention, or any act of depredation, committed for private ends by the crew or the passengers of a private ship or a private aircraft, and directed: (i) on the high seas, against another ship or aircraft, or against persons or property on board such ship or aircraft; (ii) against a ship, aircraft, persons or property in a place outside the jurisdiction of any state." the rights of those displaced by natural hazards have not been spelled out in international or regional law as has been the case with those affected by political events. nevertheless, un guidance provided to state authorities regarding displacement due to natural disasters, while not binding international law, is relevant to the issues covered in this chapter. conversely, those who are internally displaced by natural disasters (who have freedom of movement within their borders) should not be required to return to areas in which their safety may be compromised: "persons affected by the natural disaster should not, under any circumstances, be forced to return to or resettle in any place where their life, safety, liberty and/or health would be at further risk" (brookings-bern project ) . also relevant are the provisions of the sendai framework for disaster risk reduction: - that encourages greater cooperation in reducing the risks associated with disasters. the disaster risk reduction (drr) strategies adopted in the sendai framework do not provide great specificity with regard to displacement from disasters aside from recommending that development actors include displaced persons in efforts to "promote the incorporation of disaster risk management into post-disaster recovery and rehabilitation processes, facilitate the link between relief, rehabilitation and development, use opportunities during the recovery phase to develop capacities that reduce disaster risk in the short, medium and long term." (unisdr ) . nevertheless, the overall concept of disaster risk reduction would significantly lessen displacement by providing the tools with which people could remain in situ or return quickly when acute natural hazards strike. progress was made in and in filling some of the protection gaps. in , the conference of the parties (cop) of the un framework convention on climate change (unfccc) authorized establishment of a task force with its processes to identify ways to mitigate and respond to displacement. the state-led nansen initiative on cross-border disaster displacement issued an agenda for protection that spells out actions that governments can take today to provide humanitarian relief to persons requiring either admission or non-return in these contexts. its successor, the platform for disaster displacement, funded by the german government, is helping willing states adopt some of the proposed policies and programs. another state-led process, the migrants in countries in crisis (micic) initiative adopted principles, guidelines and effective practices to respond to the needs of non-nationals who are displaced by natural disasters and conflict. the un high level meeting on large-scale movements of refugees and migrants acknowledged the nansen and micic initiatives, recommending them as models for filling other gaps in protection for vulnerable migrants. taken together, however, the provisions in international law do not constitute a comprehensive framework for addressing forced migration that does not fit within the refugee context. they are particularly weak in reference to those who cross international borders during crises. rather, each displacement tends to be addressed on a case-by-case basis. whether there should be a stronger international legal framework to address non-refugee forced migration is a point that would certainly generate debate. there are a number of reasons that such a framework would be difficult to achieve. trying to identify legal standards for a broad range of potential drivers of forced migration which may have little in common with one another would present challenges, particularly in setting out appropriate criteria for determining who among forced migrants would merit specific forms of protection. see conclusions for further discussion of these issues. the immigration policies of most destination countries are not conducive to receiving large numbers of forced migrants, unless they enter through already existing admission categories or meet refugee criteria. typically, in non-crisis situations, destination countries admit persons to fill job openings or to reunify with family members. employment-based admissions are usually based upon the labour market needs of the receiving country, not the situation of the home country. family admissions are usually restricted to persons with immediate relatives (spouses, children, parents and, sometimes, siblings) in the destination country. at the same time, most overtly humanitarian admissions are generally limited to refugees and asylum seekers. many, if not most forced migrants, however, will be unlikely to meet the legal definition of a refugee since their lives are endangered for reasons that do not involve persecution on the basis of a protected characteristic such as race, religion, nationality, membership in a particular social group or political opinion. despite these limitations, there are both legislative and ad hoc policies that do permit governments to respond when there are crises that provoke migration. they fall into three categories: ( ) policies that permit migrants already on the territory of the destination country to remain for at least a temporary period; ( ) policies to respond to new movements of people leaving either directly or indirectly as a result of the crisis; and ( ) evacuation of citizens and selected others from crisis affected countries. some countries and the european union have established special policies that permit individuals whose countries have experienced natural disasters, conflicts, pandemics or other severe upheavals to remain at least temporarily without fear of deportation. the united states, for example, enacted legislation in to provide temporary protected status to persons "in the united states who are temporarily unable to safely return to their home country because of ongoing armed conflict, an environmental disaster, or other extraordinary and temporary conditions." environmental disaster may include "an earthquake, flood, drought, epidemic, or other environmental disaster in the state resulting in a substantial, but temporary, disruption of living conditions in the area affected." in the case of environmental disasters, as compared to conflict, the country of origin must request designation of temporary protected status ("tps") for its nationals. those granted tps are eligible to work in the united states. they are not considered to be residing under color of law, however, for purposes of receiving social benefits and they are not able to bring family members into the country to join them. importantly, tps only applies to persons already in the united states at the time of the designation. it is not meant to be a mechanism to respond to an unfolding crisis in which people seek admission from outside of the country. it also only pertains to situations that are temporary in nature. if an environmental disaster has permanent consequences, for example, a designation of temporary protected status is not available, even for those presently in the united states, or it may be lifted. when the volcano erupted in montserrat in , tps was granted to its citizens and was extended six times. in , however, it was ended. us citizenship and immigration services in the department of homeland security explained "that the termination of the tps designation of montserrat is warranted because the volcanic activity caus-ing the environmental disaster in montserrat is not likely to cease in the foreseeable future. therefore, it no longer constitutes a temporary disruption of living conditions that temporarily prevents montserrat from adequately handling the return of its nationals. similarly, the conditions are no longer "extraordinary and temporary" as required by section (b)( )(c) of the act." another significant factor is that the designation is discretionary, to be made by the secretary of homeland security in consultation with the secretary of state. countries or parts of countries are designated, allowing nationals only of those countries (or affected regions within them) to apply. a further issue is the difficulty of ending the status. although some early proponents of tps argued that it was temporary in the sense that it would allow time to determine whether those granted the status could return or should be granted legal permanent residence, the legislation makes it difficult for them to remain permanently with full rights of immigrants. if individuals granted tps otherwise meet the criteria for legal admissions as an immigrant, they are eligible to obtain permanent residence without leaving the united states. if it were determined, however, that as a group they cannot return home, special legislation would be needed to allow them to remain permanently. the legislation specifies that such legislation would require a super-majority (threefifths) of senators for passage. tps has proven to be a flexible mechanism for responding to a range of crises, from conflict (somalia, sudan, south sudan, syria and yemen) to acute natural disasters (el salvador, haiti honduras, nepal and nicaragua) to pandemics (guinea, liberia and sierra leone). at the same time, lifting temporary protected status has proven to be very difficult as well. tps was originally triggered by the earthquakes in el salvador ( ) and hurricane mitch ( ) in honduras and nicaragua, meaning that some of the beneficiaries have been in 'temporary' status for almost years. canada may declare a temporary suspension of removals "when a country's general conditions (for example, war or a natural disaster) put the safety of the general population at risk." according to regulation, "the guiding principle of generalized risk is that the impact of the catastrophic event is so pervasive and widespread that it would be inconceivable to conduct general returns to that country until some degree of safety is restored. the suspension order is lifted when country conditions improve and the public is no longer in danger." for example, the suspension of removal was lifted in for nationals of burundi, rwanda and liberia. recognizing that some had been in canada for an extended period, these nationals were given the opportunity to apply for humanitarian and compassionate consideration for permanent residence in canada. such considerations as the best interests of any child directly involved, establishment in canada, integration into canadian society, and other factors put forward by the applicant are taken into account in determining if an applicant will be permitted to remain in canada. canada also undertakes a pre-removal risk assessment in determining if persons denied asylum would be at risk of other serious harm if removed to their country of origin. a number of other countries provide exceptions to removal on a group or case by case basis for persons whose countries of origin have experienced significant disruption because of natural disasters, conflict and violence. after the tsunami, for example, switzerland, the united kingdom and malaysia suspended deportations of migrants from such countries as sri lanka, india, somalia, maldives, seychelles, indonesia and thailand. a number of governments announced similar plans after the earthquake in haiti (martin ) . germany uses the "duldung," a toleration permit when emergent conditions preclude immediate return (schönwälder and vogel ) . these actions are generally ad hoc, allowing governments to respond differentially to crises. the decisions to trigger such responses is based on a combination of factors, including the intensity of the crisis, geographic proximity, the assessment of whether stays of removal will become a magnet for new arrivals, the presence of a strong constituency group within the destination country that calls for stays of removal and other similar factors. return of migrants granted temporary stays of removal remains problematic in many crises. protracted crises are common, particularly in countries without the fiscal resources and governance structures necessary to reintegrate their citizens after an emergency. moreover, over time, migrants begin to integrate into the new destination country, developing equities and ties that make the decision to return difficult. this is particularly the case when migrants granted temporary stays have children who attend school, learn the host country language and develop friendships and ties with local populations. some efforts have been made to facilitate or assist return when conditions permit. after the dayton peace accord, for example, a number of countries offered aid to bosnians who had been granted temporary protection if they chose or were required to repatriate. for example, denmark and sweden funded bosnians to take 'look and see' visits home to determine if conditions had improved sufficiently to return permanently. these countries and other eu members provided financial assistance to help those who voluntarily returned and provided information services about the right to remain or return. similar programs were used in assisting kosovars to return home. at the european union level, the temporary protection directive dated july establishes temporary protection during "mass influxes." with crises in bosnia and kosovo freshly in mind, the european council meeting in tampere urged swift action in addressing the issue of "temporary protection for displaced persons on the basis of solidarity between member states." the directive itself notes that "cases of mass influx of displaced persons who cannot return to their country of origin have become more substantial in europe in recent years. in these cases, it may be necessary to set up exceptional schemes to offer them immediate temporary protection." the purpose of the directive is twofold: to establish minimum standards for giving temporary protection and "to promote a balance of effort between member states in receiving and bearing the consequences of receiving such persons." temporary protection applies to persons who have fled areas of armed conflict or endemic violence and persons at serious risk of, or who have been the victims of, systematic or generalized violations of their human rights. member states may apply temporary protection more broadly to other categories of persons affected by crises. unlike tps in the united states, temporary protection in the eu is envisioned as a mechanism to address mass influxes, not to protect already resident migrants from removal. it can apply to those who spontaneously arrive as well as to those who are evacuated from situations in which they face serious harm. it is seen as a substitute for asylum in cases when "the asylum system will be unable to process this influx without adverse effects for its efficient operation." since its adoption in , temporary protection has not been invoked, at least in part because of different views among member countries concerning what constitutes a mass influx and of concerns about whether it will be practicable to return those granted this status when it expires. on april , , the european commission set out criteria under which it would ask for its use: "the commission would also be ready to consider proposing the use of the mechanism foreseen under the temporary protection directive ( / /ec), if the conditions foreseen in the directive are met. consideration could only be given to taking this step if it is clear that the persons concerned are likely to be in need of international protection, if they cannot be safely returned to their countries-of-origin, and if the numbers of persons arriving who are in need of protection are sufficiently great." however, in the context of the mass movements in from syria, afghanistan, iraq and elsewhere, the eu refrained from triggering a response under this directive and sought, often unsuccessfully, to negotiate responsibility-sharing agreements outside of the framework (akkaya ) . nevertheless, some of the provisions of the directive are worth considering for future policymaking. individuals who would be granted the status are to receive a residence permit for the duration of the grant. member states are to ensure access to suitable accommodations, social benefits and education. those granted temporary protection are eligible to work or be self-employed but states may give priority for employment to eu citizens, citizens of the european economic area and legally resident third country nationals who receive unemployment benefit. there is also access to family reunification as long as the family relationship predated the grant of temporary protection. while the temporary protection directive addresses mass influx situations, asylum law and policies govern individual applications for protection. eu directive allows for subsidiary protection for a person who does not qualify as a refugee but in respect of whom "substantial grounds have been shown for believing that the person concerned, if returned to his or her country of origin … would face a real risk of suffering serious harm." serious harm includes situations in which there is a serious and individual threat to a civilian's life or person by reason of indiscriminate violence in situations of international or internal armed conflict. those granted subsidiary protection have a less secure status than those granted convention protection (for example, their residence permit is for one instead of three years). the eu-wide provisions do not explicitly address crises caused by natural or human made hazards but individual countries have adopted legislation that protects some categories. sweden includes within its asylum system persons who are unable to return to their native countries because of an environmental disaster. the decision is made on an individual, not group basis. although many recipients of this status are presumed to be in temporary need of protection, the swedish rules foresee that some persons may be in need of permanent solutions. similarly, in the finnish aliens act, "aliens residing in the country are issued with a residence permit on the basis of a need for protection if […] they cannot return because of an armed conflict or environmental disaster." finnish law also allows use of transit centres for a fixed term, not to exceed three months, if the number of displaced persons entering the country is exceptionally high, to give time to conduct thorough processes for registration. this provision has not yet been invoked. governments often anticipate departures during crises and establish policies to deter or intercept migrants leaving countries of origin or transit countries. a common response has been to impose visa requirements on nationals of countries in crisis. visas help to screen out those who purport to be coming as tourists or business travellers but who intend to stay for longer periods. air and other carriers have the responsibility to check that international travellers have proper documentation before they are permitted to board the plane or ship. in numerous cases, migrants attempt to enter destination countries clandestinely, across land borders and by sea. the united states, australia and countries in the european union have intercepted boats that were headed for their shores during crises. in many cases, the boats are unseaworthy and the interception is justified on humanitarian as well as border control bases. what to do with those who are intercepted, particularly those who are rescued at sea, can be a complicated issue. bringing these individuals to the territory of the states that interdict the migrants can serve as a magnet that encourages still more people to risk dangerous crossings. returning them to dangerous situations in their home country could have equally deleterious humanitarian ramifications. obviously, leaving them on unseaworthy vessels would be inhumane. one option that governments have tried is off-shore protection for those who are intercepted. the united states, for example, used guantanamo naval base in the s to provide temporary protection to haitians and cubans, rather than returning them into unsettled conditions. in the case of haiti, most of those provided temporary safe haven returned home when the elected president of haiti was returned to office. by contrast, most of the cubans were eventually resettled into the united states, but cuba and the united states signed a migration agreement that provided alternative mechanisms for legal immigration from cuba and a commitment from the cuban government to curb boat departures. australia has established off-shore processing centres in nauru and papua new guinea with the aim of curtailing access to asylum in australia. those found to have valid refugee claims would remain in those countries or be resettled elsewhere. the un human rights council, among others, has criticized the policy, especially for the harsh treatment and poor living conditions of asylum seekers in these other countries (millar ) . a further range of policies pertain to people who are endangered in the countries in crisis or in neighbouring countries and who are evacuated to other states for safety. the most common form of evacuation is of citizens who are caught in the middle of a crisis. in recent cases, governments have evacuated their citizens from earthquake, tsunami, cyclone and flood affected areas (e.g., japan, haiti, pakistan and indonesia) or conflict zones (e.g., cote d'ivoire, lebanon, libya, syria and yemen). when governments evacuate their nationals, decisions must be made about accompanying family members who are not citizens of the evacuating country. although many countries will evacuate non-national spouses and minor children of citizens, they will not necessarily feel a similar obligation to parents, siblings and other relatives of citizens. nor do they necessarily evacuate persons such as household servants who may be highly dependent on the citizens for their protection and support. immigration authorities use various ad hoc measures to admit the nonnational family members to their territory. in some cases, migrants are working in such countries and an international effort is made to evacuate them to their home countries, either from the country in crisis or a nearby location that they have reached. the evacuation of thousands of migrant workers from libya and cote d'ivoire and their bordering countries are such examples. while the majority of these migrants were able to return safely to their home countries, a minority were unable or unwilling to return because of concerns about their safety in the country of origin. the evacuations share many similarities with other forced migration situations. migrants evacuated home may face problems of reintegration and lost income. those who are unable to repatriate because of unsafe conditions at home will be in need of relocation to other countries. if they do not meet convention refugee criteria (that is, the unsafe conditions do not involve their own fear of persecution), neighbouring countries may be unwilling to provide asylum and there may be limited opportunities for resettlement in third countries. in rare cases, evacuations of large groups of vulnerable persons have been supported by the international community. the clearest case was the humanitarian evacuation of kosovars in . in order to convince the countries of first asylum to keep their doors open to kosovars, other countries agreed to bring some of them to their countries at least temporarily. with the assistance of the un high commissioner for refugees, more than , kosovars were evacuated to countries. many of the participating countries set up reception facilities for the evacuees. when the fighting ended and serb forces withdrew from kosovo, many of the evacuated returned to their homes. the kosovars were admitted without determining if they individually met the refugee definition, distinguishing this program from refugee resettlement initiatives that have been used to support first asylum in other contexts. there are fewer mechanisms for permanent admission of people during nonrefugee crises. a number of countries accelerate or facilitate processing of visas during crises so that those who otherwise would be admissible for permanent residence are able to enter. canada, for example, gave priority to processing visas for persons directly and significantly affected by the haitian earthquake. it also established a satellite office in the dominican republic and sent additional visa and control officers to the region. the united states, canada, the netherlands, and france put in place special provisions that accelerated the entry of haitian orphans who had been approved for adoption prior to the earthquake. in the context of the syrian refugee crisis, the eu has been considering a humanitarian visa through which asylum seekers could enter a member state and have the application heard in situ (neville and rigon ) . finally, a number of governments have permanently resettled discrete categories of vulnerable persons for humanitarian purposes. australia, for example, introduced the locally engaged employee policy, which enabled the permanent resettlement of iraqis and afghans who had been employed by the australian government in their home countries. the united states instituted similar programs that permitted resettlement without regard to whether the employee met refugee criteria. australia and canada also consider applications for humanitarian visas from other persons who consider themselves to be at risk. in australia's program, the individual must show that they are subject to substantial discrimination. just as the legal frameworks for addressing forced migration in all of its manifestations are weak, so are the institutional roles and responsibilities at the international level. with the exception of the refugee regime, in which clear responsibility is given to the un high commissioner for refugees, there is no existing international regime for managing international movements of people. this is not to say that there is a total absence of governance. there are a plethora of international, regional and national organizations that have some responsibilities related to forced migration. the mandates and effectiveness of these institutions in addressing forced migration varies greatly. at the international and regional levels, there is a lack of clear authority for addressing new forms of displacement that do not fit into existing mandates. the institutional arrangements differ somewhat based on whether the displacement is internal and can be addressed within the territory of the affected country or is cross border and affects other countries. as discussed above, most displacement is internal. to the extent that institutional arrangements within countries affected by crises fail to provide adequate protection and assistance, cross-border movements may increase. institutional arrangements to mitigate crises in situ are thus highly relevant to understanding how forced displacement might be mitigated. at present, the international response to humanitarian crises is based on the cluster approach. the un high commissioner for refugees is the cluster lead for protection (focusing on conflict-induced displacement) as well as for the emergency shelter and camp management clusters. the international organization for migration has responsibility for camp management in the context of natural disasters. the situation is less clear cut with regard to protection of those displaced by natural disasters. unhcr, the office of the high commissioner for human rights (ohchr) and unicef have all been designated as having protection responsibilities in natural disasters (global protection cluster ). in practical terms, iom often takes on this responsibility because of its role in camp management. cluster leads have relatively little authority over other international organizations during these crises. the interagency standing committee (iasc) guidance note on using the cluster approach explains; "the role of sector leads at the country level is to facilitate a process aimed at ensuring well-coordinated and effective humanitarian responses in the sector or area of activity concerned. sector leads themselves are not expected to carry out all the necessary activities within the sector or area of activity concerned. they are required, however, to commit to being the 'provider of last resort' where this is necessary and where access, security and availability of resources make this possible" (iasc ) . the note recognizes that "the 'provider of last resort' concept is critical to the cluster approach, and without it the element of predictability is lost" (iasc ) . for agencies with technical leads (e.g., health, nutrition, water and sanitation), the ability of the lead agency to take on responsibility is straightforward. however, the note is more circumspect regarding the leadership for cross-cutting areas such as protection, early recovery and camp coordination: "the concept of 'provider of last resort' will need to be applied in a differentiated manner. in all cases, however, sector leads are responsible for ensuring that wherever there are significant gaps in the humanitarian response they continue advocacy efforts and explain the constraints to stakeholders" (iasc ) . the cluster approach has had mixed results in filling gaps in the institutional framework for addressing the full range of issues pertaining to those who are internally displaced by the type of drivers discussed above. certainly, the willingness of unhcr to be the 'provider of last resort' in the protection of conflict induced idps is a critical issue. the numbers demonstrate a clear increase in unhcr's involvement with idps. unhcr reported that it helped . million of an estimated . million internally displaced persons in , as compared to only . million out of an estimated million in (unhcr ; internal displacement monitoring centre ). nevertheless, there are continuing concerns about the nature of the response. for example, a brookings institution report concluded: "while humanitarian reform has improved operational short-term response, it has had little effect on either protecting people from new displacement or in finding solutions for those displaced. questions of access and staff security continue to be the major limitations in protecting and assisting idps" (brookings institution ). the report called for reinvigoration of efforts to protect idps. during this period, unhcr also began responding, albeit in an ad hoc way, to forced migration stemming from causes other than persecution or conflict. although unhcr has limited its cluster leadership to conflict-induced internal displacement, it has nevertheless been drawn into providing assistance during several notable natural disasters. in the state of the world's refugees, unhcr explained its involvement in tsunami relief: "the sheer scale of the destruction and the fact that many of affected populations were of concern to the organization prompted the move. responding to requests from the un secretary-general and un country teams, unhcr concentrated on providing shelter and non-food relief. in sri lanka, unhcr's presence in the country prior to the tsunami allowed for a comparatively swift and sustained humanitarian intervention -including efforts focused on the protection of internally displaced persons" (unhcr , ) . unhcr also assisted tsunami victims in somalia and aceh, indonesia, pointing out: "the protection of displaced populations was especially urgent in areas of protracted conflict and internal displacement in aceh, somalia and sri lanka. furthermore, there was concern for some affected populations whose governments declined offers of international aid, such as the dalits (formerly known as untouchables) of india and burmese migrant workers in thailand; it was feared they might be discriminated against and their protection needs compromised" (unhcr , ) . unhcr was also involved in the international response to cyclone nargis in burma and china and haiti's earthquakes, providing shelter and supplies. unhcr is the lead international agency with responsibility for refugees who have crossed international borders. founded in , unhcr was charged from the beginning to find solutions for refugees, generally in the form of voluntary repatriation when conditions permitted, integration into a country of asylum, or resettlement to a third country. because those solutions were often not forthcoming, unhcr's day-to-day activity was generally to provide assistance to those who were unable to return, integrate or resettle. unhcr's responsibility for cross-border displacement has grown since its founding, from a focus on refugees and displaced persons from world war ii and the emerging cold war to a focus on delivering humanitarian aid to refugees in developing countries affected by international and internal conflicts. it continued to advocate for protection and solutions for refugees throughout the world. its role has been limited, however, in addressing the situation of those who migrate internationally because of non-persecution or non-conflict reasons. unhcr has, however, demonstrated increased interest in mixed migration. as stated in its point plan, unhcr recognizes that situations "in which people with different objectives move alongside each other, using the same routes and means of transport or engaging the services of the same smugglers, can raise serious protection concerns." the concept of mixed migration seems to be rooted in the assumption that the mix is between refugees and economic migrants and deals very little with other forced migrants. the point plan does not address situations in which people are migrating for a mix of reasons that include extreme natural hazards, except for one mention of migrants from aceh in malaysia, or political or communal violence, except for one mention of mexican migrants leaving because of domestic or other violence. in effect, it does little to help address situations in which crises precipitate movements that do not fit into the refugee framework but raise serious humanitarian considerations. the potential for mass displacement from climate change is also an issue that occupied the then high commissioner antonio gutteres' attention: "when we consider the different models for the impact of climate change, the picture is very worrying. the need for people to move will keep on growing. one need only look at east africa and the sahel region. all predictions are that desertification will expand steadily. for the population, this means decreasing livelihood prospects and increased migration. all of this is happening in the absence of international capacity and political will to respond" (guterres ) . then assistant high commissioner for protection, erika feller, summarized the dilemma before the executive committee: "new terminology is entering the displacement lexicon with some speed. the talk is now of "ecological refugees", "climate change refugees", the "natural disaster displaced". this is all a serious context for unhcr's efforts to fulfill its mandate for its core beneficiaries…. the mix of global challenges is explosive, and one with which we and our partners, government and non-government, must together strike the right balance" (feller ) . thus far, however, there has been no inclination on the part of the executive committee for unhcr to become involved with those who cross borders because of natural disasters or climate change. instead, following the commemoration of the th anniversary of unhcr, the governments of switzerland and norway established the nansen initiative to generate further discussion. the international organization with the longest and most sustained focus on international migration is the international organization for migration. iom's constitution sets out its role as a service organization operating on behalf of states. its first two purposes and functions pertain to its original role in making arrangements for the transfer of migrants, refugees and displaced persons. iom provides, at the request of and in agreement with the states concerned, migration services such as recruitment, selection, processing, language training, orientation activities, medical examination, placement, activities facilitating reception and integration, advisory services on migration questions, and other assistance as is in accord with the aims of the organization. it also assists in voluntary return migration, including voluntary repatriation. iom's constitution also gives it a role to provide a forum to states as well as international and other organizations for the exchange of views and experiences, and the promotion of co-operation and co-ordination of efforts on international migration issues, including studies on such issues in order to develop practical solutions. in respect to this last function, it has launched a policy dialogue with governments on policy issues. importantly, the organization has expanded significantly in terms of both staff and membership, which includes more than member states and observers. iom has been a focal point for discussion of forced migration since when it co-hosted a series of consultations on the interconnections between the environment and migration, in the context of the united nations conference on environment and development (unced) in rio de janeiro. as discussed above, iom has also taken on lead responsibility for camp management in natural disasters. in the area of pandemics, iom's health program offers travel health assistance to manage conditions of public health concern as individuals move across geographical, health system and epidemiological boundaries. these include pre-embarkation checks and pre-departure medical screenings to assess a migrant's fitness to travel and/or to provide medical clearance. these measures also ensure that migrants are linked to and given appropriate referrals to medical services once they have arrived in their destination countries. migrants who need medical assistance and care during travel are escorted by health professionals to avoid complications during transit. iom works in collaboration with the world health organization (who), whose work is guided by resolution . on the health of migrants, adopted by the world health assembly in (world health organization ). the resolution encourages who to improve understanding and capabilities to address issues related to the health needs of migrants. finally, iom takes the lead role in the evacuation of migrants in countries that fall into crisis, as seen in its role in evacuating migrant workers stranded on the libya-tunisian border, cote d'ivoire, yemen and elsewhere. it played a similar role in evacuating migrants from kuwait and iraq in and lebanon in . as discussed above, in the majority of cases, iom assists the migrants to return to their home countries, but it works with unhcr in the relocation of those unable or unwilling to repatriate because of unsafe conditions in the country of origin. until , iom operated outside of the united nations. in the context of the un high level meeting on refugees and migrants in september , iom joined the un as a related organization (that is, in a capacity similar to that of the world trade organization). as a result, iom will now be more fully integrated into the decision-making on migration issues within the un. operationally, the organization was already a member of un country teams and followed most un security and other protocols. there are a number of other international organizations that have responsibilities regarding migration. among the more significant, the ilo has a specialized office, the international migration program, which "provides advisory services to member states, promotes international standards, provides a tripartite forum for consultations, serves as a global knowledge base, and provides technical assistance and capacity-building to constituents." the un population division in the department of economic and social affairs (desa) is responsible for collecting data on international migration and took the lead within the un secretariat for organizing the high level dialogue on migration and development. the division also hosts an annual meeting for coordination of data and research on international migration. the office of the high commissioner for human rights (ohchr) supports the mandates of the un special rapporteur on the human rights of migrants and the un special rapporteur on trafficking and services the committee on migrant workers, the treaty body supervising compliance with the international convention on the protection of the rights of all migrant workers and members of their families. the un office for drugs and crime (unodc) coordinates activities related to human trafficking and human smuggling, as the key agency responsible for implementation of the un convention against transnational crime and its smuggling and trafficking protocols. none of these agencies have evidenced a particular interest in the interconnections between climate change and the areas of their specific responsibilities. the un maritime organization has responsibilities regarding the suppression of piracy at sea as well as the safety of persons rescued at sea. recognizing the complex set of organizational responsibilities, the global migration group (gmg) was established to promote coordination and identify gaps in the international system. the gmg grew out of an existing inter-agency group, the "geneva migration group", established in april by the heads of the ilo, iom, ohchr, un conference on trade and development (unctad), unhcr and unodc. in membership in the geneva migration group was expanded to include desa, un development program (undp), un population fund (unfpa) and the world bank. following a recommendation by the global commission on international migration for strengthened coordination, the group was renamed the "global migration group" that same year and expanded to include the un regional commissions, unesco, unicef and unitar. other agencies have since joined. while some participants in the gmg have noted that the group has too large and diverse a membership to be effective, the gmg is missing repre-sentatives that would be useful in gaining progress on issues related to forced migration. for example, the office for the coordination of humanitarian affairs is not actively engaged. forced migration has not been a prominent issue on the agendas of regional organizations or regional consultative processes (rcps), except in the area of refugees and asylum-seekers. the european union is a notable exception, particularly in regard to the temporary protection directive. several regional groups have discussed related issues. the inter-governmental authority on development regional consultative process on migration (igad-rcp), established in , includes mixed migratory flows, environmental migration, and movements of pastoralists on its agenda. the dialogue on mediterranean transit migration (mtm) has also focused attention on mixed migration. the inter-governmental asia-pacific consultations on refugees, displaced persons and migrants (apc) was established in to "provide a forum for the discussion of issues relating to population movements, including refugees, displaced or trafficked persons and migrants." the aim of the consultations is to "promote dialogue and explore opportunities for greater regional cooperation" (apc ). although not regional, the intergovernmental consultations on migration, refugees and asylum (igc) brings together participating states , the united nations high commissioner for refugees, the international organization for migration and the european commission to discuss forced migration, among other issues. generally, the rcps are not forums for discussion of emerging crises, even when these crises are within the region of the consultative body. although libya, egypt and tunisia are members along with european countries of the mtm, it does not appear that a meeting was called to discuss the evacuation of migrant workers or the increase in boat departures that corresponded with political events in libya. a expert meeting in malta did address issues related to irregular migration. addressing forced migration at the national level generally requires a 'whole of government' approach because of the complexities involved. often, institutional responses are ad hoc, designed for a specific crisis. they may differ significantly depending on geographic considerations (e.g., the extent to which migrants are likely to reach the shores of the destination countries), the causes of the crisis (e.g., natural hazards versus political instability), the domestic political and economic climate, the extent of humanitarian need, and other similar factors. this presents challenges, particularly related to coordination across ministries and departments that do not necessarily have ongoing reasons to communicate or cooperate in managing movements of people. policies on and responsibilities for implementation on immigration issues generally fall to interior or homeland security ministries or dedicated immigration or border security agencies in destination countries although foreign ministries play important roles. a much wider set of government agencies become involved in responding to humanitarian crises. which ministries are involved depends largely on the type of crisis, but it is not unusual for large scale crises to bring defense, foreign ministry, development, health, emergency response and other ministries into the process. again depending on the nature and scale of the crisis, governments may establish a taskforce within the prime minister or president's office to coordinate actions across multiple ministries. situations vary but the ministries responsible for immigration issues may not initially be part of these taskforces, particularly if the migration ramifications are not clear at the start of a crisis. for immigration ministries that are addressing the impacts of pandemics, natural disasters, and political instability, gaining needed information about, for example, the need for quarantine of travelers or need for temporary protection can be difficult. similarly, migration ministries may not be part of discussions taking place on climate change adaptation funding even though there is increasing recognition that migration is an age-old way in which people adapt to environmental changes. forced migration is unlikely to disappear in the future. in fact, the number and frequency of crises that generate large scale displacement may well increase substantially in the years ahead. climate change is expected to generate substantial internal and international displacement from increases in the intensity and frequency of natural hazards, rising sea levels, persistent drought and desertification, and, potentially, new conflicts over scarce resources. at the same time, recent events demonstrate that the process of political change taking hold in many parts of the world can be destabilizing, causing new movements of people. increased mobility also means greater potential for pandemics to spread quickly throughout the world, as was seen in the sars and h n cases, and for governments to make decisions regarding non-return, as seen in the ebola crisis in west africa. all of these trends mean that governments will likely be facing recurrent crises that spark migration and accompanying humanitarian needs. although much of this forced migration will be internal to countries facing emergencies, movements across borders are likely as well. this review of laws, policies, practices and institutions reveal weaknesses and challenges in the current capacities to respond effectively, efficiently and humanely to the challenges presented by forced migration. although many countries have advanced and tested systems to respond to refugees and asylum seekers, responses to migration emanating from other crises-natural disasters, political instability and violence, pandemics, human made disasters-are ad hoc and, in many cases, untested. most countries have mechanisms to provide temporary suspension of removal if conflicts or natural disasters preclude immediate return. with little underpinning from international and, sometimes, national law, the application of these provisions tends to be uneven and often dependent on factors that have little to do with immigration or humanitarian considerations or the balancing of these two factors. crises that generate greater visibility, such as the earthquake in haiti or ebola pandemic in west africa, may result in suspensions of removal whereas less known but potentially equally dangerous situations may not yield this response. when taken into account, immigration issues can work in different directions in determining whether to suspend removals or provide temporary protection. in some cases, concern that temporary protection may spur new movements of people is determinative in not granting suspension or triggering temporary protection, whereas in others, flow of remittances to countries in crisis may push a government towards the decision to grant the status and provide work authorization. once granted, temporary protection and suspension of removals have proven to be problematic vehicles to manage forced migration. once granted, it is very difficult to lift the designation even if conditions change sufficiently in home countries to permit return. often, the conditions do not change and the temporary grant of protection becomes a protracted one. in the absence of durable solutions, the forced migrants may end up in limbo for many years. as the stay prolongs, return becomes even harder as those granted permission to remain develop equities and connections to the country in which they are residing. temporary protection is an especially weak policy instrument when the conditions that cause flight are permanent. this may be the situation that arises in the context of climate change. nationals from some low-lying island countries may be unable to return to their home countries if some of the projections of rising sea levels prove to be accurate and their countries are submerged. even weaker than policy frameworks for temporarily suspending removals of migrants already in the country are those for dealing with mass migration resulting from crises. as discussed, the european union passed a directive on temporary protection with new flows in mind but it has never been used. the united states had experience with such movements from haiti and cuba in the s, using guantanamo naval base to house the migrants until a determination could be made on their status. the aim of policies adopted in was to provide safe haven but no access to u.s. territory. mixed migration is a challenge in handling mass movements in the context of humanitarian crises. some of those leaving may be bonafide refugees deserving of asylum, others may have serious reasons to fear for their safety though they do not meet the refugee criteria, but still others may be leaving to seek better economic opportunities. distinguishing among these groups is always challenging and, in the context of a mass migration emergency, even more difficult. the absence of effective policy tools is especially troubling because these crises have implications that go well beyond immigration and touch on basic humanitarian and human rights interests. just as refugees are at risk of serious harm if returned to their home countries, migrants from countries experiencing crises may face life threatening situations. they may also have immediate need for humanitarian assistance, including shelter, health care, food and other basic items. the promulgation of guidelines and the development of policies to respond to forced migration will require new modes of international cooperation. given the potential for significant increases in such migration, efforts to build an effective toolkit should begin now. whether a new convention on forced migration is desirable, or, for that matter, is feasible, are questions that beg easy answers. the history of international conventions related to migration is a mixed one. while the refugee convention and trafficking protocol are widely ratified, the conventions on labour migrants have had very low levels of ratification. because the complex categories of forced migration discussed herein will likely have elements of both forms of migration, depending on whether the trigger is slow or rapid onset, the future of such a convention would be questionable. beyond feasibility, a number of other issues would need to be addressed before determining that a new convention is the best way to improve policies to respond to forced migration. first, to what extent can existing legal frameworks be stretched to include a wider range of people who are forced to move? how should forced migrants be defined? for that matter, what term should be used in categorizing this form of migration; this paper has used forced migration and displacement as short hands. in other contexts, the terms crisis migrants and survival migrants have been used to describe those who do not fit current legal categories. even more important, a new framework for protection-whether a new convention or stretching of existing ones-would need to specify who among forced migrants are deserving of international protection-as distinct from those who can rely upon the protection of their own countries. and, the list goes on. in the end, though, international agreements-whether binding or soft law-will not be a substitute for national action. states should prepare for future crisis responses by preparing a menu of policy options that they could choose to implement in the event of large scale displacement that does not fit into current refugee frameworks. this process is already underway with the nansen and micic initiatives and the similar state process on other vulnerable migrants recommended by the high level meeting. these are forms of what sir peter sutherland, the former special representative of the secretary general on international migration has called mini-multilateralism, that is, initiatives by a small set of representative governments to build norms and identify good practices to be adopted more universally. a further opportunity is negotiation of a global compact on safe, regular and orderly migration, an outcome of the high level meeting. sir peter sutherland, in his final report as the special representative of the secretary general, stated that a principal aim of the compact should be to identify mechanisms for "managing crisis movement and protecting migrants in vulnerable situations." (sutherland ) . in developing an appropriate set of policies for responding to forced migration, consideration needs to be given to the following questions: • what policies and practices are needed to address the situation of migrants already in destination countries when return to home countries may be lifethreatening or otherwise inadvisable? what are the criteria for determining to suspend removals? for how long should the suspension be granted? what criteria should determine if the suspension should be renewed or revoked? what information is needed and from whom to make these determinations? • what policies and practices are needed to address individuals arriving from countries in crisis? should individual determinations be made as to whether to allow them to enter or should decisions be made on a group basis? • what policies and practices are needed to address mass migration flows? under what circumstances is interdiction appropriate? what criteria should be used in determining whether to return or relocate interdicted migrants? what criteria should be used in determining whether to admit such persons on to the territory of other countries? what information is needed and from whom to make these determinations? • if new policies are put in place for forced migration, how should these intersect with established refugee and asylum policies and systems? • if there is a determination that conditions have changed and forced migrants can return safely, what if any assistance should be provided? if there is a determination that return will not be possible for an extended period, what steps should be taken to find durable solutions? should third country resettlement, for example, be part of a policy toolkit for addressing the broad range of forced migration discussed herein? if so, what criteria should be used in determining who should be eligible for resettlement? • should forced migrants be granted work authorization? should they have access to social benefits? under what circumstances should authorities use reception centers or camps to provide initial or longer term accommodation? what forms of documentation and registration are needed in managing forced migration? • how should authorities address potential for fraud and security risks resulting from forced migration? • which agencies within government need to be involved in decision making on forced migration? which international and regional organizations should be involved? • what forms of responsibility sharing among countries would be appropriate in managing forced migration? what are the appropriate forums for negotiating such arrangements? finally, governments should also be reconsidering the ways in which they conceptualize, fund and implement programs to help vulnerable populations adapt to changing conditions that may trigger large scale displacement. in these contexts, migration is not just a problem to be addressed. it may also be a solution for many of those who are affected by climate change and other problems. too often, migration is forced because there are no alternatives for those who anticipate future harm but are unable to move in a safe and orderly fashion. they may lack the financial, human and social capital to relocate to where there may be greater long-term opportunities, or government policies do not accommodate their movements. as governments consider national adaptation plans and disaster risk reduction strategies, more attention is needed to ways to incorporate migration as a potentially positive response to pending emergencies. demography can play an important role in improving responses. too little is known about the determinants of forced migration, especially beyond traditional refugee flows. there is consensus among researchers that no one factor-economic, social, political, environmental or demographic-is determinative but how the various drivers interact to produce one form of movement versus another is largely unknown. in this context, demography is important in two respects. first, demographic trends are themselves drivers of displacement in conjunction with other factors. this can play out in two ways-demography as a macro-level factor and demographic composition as a micro-level driver of movement. for example, in the context of slow onset climate change, there is need for better understanding of how population density, distribution and growth as well as household composition affects vulnerability and resilience to environmental change (martin and bergmann ) . understanding the ways in which these demographic and environmental factors intersect with each other and with political and economic drivers would be useful in assessing likely need for planned relocation as environmental conditions worsen. second, the demographic profile of forced migrants often affects the efficacy of policy and programmatic responses. data on demographic as well as socio-economic characteristics of forced migrants are weak in general and, in the case of many types of forced migrants, non-existent. while some progress has been made in compiling aggregate numbers of persons who are displaced by natural disasters (see, for example, idmc's data (idmc )), there are no comprehensive sources of data broken down by age or sex. even in the case of refugees and conflict idps, the demographic breakdowns are lacking, particularly when they spontaneously settle and may not register with unhcr. unhcr reports that it has sex disaggregated data on % of those persons of concern, with sex disaggregated data on refugees at %, idps at % and stateless at only %. age disaggregated data were available for % of the population of concern; while it was available for % of refugees, it was available for only % of idps of concern (unhcr ). improving sex and age disaggregated data on all forms of displacement would help ensure that policies and programs are appropriate for all of those who are forced to move. it is difficult to plan for protection or assistance programs in the absence of such data. this is true in both acute and protracted phases of displacement. an absence of such data is particularly harmful with regard to needs linked to gender and age, including those related to health, education, food distribution, access to livelihoods and gender and sexual violence. demographers could play an extremely important role in helping governments, international organizations and ngos to collect basic data on forced migrants and thereby, improve protection and assistance for some of the world's most vulnerable persons. why is the temporary protection directive missing from the european refugee crisis debate? harvard humanitarian initiative iasc framework on durable solutions for internally displaced persons ten years after humanitarian reform human rights and natural disasters: operational guidelines and field manual on human rights protection in situations of natural disaster statement by unhcr assistant high commissioner for protection, ms. erika feller. the nd meeting of the standing committee available at global estimates : people displaced by disasters inter-governmental asia-pacific consultations on refugees, displaced persons and migrants (apc) environmental change and migration: legal and political frameworks environmental change and human mobility: reducing vulnerability & increasing resilience humanitarian crises and migration: causes, consequences and responses australia's asylum seeker policies heavily criticised at un human rights council review towards an eu humanitarian visa scheme? policy department for citizens' rights and constitutional affairs, european parliament giuseppe sciortino migration and illegality in germany report of the special representative of the secretary-general on migration presidency conclusions, and october global report. geneva: unhcr united nations international strategy for disaster risk reduction (unisdr) united nations international strategy for disaster risk reduction (unisdr) united nations high commissioner for refugees (unhcr) termination of tps for nationals of montserrat the state of the world's refugees : human displacement in the new millennium key: cord- -zjr csla authors: hillman, john r.; baydoun, elias title: food security in an insecure future date: - - journal: water, energy & food sustainability in the middle east doi: . / - - - - _ sha: doc_id: cord_uid: zjr csla food security in the middle east is directly affected by a challenging combination of ongoing destructive conflicts, a global economic downturn, widespread poverty, high population growth, corruption, intolerance, and the potentially damaging consequences of climate change. many arab countries demonstrate nearly all the features of those countries classified as poor, less developed, or failing to achieve the eight millennium goals. even the economies of the richer oil-exporting countries in the region have been seriously damaged by the downturn in oil and gas prices as new sources come on stream elsewhere and demand falls as a result of renewable sources of energy becoming available. in a previous article , we considered definitions of food security in the modern era of rising global populations, discussing how food security might be attained in terms of security of water and fossil-fuel-derived energy supplies, climate change, rapid urbanisation, changing dietary trends, and modification of the natural environment leading to depleted natural resources, increasing environmental pollution, and the need to introduce modern technologies. the concepts of sustainable agriculture and uncertainty were also addressed, notably in respect of fresh thinking about key components of agricultural systems. these included (babu and blom ) vertical and horizontal integration of farming-related businesses to allow adequate capitalisation for enhanced efficiency measures; (bardshaw and brook ) policy shifts to remove market-distorting subsidies, tariffs, import and export bans, and excessive bureaucracy; improved crop and livestock breeding, including entirely new species; (bolukbasi et al. ) automation in agriculture and horticulture; (breisinger et al. ) protected cropping; (cong et al. ) new-generation agrochemicals; (elasha ) new agronomic practices; (fan et al. ) novel foodstuffs; (fao ) habitat reconstruction and land renovation; (fao ) biofuels and biodiesel; (garland et al. ) periurban and urban agriculture; (grebner et al. ) industrial biotechnology; (grivetti and ogle ) farming the seas and oceans; long-term carbon storage; and (hillman and baydoun ) new ways of thinking about carbon trading. more recently, we reviewed mitigation and adaptation processes and strategies to address the impacts of climate change on food, water, and energy security in the arab middle east (hillman and baydoun ) . here, we consider potential adaptations to an insecure global future generally, and to the concerns in the arab middle east specifically, in the light of the economic realities of wide disparities in wealth, competition for resources, and widespread poverty in many parts of the globe, coupled to a relatively high population growth, on-going conflicts, attempted cultural genocides, potential conflicts, endemic corruption and nepotism, and epidemics of infectious diseases. most arab countries are classified as poor, less developed, or failing to achieve the eight millennium goals of the united nations, and these arab countries share several undesirable features (table ) . even the much richer oil-exporting arab nations are under pressure. after a decade of relatively high oil prices, these nations have accumulated more $ . trillion in sovereign assets reinforced by substantial infrastructural investments supplemented by high levels of spending on imported military hardware. now, however, oil prices are under pressure as global oil and gas prices slumped in and remain depressed, possibly for the medium to long term as new sources of oil and gas come from hydraulic fracturing (fracking) and from iranian exports as the economic blockade on iran is being relaxed, coupled to greater energy efficiency in industry and new sources of renewable energy. this price depression has exposed the degree to which the economies of these arab oil exporters are dependent on oil and their failure in most instances to diversify their economies as their populations continue to expand alongside public expectations of continuing governmental largesse. nearly all of the immediate adaptations arab countries must undertake in order to adjust to a raft of severe insecurity issues require strategic planning and value-for-money infrastructural and civil-society improvements, and any preparatory changes in rural and urban areas will differ in scale and design. longer-term adaptations will be reliant on more stable conditions and a stepwise improvement of educational standards and attitudes. at the time of writing, no arab country is deemed to have acceptable levels of budget transparency according to the latest open budget index released by the international budget partnership (see www.internationalbudget.org). the future is especially insecure because of the persistence in the region of a combination of incompatible political and economic ideologies, religious and ethnic groupings overtly intolerant of others, introvert nationalism and disrespect of others, disconnection from democratic principles, profound cultural divides, ignorance -some wanton, inability to adapt to modernity, and malevolent community and national leaders. from a noble history of toleration, hospitality, and learning, arab society is fragmenting, defiled by the actions of relatively few. arabs are killing arabs either directly or indirectly; arabs are inflicting as-yetuntold horrific crimes on other arabs either directly or indirectly. attacks on arab countries by their neighbours might be used as an excuse to divert attention from their own failing donor-dependent economies or social structures, or most often to steal resources and ensure that the neighbouring country is suppressed from developing normally. at the global level, many would say that future conflicts and insecurity in much of the world are inevitable, simply because of the impacts of expanding global populations and the obvious competition for limited resources. the intensity of this competition must be analysed in context of the alarming table fourteen features of countries classified as poor, less developed, or failing to achieve the eight united nations millennium goals. the listed features are closely interrelated . poverty common in both the urban and especially the rural poor, poverty is sometimes concentrated in regions, often in marginalised ethnic or religious groups, and may relate primarily to girls and women. many of the urban poor operate in the unofficial economy. the rural poor tend to be land-constrained, dependent on rain-fed, low-yield subsistence agriculture with little or no access to modern technology (modern cultivars and livestock breeds, fertilisers, pesticides, automation, agronomy advice, veterinary support), and usually do not own their land. the rural poor encounter barriers to trade (e.g. transport, storage) and are unable to meet quality assurance standards. with no or limited access to social benefits (primarily pensions, child support, education, training, and healthcare), the poor may be hungry, thirsty, suffer ill health and low standards of accommodation, and die early. the poor are susceptible to exploitation. . hunger and thirst access to food and potable water may involve substantial travel on foot, and the basic requirements may only be met wholly or in part by humanitarian assistance. food quality and safety are usually low, and cooking is often dependent on wood for fuel. symptoms of malnutrition are prevalent. . disease slum dwellings, insanitary conditions, poverty, and hunger lead to a vulnerability to pandemics, made worse by poor or no public health provision. high maternal and child mortality and low general life expectancy characterise poverty and there is a reliance on traditional and/or herbal medicine. crops and livestock are subject to catastrophic attacks by pests and diseases. . poor environmental management poor countries suffer a depletion of their natural resources, including freshwater supplies and native flora and fauna. mineral and fossil-fuel resources are extracted to be exploited by industries in other more-developed countries. land, water, and the atmosphere may be polluted with few or no remediation efforts. national, regional, and international environmental regulations are not properly implemented. agricultural soils tend to be subject to erosion, salination, solarisation, desertification, and nutrient depletion. even without climate-change predictions, the general anthropogenic environmental degradation currently taking place increases the vulnerability to flooding, sand storms, ill health, and displacement of peoples. most poor countries are enduring adverse climate trends, and climate-change predictions point to even harsher conditions (erratic rainfall with rising temperatures, heat waves, hot extremes, and storms; rising sea levels and acidification of seas and oceans; increased desertification with effects on agriculture as well as the natural flora and fauna; socio-economic and health implications). . poor infrastructure quantity and quality of the built infrastructure tends to be low, or even absent (e.g. roads, ports, airports, telecommunications and access to the internet, hospitals and clinics, reliable power and fuel supplies, potable water sources, sanitation systems and sewage disposal, protected natural environments, cold and pest-free storage of agricultural and horticultural produce). the cost of living is worsened by relatively high overland transport costs. facilities may be inadequate to meet demand and maintenance neglected. rapid urbanisation and conflicts exacerbate infrastructural deficiencies. . corruption political autocracy coupled to a lack of transparency in government and public services, a weak judiciary, lack of consultation on major issues, and suppressed media enable a climate of corruption and nepotism to permeate all areas of society, including schools, colleges, and universities. a low regard for human rights, democratic processes, health and safety measures, and international law, is made worse by an overburdensome bureaucracy (staffed by poorly paid civil servants and police) dependent on bribery to function. corruption allows laws to be broken with impunity, and protests ignored. in most areas of society, a lack of altruistic leadership and (continued) poor countries manufacture few value-added products, offer little or no advanced training, and lack participation in the global knowledge economy. there is little or no foreign direct investment and free trade is constrained. financial assistance from donor countries is increasingly being audited to ensure compliance with attempts to prevent unauthorised expenditure. many poor countries have not managed to have constructive relationships with potential donor countries, and some try to align themselves with one of the main international political power blocs. unrelieved debt burdens have led to high interest rates on loans and difficulty of obtaining credit. private savings are minimal and the country may be subject to periodic flights of capital. their economies are grossly imbalanced with little spent on healthcare, education, and other social benefits compared with defence and vanity projects. the economy may be damaged by previous and/or ongoing conflicts, and may in any case have limited absorptive capacity properly to manage additional resource inflows and outflows. agriculture, unofficial transactions, and remittances from those working abroad contribute disproportionately to the real economy. . poor education limited or no access to free schooling accounts for a general low level of literacy and numeracy, especially of females. this is reflected in the absence of high-grade internationally competitive universities, colleges, and research institutes, despite a high level of parental financial sacrifice to secure a supposedly good education for their children. science and technology tend to be poorly taught and there is undue influence of religions with regressive attitudes to modernity. a lack of investment in research and development (r&d) and a lack of a critical mass of scientists, engineers, and technologists impede industrial development, and prevent those that remain from joining international consortia, participate in learned societies, access essential literature and training programmes, and have the opportunity to use state-of-the-art instrumentation, software, and laboratory consumables. the best educated and the most talented and entrepreneurial usually emigrate, leading to a brain drain. intellectual property rights are often ignored and little benefit is derived from traditional knowledge and its products tend to be exploited in other countries. crucial demands and needs of less-developed countries are rarely the targets of major international r&d projects. . gender inequality low educational attainment in most girls and women is reflected in female political, economic, and social representation and participation failing to match their proportion of the general population. cultural and religious influences often lead to females being regarded as inferior to males. family planning is limited, and in the absence of social security and reasonable incomes, large families are the norm. . high population growth this is a feature of the poorest social groups, and correlates with low life expectancy and gender inequality. in some countries high population growth may exceed the economic capacity of the country to feed itself, leading to a propensity to generate refugees, displaced persons, and terrorists. . vulnerability to transnational terrorism terrorism often relates to a combination of one or more of the following: poverty, hunger, poor educational attainment, disconnection from democratic principles, susceptibility to indoctrination by intolerant religious ideologies, criminal activities, and psychiatric disorders. poor countries are usually unable to defend themselves from terrorists, and groups of terrorists may receive covert support from other countries and agencies. poor countries may form the battlefield for fighting between different groups of terrorists. recovery from terrorism and conflicts in general may take several generations, and lead to psychological and physiological after-effects in the survivors and their progeny. projected changes and options for adaptation as well as mitigation (curbing emissions) detailed in the latest fifth assessment report of the international panel on climate change (ipcc, www.ipcc.ch/). the immediacy of food security during social instability in the arab region forms the backdrop to this article, rather than the longer-term infrastructural and social transformations needed to mitigate and adapt to climate-changing emissions, transformations that demand political stability and sophistication. the global population is estimated to be around . billion at present and there is an % probability that it will increase to between . billion and . billion in (garland et al. ) , so stabilisation of the population is highly unlikely this century. moreover, human population reduction is not a quick fix for environmental problems, and even a catastrophic event that killed billions of people would have relatively little effect on the overall impact of humans on the environment . weak public sector low salaries, complex and inefficient bureaucratic processes, poor educational attainment, incompetence, widespread acceptance of corruption through bribery and political interference, and the lack of an investigative free media, account for the justifiable lack of confidence in the public sector. a low regard for human rights, legal processes, and justice undermines societal advancement. there is also poor custodianship of cultural heritage and essential infrastructure. . neighbouring countries many poor countries have reliance on and vulnerability to neighbouring countries for access to water, transport and communication networks, foodstuffs, energy, control of environmental issues (e.g. desertification, flooding, biodiversity protection, pollution etc.), and security. neighbouring countries may (a) create security problems by aiding terrorists and insurgents, (b) provide an uncontrolled source of refugees, (c) invade, (d) steal water or other natural resources, and/or (e) issue mendacious media releases or operate diplomatically to undermine the confidence of donor countries, aid agencies, and investors. the more-developed countries rarely understand the sheer difficulty of managing a poor country facing inter-ethnic conflict, and terrorism and poverty. . international agencies, non-government organisations, international media and the united nations poor countries are monitored by a plethora of international and national bodies, and extensive reports generated, but the necessary actions -political and military -to solve the main issues and problems are rarely carried out. unwarranted aggression inflicted on other countries -poor or not, or the suppression of their populations or specific parts of their populations by nation states eventually must be counteracted by military intervention. sadly, poor nations are oftentimes regarded as pawns in international power struggles, and remain either exploited for their resources, or ignored. moreover, economic downturns in donor countries reduce the level of aid and absorption of refugees, made worse by certain countries cynically failing to meet their initially well-publicised aid pledges. (bardshaw and brook ) . population increases could undermine attempts to ameliorate attempts to reduce climate-modifying emissions. climate-change predictions for the arab region are deeply concerning. most scientists support the conclusions of the latest fifth assessment report of the ipcc. formed in by the united nations environment programme (unep) and the world meteorological organization (wmo), and relating closely to the un framework convention on climate change -the main multilateral forum for addressing climate change, ar comprises three working group reports and a synthesis report with its summary for policymakers. the main issues are covered in detail: observed changes and their causes; future climate changes and their risks and impacts; future pathways for adaptation, mitigation and sustainable development; and a more detailed analysis of adaptation and mitigation including policy options, technology and finance. in the arab human development report authored by balgis osman elasha, ( ), the impacts of climate-change projections in the arab region are given in stark detail. in the coming decades, arab societies and their industries will be profoundly and adversely affected by projected temperature increases in excess of c and severely reduced rainfall, threats of increasing frequencies of impacts originating from el nino events, changes in the seasonal distribution and predictability of rainfall, depleted aquifers, reduced river flows, rising sea levels, flash floods, in addition to increased numbers of dust storms and hurricanes. as the arab region itself is a relatively small direct contributor to global greenhouse-gas emissions, although its fossil-fuel exports and its importation of goods that took energy to create are substantial contributors to them, adaptation must be a crucial factor in policy developments in more settled times that will themselves be dependent on stable and peaceful arab countries. questions arise as to whether organisations such as those overseen by the united nations, multilateral groups such as the european union, individual nations and several charities will be capable of initiating and then maintaining peaceful conditions and food security. food and other forms of aid are likely to face increasing demands at a time when the economies of many donor countries are enduring continuing austerity and recessionary conditions, and when there is growing but unjustified cynicism about the effectiveness of these aid organisations. irrespective of the many estimates that total global food production can readily meet the needs of the present global population, political reality is that all countries and people are patently not equal and are unlikely to be so for the foreseeable future. aid can assist in partially rebalancing the inequalities, not least where several countries in the arab region are currently in turmoil and others are deeply troubled. some regard most of the arab world as regressing, out of synchrony with, and lacking sympathy from, the world at large. food costs and poverty are primary concerns, exacerbated by insecurity of energy and water supplies as well as rampaging insurgents and those wishing to impose unacceptable regimes and suppression of minorities, denying their citizens proper democratic freedoms. wars and conflicts are all too easily incited in the absence of strong democratic civil society involvement and usually quickly bankrupt countries; destroy nearly all parts of their economies; ruin infrastructure including homes, businesses, transport and communication networks; disrupt family life and social interactions; generate displaced people and refugees; and attract foreign interference, including active participants. war crimes are commonplace. psychological aftereffects are noted in civilians and combatants long after fighting has died down. populations in the arab middle east have endured asymmetric warfare between countries with vastly different military capabilities, provoking guerrilla tactics, chemical warfare, civil war, and even unconventional warfare through acquiescence, capitulation, and clandestine support for long-term insurgencies. wherever they occur, warfare and conflicts are always associated with the participants having distorted views of history -some drawing on ancient history -with widely diverse concepts of ethics, and complicated by ethnic and profound religious differences. little consensus exists on triggering factors, theories, and outcomes. prodigious sums of money have been expended in the arab middle east on armaments and defence forces to the exclusion of adequate investments in social welfare, education, and research and development. political instability for whatever reason usually leads to food insecurity and conflict. during social disturbances and the onset of widespread conflict, the normal mechanisms underpinning food production, importation, storage, processing, transport and retailing are profoundly disrupted, creating conditions that promote the formation of ghettos, and further stimulate corruption, robbery, and the black market. normal policing and social order collapse, social behaviour degrades, and criminal activities dominate. as the economy collapses, the terms of trade are transformed. disease epidemics become manifest. the restoration of domestic and business normality takes years and may never be achieved within one or more generations. food insecurity itself may lead to political instability, not least in a world of global intercommunications when citizens of a poor country or region can view with understandable envy the lifestyles of those in rich countries or communities. it is therefore a basic duty of political and community leaders to ensure that food security is a foremost priority for those people within their sphere of responsibility. insecurity of food supplies can be created by adverse weather conditions; the depredations of pests, weeds, and diseases; and salt contamination that can be caused by poor irrigation and agronomic practices. around million hectares of hitherto fertile land on earth have been damaged by salt. according to economics of salt-induced land degradation and restoration (qadir et al. ) , only tree planting, deep ploughing, and growing salt-tolerant crops coupled to digging drains and dykes around the affected area can address the problem. neglecting the health of africa's soils, many of which suffer almost irreversible degradation and nutrient deficiency, will lock the continent into cycles of food insecurity for generations to come, according to the montpellier panel report. indeed, was designated the 'international year of soils' by the th un general assembly. since the s, there are particular issues relating to selection pressures on destructive pests, weeds, and diseases in the vast monocultural single-cultivar agricultural systems that are also the present-day main sources of global food aid. many of these main producing areas are experiencing irregular rainfall patterns and failing irrigation arrangements. crop failures in these areas have quick knock-on effects on volatility of the global agricultural commodity markets; this is a situation likely to get worse as the population inexorably increases and demands more food. moreover, the world has yet to experience the sort of dramatic harvest failures that occurred in the s and before. another aspect of the agriculture sector (generally accepted to include crops, livestock, fishing, and forestry) in the developing world is that it absorbs circa % of the economic impacts caused by medium-and large-scale natural hazards and disasters. between and , these events in developing countries affected more than . billion people and caused more than $ billion, but agriculture only received about . % of all humanitarian aid (fao www.fao.org/emergencies/how-we-work/resilience/en/). delegates from fao at the conference announced the launch of a facility that will focus on bringing together technical expertise and financial resources with the aim of building greater resilience of agriculture to natural extreme weather events. the combination of advanced crop and livestock breeding, agrochemicals, automation, better agronomy and livestock husbandry, increases in the land area farmed, and efficient larger-scale better-capitalised production units have collectively prevented malthusian disasters. since , food production has more than quadrupled, using less than % more cultivated land, allowing civilisation to proceed and expand. food security is no longer an issue in many countries, and the global economy, human health, and societal development have been, for the most part, positively influenced by agricultural advancement. in the period - , when the global population increased from around . billion to around billion, average agricultural commodity prices decreased by an average of . % p.a. because supplies rose faster than demand (unpublished presentation by prof. ingo pies in to biennial development meeting of pottinger). nonetheless, feeding any substantial increases in the global population will only be possible by technological innovations because of the ecological limitations on increased water and fertilizer supplies and increasing the area farmed. likewise, various climatechange predictions amplify justifiable concerns about global agricultural productivity. supply and demand market dynamics are complex and ultimately resilient to political interference, although many countries and trading blocs try to manipulate production by tariffs, export bans, subsidies, inhibiting technological developments and market processes. the spikes in prices of traded wheat, rice, maize, and soya in and were initially blamed on speculation, especially the index tracking funds and derivatives markets. yet this type of speculation does not trade physical goods but price risks, and is therefore a form of insurance market. in addition, speculation would be expected to be associated with high stocks as farmers opt for storage rather than sales. in and , however, stocks were very low and caused the price rises. even so, government policy failures, including protectionist export bans and inadequate promotion of agricultural efficiency, contributed to panic buying, as exporters reduced their offer and importers increased their demand in response. calls by civil society groups to ban speculation by index-tracking funds and derivatives markets were always and continue to be profoundly misguided. all countries should have policies to sustain and constantly review food production and supply, especially if there is a significant dependence on food imports. reasonably substantial reserve food stocks are essential cushions to prevent price bubbles and food shortages, but excessive stocks can distort markets such as when they are released in large quantities as general food aid and undermine the operation of normal agriculture markets in developing countries. some price volatility is an essential component of healthy competitive markets, driving adaptation, risk taking and innovation. debates about the environmental costs of different kinds of agriculture, not least in terms of water and energy security in respect of the arab middle east, and in terms of the destruction of natural habitats and loss of biodiversity, as well as cultural and other changes, have stimulated possible strategies to address these concerns. one approach is for each country to have a "roadmap" for its agricultural development, and these roadmaps might be aggregated into a regional roadmap. the us report: a science roadmap for agriculture -cited as task force on building a science roadmap for agriculture, national association of state universities and land-grant colleges, experiment station committee on organisation and policy, "a science roadmap for the future", november (www.nasulgc.org/comm_food. htm) http://agsci.oregonstate.edu/files/main/roadmap .pdf pioneered a way to define the needs of agriculture and help shape the future direction of the various strands of agriculturally relevant science. this impressive us-specific study followed a conceptual framework of needs to (a) be competitive in a global economy; (b) add value in future harvests; (c) adjust agriculture to a changing climate; (d) be good stewards of the natural environment and natural resources; (e) make agricultural enterprises profitable; (f) make families and communities strong; and (g) modify foods for improved health and safety. one important relevant outcome of this work is the obvious requirement to grow crops and practice livestock husbandry in the most appropriate environments, enabling different environmental zones to have a critical mass of expertise and facilities. for the water-constrained arab middle east, this would mean increased reliance on food imports that could also be regarded as a form of water importation. but this would be possible only if there were formal agreements between food-producing and food-recipient countries, and these agreements were economically and politically stress-resistant. to this caveat would be questions of how to pay for imports, and acquiring resources required to redirect the agricultural workforce into other wealth-creating activities. introduction of a logical, science-led agricultural roadmap in the region may be impossible at present but needs to be initiated. on a global level, food commodity and non-food agricultural commodities prices have declined by - % in the period mid-september to mid-september (see the economist commodity-price index ( ) in www.economist.com/indicators), reflecting relatively clement weather conditions in most of the producing areas, greater production efficiency, balance sheets strong enough to bear losses, competition to gain market share, and continuing investments. importing countries, however, are affected by the strength of their currencies amongst other factors, such as social upheaval. unlike other commodities whose prices direct reflect industrial demand, prices of foodstuffs reflect the effects of weather, pests and diseases, the demands of a rising global population, and many kinds cannot be readily stockpiled. a further factor operating at the global level is the domination of farm supplies by six international companies: monsanto (the largest seed producer), syngenta (the largest agrochemical producer), bayer, basf, dow chemical, and du pont). all of these companies have been active in acquiring other companies and patents, thus reducing competition, and potentially reducing innovation as they robustly defend their intellectual property. in this era of low commodity prices and developing resistance to older-type herbicides, farmers are constrained by input costs of fertilisers, seeds, agrochemicals and veterinary medicines that have steadily risen in over the past decade, only partially alleviated by the recent reduction in fuel and lubricant costs. pandemics -epidemics of infectious or contagious disease that have spread through populations across a large region, crossing international boundariesdrastically curtail food production and distribution, aggravating poverty in both the rural and urban poor. pandemic-causing diseases include the ever-present cholera, influenza such as the and h n outbreaks, typhus, smallpox, measles, tuberculosis, plague (yersinia pestis), leprosy, malaria, human immunodeficiency virus infection and acquired immune deficiency syndrome (hiv/aids), viral haemorrhagic fevers (ebola, marburg, crimean-congo, lassa, rift valley, dengue, yellow fever, etc.), and now there are new diseases such as severe acute respiratory syndrome (sars). vaccine development is necessarily slow, and treatment of bacterial diseases is hampered by the rapid development of antibiotic resistance. the propensity of diseases to mutate, acquire new vectoring capabilities, have reservoirs in wild animals, and even persist in spore form, mean that there must be constant vigilance. as one of the major global food-producing bloc of nations, and as one of the major food importers and donors of food and other forms of humanitarian aid, the european union (eu) bears crucial responsibility for the deleterious effects of its complex and highly bureaucratic common agricultural policy. its massive subsidy regimes impact adversely on global markets and its well-meaning but often poorly thought-through environmental regulatory decisions are not based on sound scientific evidence. so-called "greening" policies are being introduced that may be deemed to enhance the environment but are likely to decrease profitable production. social measures to support small-scale inefficient producers also distort the global marketplace. likewise, the series of restrictions being introduced on the use of a wide range of agrochemicals within the eu and for imported commodities, without carrying out proper impact assessments and fast-tracking alternatives, imperil production. in the medium to long term, a more serious issue is the virtual ban in genetically modified (gm)) crops, inhibiting their uptake in countries intending to export to the eu as well as suppressing state-of-the-art research and development and associated investments in eu countries. of particular relevance in this regard is the recent and largest statistically rigorous review of the agronomic and economic effects of the current range of commercially available gm crops on farming (klümper and qaim ) . in examining publications between and march , it is therefore a near-complete survey. in essence, the two main types of gm crop -resistance to insect pests and tolerance to the wide-spectrum weedkiller glyphosate -conferred considerable yield improvements and much higher profits than conventional crops. gm crops and related products in the development pipeline were not considered, and these promise great advances in nutrition enhancement, environmental clean-up, new medicines, new products for manufacturing industries, and improved crop and forest species. moreover, existing gm crops have greater impacts in poorer countries than in richer countries because their insect pests and pernicious weeds are more difficult to control. by including non-peer-reviewed papers (book chapters, working papers, conference papers etc.) as well as peer-reviewed papers for the meta-analysis, it was possible both to correct for academic bias in focusing just on the most dramatic effects, and include data for many ancillary effects, such as the effects of fertilisers. the eu ban on gm crops is therefore denying poor exporting countries from reaping the full benefits in yield, profitability, and commodity quality, in addition to reducing potential eu food-aid exports. one positive feature of the eu is the bureaucratic system to improve and monitor the quality and safety of foodstuffs, from raw ingredients through to ready-meals, and gm crops have been found to be safe. that for many years most of the feed protein in the eu comprises imported gm maize and soya bean, the issue of gm crops should not be ignored for much longer. opposition to the processes of modern genetic modification and ownership of the processes (often deeming them to be "unnatural"), and disregarding the quality, safety, and valuefor-money of the product, actually condemns conventional agricultural practice, and demonstrates ignorance of naturally occurring mutations and horizontal gene transfer. even so, in early november , the newly elected president of the european commission, j-p juncker, in what is widely regarded as a blatant act of appeasement to greenpeace and other so-called "environment" pressure groups, sacked the eu's chief scientific advisor, professor anne glover, for her support of gm technology, compounding this regressive stance with abolition of the post. all countries and trading blocs should have influential and competent teams of chief scientific advisors. research and development in gene identification, construction, insertion, editing, and expression, coupled to high-throughput phenotyping are collectively revolutionising agricultural, horticultural, and forestry sciences. gm technology is not simply the insertion of genes using various technologies from a similar or different species into a recipient organism. it includes the concept of gene silencing -the prevention the reduction of expression of certain genes -a process that can take place at either the transcription or translation cellular processes. it is not the equivalent of gene knockout but is essentially gene knockdown because the methods to silence genes do not completely eliminate the expression of a specified gene. the methods to silence genes include rna interference (rnai or posttranscriptional gene silencing), small interfering double-stranded rna (sirna), and crispr. of special interest is the crispr (clustered, regularly interspaced, short palindromic repeats) toolkit that is derived from research on prokaryotic antiviral systems and currently involving the cas and cpr endonucleases (jinek et al. ; cong et al. ; bolukbasi et al. ) . as viruses constantly evolve to escape from these antiviral systems, bacteria probably evolve new systems. crispr technology is able to recruit heterologous domains that can regulate endogenous gene expression as well as label specific genomic loci in cells, so that is feasible to engineer germ lines and thus the path of evolution. this technique is replacing methods using mutagenic agents, virus vectors, zinc-finger nucleases and transcription activator-like effector nucleases (talens). its relative simplicity and evolutionary significance for all life forms, including humans, means that internationally agreed regulatory frameworks are essential. the technology does not involve implanting genes from one organism into another, and is not therefore creating transgenic organisms; it is gene editing. there is now realistic expectation of new perennial cereals; incorporation of c- photosynthetic characteristics in existing c- crops; enhancement of nitrogen fixation by free-living soil microorganisms in the vicinity of crop roots; tolerance and resistance to biotic and abiotic stresses; and modification of lignification, texture and endogenous components (such as vitamin content, acrylamide in potatoes, antinutritionals, toxins, proteins, oils, and carbohydrates) of a wide range of existing and potential crop species (see www.isaaa.org/kc/cropbiotechupdate). besides the present-day generation of improved livestock species and new forms of husbandry, the use of balanced diets based on competitively priced synthetic amino-acid and fatty-acid products will lessen the need for large-scale soya and maize production. ancillary advances are taking place in mechanisation; diagnostics; predictive modelling and decision-support systems; remote sensing; protectedcropping systems; and weed, pest, and disease control. diminution of abiotic and biotic stresses in the field and under protective cropping is now the focus of major research initiatives. of the circa , species of angiosperms, according to the food and agriculture organisation of the united nations (fao ) , only species provide % of human energy needs and only four species (rice, wheat, maize, and potato) account for % of energy intake, and % of crop diversity was lost in the last century. around % of human calorie intake comes from crop species (grivetti and ogle ) and % comes from just three grasses -wheat, maize and rice (see www.knowledgebank.irri.org/ericeproduction/importanceofrice.htm) dependency on such a narrow genetic base is a threat to food security and is only partially alleviated by investments in in situ and ex situ plant gene/seed banks, germplasm collections, and dna libraries. just species of angiosperms and gymnosperms have been cultivated for human consumption in human history, with around , angiosperm species yet to be discovered. in theory, most angiosperms should be capable of being biotechnologically modified for food and non-food uses. will scientists in the arab middle east fully participate in these exciting developments? valuable collections in the arab region are inadequately respected for their worth under peaceful conditions but are now extremely vulnerable during this period of war-like conditions and enduring financial pressures. coming into force in , the international treaty on plant genetic resources for food and agriculture (international seed treaty) was designed to complement the convention on biological diversity (cbd) and was designed to guarantee food security by (a) conservation, exchange, and sustainable use of all types of plant genetic resources; (b) offering fair and equitable benefit-sharing; and (c) recognition of farmers' rights. critics of the international seed treaty point to great variability across countries of access to collections and interpretation and implementation of farmers' rights. moreover, in adopting the cbd's outlawing of biopiracy -the uncompensated commercialisation and profiteering of seeds, propagules, growing plants, and their products from source areas -has severely inhibited the acquisition and exchange arrangements in collections until better processes come into force. gap analyses are methods to identify gaps in ex situ collections of wild-plant relatives of agriculturally relevant species as a means to guide efficient and effective collection strategies (villegas et al. ) . a gap analysis by the international center for tropical agriculture managed by the global crop diversity trust and the millennium seed bank in kew examined priority gene pools of the globally most important food crops and their wild relatives. most at risk were eggplant, potato, apple, sunflower, carrot, sorghum, and finger millet (see www.cwrdiversity. org/conservation-gaps/). ongoing conflicts and disorder in the arab region justify an independent review of a regional red list index based on the list of threatened species released by the international union for the conservation of nature (www. iucn.org) in order to evaluate the extinction risk of species and subspecies of the natural flora and fauna. certain individual countries in the eu are important donors of humanitarian aid in their own right. according to a recent report (november , ) from the organisation for economic co-operation and development, economic stagnation especially in the eurozone portion of the eu poses a major risk to world growth. if the stagnation were to continue or even get worse, humanitarian assistance would inevitably be reduced, and countries that hitherto were willing donors would become increasingly introverted. as evidenced by growing problems of graft, corruption and authoritarian government in certain (but not all) members of the eu that were formerly dictatorships or in the sphere of influence of the former soviet union, democratic norms (human rights, respect for minorities, tolerance, free press, independent judiciary and rule of law, active civil-society groups, transparency of accounting for taxpayers' money etc.) take time to become bedded into the fabric of society. in considering the medium-to-long-term future of the eu, it is sobering to note that throughout european history, confederations between its diverse nations and subsets have rarely persisted unless full political, legal, monetary, and more profoundly, cultural fusion had taken place. all governments worthy of the title must ensure that there are relief mechanisms to enable the provision of basic food supplies and fresh water together with functioning standby electricity-generating equipment in unsettled times caused by natural or man-made disasters. surely governments have the ultimate responsibility to attend to the needs of their people and not themselves. rarely observed, governments need genuine food, nutrition and agricultural experts as an integral part of the decision-making hierarchy. such experts must have a proper understanding of the pre-conflict or pre-disaster food, fresh-water, and energy supplies and their distribution systems, and how they can be safeguarded, modified and employed to proper effect, and how alternative mechanisms can be deployed. sadly, this aspect seems to be neglected at the present time in the chaotic condition of certain countries in the middle east. much can be learned from countries in europe during the wars that raged in the nineteenth and twentieth centuries. simply standing by and watching the population adapt slowly to acquiring barely adequate water and food supplies inflicts untold misery on innocent people. all governments should have readily accessible emergency supplies (reserve stocks) and transport systems, and be willing to introduce rationing if need be. special protection measures are needed for water supplies and farms to make sure production can continue no matter the degree of impairment. in more settled times, each government should establish a group of experts to construct interactive databases as the foundation of an agriinformatics and metrics organisation. this would collate information on supply and demand changes, supply-chain details, imports, crop and livestock genetics, commodity production levels, labour-force composition, pricing, inputs, availability of decision-support systems, advisors and research bodies, grant funding, biotic and abiotic stress factors, natural resource constraints, predictive modelling of shocks to the agricultural system and disruptive events, etc. other research organisations would interact with this organisation to ensure best practice and enhance agricultural resilience, demonstrate efficient use of inputs, exploit wastes, optimise the use of mechanisation, and foster skills. arab countries still have to utilise fully the international capabilities and potential of (international centre for agricultural research in the dry areas -currently based in beirut given the conflicts in syria) and other members of the cgiar consortium (formerly the consultative group on international agricultural research). the plethora of aid agencies offering humanitarian and development aid encompass those that are organised by a single government, multilateral donors, non-governmental organisations, philanthropic and charitable organisations, businesses, and individuals. reliefweb (www.reliefweb.int) provides a relatively comprehensive directory of humanitarian organisations. fragmentation of the total aid effort is becoming a worrisome issue. the international committee of the red cross, part of the international red cross and red crescent movement along with international federation of red cross and red crescent societies and national societies, is mandated internationally to uphold the four treaties and three additional protocols of the geneva conventions. these conventions are rules that apply in times of armed conflict both within and between countries, and define the rights of civil and military prisoners and protections for wounded people and for civilians. weapons of war are dealt with by the hague conventions and the biochemical warfare geneva protocol. enforcement of the conventions is through the un security council but is rarely invoked, primarily because of profound ideological differences about democracy and human rights between the five permanent members of the security council with veto powers, so there tends to be diplomatic reliance on regional treaties and national laws. parenthetically, there are ten non-permanent members of the security council without veto powers that are elected by the general assembly of the united nations for a two-year period. on november , the un security council pledged to counter the global terrorist threat and increase cooperation to address the perils posed by foreign terrorist fighters such as those that are a notable feature of conflicts in the arab region. the un office on drugs and crime is also involved in this initiative. other international related treaties include the united nations multilateral treaty referred to as the geneva protocol or convention relating to the status of refugees as well as the declaration on the protection of women and children in emergency and armed conflict adopted by the united nations in . humanitarian aid is distinguished from humanitarian intervention, which involves armed forces protecting civilians from violence or genocide. the united nations office for the coordination of humanitarian affairs is mandated to coordinate humanitarian responses, usually in concert with the international committee of the red cross. valuable reference material can be found in (a) grebner et al. ( ) , the state of hunger in developing countries as a group has improved by % since . even so, the level of hunger is still serious with an estimate of million people continuing to go hungry. the highest levels are south of the sahara and south asia. in the ifpri global nutrition report , evidence is summarised to show that improvements in nutrition status will make large contributions to sustainable development goals, namely poverty, food, health, education, gender, and employment investment in nutrition has a highest benefit ratio. projections from the world health organization (who) and unicef demonstrate that the world is not on track to meet any of the six world health assembly (wha) nutrition targets (reducing child stunting, reducing anaemia in women of reproductive age, reducing low birth weight, reducing the number of overweight children, increasing exclusive breast feeding, and reducing child wasting), although many countries are making good progress in meeting nutrition outcomes. the manifestation of malnutrition is changing as countries are now facing complex, overlapping, and connected malnutrition burdens. three of the chapters in the ifpri publication resilience for food and nutrition security (fan et al. ) are germane to this article. breisinger et al. ( ) briefly mention the arab spring and uses egypt, somalia, sudan, and yemen as case studies of conflict-affected countries. mabiso et al. ( ) have specific reference to the syrian refugee crisis, and take a global overview of the complex relationships between refugees and host countries. babu and blom ( ) introduce a model that seeks to delineate the key capacity components of a resilient food system, considering a country's capacity to create, manage, and utilise human resources for a resilient food system. significant challenges to aid provision include (a) harnessing the necessary stream of funding when grandstanding promises by countries are often never met; (b) establishing and coordinating the basic support network; (c) ensuring the logistics arrangements are effective, including communication networks; (d) prevention of resource misappropriation; (e) protection for officials and support workers on the ground; (f) protecting the vulnerable people needing aid; (g) operating with transparency and integrity; and (h) laying the structural and procedural foundations for self-reliance. effective lines of communication with donors and international agencies and charities are pivotal so that emergency arrangements can be established without delay and hindrance. these bodies need to deal with those individuals in the recipient countries truly knowledgeable about the capacity and specific problems facing food and water security, and fast-moving internal developments. the experts in the recipient countries must have the authority to be able to (a) quantify the levels of demand, (b) direct supplies, (c) recommend the siting of depots and distribution centres, and (d) highlight points of accessibility and vulnerability. in poorly governed countries, experts must be prepared to deal directly with these donors, agencies, and charities, difficult as that might be. the complexities of globalisation extend beyond food and water security (lerche ) . when people are deliberately persecuted, and honest law enforcement collapses, then non-partisan protection must be afforded, usually with outside security forces. unfortunately, ideological differences mean that the international community has often been shown to be ineffective in bringing about rapid termination of conflicts by imposing observers or armed forces, although thanks to relatively few major international donors, humanitarian relief has been forthcoming, albeit frequently late and inadequately funded. dealing with refugees and displaced people requires expertise and sympathetic support. housing provision together with monitoring and combatting infectious diseases, usually run in parallel with the issuance of food supplies. governments that prepare for worst-case scenarios are to be commended. even the distribution of authoritative guidance for populations in stress would represent a small step in the right direction, as would reinforcing the institutions that bind civil society, such as voluntary rescue and care organisations. networks of low-temperature clean and secure depots with associated distribution centres should be set up at the outset of disasters and conflicts. even in peaceful times, a marked cut in food waste helps food security. according to m. m. rutten (rutten ) around a third of the food for humans produced annually (about . billion tonnes) is either lost or wasted, and in developing economies the situation tends to be worse, with in excess of % lost during harvesting, processing and storage (fao. . global food losses and food waste -extent, causes and prevention (see www.go. nature.com/um vga). basic needs of refugees, as recommended by the unhcr and related organisations, are modest but are directly applicable to those displaced or besieged in their own country. unhcr recommends each refugee receive more than calories per day, recognising that a lack of food variety and inadequate supply of fruit and vegetables lead to deficiencies in essential vitamins and minerals. calorific intake can be reduced if the provided foodstuffs do not conform to traditional diets, or if the rations are traded to acquire other non-food goods and services. encouragement is needed to set up temporary gardens. fresh-water provision is of primary importance, with a minimum of litres per person. a greater volume is needed, though, to prevent public-health problems of diarrhoea, cholera, and even polio. thus, clean-water sources and pumps are required along with taps within walking distance. vessels are needed for transfer and storage of water. water-purification tablets should be provided. sanitation systems are essential for hand washing and the safe disposal of urine, faeces, sanitary towels, wound dressings, infected and contaminated materials, and for the disposal of dead bodies. monitoring of faecal contamination is recommended. housing refugees and displaced people at short notice demands special expertise to avoid overcrowding and give adequate protection against inclement conditions. overlaying the fundamental needs for food, water, and shelter are meeting basic medical needs, particularly of the young, women, and the old and frail. in addition, within a short time, children require to be educated. host communities and host countries sometimes resist integration of forcibly deracinated people and can grow resentful at the costs incurred, especially if the host economy is weak. most financial assistance from donor countries is given to aid agencies rather than host countries. large-scale influxes of refugees can soon overwhelm the host country's infrastructural resources (chiefly fresh water, energy, housing, hospitals and healthcare systems, education, and waste disposal). other problems arise from combatants embedded in refugee cohorts, spreading the conflict and increasing policing costs. cultural incompatibilities between refugees and the host population create hostilities. refugees can suffer the dire consequences of being rendered stateless. in general, it is fair to say that humanitarian care is not able to sustain basic needs in the medium to long term. as a consequence of a funding crisis for humanitarian aid in the arab middle east, the world food programme was forced to suspend its desperately needed food-aid-voucher scheme for more than . million syrian refugees at the beginning of december , the onset of winter. this suspension meant that refugees were less welcome in host countries and border closures are already being implemented in the immediate area as well as in the european union. axiomatically, just as responsible governments must be alert to and prepared for civil and other forms of unrest, they should always promote food production and remove any impediments to the uptake of improved technologies so that their economies have inbuilt resilience to dreadful events. likewise, governments should have in their ranks, or instantly available for consultation, competent scientists, technologists, and engineers able to advise on food, water, and energy resource distribution and allocation. over the past few decades, public-sector agricultural research and development in virtually all countries have suffered financial reductions and financial resources have been switched to activities regarded as more exciting and with greater wealth-creating potential; history shows this to be monumentally misguided. the urban disregard for agriculture is likely to continue as urbanisation increases, until the point food security threatens social stability. active or benign neglect of food-producing, food-processing, and food-distribution industries as well as of the scientists, technologists, and engineers underpinning its productivity, improvement and efficiency reveal incompetent governance. as an aside, the dearth of scientists, technologists, and engineers in active politics accounts for numerous policy failures. graduates in the arts (such as history and politics) and social sciences dominate politics and the upper echelons of the machinery of government (civil service) worldwide, people with little understanding or appreciation of business let alone of the "hard" sciences and engineering and their essential utility (and limitations) for mankind. perhaps this explains the growing dissatisfaction with the prevailing political classes. the scientific approach is that of the quest for knowledge by constantly questioning, developing and testing hypotheses by experimentation so that opinions change as "facts" change, oftentimes undermining policies that are not evidence-based, whereas many political parties are founded on inflexible belief systems, as are almost all religions. one aspect of food security in times of conflict and community disharmony has been the remarkable resilience of researchers to continue their studies or just maintain libraries, databases, records, laboratories, and genetic resources under the most trying conditions. the pursuit of knowledge is a fundamental feature of humans, as is the search for improvement. when there is blatant disregard of national constitutions as well as united nations treaties, protocols and conventions, and universities, colleges, schools, and research institutes become targets of malevolent forces, then the rest of the world must have no other option than to intervene, regardless of diplomatic niceties, in order to restore at least the vestiges of societal normality. as a first step, food security and the provision of fresh water for the besieged people must be a priority. if and when particularly large, heavily populated countries become embroiled in conflicts and/or major natural disasters, the existing international support efforts are likely to fail. this, in turn, may lead to a series of related conflicts, as opposing ideological pressures culminate in outright wars, invasions, and suffering on a huge scale. throughout the world, history has shown that unless they are relatively rich (and that may not be enough), smaller or militarily weak larger countries are influenced, for good or ill, by their more powerful and sometimes aggressive neighbours. as recent events demonstrate, conflicts in smaller countries rarely bring about rapid corrective measures from the international community, and adverse and damaging propaganda actively promoted in donor countries can prolong the suffering. ultimately though, food and fresh-water security are a prerequisite and eventually underpin stability, peaceful and thriving economies. today, much of the arab world is poorly governed and insecure for its citizens; they urgently deserve a better life. many of the most talented arabs seek a better life elsewhere. the warfare must be ended forthwith. grossly and unfairly misunderstood by much of the rest of the world, arabs demonstrate admirable resilience and stoicism yet retain their sense of humour tempered by understandable cynicism and justifiable suspicion of conspiracies. enemies of the arabs subject them to a tirade of insults and demeaning innuendos, often designed to deny them basic rights and international support. nonetheless, arabs must not be the continuing authors of their own misfortune, and a first step would be an end to internal conflicts followed by an effective region-wide clampdown on corruption at all levels. remember -it is the victor who determines the writing and shape of history. if the level of insecurity in the region were to get worse, then not only the arabs but also the rest of the world would pay a high price, so it is in everybody's interest to help restore peace. bluntly, the solution to their problems lies in the actions of the arabs themselves. in fully grasping the opportunities available through top-quality education , high standards of integrity and tolerance can be demanded from those in leadership roles in communities, organisations, businesses, and local and national government. ignorance can be reduced, even if not eliminated. essential components of democracy can be established, including independent and diverse news media, an autonomous judiciary operating to high standards of justice and unaffected by pressure groups and politicians, freedom of speech, and dynamic humanities and artistic sectors. wealth, and security of food, water, and energy, can and must be assured through the knowledge economy. harmony can be restored to communities suffering deep-seated divisions. furthermore, countries in the arab middle east will then be in a position to interact much more effectively and comprehensively in the international arena so that, if needed, external support and assistance can be fully and timeously harnessed. despite all the odds, this transition must be accelerated from the current dangerous condition to a much more enlightened and prosperous existence. education throughout society has proved to be a slow process, and can be resisted by regressive forces and indolence, so responsible leadership is a prerequisite. arab scientists, technologists, and engineers must contribute actively to this transition, thereby securing a safe, healthy, and buoyant future for all arabs. research and development priorities must be reassessed in the light of worsening nexus of water, food, and energy insecurity, and the desperate need to return to peaceful conditions. in legal jargon: time is of the essence. finally, a buoyant growth potential for the arab middle east is dependent on the fundamentals of demography, education, access to capital, technology, careful custodianship of its natural resources and environment, and social stability; all are threatened by this insecurity nexus. building capacity for resilient food systems human population reduction is not a quick fix for environmental problems the future of universities in the arab world. arab academy of science creating and evaluating accurate crispr-cas scalpels for genomic surgery food security policies for building resilience to conflict multiplex genome engineering using cripr/cas systems mapping of climate change threats and human development impacts in the arab region ( 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www.internationalbudget.org organisation of economic co-operation and development economics of salt-induced land degradation and restoration what economic theory tells us about the impacts of reducing food losses and/or waste: implications for research, policy and practice. agriculture and food security national association of state universities and land-grant colleges, experiment station committee on organization and policy, a science roadmap for the future. www.nasulgc.org/comm_food.htm the economist commodity-price index a gap analysis methodologhy for collecting crop genepools: a case study with phaseolus beans key: cord- -z oya kz authors: liu, meijun; bu, yi; chen, chongyan; xu, jian; li, daifeng; leng, yan; freeman, richard barry; meyer, eric; yoon, wonjin; sung, mujeen; jeong, minbyul; lee, jinhyuk; kang, jaewoo; song, min; zhai, yujia; ding, ying title: can pandemics transform scientific novelty? evidence from covid- date: - - journal: nan doi: nan sha: doc_id: cord_uid: z oya kz scientific novelty is important during the pandemic due to its critical role in generating new vaccines. parachuting collaboration and international collaboration are two crucial channels to expand teams' search activities for a broader scope of resources required to address the global challenge. our analysis of , coronavirus papers suggests that scientific novelty measured by the biobert model that is pre-trained on million pubmed articles, and parachuting collaboration dramatically increased after the outbreak of covid- , while international collaboration witnessed a sudden decrease. during the covid- , papers with more parachuting collaboration and internationally collaborative papers are predicted to be more novel. the findings suggest the necessity of reaching out for distant resources, and the importance of maintaining a collaborative scientific community beyond established networks and nationalism during a pandemic. newton developed the basis for his groundbreaking work during the great plague, having far-reaching impacts on classical physics and many other domains. the experience of newton has been raised repeatedly in the context of the global covid- pandemic. will scientists be more novel during the pandemic like newton? truly breakthrough ideas rarely occur overnight, while novelty is sometimes sparked by extreme time pressure and urgent needs. these two points of views provide contrasting possibilities regarding the association between scientific novelty and the disruption of a pandemic. as the seed of innovation ( ), scientific novelty could be considered the recombination of prior knowledge components in an unfamiliar or atypical fashion ( ) ( ) ( ) . novel research is more likely to advance the frontier of scientific discoveries, and becomes more important than ever during the pandemic because of the urgent need for new vaccines for public health. scientific teams' search activities that are important for scientific novelty might be reshaped during the pandemic, while it is unknown whether parachuting collaboration and international collaboration that are closely associated with teams' "search space" are accelerated or reversed. during the pandemic, the lack of access to resources that might be only available in special localities motivates scientific teams to overcome the constraints of localized search by collaborating outside their established networks and across national borders ( ) . on the other hand, the novel global challenge and the urgent need for effective vaccines might encourage the adjustment of team assembly towards effective teamwork that produces new ideas by including newcomers beyond team members' pre-existing relationships and reaching international networks ( ) ( ) ( ) . given the importance of international collaboration and parachuting collaboration measured by the faction of team members without prior collaboration in a team, in reaching out for distant resources and producing novel knowledge, these two types of collaboration patterns might increase during the pandemic. however, the urgent pandemic situation might lead to a reduction in search and outreach ( ) and increased costs of communication and coordination, which thus causes a decline in these two collaboration patterns. a disaster of global scale, as of september , covid- has infected at least . million people, proving deadly to , individuals. we use this unexpected outbreak as a natural experiment and find that ( ) coronavirus research became far more novel during the pandemic; and ( ) scientific teams involved more parachuting collaboration defined as collaboration between two authors without prior collaboration, while international collaboration suddenly decreased; and ( ) during the pandemic, papers with a higher parachuting ratio, and internationally collaborative papers are predicted to be more novel. building on the "knowledge recombination" theory ( ) and the combinatorial perspective of novelty ( , ) , we assess papers' scientific novelty by quantifying how extraordinary a combination of bio-entities is in a coronavirus-related paper using biobert (bidirectional encoder representations from transformers for biomedical text mining) ( ), a language model that is pre-trained on million pubmed articles. in medicine, represented by bio-entities (e.g., drug, disease, and gene) in publications ( ) , knowledge is combined to form new ideas; especially uncommon combinations of bio-entities form especially novel ideas ( ) . in this study, when the distance between two bio-entities is in the upper th percentile in the distribution of the distance of all entity pairs extracted from , coronavirus research articles, the combination of two bio-entities is considered novel. paper's novelty score is measured by the fraction of novel entity combinations extracted from the paper, ranging between and . the higher paper's novelty score, the more novel entity combinations in the paper. the framework and an illustrative example of calculating papers' novelty scores are shown in fig.s in the supplementary material. the details of quantifying papers' novelty regarding entity combinations are shown in measuring scientific novelty of papers in the supplementary material. we treat the outbreak of covid- as a natural experiment to explore how scientific novelty, parachuting collaboration and international collaboration evolve during such a disaster. we use a difference in differences (did) approach based on , coronavirus articles published from january to april by the top prolific countries ranked by the number of coronavirus papers published during the study period. the details of the data source and sample selection are shown in the section of data and sample in the supplementary material. we examine the association between monthly change in scientific novelty, parachuting collaboration ratio and international collaboration of coronavirus papers by sampled countries and their status as a confirmed covid- infection site from january to april by month. variables and the did strategy are specifically reported in the sections of variables and method: a difference in differences strategy, respectively in the supplementary material. our findings suggest that coronavirus research has become more novel since the outbreak of the covid- . after , the year of the covid- outbreak, there is a dramatic increase in the average novelty score of global coronavirus research relative to the earlier years (see fig. (a) ). since the global first covid- case was officially confirmed in december , the average novelty score of global coronavirus papers sharply went up (see fig. (b) ). the results of the did regression show that "treated" countries (i.e., countries with an infection) have a . (p< . ) higher novelty score than "untreated" countries (i.e., countries without infection)-this is an increase of . % standard deviation (see column in table s in the supplementary material). the estimated dynamic impact of a covid- outbreak in a creative ideas could be reflected by two dimensions, namely usefulness and novelty. novelty is the key distinguish feature of creativity beyond ideas that are well conceived. the notion that considers novelty as a process of recombination has bene shown as valuable, while some criticized that many unusual configurations might be worthless. in this study, we only consider the aspect of novel recombination of knowledge as for recently published papers, the time is too short to receive citations from subsequent research. we conduct analyses of the relationship between coronavirus papers' novelty and citation, and do not found that papers' novelty is significantly negatively related to citations papers gained, which suggests that at least, novel papers according to our definition, are not useless papers. the details of the relationship between papers' novelty score and citations paper received are illustrated in the section of the relationship between papers' novelty scores/teams' characteristics and citations in the supplementary material. country on the country's scientific novelty score of coronavirus literature is shown in fig. (a) , which illustrates a jump in countries' average novelty scores in the first month (i.e., t+ where t refers to the month the first covid- case was confirmed in a country) after the first occurrence of covid- case in a country, while there is no significant difference between treated and untreated countries before the first covid- case in the country. the regression results show that more covid- cases and deaths in a month predict a higher scientific novelty (see table s in the supplementary material), suggesting that the increased scientific novelty might be associated with the severity of the local outbreak. after the global first covid- case, fig. (b) presents a sudden decrease in global coronavirus papers' international collaboration ratio. did estimates suggest that countries' parachuting collaboration ratio increased by . % (coefficient: . , p < . in column in table s in the supplementary material) after the report of the first covid- case in a country. this suggests that after the first case confirmed in the country, more parachuting collaboration is found in coronavirus research for the country. we further find that country's proportion of internationally collaborative papers in coronavirus research shrunk by . % (coefficient: - . , p < . in column in table s in the supplementary material) after the occurrence of the first covid- case in a country. the dynamic impact of the first covid- case in the country on its average parachuting collaboration and international collaboration ratio is estimated in columns and in table s in the supplementary material, respectively, and is illustrated in fig. we also observe a sudden change in scientific novelty, international and parachuting collaboration ratio around the year of the outbreak of sars, with the same direction we find during the covid- (see fig. (a) ). figure.s (a) in the supplementary material illustrates papers' estimated novelty score estimated by a regression model including interaction terms between papers' parachuting collaboration ratio or international collaboration and the occurrence of the first global covid- case. it suggests that before covid- , papers' parachuting collaboration ratio is significantly negatively related to papers' novelty scores. however, this relationship turns significantly positive for papers published during the covid- . this pattern holds for the association between papers' international collaboration and novelty scores ( fig. s (b) in the supplementary material). the subsample analyses also confirm these findings (see columns and in table s in the supplementary material). the methods to conduct sub-sample analyses and regression analyses including the interaction terms between papers' parachuting collaboration ratio/international collaboration and the occurrence of the first global covid- case are shown in sub-sample analyses and regression including interaction terms in the supplementary material. our results show that in the initial period following a coronavirus outbreak, scientific novelty dramatically increased, which suggests scientists' efforts to try novel recombination of existing knowledge to combat this global pandemic. the fraction of parachuting collaboration, i.e., collaboration between team members without prior collaboration, in the scientific teams of coronavirus research grew, while the proportion of internationally collaborative papers sharply decreased. in the pre-covid period, parachuting collaboration is significantly negatively associated with paper's novelty score, while this relationship turns significantly positively related to paper's novelty during the pandemic. teams' characteristics are important determinants of team efficiency and the production of novel knowledge. parachuting collaboration, the foil of repeat collaboration, entails both advantages and costs that influence teams' novelty, making its contribution to scientific novelty not straightforward. unlike repeat collaboration, parachuting collaboration involves more search, coordination and innovation costs, less risk-sharing, trust and reciprocity, which might dampen scientific novelty ( , , ) . however, parachuting collaboration allows pooling together a broader scope of information, data and resources outside the preexisting relationships and conflicts that might improve scientific novelty ( , ) . during the pandemic, papers produced by teams with a larger proportion of parachuting collaboration are more novel, which suggests greater importance of a broader scope of search activities and quick access to non-local information that is only available outside teams' pre-existing networks in tackling global challenges timely. we find that internationally collaborative papers are more novel than their counterparts during the pandemic. international collaboration trends to produce more conventional knowledge combinations since transaction costs and communication barriers to international collaboration might hinder novelty ( ) . this is consistent with what we find in the normal science period. however, during covid- , producing novel knowledge might require collaborative efforts across national borders that pool global resources more than ever. the best example is the discovery of the causative agent of sars, a result of close international collaboration among laboratories from countries. most science of science studies assumes that the research system operates with institutional stability, in the framework of "normal science" ( ) . with rapidly developing globalization and the increasing complexity of economic, societal, political and environmental issues, the traditional perception of normal science is no longer sufficient to address issues or problems in the scientific community. local and even global research systems could be immediately influenced by exogenous and unexpected events. this study provides evidence on how science progresses differently during a pandemic from a normal science period. the left vertical axis in each sub-figure indicates the novelty score of papers and the right one refers to parachuting/international collaboration ratio. in sub-figure b, the study period is from january to april , with a total of months. the global first covid- case is officially reported in the th month, december ; the number in the x-axis indicates n month since the start of the study period (jan ). the solid and dash lines indicate the actual value and the predicted value of variables based on the trend of variables before december , respectively. the purple and blue dash lines indicate the time series prediction of parachuting/international collaboration ratio, respectively. the orange dash line refers to the predicted values for novelty score after a linear regression where country's monthly novelty score is the dependent variable, and explanatory variables include country's parachuting/international collaboration ratio, team size and productivity, with all values of explanatory variables in and after december replaced by their time-series predicted values. in this way, we construct a counterfactual-like framework where the novelty score evolves if covid- did not occur, in other words, all explanatory variables follow their trends in pre-covid period after december . the shaded areas represent upper and lower bounds of % cis. fig. . the did estimates of the relationship between the occurrence of the first case of covid- in the country and countries' average novelty scores, parachuting collaboration ratio and international collaboration ratio in a month. t-n indicates n month(s) before the month (t ) when the first covid- case was confirmed in the country, and t+n indicates n month(s) after t . ***, ** and * represent significance at the %, %, and % level. the shaded areas represent upper and lower bounds of % cis. figs. s -s tables s -s references two major datasets are used in this study, with one including publication data on coronavirus research that is used to measure an individual paper's scientific novelty and capture authors' country information, and another including country-by-country patient data about covid- that is used to identify the timing when the first covid- case is confirmed in a country. publication data on coronavirus research is collected from the covid- open research dataset (hereafter cord- ) that covers , research articles about covid- and related historical coronaviruses, such as sars and mers, that were published during the -april period. this dataset includes title, abstract, author name, doi, pubmed id, and publication date. this dataset is constructed by the allen institute for ai and other leading research groups to facilitate researchers to discover relevant information more quickly from the literature. cord- papers are sourced from pubmed central, biorxiv and medrxiv, with titles, abstracts or full text including the following keywords: "covid- " or "coronavirus" or "corona virus" or " -ncov" or "sars cov" or "mers-cov" or "severe acute respiratory syndrome" or "middle east respiratory syndrome". cord- dataset has been recently used in analyzing coronaviruses literature ( - ), and is viewed as a reliable data source to map coronavirus-related research. the distribution of papers per year in cord- is illustrated in fig. s (a), which indicates a sudden growth of papers in the years of significant pandemics. we identify authors' country information based on authors' address information provided by cord- dataset and the million pubmed dataset that covers - with author names disambiguated ( ) . based on doi and pubmed id provided in cord- dataset, , cord- papers are linked to their versions in the pubmed dataset where all author names have been disambiguated and thus the following information of cord- papers was obtained: authors' unique identifiers and authors' address information. authors' unique identifiers allow us to know whether authors in a paper have collaborated in the past according to their publications records in the pubmed database, which enables us to identify parachuting collaboration. authors' affiliation information helps us to identify country names from authors' address information in each article by manually merging variations (e.g., iso two-letter or three-letter country codes, alternative country names, country names in other languages, and country names with typos) of country names into the same country. finally, standard country names corresponding to authors' locations in , cord-papers are found. papers with the number of authors larger than have been removed as the inclusion of papers with hyper-authorship might make the calculation of team variables biased because of the outliers. additionally, we use the patient data on covid- derived from the website of our world in data that covers countries from december to may, to capture the timing when the first covid- case is officially confirmed, and the daily number of new covid- cases and deaths in each sampled country during the december -april period. the sampled countries account for . % of cases and . % of deaths related to covid- from december to april . the distribution of covid- cases and deaths in each month is illustrated in fig. s . the final dataset used for the regression analysis includes , research articles published from january to april by the top prolific countries that are ranked by the number of coronavirus-related papers published during the study period. the research goal of this study is to compare monthly changes in countries' scientific novelty before and during the covid- . the period of janurary- november is considered a sufficient time window to present scientific novelty in the pre-covid- period ( ). to measure the country's productivity, we use a full counting method ( ) based on the authors' address information. for example, for a paper authored by two scientists with chinese affiliations, one scientist with a us affiliation and three scientists with uk affiliations, china, the us and the uk get two, one and three papers, respectively. hence, overall six publications are allocated to these three countries. more than countries published coronavirus research during the study period, among which the top prolific countries are selected as the sampled countries. the variable that measures the monthly average novelty score for countries that did not publish any or publish very few coronavirus papers would be missing. the observations that have a missing value for any one of the variables used in the regression model would be dropped by stata. this is why we limit the regression analysis to the top most prolific countries, which account for more than . % of the total coronavirus-related research articles over the study period. the productivity of the sampled countries/regions is shown in table s . the distribution of cord- papers by month and country from january to april is indicated in fig. s . entities extracted from cord- papers' titles and abstracts are the basic elements used for calculating novelty scores of entity combination in each cord- paper and thus allow capturing the changes in the sampled countries' novelty score of coronavirus research by month. we extract bio-entities from titles and abstracts of cord- papers from january to april using pubtator central (ptc), a web-based application that automatically tags the input text with standardized biological entities ( ) . as ptc has annotated entities for all the papers indexed by pubmed, for those cord- papers that have pubmed ids, we programmatically retrieved their annotations by submitting pubmed ids, in batches of to ptc. for those not having a pubmed id, we first submitted the request with their abstracts and titles, in which entities will be annotated by ptc server, then retrieve the annotated files by submitting the session id returned by the previously submitted request. , unique bio-entities from , cord- papers were identified by ptc and were automatically categorized into four types: species, disease, gene and chemical. the major reason why ptc fails to extract any entities from titles and abstracts of % cord- papers is that terms in those papers' titles and abstracts do not include any standardized bio-concepts detected by ptc. the distribution of entities extracted from cord- papers by type is illustrated in fig. s . measuring papers' novelty score using biobert building on the knowledge recombination theory ( ) and the perspective of combinatorial novelty ( , ) , an indicator that measures the degree of novelty to which knowledge entities are combined in a paper has been proposed. in medicine, these knowledge entities can be represented by biological entities (e.g., drug, disease, and gene) in publications. innovative discoveries and creative ideas usually stem from the recombination of more distant and diverse sources ( , ( ) ( ) ( ) . novelty is a recombination of pre-existing knowledge components in an atypical way ( , ) . the key idea of the entity-based approach proposed in this study is that two entities that are more distant in the preexisting knowledge base, i.e., million pubmed articles, their combination is perceived more novel. to measure the novelty of entity combination of cord- papers, we use biobert (bidirectional encoder representations from transformers for biomedical text mining) to capture the distance between two bio-entities in each entity pair extracted from cord- papers. biobert is a language model pre-trained on biomedical literature, pubmed articles ( ) . following the structure of bert by devlin, chang, lee and toutanova ( ) , biobert consists of multi-layer bi-directional transformers and is pre-trained by masked language model and next sentence prediction tasks. biobert can generate a contextual representation for biomedical corpora, which allows different embeddings for the same word in different contexts, instead of producing context-independent word embeddings like word vec ( ) or glove ( ) does. biobert has hidden layers. the first layer, also known as input embedding or sub-word embedding layer, is the sum of token embeddings that are obtained from the wordpiece tokenizer ( ), the segmentation embeddings and the positional embeddings. the last layer is the contextual (sub-word) representations (token-level). biobert has five versions ( ), among which we use the version of biobert-base v . that is pre-trained on pubmed million articles with titles and pre-trained for one million steps based on bert-base-cased with the same vocabulary. the batch size for this model is set to and the maximum sequence length is set to tokens. in the former stage, we recognized bio-entities using pubtator and generated entity pairs from cord- papers. we generate a sub-word representation for each bio-entity extracted from cord- papers. the pipeline is shown in fig. s . then we calculate bio-entities' distance between the two sub-word representations for each bio-entities pair generated from cord- papers. in fig. s , entity n is segmented by the wordpiece tokenizer ( ) into a sequence of sub-words to mitigate the out-of-vocabulary (oov) problem. (cls) is added at the beginning and (sep) is added at the end of, and get sub-words s={ , , , ..., , .. for example, entity "coronaviruses" is transformed into "(cls) co##rona##virus##es (sep)". the segmented entity s is then fed into the biobert. we use the last layer of biobert as the contextual representation, which generates a sequence of sub-word representations v in ×( + ) where d denotes the dimensions of a hidden layer in biobert and i indicates the number of tokens except cls and sep for entity n. for instance, for the entity of "coronaviruses", the model generates a vector, with × dimensions. the sub-word representations of cls and sep are ignored and the rest of the sequence of sub-word representations v are fed into average pooling that is used to calculate the average for each patch of the feature map with the kernel size of (number of tokens, ) to get the final vector v in . based on the embedding of bio-entities extracted from cord- papers, we calculate the cosine distance defined in equation between two resulting vectors corresponding to each entity in an entity pair extracted from cord- dataset ( ) where and indicate two entities in an entity pair; • refers to the dot product of and ; ‖ ‖ ‖ ‖ means the product of 's euclidean norm and 's euclidean norm. we extract , unique bio-entities using pubtator central from titles and abstracts of cord- papers published from january to april and pair them up (i.e., − , , … ). the cosine distance of two entities in each of , entity pairs detected in cord- paper is captured from the resulting embedding using biobert that is pre-trained on million pubmed articles. the distribution of the distance between two entities in entity pairs extracted from cord- papers is shown in fig. s (a) . we consider an entity pair in which the distance of two entities is in the upper th percentile of this distribution as a novel entity combination. the novelty score for each paper is measured by the proportion of novel entity pairs according to our definition of novelty entity combination to the possible number of entity pairs in a paper. the formula used to calculate the novelty score for a paper is shown in equation . where denotes paper ; indicates the number of bio-entities extracted from paper ; refers to the number of combinations of two that can be drawn from the set of n bio-entities extracted from paper , i.e., the number of entity pairs generated by n bio-entities; denotes the number of entity pairs in which two entities' distance is in the upper th percentile of the distribution of the distance of two entities in all entity pairs generated from cord- papers. for example, for a paper that contains three bio-entities (i. e., entity a, b and c) , the number of entity pairs for this paper is three. if the distance between a and b is in the upper th percentile of the distribution shown in fig. s (a) , the novelty score for this paper is / . the higher the novelty score, the more novel entity combination in a paper. the distribution of cord- papers' novelty scores is indicated in fig. s (b) , suggesting that most of cord- papers include no novel entity combination. this study investigates the relationship between the country-level monthly change in scientific novelty regarding entity combination of coronavirus papers and the occurrence of the first covid- case in the country in a given month from january to april . the major independent variable is whether the first case of covid- (covid ) has been confirmed in the country by the month. we identify the month when the first case of covid- is officially confirmed in each of sampled countries according to the patient data from the website of our world in data. for example, china is the country where the first case of covid- in the world was found in december , followed by the us (jan ), the uk (jan ) and so forth. once the first covid- case has been confirmed in the country, the country gets treated in the month and the succeeding months. the distribution of treated countries (i.e., the countries where the first covid- case has been confirmed) and untreated countries (i.e., the countries where the first covid- case has not been confirmed) by the month is indicated in fig. s , suggesting that for most of the sampled countries, the first case was detected in either jan or feb . all sampled countries have been exposed to covid- by the end of the study period. paper-level variables: the way to generate the novelty score of each paper is explained in the section of measuring papers' novelty score using biobert and the formula to calculate a paper' novelty score is shown in equation . besides papers' novelty scores, we are also interested in the change of papers' parachuting collaboration ratio and international collaboration before and during the pandemic. parachuting collaboration is defined as a co-authorship in which two authors never collaborated in the past. parachuting collaboration ratio for a paper indicates the fraction of author pairs where two authors did not collaborate in the past to the total number of author pairs in a paper, measuring the degree to which parachuting collaboration is involved in the team, which is defined in equation where denotes paper ; refers to the number of combinations of two that can be drawn from the set of authors listed in paper ; indicates the number of author pairs in which two authors have no prior collaboration. the higher the parachuting collaboration ratio for a paper, the more parachuting collaboration involved in the team of the paper. international collaboration for a paper is a binary variable that is determined by whether authors listed in a paper are from at least two countries. it is one if at least two authors are from different countries, and zero otherwise. we also calculate team size for each paper defined as the number of authors listed in a paper as a control for papers' novelty score, since team size is considered an influential factor of scientific novelty from prior literature ( , ( ) ( ) ( ) . country-level variables: all paper-level variables need to be aggregated to the country level since this study examines the relationship between countries' scientific novelty and the occurrence of the first covid- case in the country. based on a full counting method ( , ), we use an example to demonstrate how paper-level variables are calculated to country-level variables. as shown in fig. s , there are two papers, p by five authors from three countries (i.e., c , c and c ), and p by three authors from two countries (c and c ), respectively. a who is an author of p , and a who is in the author lists for p and p , both belong to the country, c . we generate a vector, { , ,…, ., for p , and a vector, { , ,…, ., for p . the element in the vector represents a variable for a paper, such as paper's novelty score ( ) , parachuting collaboration ratio ( ), whether or not the paper is internationally collaborative ( ) and team size ( ). for example, and indicate novelty score for p and p , respectively. c 's average novelty score is the sum of , and weighted by the unique number of author-paper pairs (i.e., a -p , a -p and a -p ), three. similarly, c 's average novelty score is equal to the sum of , and weighted by the unique number of author-paper pairs (i.e., a -p , a -p and a -p ), three. the country-level versions for the remaining three paper-level variables are shown in the table in fig. s . the dependent variable is a country's average novelty score (novelty score) of entity combination for papers by this country published in a given month, which quantifies the monthly average extent to which entities are combined rarely for knowledge production of the country. the higher the novelty score, the more novel countries' knowledge production in a month. we are also interested in the association between new covid- cases and deaths, and countries' scientific novelty. therefore, the daily numbers of new covid- cases (covid case) and deaths (covid death) confirmed in each sampled country are aggregated to the month level and considered two explanatory variables. various characteristics of scientific teams might be related to novelty, such as team size ( , ) , international collaboration ( ) and collaboration of two authors who have not worked with each other before ( ) . to control these influential factors, the following control variables are introduced to the model. the country's monthly average number of authors in cord- papers is used to measure the average team size (team size) of coronavirus papers in a country. the proportion of internationally collaborative papers in a country in a given month is used to reflect the degree to which the papers are internationally collaborative (international collaboration ratio). the country's average parachuting collaboration ratio (parachuting collaboration ratio) is used to measure the extent to which parachuting collaboration is involved in teams for cord- papers published in the month. summary statistics of variables and the correlation matrix across variables are shown in tables s and s , respectively. we use the unexpected outbreak of covid- as a natural experiment to explore how scientific novelty evolves before and during the pandemic by using a difference in differences approach based on the data on sampled countries over months from january to april. our major goal is to estimate the association between the countries' monthly average novelty scores of entity combinations for all papers published in a given month and whether the first covid- case in a country has been confirmed by that month. to estimate the potential impact of the outbreak of covid- in the country on scientific novelty of entity combination, we regress the dependent variables, i.e., novelty score, on whether the first case of covid- in the country (covid ) has been confirmed by the month and other covariates that might influence scientific novelty as shown in equation . we apply an ols linear model that contains fixed effects for country, , those for month, , to control the time-invariant and countryinvariant factors. the coefficient on covid is a before-after estimate of the impact of the pandemic on scientific novelty. , = + , + , + + + ( ) to investigate the dynamic effect of the outbreak of covid- in the country on countries' novelty, we introduce a set of dummies variables that reflect the timing of the occurrence of the first cases. if the outbreak of covid- in month t truly impacts countries' novelty, we expect to find the effect coming solely after the first cases are confirmed with similar patterns of change for the treatment and control groups before the first cases are detected. following ( ), we test this by replacing covid in equation by a set of dummies variables that relate countries' novelty score to the outbreak of covid- in the prior, current and succeeding years: where t refers to the month when the first case is confirmed: t-n indicates whether the observation occurs n month(s) before the month of the first case; and t+n represents whether the observation occurs n month(s) after the month of the first case. the outbreak of the covid- that causes an effect in a given month can be effective in t or later years, but it cannot have an impact before the month of the outbreak. controls include variables that might be related to scientific novelty: countries' monthly average parachuting collaboration ratio, the fraction of internationally collaborative papers by the country in the month, the average team sizes of papers by the country in the month and countries' monthly productivity in coronavirus research. similarly, using the did strategy, we investigate the association between countries' parachuting collaboration ratio in the month/the fraction of internationally collaborative papers by the country in the month and the outbreak of the covid- in the country. the fixed effects of countries and months are included. to explore the relationship between the severity of covid- in the country and the country's novelty score, we regress the country's average novelty score in the month on the monthly number of new covid- cases and deaths. control variables are the same with those in equation . fixed effects of country and month are included. by conducting sub-sample analyses and regression analyses including interaction terms, we investigate the association between the occurrence of the first global covid- case and papers' novelty score, as well as the relationship between papers' novelty score and two collaboration patterns (i.e., papers' parachuting collaboration ratio and whether the paper is internationally collaborative) at the paper level in the normal science period and during covid- . the association between papers' novelty scores and the occurrence of the first global covid- case is estimated by equation : where i denotes a paper; novelty score indicates the proportion of entity pairs that are highly distant to the possible entity pairs in a paper; covid is a binary variable that is one if the paper is published in and after december , and zero otherwise; parachuting ratio indicates the proportion of author pairs in which two authors have no prior collaboration in the past to the possible author pairs in a paper; international collaboration is a binary variable that is one if the team includes authors from at least two countries, and zero otherwise; team size indicates the number of authors listed in a paper; fixed effects regarding papers' publication year ( ) is included; to explore the relationship between parachuting/international collaboration and papers' novelty score before and during the covid , the interaction terms between parachuting/international collaboration ratio and the occurrence of the outbreak of covid- are introduced to the model, i.e., ℎ × , and × . sub-sample analyses are conducted to confirm the relationship between papers' novelty score and two collaboration patterns before and during the pandemic by separating all coronavirus papers into two groups, with papers published before the occurrence of the first global covid- case, i.e., december , and those published after that month. then, we estimate the relationship between papers' novelty and two collaboration patterns based on these two groups of papers, separately. we explore the association between paper's novelty scores and citations the paper received in a two-year (citation_ ), five-year (citation_ ), ten-year citation (citation_ ) window and whether or not the paper is the top % highly cited papers (top % citation) among the papers published in the same year. cord- articles are linked to their versions in microsoft academic graph dataset (mag) according to papers' doi and pubmed id. mag includes more than million publication records and their metadata (e.g., doi, title, journal/conference, keywords, fields/disciplines, abstract, authors and their affiliations, etc.), as well as the more than . billion citation relationships among them. we found that , cord- papers get at least one citation. equation is used to estimate how papers' novelty scores and teams' characteristics are related to papers' citations. = + + ℎ + + + + + ( ) where i denotes a paper; citation indicates citation counts papers received in a two-year, five-year or ten-year citation window; novelty sore indicates the proportion of entity pairs that are highly distant to the possible entity pairs in a paper; parachuting collaboration ratio indicates the proportion of author pairs in which two authors never collaborated in the past to the possible author pairs in a paper; international collaboration is a binary variable that is one if the team includes authors from at least two countries, and zero otherwise; team size indicates the number of authors listed in a paper; fixed effects regarding papers' publication year is included. the equation is estimated by ordinary least squares regression models (ols). the results are shown in table s . papers' novelty scores are insignificantly negatively related to citations of papers in different time windows, and whether the paper is the top % receivers of citations among papers published in the same year. this result suggests that papers in which entity combinations are novel are not "useless" papers, i.e., papers that are less cited. besides, papers' parachuting collaboration ratio, and whether the paper is international collaborative are significantly negatively related to citations papers received, irrespective of the length of the citation window. papers' team size is significantly positively correlated to citations of papers. we use multiple strategies to confirm the major findings of this study. first, we change to the th percentile as the threshold of the location of the distance between two entities in a novel entity pair discard bio-entities that appeared less than five times in cord- papers, and conduct all the analyses. . % of bio-entities only appear once in cord- papers, and the inclusion of bio-entities with a small frequency might make the distance between entities unreliable. we discard bio-entities with a total frequency lower than five, with , entity pairs remaining. we still use the biobert model pre-trained on million pubmed articles to calculate the distance between entities for each entity pair obtained. besides, we use the th percentile as the threshold of the location of the distance between two entities in a novel entity pair. generally, we obtain consistent results shown in tables s to s . most studies on science of science assume that the system operates under the condition of institutional stability. the current studies on the scientific community are restricted to the framework of "normal science" ( ) which is analogous to a gradually evolving ecological system proposed by charles darwin. but what would the scientific community react if the stable social and institutional conditions are punctuated by unexpected and exogenous events, such as natural or human-made disasters? the ongoing covid- pandemic leads to significant disruptions on every aspect of economy and society, while little is known about whether and how extreme events or shocks, such as pandemics, reshapes the scientific community and scientific production, especially collaboration and innovation, as well as the nature and magnitude of this impact. most studies that evaluate disasters mainly focus on the impacts on economy ( , ) , politics, public health system ( , ) , psychology ( , ) , human life, social infrastructure, environment ( ) and so forth. as an important component of society, science should be also impacted, whereas how science responds to disasters remains open. the outbreak of the covid- pandemic stimulates the emerging studies on this topic, while neither survey-based research nor studies that focus on the short-term effect of a particular event ( , ) fails to capture an overview landscape of the effect of pandemics on science in the long run. there is a lack of understanding of how disasters influence collaboration and innovation, with only a few studies providing initial evidence on both disruptive and positive changes in research productivity after disasters. on the one hand, disasters increase knowledge production linked to the disaster ( , ) and lead to changes in research topics. on the other hand, evidence shows a negative impact of disasters on research outside the related topics. a recent study shows the expansion of knowledge related to the disaster after the fukushima daiichi accident ( ) . the analysis of terrorism studies from to presents a positive relationship between the occurrence of terrorism events and productivity in the domain, with a declining trend of this productivity ( ) . this study also indicates after the / attacks, the terrorismrelated academic literature has grown substantially in the us. however, using the data on journals in material science, magnone ( ) find the number of submitted papers and the number of contributing authors in the areas affected by disaster decrease immediately after japan's triple disaster. an analysis of the evolution of research topics pertaining to the chernobyl accidents suggests that disasters could generate new scientific trends by motivating scientists to identify the important research problems caused by the disaster that requires solutions ( ) . specifically, in the early years following the disaster, publications tend to address research questions in biochemistry, genetics and molecular biology, while the topics change to humanity-and environmentrelated topics in later years ( ) . a recent survey including , pis in the us and european countries shows how scientific workforce is affected by the outbreak of the covid- , as well as how research output is influenced in the near future ( ) . this survey finds a dramatic decline in time spent on research on average, especially on laboratory-based research after the onset of the pandemic with significant heterogeneities due to differences in fields, genders and individual characteristics. another strand of the literature shows that the structure of scientific collaboration is impacted by disasters in both directions. with several exceptions, most literature provides descriptions of collaboration patterns after the disasters, failing to show a comparison between pre-and post-disaster periods ( , , ) . a study found that scientific teams become more collaborative and more productive with new collaborative relationships developed following natural disasters ( ) . however, a recent study reveals smaller-sized teams on coronavirus-related research during the pandemic relative to those before the outbreak of the covid- ( ). this study also indicates scientific teams with fewer nations, despite an increasing level of collaboration between china and the us. existing approaches that measure scientific novelty as one aspect that reflects the core value in science, creativity or novelty is of great importance for scientific progress ( ) ( ) ( ) . innovation is highly recognized in the research system and is often associated with critical criteria based on which decisions of funding allocation, hiring, promotion and scientific awards are made ( ) . because of its significant importance, extensive efforts have been made to measure the degree to which a scientific discovery provides unique knowledge that is unavailable from prior studies, and explore factors that influence the creation of innovation. in the early years, novelty is often evaluated through peer reviews or surveys ( ) ( ) ( ) , which is practical only on a small scale. the development of computing power and enriched bibliometric data encourage the advancement in measuring various aspects of scientific discoveries including novelty. the first approach considers novelty as the degree to which scientific discovery is reused by subsequent literature regardless of the intrinsic quality of the study ( ) . therefore, it is argued that citations could be a measure of usefulness and thus a proxy for creativity ( ) . integrating the quality aspect of research articles, the second approach focuses on either the newness or the diversity of knowledge, with the first one related to the introduction of a new concept or objective in a study, and another linked to a broader range of knowledge embedded in research. for example, the novelty of a life sciences study is measured based on the age of keywords assigned to the article, which captures the extent to which a scientist's work is novel relative to the world's research frontier ( ) . in the field of biochemistry, another strategy to measure novelty is based on the introduction of a new chemical entity in research ( ) . the second strategy that focuses on the quality of scientific discovery is to measure the diversity of technological domains a patent cites using herfindahl-type index of patent class cited by the focal patent ( , ) . the combinatorial perspective of novelty is often applied in measuring scientific novelty or originality. novelty in science, technology and artistic creation, is often conceptualized as recombination of antecedent knowledge elements in an atypical way ( , , ( ) ( ) ( ) ( ) , which has become standard in the study of innovation. for example, according to schumpeter ( ) , "innovation combines components in a new way, or that it consists in carrying out new combinations." from nelson and winter ( ) , the creation of novelty in various fields ranging from art, science to practical life, is a result of the recombination of pre-existing conceptual and physical materials. an invention is considered as either a new combination of components or a new relationship between previously combined components ( ) . building upon the perspective of combinatorial novelty, some researchers view novelty as a new or unusual combination of pre-existing knowledge components that could be operationalized by patent classes ( ) , keywords ( , ) , referenced articles ( , ) , referenced journals ( , ) and chemical entities ( ) . fig. s . an example demonstrating the procedure to aggregate four paper-level variables to the country level. the element in the vector represents a variable for paper , such as paper's novelty score ( ), parachuting collaboration ratio ( ), whether or not the paper is international collaborative ( ) and team size ( ) fig. s . an example of calculating a paper's novelty score. and indicate papers and entities respectively. the formula used to calculate the novelty score for a paper is shown in the following equation. where denotes paper ; indicates the number of bio-entities extracted from paper ; refers to the number of combinations of two that can be drawn from the set of n bio-entities extracted from paper , i.e., the number of entity pairs generated by n bio-entities; denotes the number of entity pairs in which two entities' distance is in the upper th percentile of the distribution of the distance of two entities in all entity pairs generated from cord- papers. for example, for paper that contains three bio-entities (i.e., , and ), the number of entity pairs for this paper is three. if the distance between and is in the upper th percentile of the distribution of the distance of two entities in all entity pairs generated from , coronavirus-related research articles, the combination of and is considered novel and thus the novelty score for this paper is / . the way to generate the novelty score of a paper is explained in the section of measuring papers' novelty score using biobert. notes: fixed effects regarding publication year are included; robust standard errors are in parentheses; ***, ** and * represent significance at the %, %, and % level. table s . the did estimates of the relationship between the occurrence of the first covid- case in the country and countries' novelty scores in the month when using the th percentile as the threshold of the location of the distance between two entities in a novel entity pair. ( ) notes: the independent variable in columns is whether the first covid- case in the country has been confirmed by the month; fixed effects regarding month and country are included; robust standard errors clustered by countries are in parentheses; ***, ** and * represent significance at the %, %, and % level table s . the ols estimates of the relationship between the logged number of new covid- cases and deaths in the country and countries' novelty score in a month when using the th percentile as the threshold of the location of the distance between two entities in a novel entity pair. ( ) notes: the independent variables in columns and are the monthly logged transformed number of new covid- cases and that of death, respectively; fixed effects country are included; robust standard errors clustered by countries are in parentheses; ***, ** and * represent significance at the %, %, and % level. table s . the estimated relationship between papers' novel scores and teams' characteristics when using the th percentile as the threshold of the location of the distance between two entities in a novel entity pair. ( ) notes: fixed effects regarding publication year are included; robust standard errors are in parentheses; ***, ** and * represent significance at the %, %, and % level table s . the did estimates of the relationship between the occurrence of the first covid- case in a country and countries' novelty scores and two collaboration variables in the month. ( ) notes: the independent variable in columns , and is whether the first covid- case in the country has been confirmed by the month; fixed effects regarding month and country are included; robust standard errors clustered by countries are in parentheses; ***, ** and * represent significance at the %, %, and % level notes: the independent variables in columns and are the monthly logged transformed number of new covid- cases and that of death, respectively; fixed effects of country and month are included; robust standard errors clustered by countries are in parentheses; ***, ** and * represent significance at the %, %, and % level table s . the estimated relationship between papers' novel scores and teams' characteristics. ( ) notes: fixed effects regarding publication year of papers are included; robust standard errors are in parentheses; ***, ** and * represent significance at the %, %, and % level. the direction of coefficient (- . , p> . in column of table s ) on international collaboration ratio on novelty score for papers published before covid- is opposite to that ( . , p< . in column of table s ) for papers published during covid- . furthermore, the coefficient (- . , p< . in column of table s ) of parachuting collaboration ratio on novelty score is significantly negative for papers published in the normal science period, whereas it ( . , p< . in column of table s ) becomes significantly positive for papers published during the pandemic. creativity and innovation in organizations atypical combinations and scientific impact recombinant uncertainty in technological search an evolutionnary theory of economic change consolidation in a crisis: patterns of international collaboration in covid- research team assembly mechanisms determine collaboration network structure and team performance human capital heterogeneity, collaborative relationships, and publication patterns in a multidisciplinary scientific alliance: a comparative case study of two scientific teams international research collaboration: novelty, conventionality, and atypicality in knowledge recombination knowledge of the firm, combinative capabilities, and the replication of technology biobert: a pre-trained biomedical language representation model for biomedical text mining building a pubmed knowledge graph tradition and innovation in scientists' research strategies economic action and social structure: the problem of embeddedness the effects of repeat collaboration on creative abrasion the structure of scientific revolutions consolidation in a crisis: patterns of international collaboration in covid- research cord- : the covid- open research dataset comprehensive named entity recognition on cord- with distant or weak supervision rapidly deploying a neural search engine for the covid- open research dataset: preliminary thoughts and lessons learned building a pubmed knowledge graph a review of the literature on citation impact indicators pubtator central: automated concept annotation for biomedical full text articles an evolutionary theory of economic change atypical combinations and scientific impact international research collaboration: novelty, conventionality, and atypicality in knowledge recombination bias against novelty in science: a cautionary tale for users of bibliometric indicators measuring originality in science recombinant uncertainty in technological search biobert: a pre-trained biomedical language representation model for biomedical text mining pre-training of deep bidirectional transformers for language understanding efficient estimation of word representations in vector space proceedings of the conference on empirical methods in natural language processing (emnlp google's neural machine translation system: bridging the gap between human and machine translation creativity in scientific teams: unpacking novelty and impact team-level predictors of innovation at work: a comprehensive meta-analysis spanning three decades of research large teams develop and small teams disrupt science and technology the effects of repeat collaboration on creative abrasion the impact of investor protection law on corporate policy and performance: evidence from the blue sky laws the structure of scientific revolutions what will be the economic impact of covid- in the us? 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knowledge creation in collaboration networks: effects of tie configuration incentives and creativity: evidence from the academic life sciences tradition and innovation in scientists' research strategies using a distance measure to operationalise patent originality university versus corporate patents: a window on the basicness of invention an evolutionnary theory of economic change hybridizing growth theory knowledge of the firm, combinative capabilities, and the replication of technology thematic fame, melodic originality, and musical zeitgeist: a biographical and transhistorical content analysis business cycles architectural innovation: the reconfiguration of existing product technologies and the failure of established firms. administrative science quarterly looking across and looking beyond the knowledge frontier: intellectual distance, novelty, and resource allocation in science breakthrough recognition: bias against novelty and competition for attention how novelty in knowledge earns recognition: the role of consistent identities when is an invention really radical?: defining and measuring technological radicalness. research policy key: cord- -p vqpazu authors: tsai, theodore f.; rao, raman d.s.v.; xu, zhi yi title: immunization in the asia-pacific region date: - - journal: plotkin's vaccines doi: . /b - - - - . - sha: doc_id: cord_uid: p vqpazu nan and inactivated vero cell-derived je vaccines from china, japan, and korea, regionally; live attenuated hepatitis a vaccine from china, regionally; live attenuated and inactivated pandemic and seasonal influenza vaccines from india and china, internationally; and oral cholera vaccine from vietnam, internationally). previously, asian manufacturers did not themselves market novel vaccines in europe or the united states, choosing to distribute their innovative products, such as acellular pertussis and live attenuated varicella vaccines, through multinational companies. however, an increasing global integration is taking place, as multinational companies acquire asian manufacturers (e.g., sanofi-aventis, france, acquired shantha biotechnics, india); asian companies acquire or obtain technologies and distribution rights from european countries (e.g., inactivated polio vaccine by serum institute of india ltd. acquiring bilthoven biologicals, netherlands; astellas, japan, acquiring recombinant influenza hemagglutinin from protein sciences, u.s.; thai government pharmaceutical organization acquiring chimeric je vaccine from sanofi-pasteur, france; and biological evans, india, acquiring je vaccine from intercell ag, austria); and vaccine codevelopment is agreed between entities in developed and asian countries (e.g., genetically modified, inactivated hiv vaccine codeveloped by sumagen, korea, and the university of western ontario, canada; mycobacterial proteinag a candidate tuberculosis vaccine codeveloped by tianjin cansino biotechnology, china, and mcmaster university, canada; universal influenza vaccine codeveloped by xiamen wantai and sanofi-pasteur, france; and novel pneumococcal conjugate vaccine codeveloped by sk chemicals, korea and sanofi-pasteur, france). , , the role of asian companies as developers and providers of neglected and improved vaccines for the region and, for developing countries more generally, is an emerging trend as illustrated by the joint research activity agreement between the national research council, canada, and the chinese national biotec group that covers development of h. influenzae type a and hib bivalent conjugate vaccine, novel mucosal adjuvants and therapeutic vaccines against helicobacter pylori infection, and cell culture manufacturing platforms for viral and vectored vaccines. a korean-manufactured biosimilar (generic) biological, infliximab, now is licensed in europe, a step toward commercial expansion of asian region-manufactured biologicals to developed countries. the emergence of asia as the base of new multinational vaccine companies with broad development, production, and distribution capabilities is on the horizon, even as consolidation of existing companies occurs elsewhere. [ ] [ ] [ ] the broad income range within countries in the region results in large population segments that have sufficient means to pay for vaccines out-of-pocket. even among countries that otherwise qualify economically for gavi funding (e.g., india), substantial numbers of families can avail themselves of vaccines not covered by the national epi, resulting in a two-tiered system of vaccination, paralleling the public-private dichotomy of healthcare delivery in general. practitioners serving these and expatriate families generally follow current u.s., european, or australian vaccine recommendations, or some modification of those schedules. five je vaccines have been developed and licensed in asian countries. the widely used first-generation inactivated suckling mouse brain (smb)-derived vaccine is being replaced rapidly in economically disadvantaged countries by the chinese developed and manufactured live attenuated or inactivated vaccine (sa - - strain) grown in primary baby hamster kidney (phk) cells and in higher-income countries with vero cell-derived inactivated vaccines (licensed in the united states, australia, canada, and europe, as well as several asian countries) or a replicating chimeric yellow fever-je virus recombinant vaccine (manufactured in thailand). details are provided in chapter . to control cases and occasional outbreaks of the far eastern subtype of tickborne encephalitis virus in northeastern china, the changchun biologicals institute developed a formalininactivated vaccine, derived from a human isolate, senzhang strain, and grown in phk cell cultures. related vaccines prepared from central european strains and distributed in europe are described in chapter . the kyasanur forest disease virus (kfdv) is a highly pathogenic member of the family flaviviridae causing a zoonosis, kfd, that is transmitted by the bite of infective ticks (haemaphysalis spinigera) primarily in its nymphal stage, and characterized by acute febrile illness with severe hemorrhagic manifestations. it was first described from outbreaks centered in karnataka state, india, among herders and villagers with forest exposure and was considered to be localized in the shimoga district area of the state. however, since first being reported in , the virus has been found in other areas of india including the kutch and saurashtra parts of gujarat state, andaman islands and west bengal. it is estimated that close to cases of kfd occur in india every year and, from to , among confirmed cases, were fatal. following the outbreak in india various vaccines including a formalin inactivated russian spring summer encephalitis virus, a russian spring-summer encephalitis virus-based mouse-brain vaccine, and a live attenuated vaccine that was serially passaged in tissue culture were tried but with limited success. finally, a formalin inactivated vaccine with the kfd virus grown in chicken embryo fibroblasts was tested in a large field trial from to among inhabitants of affected villages. the disease attack rates reported were . % ( / ) among persons receiving one dose and . % ( / , ) among recipients of two doses, respectively, compared to an attack rate of . % ( / , ) in unvaccinated persons, for vaccine efficacies of . % and . %, respectively. the vaccine was subsequently commercialized and is produced by the state institute of animal health and veterinary biologicals, hebbal, bangalore, and has been central to kfd prevention efforts in the state of karnataka. annual vaccinations have been done since in the shimoga and adjacent districts wherein two doses of the vaccine were administered in individuals to years of age at an interval of month. periodic boosters were also administered after to months. however, recent observations suggest a lower field effectiveness than had been reported previously, especially following a single dose, while overall coverage has also been low. between and , effectiveness among individuals perceptions of the value of vaccines and their risks also range widely, regionally and within individual countries, from largely enthusiastic acceptance and even demand for additional routine vaccinations (e.g., for je vaccine in southern and southeast asia) to a degree of skepticism equal to, if not more deeply and widely held, than vaccine hesitancy in europe and the united states. within the last years, japan discontinued routine childhood vaccine programs for combination measles-mumps-rubella, influenza, and je, and withdrew recommendations for the human papillomavirus (hpv) vaccine for adolescents, owing in several of instances, to incorrectly thinking that coincidental adverse events were causally related. the requirement for subcutaneous, as opposed to im administration for all vaccines, exemplifies the misattribution of adverse reactions, arising in this case from an extrapolation of muscle contractures resulting from repeated im administration of antibiotics, to other intramuscularly administered products, including vaccines. , the extrapolation has had unintended consequences of impeding the licensure of vaccines with newer adjuvants with mechanisms of action that require im administration. with the global spread of information, concerns over the thimerosal content of childhood vaccines and vaccine-associated autism have been as active a parental concern among middle-class families in developing countries as elsewhere. parental refusal of routine je vaccination in korea and significant declines in vaccine coverage occurred in a different context after seven cases of temporally related cases of anaphylactic shock and neurological disease, including five deaths, occurred in . the cases could not be excluded as causally related to administration of the mousebrain-derived vaccine, prompting a national debate and establishment of a vaccine adverse events reporting scheme, a national vaccine injury compensation system, and introduction of a live attenuated je vaccine derived from a nonneural tissue substrate. from this mosaic, we describe some common themes, highlighting representative approaches and unique issues that hold a wider interest. because they are covered elsewhere in this volume, we have not reviewed specific vaccines of regional concern (e.g., pandemic influenza and je vaccines) or vaccination topics common to developing countries (e.g., initiatives surrounding injection safety, measles and neonatal tetanus elimination, and polio eradication, nor financing mechanisms). we concentrate, instead, on other aspects of vaccine development and implementation, organized by the steps of vaccine development, approval, production, recommendation, and delivery. we also focus on childhood vaccines and vaccination and on selected countries in the region. japan is acknowledged as the innovator of several vaccines now used internationally, including acellular pertussis and live attenuated varicella vaccines, but other novel vaccines have been developed by japan, china, india, australia, and vietnam for region-specific needs (table . ). these include vaccines for je, hantaan (htn)-and seoul (seo) virus-related hfrs, russian spring-summer encephalitis, kfd, cholera, severe acute respiratory syndrome, and q fever. in addition, novel attenuated strains of measles, mumps, hepatitis a, rotavirus, and intranasally delivered pandemic h n virus have been derived for products distributed principally within the region. additional novel vaccines for hepatitis e and ev-a have potential for broader use internationally, an indicator of the region's transition from a provider of fill-finish and manufacturing capacity to a full-fledged participant in biotechnology research and clinical development. text continued on p. the reasons for low vaccine efficacy and coverage rates need to be investigated and the appropriate vaccine regimen for effective control requires further definition. newer vaccine approaches (e.g.., chimeric or virus protein subunit vaccines) are being investigated to potentially replace the current vaccine. elsewhere, a nearly identical strain to the kfdv was isolated from a patient suffering from acute febrile illness from yunnan province, china in . seroprevalence studies indicate that kfdv (or the nanjianyin virus or a related tickborne flavivirus) may be present in various parts of southwestern china. in a virus similar to kfdv called alkhurma hemorrhagic fever virus was isolated from patients with febrile illness in saudi arabia. overall, cases with two deaths occurred in sheep and camel handlers exposed to a tick ornithodoros savignyi. the disease has now been confirmed to be more widespread in the country than previously considered. as tickborne diseases are "diseases of place," kfd virus itself, if it spreads, is likely to disseminate locally. nevertheless, the discovery of antigenically related viruses elsewhere, such as alkhurma hemorrhagic fever virus, suggests a potential for more widespread use of kfd vaccine, depending on public health needs. hfrs, a widespread rodent-borne bunyaviral zoonosis in asia, is a pantropic infection with prominent capillary hemorrhages, interstitial nephritis, and a % to % case-fatality ratio that, until the last decade, caused more than annual cases in the republic of korea and more than , cases in china. although the disease had been well known in parts of russia and asia as a sporadic and occasionally epidemic disease among farmers, soldiers, and others exposed to campestral and sylvatic habitats, it was largely unknown in the west until thousands of military cases and deaths occurred during the korean war, when the disease was described as korean hemorrhagic fever. the etiologic agent eluded investigators until , when a novel bunyavirus, htn virus was isolated from the striped field mouse, apodemus agrarius, which proved to be the principal viral reservoir in most areas of asia. later, antigenically related seo virus was isolated from rattus rattus and rattus norvegicus, explaining the occurrence of sporadic hfrs cases and outbreaks in urban areas. subsequently, sin nombre and related hantaviruses were discovered in the western hemisphere, where rare encounters with infected rodents lead to small numbers of cases that feature prominent pulmonary involvement. a multitude of hantaviruses now have been described globally. the widespread impact of hfrs in china led public health authorities in the s and s to pronounce the disease second only to hepb as a public health menace, and, beginning in , several chinese vaccine manufacturers used smb, primary baby gerbil kidney cells (gkcs) or phk cells to produce inactivated, monovalent vaccines against htn or seo viruses. the gkc vaccine was inactivated by β-propiolactone and the other two by formalin. subsequently, vero cell linederived vaccines have been developed. these vaccines were evaluated in nine chinese provinces hyperendemic for hfrs during to . the gkc-derived vaccine against htn virus produced seroconversions to putatively protective titers of neutralizing antibody in . % of subjects after three primary doses at , , and days, the proportion rising to . % after a booster at year, and declining to . % at years and . % at years. similar immunogenicity results were reported for the phkderived vaccine and the purified smb vaccine. in a randomized, controlled, three-arm trial of gkc vaccine in which vaccinated subjects received three primary doses and a booster at year, hfrs cases were observed in the age-, sex-, and residence-matched controls, and cases in the , unvaccinated subjects of similar age ( to years), compared with none in vaccinees during months of follow-up, for a protective efficacy of % ( % lower confidence limit of . %, p = . , cumulative binomial probability). efficacy of the three primary doses alone was shown in the year between administration of the three primary dose series and the booster dose: with zero cases in the vaccinated, and nine and cases in the unvaccinated and control groups respectively. among cases in the control and unvaccinated groups, were caused by htn virus, were caused by seo virus, and four by a virus of indeterminate serotype. thus, the monovalent gkc-derived htn virus vaccine was protective not only against the homologous virus, but also cross-protective against seo virus. no vaccine-related serious adverse event was reported during the trial, and mild local and systematic reactions were reported in . % of vaccinees. the efficacies of the phk vaccine and the purified smb vaccine were similar: in nonrandomized trials, one hfrs case was found in , recipients of phk vaccine, compared with in , unvaccinated subjects, a reduction of . %; for the purified smb vaccine, the rates were . per , ( / , ) versus . per , ( / , ) for vaccinees and unvaccinated subjects, respectively, a reduction of . %. the observed reductions were maintained through years of follow-up. nonsevere reactions were found in . % of phk vaccine recipients and in . % of smb vaccine recipients. , bivalent htn and seo gkc-and phk-derived vaccines were developed and improved by purification procedures through gradient density ultracentrifugation or chromatography to be more immunogenic and less reactogenic. the purified bivalent gkc vaccine induced neutralizing antibody seroconversion against htn virus and seo viruses in . % ( / ) and . % ( / ) of volunteers, respectively, after two doses with an interval of days, and . % ( / ) and . % ( / ), respectively, after a booster dose at months. only mild reactions were observed; local reactions in . % ( / ) and systemic reactions in . % ( / ) of the vaccinees. the purified bivalent phk vaccine induced neutralizing antibody seroconversion against htn virus and seo virus in . % ( / ) and . % ( / ) of subjects, respectively, after two doses separated by days, and . % ( / ) and . % ( / ), respectively, after a booster dose at months. no systemic reaction was found among vaccinees and mild local reactions were observed in two ( . %). the purified, bivalent gkc vaccine was tested for protective efficacy in a nonrandomized trial among , subjects, to years of age; , persons received the two primary doses with an interval of days and a booster dose at months; , persons were unvaccinated. the two groups were similar in age distribution. during years of follow-up, hfrs cases were found in , person-years among the unvaccinated, a rate of . per , , compared with none in the vaccinated , person-years, a reduction of %. several manufacturers have adapted their processes from primary gerbil or hamster cells to continuous vero cells. the purified, bivalent vero cell-derived vaccine administered in two doses separated by days, induced neutralizing antibody against htn virus and seo viruses in . % ( / ) and . % ( / ) adult volunteers, respectively. mild systemic reactions were observed in . % ( / ) and mild local reactions in . % ( / ) of vaccine recipients. the immunogenicity and safety profiles of the vero cell-derived, purified bivalent vaccine were similar in children and older adults. based on the above data, a schedule of two primary doses with an interval of days, plus a booster at months, has been recommended for the purified bivalent gkc-, phk-, and vero-cell-derived vaccines. a postlicensure, retrospective study was conducted to measure the long-term effectiveness of the gkc vaccine among , adults to years of age, in villages located in a hyperendemic area of shaanxi province. hfrs incidence rates were compared between the vaccinated and the unvaccinated adults: . % ( / ) versus . % ( / ), respectively, for the first years after vaccination; . % ( / ) versus . % ( / ) in years to ; . % ( / ) versus . % ( / ) for years to ; and . % ( / ) versus . % ( / ) at to years. the vaccine's effectiveness was thus estimated at . %, . %, . %, and . %, respectively, for the four study periods. the effectiveness was underestimated because the year of onset of hfrs was unknown for cases, all of whom belonged to the unvaccinated group and were not included for analysis. the overall hfrs attack rate was . % ( / ) in the vaccinees and . % ( / ) in the unvaccinated subjects, a reduction of . %. a long-term study of the monovalent phk-derived seo virus vaccine also was conducted among adults to years old in a seo virus-predominating area, from through . only three primary doses were given at , , and days without a booster. seven hfrs cases were found in , , subjects in the vaccine group, a rate of . per , , and cases were found in , , controls, a rate of . per , , with an overall reduction of . % ( % ci, . % to . %) during the years of the study. the vaccine's effectiveness was estimated at % for the first year, . % for the second year, and . % for the th year. the rate reductions in other years were approximately %. a smb-derived htn virus vaccine also was developed in the republic of korea and is available for at-risk individuals. the incidence of hfrs in china and korea has declined in the last years with the introduction of vaccination and probably, more importantly, because of urbanization, rural economic development leading to improved (cement) houses, and grain harvesting and storage practices, resulting in reduced exposures to the rodent reservoir. this trend has been most evident in rapidly developing areas of southeastern china and likely will continue in other regions, leading to a diminution of disease incidence and, potentially, discontinuation of routine vaccination in endemic provinces. see table . . two similar live attenuated hepatitis a vaccines, based on the h and la- strains, and measles vaccines, based on the shanghai s- and changchun- strains, have been licensed in china and are used domestically and exported. the national institute of hygiene and epidemiology in vietnam developed an oral bivalent o -o killed whole-cell cholera vaccine that now is produced and distributed by vabiotech, company for vaccine and biological production no. , in hanoi; another oral bivalent o -o vaccine based on the vabiotec vaccine but with improved production design is produced in india by shantha (sanofi, france). both vaccines are used domestically and also exported. similarly, live rotavirus vaccines based on local strains have been developed in india and china for local use. ev-a and related enteroviruses have emerged in major seasonal epidemics in asia and australia, leading to millions of cases and extensive social disruption as daycares and schools are closed. the extent and impact of seasonal outbreaks stimulated vaccine development in china, taiwan, malaysia, singapore, and japan, with government prioritization and support in some countries, analogous to mechanisms that facilitated pandemic influenza vaccine development. an escherichia coli-expressed capsid peptide virus-like particle hepatitis e vaccine, approved by the china food and drug administration, is the first novel recombinant vaccine developed and licensed in asia. its potential use in africa, south asia and, possibly, even in developed countries in immunocompromised or other risk groups could be envisioned. implicit in the region's progress toward novel vaccine development is a maturing capacity to conduct clinical trials and improvements toward more robust regulatory processes and capacity, including pharmacovigilance systems. in addition, multinational companies increasingly have turned to countries in asia to conduct clinical trials because of lower costs and more streamlined regulatory approvals of clinical trial applications. international contract research organizations operate in many countries, and a growing local infrastructure to conduct clinical trials in compliance with the international conference on harmonization of technical requirements for registration of pharmaceuticals for human use and good clinical practices standards will improve clinical research conducted in the region. unlike europe, asian countries are not unified in a central regulatory approval process. nor is there a regional public health presence as in latin america, where the pan american health organization (paho) leads regional vaccination programs and also provides central purchasing of certain qualified vaccines. however, the -nation association of southeast asian nations (asean; includes brunei-darussalam, cambodia, indonesia, lao pdr, malaysia, myanmar, philippines, singapore, thailand, and vietnam) in initiated efforts for a subregional regulatory harmonization scheme to reduce differences in technical requirements and regulatory procedures for pharmaceuticals. a harmonization initiative, under auspices of a pharmaceutical product working group, aimed to remove barriers to regional commerce and to eliminate technical barriers to trade without compromising product quality, efficacy, and safety. eventually, a subregional central or mutual-recognition procedure similar to that of the european union could be envisioned. importantly, local clinical trials are not required for registration under abbreviated pathways specified by the asean common technical dossier if the vaccine was approved and licensed by a benchmark regulatory agency, resulting in a certificate of pharmaceutical product. by contrast, the national regulatory authorities of china, india, japan, korea, and taiwan have required local clinical trials before or after registration, and in other countries, while data in local populations may not be required for registration, those data are important in deliberations on a vaccine's inclusion in the national schedule. for dengue, a disease of special public health urgency regionally, the global debut of candidate vaccines in the region is being considered, with individual country vaccine registrations ahead of approval by a benchmark agency and provision of a certificate of pharmaceutical product. the text continued on p. various countries in the region have had the effect of delaying the registration of proven vaccines that otherwise could have prevented significant morbidity and mortality with more timely introductions. descriptions of individual regulatory requirements for clinical trial applications and new product approvals are beyond the scope of this chapter; see the previous edition for a more detailed introduction. governments have had a greater role in vaccine manufacturing in the region than elsewhere, although devolution toward privatized or state-owned enterprises (i.e., government-owned corporations) has occurred (e.g., commonwealth serum laboratories in australia was privatized, and the six major government vaccine institutes in china now operate as a state-owned enterprise, china national biotech group; see table . ). although a growing number of private manufacturers have emerged, especially in china and india, in other countries, national and local government manufacturers continue to be important sources of certain vaccines and biologicals for domestic needs (e.g., the government pharmaceutical office in thailand, research institute for tropical medicine in the philippines, biofarma in indonesia, the national institute of hygiene and epidemiology in vietnam, and the central research institute and local government institutes in india). these and other facilities also fill and distribute bulk vaccines supplied by international manufacturers. several private and state-owned enterprise manufacturers in the region are members of the dcvmn, a consortium that seeks to identify and develop solutions to common challenges faced by manufacturers in developing countries. , , , a number of manufacturers (including in five asia-pacific countries) operate under practices and procedures that have prequalified them to produce certain vaccines for unicef, paho, and gavi purchases (e.g., pentavalent dtp combinations, oral polio vaccine, inactivated polio vaccine, hepb, rabies, influenza, oral cholera, and measles-containing vaccines) or that allow them to export vaccine to other countries in the region. a reliable supply of inexpensive diphtheria and tetanus toxoids combined with whole-cell pertussis (dtwp)-hib-hepb combination vaccines, made possible largely by indian and korean manufacturers, has facilitated the introduction of hib antigen into schedules of economically disadvantaged countries that otherwise would not have adopted the monovalent vaccine. similarly, provision of measles and measles containing vaccine by indian manufacturers was key to the elimination of that disease in latin america and the current state of polio elimination could not have been achieved without supplies from asian regional manufacturers. the provision of oral cholera vaccine for outbreak control in haiti, pakistan and other countries is an important example of the increasing ability of and global dependence on these manufacturers. who prequalification requires that the manufacturers and plants not only must satisfy who good manufacturing practices inspections, but, in addition, that national notifications of adverse events following immunization are captured and analyzed satisfactorily. this last requirement has been the principal impediment to prequalification of products from some countries and prequalification aided by who blueprint and other vaccine safety-related guidelines have facilitated the improvement of vaccine-related pharmacovigilance in the region. in china, the state-owned china national biotec group is the dominant supplier of vaccines in the country, providing % of doses used in the public program and % taken up initiative is a collaboration among the nongovernmental organizations, the dengue vaccine initiative, and the world health organization (who) developing countries vaccine regulatory network (dcvrn). the who through the dcvrn has been actively working toward harmonizing procedures in affiliated countries, including china, india, and indonesia, to bring those regulators under the who prequalification umbrella and to facilitate approval and supply of their products for gavi and united nations children's fund (unicef). the requirement of some national regulatory authorities for clinical data in local populations is based on a concern that racial, ethnic, or environmental differences could affect responses of the local population, both immunologically and in their risk for adverse events. genetically based differences in drug pharmacokinetics and pharmacodynamics, as well as disease risk, increasingly have been recognized, including immune responses to vaccines. studies of antibody responses to pneumococcal conjugate vaccines in asia, for example, have found higher prevaccination and postvaccination antibody titers among philippine and taiwanese infants compared with european or historical control subjects, and in korea, a considerably higher proportion of subjects were seropositive to meningococcal serogroup w polysaccharide at baseline than in the united states. [ ] [ ] [ ] while the basis for these differences may be an earlier exposure in life to cognate or crossreacting antigens (e.g., because of regional differences in host microbiomes), genetically restricted responses, as have been observed with hepb, measles, vaccinia, rubella, hib, and other antigens, or, in the case of oral rotavirus vaccine, in genetically determined viral attachment or receptor binding molecules, have been described. [ ] [ ] [ ] [ ] from the perspective of adverse events following immunization, the example of narcolepsy occurring in some recipients of an adjuvanted pandemic h n vaccine illustrates the role of genetic background as a cofactor in risk. in many examples, regulatory systems and processes in the region have had the effect of markedly slowing or effectively blocking the introduction of novel vaccines developed externally. in china, the introduction of an internationally registered and otherwise widely used product nevertheless necessitates recapitulating the entire clinical development program in china, including phase i studies, despite an abundance of previously scrutinized evidence. this requirement introduces a delay of a decade or more for registration of internationally developed, as opposed to domestically developed, vaccines. specifications in national pharmacopeias that deviate from established compendia, for example, exclusion of well-accepted excipients or methods, also have seriously impeded or prevented registration of foreign products or, when imposed with a revision of the pharmacopeia, have led to withdrawal of a previously registered product. clinical trial processes also have hindered local introduction of established or novel products (e.g., a indian supreme court ordered suspension of ongoing clinical trials and reexamination of previously approved trials was followed by a wholesale revision of clinical trial guidelines, leading to a temporary cessation of all industry-sponsored clinical trial activity). the potential inclusion of video recording of the informed consent process, newer insurance requirements and further proposed but unclear amendments to the drug and cosmetics act that could impose criminal penalties against trial investigators for poorly defined violations may further limit trial activity. china and indonesia place severe restrictions on the exportation of clinical samples from study subjects, thereby requiring that validated laboratories and procedures are established locally, adding a barrier that has led to delays of or avoidance of clinical studies in those countries. whether resulting from inexperience, a dearth of trained personnel, trade protection, or other reasons, administrative mechanisms in in most countries in the region, public health authorities now draw on external advisors to help formulate national vaccine recommendations in national immunization technical advisory groups (nitag), resulting, in part, from activities of the supporting independent immunization and vaccine advisory committees initiative (at the agence de médecine préventive). [ ] [ ] [ ] [ ] the advisory committee on immunization practices (acip) in taiwan and korea, expert committee on immunization in singapore, chinese expert committee on epi, hong kong scientific committee on vaccine preventable diseases, immunization committee of the indonesian pediatric society, national technical advisory group for immunization in india, and the australian technical advisory group on immunization are examples of such medical advisory groups. in china, vaccine recommendations are made through the national centers for disease control based on recommendations of the chinese expert committee on epi under the ministry of health and family welfare; however, provincial or local centers for disease control may issue independent recommendations for specific vaccines or modify the national recommendation for routine vaccines (see tables . the issues considered by asian nitags in formulating vaccine recommendations parallel those of other nitags, focusing on medical need, vaccine safety and efficacy, national resources, as well as implementation issues, including supply, cold-chain, fit within the national schedule, vaccine presentation, etc. health economic analyses are considered in the deliberation of some committees or are provided by an independent body (e.g., the health intervention and technology assessment program in thailand); although, in general, the use of health technology assessments in the region lag behind the united states and united kingdom. in some cases, industry sponsors, in providing such analyses to nitags in their justifications to include new vaccines into national programs, have played a role in introducing cost-to-benefit analyses to the recommendation process. in indonesia and malaysia, the halal status of vaccines is an important factor in public acceptance of a product and also is a consideration in the vaccine recommendation process, although there is movement to remove this consideration from debate. in certain asian countries, as well as in latin america, the approval process to include a new vaccine into the national program is used to leverage multinational companies to foster local manufacturing expertise. in brazil, technology transfer of the vaccine production process is required in turn for the vaccine's inclusion into the national schedule while, in indonesia, all epi vaccines are locally produced by biofarma, and no new vaccine has been introduced into the national schedule unless it was produced locally. technology transfer of some element of the manufacturing process also is a factor in introduction of new vaccines to thailand and malaysia. such requirements may be tested as costly vaccines manufactured by more complex technologies are introduced to the region. the recommendation process in japan illustrates how, even after registration, organizational and administrative processes can result in a lengthy interval before a new vaccine is introduced to the national schedule. although, since , japan has recovered from a "vaccine gap"-the self-acknowledged interval during which antigens such as hib and pneumococcal conjugate, rotavirus, hpv, inactivated polio and various combination vaccines were not introduced into japan despite their widespread use in other developed countries-adoption of new vaccines into the national immunization program after their registration still lags several years. a number of sequential approvals lengthens the process: the immunization policy and vaccination committee provides an initial recommendation whether the newly registered vaccine should privately. the group comprises manufacturing sites, which produce some products, including the first who prequalified vaccine produced in china (sa - - je vaccine). other private companies compete principally to provide vaccines for out-of-pocket sales at local centers for disease control and prevention and hospitals. within the asean community, comprised principally of low-and middle-income countries, regional vaccine security has been a focus of discussion, reflected in the establishment of the asean-network for drug, diagnostics and vaccines innovation that focuses on a broad agenda of health technology development and collaborations on vaccine manufacturing and plans for regional vaccine purchasing-similar to paho's revolving fund. similarly, the eight-nation south asian association for regional cooperation includes biotechnology in its agenda for cooperative research. a goal to achieve self-reliance in vaccine supply also has been articulated in korea, in its horizon-setting. to a growing extent, multinational companies are acquiring or partnering with local companies in the region, with the result that manufacturing standards and their regulation should improve toward meeting international specifications. table . lists the region's principal vaccine manufacturers and their licensed products. the list is not intended to be comprehensive, as the sometimes rapid emergence or disappearance of pharmaceutical and vaccine companies in china and elsewhere is difficult to track. vaccines that are manufactured elsewhere and refilled and distributed by local manufacturers are not listed. countries in the region can be divided broadly into countries with a single national schedule and countries in which a basic schedule of free epi vaccines is supplemented by recommendations of a professional organization (such as the national pediatric society) for additional antigens that are paid for outof-pocket. countries in the first group include, on the one hand, mainly developing countries offering a basic epi schedule and, on the other, countries like australia, new zealand, and taiwan that provide a universal vaccination program that includes an array of antigens or combination vaccines paralleling those of european and u.s. schedules. the continued introduction of new and frequently expensive vaccines is an ongoing tension for vaccine recommending and funding entities that must weigh the relative value of such innovations against other preventive and therapeutic health expenditures. even for low-middle-income countries in the region, the total per capita expenditure for all healthcare may be less than the cost of a full course of a novel vaccine! on the other hand, national schedules in the region can be as comprehensive as to include the hpv vaccine (australia) and influenza and varicella vaccines (e.g., korea, taiwan). at the same time, hib vaccine still is not recommended in some jurisdictions with high per capita income (hong kong, singapore). to some degree, the seemingly paradoxical recommendations of relatively high-income countries in the region reflect different social expectations of personal responsibility in healthcare purchases (see subsequent text). as shown in table . , some national schedules provide optional recommendations for some antigens; in many countries where government tenders choose specific manufacturer products, specific combinations are recommended in the national schedule. in addition, for some antigens, provincial-specific recommendations address regional differences in risk (e.g., for routine group ac meningococcal vaccine in china; for je vaccine in sarawak, malaysia, and for the torres straits, australia; and for rabies vaccine [preexposure] in areas of the philippines). be classified as either "routine" or "voluntary," based on available data; the technical recommendation is considered by the tuberculosis & infectious diseases control division which makes the administrative decision for the vaccine's inclusion in the national schedule; however, that decision requires additional legislative approval whether the disease (category a or b) qualifies for full or partial vaccine funding (up to circa %), respectively. the recommendation process is even lengthier than appearances suggest, as the immunization policy and vaccination committee does not convene a deliberative vaccine working group until after the product is registered, unlike the parallel activities of the u.s. acip and food and drug administration. only then does the committee assemble a dossier (fact sheet) that establishes the epidemiology of the disease and its local burden; if insufficient data are available, de novo studies might be required to establish need. the overall interval between vaccine approval and issuance of a recommendation typically is years. other asian countries have similar or even lengthier intervals between vaccine registration and full epi implementation. in thailand, for example, after a preliminary nitag recommendation, a new vaccine is implemented in a pilot program to establish effectiveness and to collect additional safety experience. such a program may be gradually extended to other localities over a period of as long as a decade before the antigen is provided nationally. for diseases with regional differences in disease burden, high-risk provinces may be covered first (e.g., je vaccine initially was introduced in thailand to eight high-incidence provinces and progressively, from to , to all provinces, while local production was established and expanded). for new, often costly vaccines, phased introduction provides a mechanism to accommodate their full epi coverage costs over time. in the interim, local governments of wealthier provinces or municipalities have issued their own recommendations for vaccines to be reimbursed (e.g., shanghai provides pneumococcal polysaccharide vaccine free of cost to older adults and bangkok established a school-based hpv vaccination program, while neither vaccine is included in respective national schedules). innovative financing mechanisms have played an important role in the introduction of vaccines to low-income countries, and their extension to graduating gavi will enable more rapid adoption of new vaccines in those countries. at the same time, tiered pricing, negotiated between sponsors, local government and other entities will aid middle income countries to accelerate vaccine adoption, as exemplified by introductions of pcv and rotavirus vaccines. during the interval between a vaccine's registration and its inclusion in the national schedule, after which it is available without cost, out-of-pocket sales still may result in considerable uptake. while rotavirus vaccine is still considered a voluntary vaccine in japan, coverage among infants is estimated to be approximately %. in korea, although almost all pediatric vaccines are self-paid by parents, vaccine coverage for antigens such as hib and pneumococcal conjugate vaccine rapidly reached coverage rates of approximately % that, with herd effects, led to disappearance of the respective diseases as quickly as in other countries. although in japan, the "voluntary" vaccine recommendation emanates from a government committee, in other countries, academic societies play the principal role in recommending vaccines that are not included in the epi schedule. the malaysian pediatric association, the pediatric society of thailand, and the philippines foundation for vaccination not only advise their respective ministries and nitags in formulating national recommendations, but also promulgate recommended schedules of administration for other approved but not epi-covered antigens, emulating in large part or entirely from u.s., australian, or european schedules. vaccines are delivered in varying proportions through public or private channels, depending mainly on local income levels and accessibility to private practitioners. in general, vaccines on national schedules are available at no cost in primary health centers or their equivalent (e.g., puskesmas in indonesia; polyclinics or government hospital clinics in singapore, malaysia, and thailand; village and county level centers for disease control in china; village communes in vietnam; public health centers and clinics in india and japan; and at general practitioner offices in japan, and australia). as vaccines generally are available free in public clinics, even in affluent countries, families may obtain them in government clinics or hospitals (e.g., in singapore, ≈ % of families obtain vaccines through the government system of polyclinics and hospitals). however, to avoid long waiting times and rotating staff at public clinics, many families opt to obtain these otherwise free vaccines privately and to pay out-of-pocket at pediatric, general practitioner, or other private clinics. in addition, as newer vaccines may be delayed in their introduction to the national reimbursement scheme, it is common for parents to pay voluntarily for these vaccines (see earlier). as might be expected from the distribution of income, the proportion of children vaccinated in government primary health centers is higher in rural areas. overall, approximately % of children in thailand and % in malaysia are vaccinated through public channels. in china, all vaccinations are under control of centers for disease control and prevention; therefore, nearly all chinese children receive free epi vaccines, as well as payable optional vaccines (e.g., hib, pneumococcal conjugate vaccines, varicella, rotavirus, and others) at public clinics. fig. . summarizes the coverage for epi vaccines for selected countries. supplementary immunization activities have played a critical role in the elimination of polio from the who southeast asian region that was achieved in , and in ongoing efforts to eliminate measles and congenital rubella syndrome. routine and supplementary immunization activities tetanus vaccinations have eliminated maternal and neonatal tetanus in all but four countries in the region: cambodia, indonesia, papua new guinea, and pakistan. economic growth and development in asia and secular trends in population structure and the evolution of healthcare systems are forces that inevitably will change various aspects of immunization in the region, if in as-yet unforeseeable ways. , the population of asia, as in other regions, is aging and shifting toward a structure with a larger proportion of adults and elderly persons. between and , the birth cohort of asia will decrease slightly from . to . million, and the population of children to years old will hold nearly constant while the number and proportion of adults from to years will increase dramatically, and the number of people older than years of age will nearly double, from . to . million. a demographic crossover point with more adults + years of age than children younger than years of age was reached in europe in the s, and will occur within another generation in asia (fig. . ) . with the exception of almost universal epi programs of tetanus toxoid vaccination of pregnant women, adult vaccination has been viewed mainly in the context of travel, as in group a meningococcal vaccine for the hajj, and in tropical asia, influenza vaccine alliance for vaccines and immunization-eligible countries (shaded) have similar coverage rates of basic vaccines as countries at higher levels of economic development, illustrating the success of expanded programme on immunization. hepatitis a, interestingly, is now principally a risk in the cohort of young adults who were raised in an era of economic development and improved sanitation and who therefore lack natural immunity but were born before routine childhood vaccination was implemented. a catch-up program to address this epidemiological shift has been recognized by adult vaccination recommendations in some countries (see table . ). in china, adult measles vaccination is under discussion, as more than , cases have occurred annually in recent years, in equal proportion in adults older than years and in infants who had not received their first vaccine dose. growing awareness of adult vaccination is reflected in an increasing number of countries with adult vaccination recommendations (see table . ). two other population trends that will influence the demand for vaccines and channels for their delivery are urbanization and income disparity. the urban-dwelling population in asia is projected to increase by almost a billion persons between and , from . billion to . billion, while the rural population will decline only slightly. urban crowding is likely to affect the transmission patterns of certain person-to-person transmitted diseases and even of infections acquired from environmental sources. dengue, for example, is transmitted by mosquito vectors that are more prevalent in urban environments; the already great need for a dengue vaccine will almost certainly increase with the growth of urban centers. while the growing size and number of large cities may increase transmission of certain infections, delivery of vaccine and of healthcare in general is better organized in cities than in rural areas. specific interventions are needed to ensure that the existing disparity in access to healthcare between urban and rural dwellers does not widen. associated with urbanization is the increasing income gap in many countries that, in the health arena, has translated into a two-tiered system of healthcare, including preventive medicine. while vaccines are regarded by many as a public good to be provided as a government service, as mentioned, access to the increasing number of new vaccines is likely to be stratified by income level and ability to pay, as governments must choose among increasingly costly vaccines and other health interventions. as shown in table . , pediatric societies in a number of countries promulgate recommendations emulating those of the u.s. acip, and these schedules, aimed at practitioners serving private-paying families, may diverge increasingly from the national epi schedules benefiting the majority of children in those countries. how the public and governments will respond to an increasing disparity of what has been perceived as a basic medical service remains to be seen. in coming years, more novel vaccines are likely to be developed in asia or licensed first in asia for a regional, developing world, or international market. governments and asean have expressed increased interest in providing for national and regional vaccine security. the collaboration of industry sponsors with nongovernmental organizations and government in public private partnerships for new product development has been highlighted by the successful introduction of vaccines and drugs for several neglected diseases, for which the dcvmn view a responsibility. for example, the japan international cooperation agency and kitasato daiichi sankyo provided technical assistance to establish domestic measlesrubella vaccine production in vietnam's public corporation, center for research and production of vaccines and biologicals, polyvac. at the same time, the entry of nongovernmental organizations as actual sponsors of novel vaccine development for certain target diseases introduces competition with dcvmn manufacturers and multinational companies that might also consider similar development programs. asian academic institutions and companies possess elements the crossover point when the population of adults older than years of age exceeded the population of children younger than years of age was crossed in europe around ; that crossover is projected to occur in asia around , within a generation from now. for travelers to temperate locations. however, the severe acute respiratory syndrome and pandemic h n outbreaks and the regional threat of h n influenza have focused attention on routine seasonal influenza vaccination for the first time in many countries, beginning with elderly populations, and the role of children in influenza transmission is being recognized while it is rediscovered in japan. as a result of high pediatric vaccination coverage in developed countries in the region, je has become almost exclusively a disease of adults older than years of age, reflecting the intrinsic biological susceptibility of older adults to neurotropic flaviviruses and suggesting a of the scientific and technical expertise needed to develop vaccines for current and emergent needs and, seemingly, the will to establish themselves on the global stage and contribute to their development. regional institutions responded rapidly to threats of middle east respiratory syndrome virus and ebola virus with candidate vaccine development even when transmission was geographically remote. further participation of regional institutions in global responses in the future is likely. trends toward increasing local development and manufacturing in the region and the accompanying need to strengthen respective regulatory agencies have been recognized by the who and local national regulatory authorities. revising and harmonizing guidelines and procedures to international standards and enforcing procedures in a consistent and predictable manner will improve the timely regional introduction of vaccines developed internationally. as important, compliance with international standards will be required of regional manufacturers hoping to license locally developed vaccines more broadly. indian and chinese manufacturers currently export a limited number of vaccines, mainly regionally and to african and latin american countries, but their horizons undoubtedly will expand. in the six-component framework of product development capability-manufacturing; national and international distribution systems; private and public r&d capabilities; intellectual property system; and drug and vaccine regulation-regional manufacturers are at different stages of maturation. in its ascendance to an advanced country producing complex biologicals as well as other high technology products, korea followed a path that might be emulated by others in the region, highlighted by its arrival at a stage with a national system of innovation in science and technology, linking government, universities and industry, a strong regulatory system and observation of intellectual property rights, including adherence to trade-related aspects of intellectual property rights (trips agreement). a specific area of regulatory control needing particular attention is the strengthening of national control laboratories. many countries lack the laboratory capacity to test samples for lot release, and because manufacturing and testing technologies change rapidly, keeping up with new procedures and purchasing needed equipment are ongoing challenges. continuous support also is needed to produce working quantities of reference standards, validation of new assays, staff training, and proficiency testing. as resources are unavailable in many countries to establish and maintain a fully functioning national control laboratory, a regional network has been proposed as an approach to share expertise and to divide workload, while at the same time standardizing methods and criteria. field surveillance of adverse events following immunization is another area requiring strengthening. investigations of adjuvanted h n and h n pandemic and prepandemic vaccines administered in korea and taiwan, respectively, illustrated the interest in and epidemiological capacity of local investigators but also the limitations of existing systems and databases. japan is establishing a database of clinical encounters that if linked to immunization records could be used as a future adverse events surveillance system. regulatory oversight of clinical trials and human subjects protection are other areas that are under growing pressure for improvement. multinational companies have increased the number of clinical trials in asian countries to reduce costs and to obtain local registration of products. their activities serve an important role in strengthening local compliance with good clinical practices, as many groups conducting trials in the region have limited experience with these precepts and procedures. countries in the region have an interest to establish and enforce clear guidelines, not only as hosts to an increasing number of trials but also because their manufacturers, as future sponsors of new products, will be accountable internationally to uphold recognized standards. references for this chapter are available at expertconsult.com. immunization in the asia-pacific region .e references . country hub. gavi, the vaccine alliance role of vaccine manufacturers in developing countries towards global healthcare by providing quality vaccines at affordable prices asia's ascent-global trends in biomedical r&d expenditures emergence of biopharmaceutical innovators in china, india, brazil and south africa as global competitors and collaborators developing countries can contribute to global health innovation the indian and chinese health biotechnology industries: potential champions of global health? chinese health biotech and the biollion-patient market indian vaccine innovation: the case of shantha 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long-term epidemiological effect of vaccine against hemorrhagic fever with renal syndrome in a large population harmonization of standards and technical requirements in asean dengue vaccines regulatory pathways: a report on two meetings with regulators of developing countries greater antibody responses to an eleven valent mixed carrier diphtheriaor tetanus-conjugated pneumococcal vaccine in filipino than in finnish or israeli infants safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in taiwanese infants immunogenicity and safety of a novel quadrivalent meningococcal conjugate vaccine (menacwy-crm) in healthy korean adolescents and adults identification of antigen-specific b cell receptor sequences using public repertoire analysis profiling of measles-specific humoral immunity in individuals following two doses of mmr vaccine using proteome microarrays both lewis and secretor status mediate susceptibility to rotavirus infections in a rotavirus genotype-dependent manner genetic polymorphisms of cxcr and cxcl are associated with non-responsiveness to the hepatitis b vaccine india's proposed amendments to the drug and cosmetics act: compensation for injuries to clinical trial participants and the criminalization of clinical research. life sciences law and industry report. lslr , / / bloomberg bna vaccines, our shared responsibility immunization policy development in thailand: the role of the advisory committee on immunization practice an overview of the national immunization policy making process: the role of the korea expert committee on immunization practices progress in the establishment and strengthening of national immunization technical advisory groups: analysis from the who/unicef joint reporting form, data for recent progress and concerns regarding the japanese immunization program: addressing the "vaccine gap who-unicef estimates of dtp coverage world health organization department of economic and social affairs population division vaccine preventable diseases surveillance program of japan. japanese encephalitis: surveillance and elimination effort in japan from to seroprevalence of hepatitis a and associated socioeconomic factors in young healthy korean adults urbanization and geographic expansion of zoonotic arboviral diseases: mechanisms and potential strategies for prevention development of health biotechnology in developing countries: can private-sector players be the prime movers? we are grateful for the help of john o'shea, jason humphries, takashi sugimoto, and hyun-ah chang. key: cord- - yrh ab authors: susskind, daniel; vines, david title: the economics of the covid- pandemic: an assessment date: - - journal: nan doi: . /oxrep/graa sha: doc_id: cord_uid: yrh ab the covid- pandemic has created both a medical crisis and an economic crisis. as others have noted, we face challenges just as big as those in the spanish flu pandemic and the great depression—all at once. the tasks facing policy-makers are extraordinary. many new kinds of intervention are urgently required. this issue of the oxford review of economic policy has two objectives. the first is to explore these new interventions: evaluating their use, suggesting how they might be improved, and proposing alternatives. the second is to show that the challenges facing us are global and will require international cooperation if they are to be dealt with effectively. this short introductory essay positions the papers in the issue within an overall conceptual framework, with the aim of telling an overarching story about the pandemic. the covid- pandemic has created both a medical crisis and an economic crisis. as others have noted, we face challenges just as big as those in the spanish flu pandemic and the great depression-all at once. the tasks facing policy-makers are extraordinary. many new kinds of intervention are urgently required. this issue of the oxford review of economic policy has two objectives. the first is to explore these new interventions: evaluating their use, suggesting how they might be improved, and proposing alternatives. the second is to show that the challenges facing us are global and will require international cooperation if they are to be dealt with effectively. just months ago we all knew very little about any of this. aspects of the story have emerged with greater clarity as more information has been revealed, and as the results where to begin? only months ago few economists knew anything about sir models. now we all know that the central framework for studying the spread of any infectious disease is the sir model. and we know that the only way to control a pandemic is to keep the reproduction number, r, the expected number of cases directly generated by an infectious case, below . when that happens, each infected person will infect less than one new person on average and the epidemic will come to an end (cleevely et al., , this issue) . but despite the central nature of the sir model in the epidemiological literature, until recently most versions of that model did not adequately capture the economic costs associated with the interventions that are being made to control the disease. there are now any number of papers available which begin to do this (see, for instance, acemoglu et al., and eichenbaum et al., ) . rowthorn and maciejowski ( , this issue ) make another welcome contribution to this set of ideas. at the core of these papers is the challenge of how to understand the trade-off between the cost of, on the one hand, the likely illness and deaths-however valued-and, on the other hand, the costs of the policies being adopted to reduce such illness and death. this trade-off is not simple to understand because it is an intertemporal one. policies adopted now, with immediate costs, have implications for future infections and future deaths, and these implications work themselves out in highly non-linear ways. clearly how one thinks about this depends on the value which one places on human life. the particular attraction of rowthorn and maciejowski ( ) 's paper is that it provides a mapping from the value attached to human life to the severity of lockdown that is justified, after allowing clearly for the intertemporal nature of the problem. and it does this in an intuitively clear and elegant manner. (see figure of rowthorn and maciejowski ( ) . ) the paper argues that that the optimal response to covid- would have been to lock down the economy very swiftly, to bring r down below , before the infection had taken hold; just one week of delay makes a huge difference. but when saying this we need to be clear how little was known at the beginning. would it have been optimal to lock down so swiftly, knowing what we knew at the time and given the enormous uncertainty around the parameter estimates? this is difficult to judge, as experience of previous epidemics has shown. for instance, neil ferguson and his modelling team at imperial college, who have played a critical role in influencing the uk's response to covid- , were also responsible for shaping the decision to cull several million uk cattle to bring the foot-and-mouth disease outbreak to an end: but a more recent study, which found the disease had a shorter infectious period, suggested that such an aggressive approach may not always be optimal (cressey, ; charleston et al., ) . lockdowns can only eliminate the transmission of disease if they remain in place more or less for ever, i.e. until a vaccine is available. that is because many people will go on being susceptible to infection so that, if lockdown is abandoned, the unstable spread of the disease will again become likely. but because of the enormous economic cost associated with lockdowns, they cannot be allowed to continue more or less for ever. rowthorn and maciejowski ( ) argue that how long lockdown should be made to last depends fundamentally on the valuation attached to life: a lower value implies that a shorter lockdown is desirable. the study is based on a standard but simple epidemiological model, and should be regarded as presenting a methodological framework rather than giving actual policy prescriptions. they argue that a full lockdown of even as little as weeks would only be optimal if the value of life for covid- victims exceeded £ m (rowthorn and maciejowski, , figure ). this number is much larger than the figure implied by official guidelines for drug evaluation, which is £ , to £ , . a robustness check, performed by changing the parameter values in the social welfare function used in the policy optimization algorithm, reduces this number to £ m. but that is still a larger number than the numbers used in the official guidelines. the paper also suggests that it would be optimal to dispense with lockdown altogether if the value of life were to drop below £ . m (see figure ). it is clear that this troubling trade-off between reducing the number of lives lost and rising economic costs raises significant questions about how exactly life should be valued. colmer ( , this issue) discusses just how hard these questions are. he argues that efforts to engage with this issue have lacked clarity. he argues that the choice of numbers used to represent the 'value of lives saved' from covid- interventions, more than likely, substantially understate the social benefits. in light of what are very large uncertainties over how much larger the social benefits could be, this raises concerns about how useful traditional benefit-cost analyses can be in contexts such as the current crisis. if a full lockdown cannot continue indefinitely, it is obvious that alternative interventions will be required to keep r below . the ultimate goal must be to discover, manufacture, and distribute a vaccine so as to eliminate the threat of covid- altogether. and as brown and susskind ( , this issue) argue, countries must cooperate much more actively than at present in their pursuit of this common objective. but before a vaccine or an effective treatment is available for widespread use, another strategy will be necessary to control the spread of the disease in the meantime. in part, this strategy must involve bottom-up measures adopted by individuals: social distancing, decisions by the most vulnerable to shield themselves, wearing masks, and washing hands. but it must also involve additional top-down interventions imposed by governments. the two are closely related: it is becoming clear that the use of compulsory lockdowns-by the end of march , over countries had one in place-had an important signalling effect at the start of the pandemic, making clear how critical it was for individuals to change their behaviour. this puts to one side the possibility that herd immunity, or something close to herd immunity, is achieved by allowing the disease to run rampant throughout the community. the national institute for health and care excellence (nice) assumes £ , -£ , per qualityadjusted year of life. office for national statistics life tables and statistics on the age, sex, and underlying health condition of covid- fatalities suggest that the average person dying from the disease loses about ten years of life. if the authors impose the condition that peak infection must not exceed what the health service can handle, they show that it would be optimal to dispense with lockdown if the value of life were to be below £ . million. indeed, these behaviour changes may explain why fears at the start of the pandemic about prolonged draconian intervention might have been misplaced (rowthorn and maciejowski, ) . alongside a full lockdown, though, there are other important interventions available to governments. to begin with, it is clear that targeted lockdowns, as per acemoglu et al. ( ) , will need to become part of the strategy: rather than lock everyone down, the lockdown is instead stratified by, for instance, location, age group, or other risk factor. another important intervention is an effective testing strategy: testing individuals for the infection and isolating those who test positive. however, such a strategy must also be workable: countries have finite testing resources and testing capacity can be difficult or impossible to ramp up (kasy and teytelboym, , this issue) . in cleevely et al. ( ) , the authors question the viability of universal random testing, a strategy in which a random fraction of the entire population would be selected each day for testing. they show that, on reasonable assumptions, this would not be a feasible strategy; it would require testing about per cent of the population every day (or everyone, every days). instead, the authors argue for stratified period testing: stratified because it is focused on at-risk groups, and periodic because tests would be conducted on each person at regular intervals. the authors show that this approach dramatically reduces the required testing resources. following on from this, kasy and teytelboym ( ) examine the tradeoffs involved in allocating testing resources to some individuals but not others; the so-called 'shadow cost' of a test. they explore the difficult dynamic balancing that policy-makers face, between using tests to protect people today, versus using tests to identify the prevalence of the disease in the population to benefit people in the future. if the number of infections in a population is sufficiently low, or is brought down to a sufficiently low level, then a test-and-trace strategy can be used as an important part of a strategy. with such a policy, infectious individuals and their contacts are identified and isolated so they cannot infect others. the effect of such a policy will enable lockdown to be abandoned much earlier, even although the threat of unstable spread of the disease remains present. such a policy becomes possible because an effective test-andtrace operation will quickly remove from public circulation anyone who is shown to be infectious. such an individualized (and very costly) form of intervention enables r to be kept well below , even though, without it, and without lockdown, r still remains well above . the model in the paper by rowthorn and maciejowski ( ) illuminates this process very clearly. it now appears from both theory and repeated experience that the two best investments a country could have made in the run-up to the covid- pandemic are the production and distribution of 'personal protective equipment' (ppe), including face masks, and an effective test-and-trace regime. looking ahead, there are important concerns about the consequences of existing safety regulations for such a regime: it appears that some businesses, for instance, are not testing their employees with sufficient frequency for fear of being shut down (this explains large but localized outbreaks at, for example, german abattoirs, at the time of writing). more of these outbreaks should be anticipated and can be dealt with, providing that businesses are encouraged to test and isolate their employees, rather than being encouraged not to do this by the threat of being punished (galeotti et al., ) . what we have just said explains why the economic impact of covid- has been so enormous. the deaths, and the reduction in the work which can be done by those who fall ill, are costly enough. but that is true of any infectious disease, like the flu. what is special about covid- is that it is both very infectious and very deadly. that is why the policies adopted to deal with it-which we have been discussing-have needed to be so radical. at the start of the pandemic, del rio-chanona et al. ( , this issue) estimated that, in the us, the first-order effect of the virus would threaten per cent of gdp, per cent of employment, and reduce wage income by per cent. these figures initially looked almost fantastical. but their predictions have turned out to be surprisingly close to the mark-not only in the us but around the world. but the details of how these costs have played themselves out have varied enormously from country to country. evidence from pakistan, for instance, suggests that microfinance in low-income communities now faces a drastic crisis (malik et al., , this issue) . rapid-response surveys suggest that on average, week-on-week sales among microenterprise owners and household income both fell by about per cent, households' primary immediate concern in early april became how to secure food, and about per cent of the sample of current microfinance borrowers reported that they could not repay their loans. significantly, the economic impact of covid- has also been extremely unequal. again, rio-chanona et al. ( ) correctly predicted that certain sectors would be hit by demand shocks (transport, for instance), others by supply shocks (manufacturing and mining, for instance), and others by both (entertainment, restaurants, and tourism), while some-and in particular, high-wage occupations-were relatively immune. but there are further very significant inequalities too. for instance, there are substantial gender inequalities associated with the pandemic: the requirement to stay at home, for instance, created a major shock to the demand and supply of home childcare (sevilla and smith, , this issue) . couples with young children in the uk, for example, now find themselves performing a working week's worth of additional childcare. the pre-covid- characteristic-that women do the majority of such childcare (on average, about per cent)-has continued, and women have been more likely than men to lose employment due to the pandemic (sevilla and smith, ) . in turn, there appear to be important age inequalities, too: the international labour office (ilo), for instance, argues that young people have been 'disproportionately affected' by the pandemic, which has disrupted their education and training, and forced them out of work; one in six young people surveyed by the ilo, for example, had stopped working since the start of the covid- crisis (ilo, ). and finally, there is growing evidence that the health impacts of covid- are particularly harmful for black, asian, and minority ethnic (bame) communities; the uk government, for example, is launching a review to better understand this very troubling feature of the pandemic (kirby, ). alongside the dramatic actions taken to mitigate the medical crisis are the extraordinary interventions that have been taken to tackle the economic crisis. unprecedented discretionary fiscal policies have been adopted around the world. governments have put forward swift and significant emergency lifelines to protect workers and businesses. the international monetary fund (imf) first measured these interventions in april , but as countries have stepped up their efforts it has updated its calculations: in may, the total was about us$ trillion (imf, ). this is a staggering sum: what has been spent or promised amounts to about per cent of world gdp. the breakdown looks like this: direct budget support is currently estimated at $ . trillion globally, and additional public-sector loans and equity injections, guarantees, and other quasi-fiscal operations (such as non-commercial activity of public corporations) amount to another $ . trillion (imf, ). these interventions have had an important impact in mitigating the economic crisis. in the uk again, for instance, on some measures it appears that the fall in household incomes is more evenly spread across the income distribution than the loss of jobs is distributed across the earnings distribution (brewer and gardiner, , this issue) . in turn, unlike during the financial crisis of - , the financial system has remained strong and stable during the pandemic. as giese and haldane ( , this issue) explain, this was not the case a decade ago, when both bank balance sheets and the prudential regulatory standards that banks had to follow were very different from what they are now. furthermore, monetary and financial policy have been able to support fiscal policy; the bank of england, for instance, has expanded its balance sheets by almost a third in months during the crisis (hauser, ) . in the uk, the policy centrepiece has been the job retention scheme (jrs) or 'furlough' scheme, where employers receive per cent (up to a limit £ , per month) of the wages of employees who are temporarily asked to stop working (mayhew and anand, , this issue) . this intervention not only reflects the scale of those seen in other countries, but also their imperfections. by early may, . m workers had been furloughed, and it was expected it would rise further to m, about a quarter of the uk workforce. yet as mayhew and anand ( ) explain, this bold policy still leaves large gaps and has significant flaws: the scheme, for instance, failed to cover per cent of the uk's workforce; the data were not available to judge if per cent was the right figure; and it is unsustainable in the longer run. this final point is key: around the world, many of these remarkable economic interventions were intended to be temporary emergency measures. there was a moment at the start of the pandemic when some commentators appeared to think the crisis might be relatively swift: lockdown would be imposed, but once the peak in infections had passed in a matter of weeks, extraordinary but temporary measures could be relaxed, economies would go through a swift v-shaped recovery, and economic life as it was before the pandemic would return. historians would look back at the 'great panic' of . this now seems extremely unlikely without an effective vaccine. a reasonable base case is that the virus and its consequences will be with us for some time. and so, the coming months are likely to be dominated by continued responses to both the medical and economic crises. however, if the pandemic is to be more long-lasting, interventions designed for a short-lived crisis must be revisited. with respect to the medical crisis, as noted before, as lockdowns are relaxed, other interventions to keep r below will need to be intensified. also see fiscal monitor. world gdp is somewhere between $ and $ trillion, depending on how it is measured. but in a similar way, our economic interventions must change. as devereux et al. ( , this issue) argue, as we move out of lockdown and into a tentative period of recovery, it will be necessary to consider a new set of policy options: extension of short-time work and possible temporary subsidy for re-employment; corporation tax incentives; vat reductions; and a holiday from taxes on business property. more generally, as noted before, radical fiscal measures that were designed to temporarily keep workers attached to their existing employers must be replaced with alternative, and more sustainable, measures (mayhew and anand, ) . for instance, with respect to the jrs in the uk, from the beginning of july, the scheme becomes more targeted and is due to finish at the end of october: mayhew and anand ( ) argue that, rather than go cold turkey at this point and remove employment subsidies, there is a case for the introduction of a variant of the germanstyle working time accounts scheme. nevertheless, there are difficulties ahead here. the structure of the economy which re-emerges may well be somewhat different from what it was in the past. to take one small example, it is likely that much more office work will be done remotely, setting up pressures for change in both the commercial property market and the residential property market. to take another example, some jobs are likely to just disappear, for example in retail. although cold turkey seems like a bad idea, a generous furlough scheme which keeps workers in place where they have no future is also not a good idea. what is required, mayhew and anand, ( ) argue, is a comprehensive active manpower policy in its place to efficiently match job-seekers to available jobs. other substantial challenges also lie ahead. some of the new-found economic interventions have created new risks for the corporate sector. for instance, another key policy in the uk has been the variety of covid- loans which have been made available to firms. it is not clear how these are working: many firms appear to be unable to access them, and time will tell what the default rate on these loans will be-it seems likely that default rates will be high, and the systemic consequences are likely to be large. as johnstone-louis et al. ( , this issue) argue, massive bailouts of companies may end up being needed. these will impose substantial obligations on the corporate sector to respond and to lead the economy out of the crisis. when similar bailouts were provided for commercial banks after the financial crisis of - , the banks ended up imposing significant costs on the rest of the society in that they prioritized the rebuilding of their balance sheets ahead of looking after their customers. this is something which needs to be avoided. and there is a more general point: to offset the large debt overhang problem that has emerged and avoid the wave of bankruptcies that threaten economies, financial institutions will be expected to provide substantial amounts of new equity funding as well as accepting dividend cuts. the covid- pandemic has also led to more fundamental calls to reform business and finance. the last crisis-the financial crisis of - -was clearly the fault of business, and the financial sector in particular. this time round, business cannot be blamed for causing the pandemic. but it can be blamed for leaving economies so vulnerable to its consequences. with many companies having less than months of reserves to cover their operating costs, they have been forced to cut costs draconianly, be bailed out by governments, and slash their workforces. there is a case for arguing that stress testing should be extended beyond the financial sector as a whole to business more generally, and relate to a broader range of events than the macroeconomic ones on which they have been focused to date, for example pandemics, weather, and technology-related risks (giese and haldane, ) . to some, the pandemic has exposed a failed system of corporate governance. as economies begin to recover, many are appealing to the idea of 'building back better'. but this requires a clearer conception of what exactly it is they want to build-and it is unlikely to be a corporate sector that generates profits on the back of environmental degradation, rising inequality, or social exclusion. fixing this needs a recognition that business's reason for being is to serve others than itself, its investors, or executives, and that their interests are derivative of, not the determinant of, its success in so doing (mayer, , , morris and vines, . good business can drive profits; profits do not necessarily drive good business, and good regulation does not solve the problem without good business. but business cannot do this on its own. the pandemic has shown that business needs government, as well as government needs business. mazzucato and kattel ( , this issue) argue that we should forge new relations between government and the private sector. the innovation and experimentation that will be required to recover must come from the private sector, but this must take place in the context of governance arrangements that address social concerns and avoid the types of problems that have arisen in relation to, for example, data usage. neither privatization nor public ownership have proven adequate to the task; 'government actively shaping markets rather than simply fixing failures' is how mazzucato and kattel describe an alternative approach. and as collier and mayer ( , this issue) note, public-sector funding will be needed alongside private finance, in particular in relation to the small and medium-sized enterprises (smes) that are most at risk of failure, especially in the most depressed and disadvantaged areas of a country. channelling public funding to smes in these areas may involve more than the existing banking system can provide. the authors describe why this is the case in the uk and put forward suggestions for the development of new funding institutions to cope with it. milton friedman was prescient when he said that 'only a crisis, actual or perceived produces real change. when that change occurs, the actions that are taken depend on the ideas that are lying around'. 'that', he said, 'is our basic function: to develop alternatives to existing policies, to keep them alive and available until the politically impossible becomes the politically inevitable.' the only question is how many crises will it take until we realize that he was quite wrong when he said that 'there is one and only one social responsibility of business . . . to increase profits so long as it stays within the rules of the game'? at the time of writing, covid- had already begun to reach low-income and middleincome countries. such countries face an enormous challenge in dealing with this crisis, because the institutions of government and of public administration are much less well developed in these countries than in advanced countries. this issue of the oxford review of economic policy contains only one paper which discusses this challenge, by gerard et al. ( , this issue) , but that paper provides an eye-opening account of tasks that policy-makers will face in these countries. it seems that these countries may need to use a much broader patchwork of interventions than high-income countries. and the authors provide a view of what this patchwork might need to look like. job retention programmes already exist in some countries; some governments have leveraged id-linked bank accounts opened for financial inclusion purposes to provide direct support to the poor; and even populations that live at the margins of social protection systems-like migrant workers-are being reached through associations that work with them. yet, as the authors show, any government response will be imperfectly targeted, with important inclusion and exclusion errors: government responses based on social insurance programmes will miss the informal sector; social assistance programmes are always specific to a particular dimension of poverty, and their delivery is often plagued with leakages; and involving local governments or non-state actors runs the risk of resources being diverted by local elites or used for clientelism. nevertheless, the authors conclude that fewer even imperfectly targeted transfers will reach some 'left-behind' households through family, informal, or formal sharing structures. the paper provides important examples of how, and in what way, this might happen and is already happening. the authors conclude that the challenge of mitigating the economic effects of the pandemic is enormous in low-income and middle-income countries. any solution will be flawed in many ways because speed is of the essence. but, they say, governments, donors, and civil societies have made major gains in the last years in building infrastructure to reach the poorest. if internal and external financing can be found-and this is a big if-then developing countries might be able to use this to create the economic space for an effective public health response. but the challenge really will be enormous. the covid- pandemic has created a global medical crisis, not just a national one. in brown and susskind ( ) , the authors show that the international response to the pandemic has fallen short, primarily because of a lack of effective global cooperation. many of the tasks involved in controlling an infectious disease like covid- are global public goods-a public good that spills across national borders with far-reaching consequences as a result-that can only be delivered through global cooperation. the paper discusses the discovery of vaccines as an example of the kind of cooperation that is needed: only one success, if shared with others, is needed to bring the pandemic to an end. but cooperation would also have to be strengthened because it is not enough just to discover a vaccine: it has to be mass manufactured and, if the disease is to be eradicated in every country to avoid further waves of the disease emerging in the future, distributed equitably. brown and susskind ( ) discuss just why many activities like this have been underfunded and under-provided until now, and they discuss how this might be remedied. the pandemic has also created a global economic crisis. indeed, it has caused the greatest collapse in global economic activity since the collapse of the south sea bubble in . as noted before, some advanced countries have mounted a massive fiscal response, both to pay for disease-fighting action and to preserve the incomes of firms and workers until the economic recovery is under way. but there are many emerging market economies that have been prevented from doing what is needed by their high existing levels of public debt and-especially-by the external financial constraints which they face. mckibbin and vines ( , this issue) argue that there is a need for international cooperation to allow such countries to undertake the kind of massive fiscal response that all countries now need, and that many advanced countries have been able to carry out. they show what such cooperation would involve and they use a global macroeconomic model to explore how extraordinarily beneficial such cooperation would be. their simulations of the model suggest that gdp in the countries in which the extra fiscal support takes place would be something like two and a half per cent higher in the first year, and that gdp in other countries in the world be more than per cent higher. and the percentage increase in employment in the countries in which there is extra fiscal support would be very much larger than the percentage increase in gdp. so far, such cooperation has been notably lacking, in striking contrast with what happened in the wake of the global financial crisis of - . the necessary cooperation needs to be led by the group of twenty (g ), just as happened in that crisis, since the g brings together the leaders of the world's largest economies. but this cooperation must also necessarily involve a promise of international financial support from the imf, otherwise international financial markets might take fright at the large budget deficits and current account deficits which will emerge, creating fiscal crises and currency crises and so causing such expansionary policies which we advocate to be brought to an end. mckibbin and vines ( ) do not discuss the case of the poorest countries in the world. but the problem just described has created huge problems for countries in sub-saharan africa. these are discussed in detail by adam et al. ( , this issue) . the authors capture quite what a catastrophic external position these countries are now in, something which is likely to require them to embark on massive fiscal austerity at just the wrong time. they show very clearly just how much of an increase in overseas development assistance (oda) would be required to help these countries deal with the medical and fiscal problems which the covid- pandemic has thrust upon them. in particular, they show that merely keeping the degree of domestic fiscal adjustment within reasonable bounds-i.e. ones which seem politically feasible-would require about an extra $ billion of oda. that would, in effect, mean a doubling of the aid which these countries receive. they would need three times as much aid if the aim was to fully isolate them from the covid- shock. the pandemic is also likely to have dramatic consequences for global progress on mitigating climate change. as hepburn et al. ( , this issue) note, in the short term the policy response has curtailed economic activity and thus also slashed greenhouse gas emissions. but once restrictions are relaxed, emissions will be likely to soar once again. in the medium term, then, there is an opportunity, when designing discretionary fiscal policy, to consider interventions that are likely both to promote economic recovery and displace the current fossil-fuel intensive economic system: hepburn et al. ( ) identify possible policies that score highly on both economic multiplier and climate impact metrics. in the longer term, covid- could also result in changes to human habits and behaviours, business, and global institutions, which will have impacts-positive and negative-on the likelihood of reaching net zero emissions before temperatures rise to catastrophic levels. the pandemic raises many other significant international issues. for instance, as fernández-reino et al. ( , this issue) note, the pandemic has increased public awareness of the extent to which the economy relies on a low-wage workforce. but given that many of these occupations are also heavily dependent on migrant workers, this is likely to have substantial implications for immigration policy: now, and in the future, not just in the uk but elsewhere, too. in turn, there are the enormous problems the pandemic has created for the international trading system. it has had a dramatic impact on international trade between countries: a drop by about per cent in france, and per cent in turkey and germany, for instance, relative to historical averages (demir and javorcik, this issue). and already protectionist pressures have reared their head, as brown and susskind ( ) also describe. there is a need to ensure that global cooperation in trade policy goes hand in hand with global cooperation on health and macroeconomic policy. the last time the world faced challenges as serious as those which we now face was at the end of the second world war. at that time there was an extraordinary burst of institutional creativity. the bretton woods conference in led to the creation of the imf, in order to ensure international financial stability. it also led to the establishment of the world bank as an institution which would lend money to what were then the emerging market economies of europe and asia. soon afterwards the marshall plan also started to provide money for countries in need. the next year, in , saw the foundation of the united nations (un); the world health organization became part of the un in . a conference in san francisco led to the establishment of the general agreement on tariffs and trade, which, nearly years later became the world trade organization. after the first world war things were very different. although the league of nations was established in , it never really gained the necessary authority. first the world slid into the great depression of s. then the world lurched into the second world war. the post-second world war institutions have served the world remarkably well. now, following the covid- pandemic, they need strengthening and reinvigorating. but they still provide a framework within which international cooperation can take place. because the pandemic is such a very large event we need to realize that the world faces a very large choice. we can do what the world did in the late s, when the institutional choices which were made helped to support the golden age of global growth during the s and s. or we can instead allow what happened in the s to happen all over again. that is the decision which we now face. optimal targeted lockdowns in a multi-group sir model after the lockdown: macroeconomic adjustment to the covid- pandemic in sub-saharan africa the initial impact of covid- and policy responses on household incomes international cooperation during the covid- pandemic relationship between clinical signs and transmission of an infectious disease and the implications for control a workable strategy for covid- testing: stratified periodic testing rather than universal random testing reforming the uk financial system to promote regional development in post-covid britain what is the meaning of (statistical) life? benefit-cost analysis in the time of covid- foot-and-mouth culls could be cut supply and demand shocks in the covid- pandemic: an industry and occupation perspective trade finance matters: evidence from the covid- crisis discretionary fiscal responses to the covid- pandemic the macroeconomics of epidemics from low-skilled to key workers: the implications of emergencies for immigration policy capitalism and freedom how should we allocate limited capacity for coronavirus testing? social protection response to the covid- crisis: options for developing countries covid- and the financial system: a tale of two crises seven moments in spring: covid- , financial markets and the bank of england's balance sheet operations', speech delivered at bloomberg fiscal recovery packages accelerate or retard progress on climate change? ilo monitor: covid- and the world of work, fourth edition', international labour organization tracking the $ trillion global fiscal support to fight covid- ', imf blog business in times of crisis adaptive targeted infectious disease testing evidence mounts on the disproportionate effect of covid- on ethnic minorities global macroeconomic cooperation in response to the covid- pandemic: a roadmap for the g and the imf covid- and the future of microfinance: evidence and insights from pakistan firm commitment: why business has failed us and how to restore trust in it prosperity: better business makes the greater good covid- and the uk labour market covid- and public-sector capacity capital failure: rebuilding trust in financial services a cost-benefit analysis of the covid- disease baby steps: the gender division of childcare during the covid- pandemic key: cord- - nlxqgk authors: hosseini, parviez; sokolow, susanne h.; vandegrift, kurt j.; kilpatrick, a. marm; daszak, peter title: predictive power of air travel and socio-economic data for early pandemic spread date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: nlxqgk background: controlling the pandemic spread of newly emerging diseases requires rapid, targeted allocation of limited resources among nations. critical, early control steps would be greatly enhanced if the key risk factors can be identified that accurately predict early disease spread immediately after emergence. methodology/principal findings: here, we examine the role of travel, trade, and national healthcare resources in predicting the emergence and initial spread of a/h n influenza. we find that incorporating national healthcare resource data into our analyses allowed a much greater capacity to predict the international spread of this virus. in countries with lower healthcare resources, the reporting of a/h n cases was significantly delayed, likely reflecting a lower capacity for testing and reporting, as well as other socio-political issues. we also report substantial international trade in live swine and poultry in the decade preceding the pandemic which may have contributed to the emergence and mixed genotype of this pandemic strain. however, the lack of knowledge of recent evolution of each h n viral gene segment precludes the use of this approach to determine viral origins. conclusions/significance: we conclude that strategies to prevent pandemic influenza virus emergence and spread in the future should include: ) enhanced surveillance for strains resulting from reassortment in traded livestock; ) rapid deployment of control measures in the initial spreading phase to countries where travel data predict the pathogen will reach and to countries where lower healthcare resources will likely cause delays in reporting. our results highlight the benefits, for all parties, when higher income countries provide additional healthcare resources for lower income countries, particularly those that have high air traffic volumes. in particular, international authorities should prioritize aid to those poorest countries where both the risk of emerging infectious diseases and air traffic volume is highest. this strategy will result in earlier detection of pathogens and a reduction in the impact of future pandemics. predicting the origin and emergence of new diseases is critical to preventing and controlling them [ , ] . in particular, if the early spread of a newly emerging pathogen can be predicted and curtailed before it becomes pandemic, its impact on public health and global economies may be much reduced [ , , , ] . in march and april of , a novel h n influenza a virus ( a/ h n ) with gene segments from humans, swine, and birds led to the first pandemic of influenza in forty years [ , , , ] . current evidence points to a mexican origin for the initial human-tohuman transmission of this virus, although preliminary genetic analyses suggest the virus has an older and highly-mixed lineage [ ] . the virus' lineage and rapid spread suggest that global trade and travel may have played an important role in its early emergence [ , ] . here, we attempt to elucidate how these factors may relate to the emergence and spread of this newly detected virus. one unresolved question is to what degree does a country's development affects its ability to detect and respond to an emerging disease in a timely manner? development may affect spending on healthcare infrastructure, and particularly, spending on the high cost, intensive public health surveillance needed during the early stages of a pandemic [ , , ] . socioeconomic factors will also likely affect individuals' abilities or desire to seek diagnosis or treatment, and a country's capacity to test and identify pathogens. here, we analyze socio-economic and travel data to understand the initial spread of this virus. we focus on the early stages of the epidemic, when travel from mexico was likely to be the dominant mode of viral spread. finally, we examine poultry and swine trade data prior to the a/h n pandemic to add to our understanding the processes that led to the emergence of this virus. as of may th , only two weeks after it was first reported, the a/h n influenza strain had spread to countries, u.s. states (plus the district of columbia) in the us, and provinces in canada ( figure ). this rapid spread resulted, in part, from the tight connectivity of the globe through air travel ( figure ) . a log-logistic survival analysis regression model was used to predict the time-to-reporting of the first confirmed a/h n case to each country. of all the models evaluated, a multivariate model with three predictors, ( ) total country-level healthcare spending per capita, ( ) estimated passenger volume arriving from mexico via direct flights (direct flight capacity), and ( ) passenger volume from mexico via indirect, or two-leg, flights (indirect flight capacity), provided the best fit to the data using aic, as detailed under methods (table , daic = , overall x = . on degrees of freedom, p-value, . ). the correlation between total country-level healthcare spending and the flight data was low (r, . ). although the correlation between direct and indirect flight data was high for countries with direct flights (r. . ), the indirect flight information provided critical additional information for areas without direct flights. the aic scores demonstrated this, as the model that included only direct flight information and healthcare spending did not explain the data as well as the best fit model (daic = . ). alternate socio-economic measures, even those directly related to healthcare, such as the number of physicians per capita, gdp, or population density were much less predictive than total healthcare spending per capita. notably, out of univariate analyses, the model with healthcare spending per capita as the sole predictor fit better than models with flight information alone (table ) , demonstrating just how informative this data is in predicting the date of reporting. in the best fitting multivariate model, indirect flight capacity had the largest effect size, but including healthcare spending per capita substantially increased the fit to the data (tables , ). for canadian provinces and american states, we conducted an analysis with just the flight data (table overall x = . on degrees of freedom, p-value , . ). while the direct flight information does not have a statistically significant effect, the indirect does, most likely because only a few key hubs had direct flights, and these hubs also have a large volume of indirect connections. for the country-level analysis, we compared the predicted reporting dates with the actual reporting dates, for countries where the disease arrived by may th , ( figure , supplemental online figure s ). we validated the model by determining how well a model fit to data up until may th predicted reporting dates for fourteen countries where the disease was detected between may th and may th (supplemental online figure s ). the correlation between forward predicted and observed dates was . , and the observed reporting date fell within the % confidence interval for all countries. many of the actual reporting dates are earlier than predicted, which is expected due to the nonlinear nature a of log-log survival analysis regression. in particular, countries that had not reported disease by the cut-off date were included in the analysis by designating these as locations that ''survived'' the entire study period without acquiring the disease (i.e, censoring). this appropriately extends the predicted reporting dates by including information on both countries that had reported disease by the cut-off date as well as countries that had not. using this methodology, we also estimated the reporting date of the disease in the remaining countries and the % confidence intervals ranged from april th to may th , (supplemental online figure s ). to elucidate the potential origins of this novel viral strain, and to shed light on targets for future surveillance and prevention programs, we analyzed global trade in live poultry and swine during the decade preceding the current pandemic [ ] . we estimate the trade in live swine between canada, the united states and mexico to be over . million animals over the last decade, previous studies suggest that data on air travel can be used to predict the spread of newly emerged human pathogens and better target public health measures [ , , , ] . our analyses support this, but demonstrate that the ability of a country to rapidly detect, diagnose, and report the new infection is a critical element that enhances our predictive power and control capacity. other studies suggest that analysis of the underlying drivers of disease emergence (e.g. agricultural intensification, land-use change) can be used to predict the geographic origins of new emerging diseases [ ] . the currently circulating pandemic influenza strain is a triple reassortment virus with closest known relatives from europe, asia, and north america, but there is uncertainty regarding its origin due to the large temporal separation between this pandemic a/h n strain and the nearest ancestors ( - years) [ ] . our analyses of swine and poultry trade demonstrate an enormous potential for intercontinental mixing of potentially zoonotic pathogens, including influenza a viruses. although artificial insemination is the predominant strategy for interbreeding of commercial swine, live swine are still routinely traded for breeding purposes [ ] . large numbers of poultry are also traded globally, and low pathogenicity influenza viruses are likely to spread unnoticed among poultry until they reassort or mutate to highly pathogenic forms, such as the a/h n v strain. this strain notably was the results of reassortment of several relatively low pathogenic influenza strains, as explained by garten et al. [ ] . in addition, as the recent cases of workers exposing a herd of pigs to the a/h n virus makes clear [ , ] , even dramatic reductions in the international live animal trade may not prevent the exposure of local livestock to novel viral types from distant locations [ , ] . although extensive trade of poultry and swine between continents and within the north american countries almost certainly contributed to the emergence of this virus, surveillance of influenza strains circulating among traded animals is poor [ ] , so that it is impossible to designate any single country, trade connection or market as the key point at which the new strain evolved. expanded surveillance for influenza in livestock populations may allow more of the markers of transmissibility and virulence to be identified, or factors driving higher virus transmission to be determined [ , ] . in particular, we need to analyze all influenza strains, including the non-and low pathogenic influenzas, in addition to the highly pathogenic ones, with greater regularity. only by this thorough surveillance can we begin to understand what differentiates the strains that cause pathogenesis in humans from those that do not. such that eventually we may be able to predict viral emergence and develop vaccines against pandemic influenza viruses in advance of their spread. in order to develop such capability, we need to do more surveillance of livestock and wild influenza strains now. the speed at which a/h n spread during the early phases of this pandemic is striking. it was detected in four continents within three weeks after mexican authorities first reported it. in contrast, the spanish flu took years to circle the globe [ ] . our analyses of air-travel data support the who's decision to recommend against closing all air travel from mexico, since the virus most likely had already spread to several other countries by the time it was first reported to be widespread in mexico on april th . in particular, cases had already been detected in the united states, which is a major hub for connecting flights [ ] . our current report is the first published analysis of h n spread to include indirect flight data, and this significantly increased the predictive power of our model. our analysis suggests that airports serving as major hubs could be targets for disease surveillance, and could become facilities that train people and stockpile medicines in preparation for pandemics. this approach differs from previous reports that focus on the role of travel restrictions at hubs [ , ] . our results further suggest a critical role for health care spending in determining a country's probability of detecting, confirming and reporting influenza cases in the early phases of a pandemic. the negative relationship between healthcare spending and detection of a/h n influenza may be due to a delay in testing or in the collecting of specimens from individuals in countries lower healthcare resources. these countries likely have lower rates of health insurance, less healthcare infrastructure, lower self-reporting, and lower numbers of doctors per capita. one consequence of lower health care resources is that the threshold for detection (i.e., the number of cases that need to occur before a case is detected, tested and confirmed by medical authorities) is likely higher in lower-income countries that cannot afford to invest as much in public health and healthcare infrastructure. similar socioeconomic factors have been shown to play an important role in determining spatiotemporal patterns of diseases such as tuberculosis, schistosomiasis, west nile virus, and hiv/aids [ , , , ] . we found that incorporating data on healthcare spending per capita significantly increased our power to predict the time of reporting of a/h n . this suggests important strategies for future disease control. during the early stages of a pandemic, countries with moderate to high air travel from a pandemic origin, but relatively low healthcare spending, are likely to significantly under-report cases. it is therefore in the best global health interest for intergovernmental and other aid agencies to specifically target these nations for assistance to test and report cases early in a new pandemic. we propose that subsidies for outbreak response to these nations with high connectivity and low resources would be the most effective strategy to reduce the spread and impact of a pandemic. efforts to better target pandemics would be more effective in reducing disease spread if they were set up in advance of a pandemic [ , , ] , as there is a very small window of opportunity in which to act once a new emerging disease is detected. such efforts could be strategically positioned to target emerging disease 'hotspots' [ ] that are also hubs of trade and travel for surveillance and prevention [ , ] . for influenza viruses, any future identification of a spillover of a novel strain from poultry or swine to farm workers should be rapidly followed by analyses of the travel routes out of the country where the index case was discovered. at that point, intergovernmental agencies such as who could best target limited resources to the poorer countries that are most likely to receive high numbers of airline travelers from the pandemic origin. these are the countries where reporting is likely to be poorest, and where a significant, undetected caseload is likely to exist by the time resources are allocated. these at-risk countries are also the least capable of affording control measures. on the whole, this h n strain appears to be relatively mild, although it is still inflicting additional morbidity and mortality. however, if a strain with a higher mortality rate, such as that observed with the h n avian influenza subtype, were to spread in a similar fashion, the outcome would be catastrophic both in terms of human suffering and economic damage. for example, the impact of an h n avian influenza outbreak, should the virus become easily transmissible between humans, on the united states economy has been estimated to be $ . -$ . billion [ ] . the measures we have proposed are likely to have economic benefits that far outweigh their costs. we compiled the data on international air travel from the iata database, supplied by diio, llc through their apgdat service [ ] . similar to prior analyses [ , , , ] , we used direct connection information with regards to aircraft type and passenger capacity to calculate the connectivity of mexico with all airports included in the database, and summarized this information (as direct flight capacity) at the country level. additionally, we estimated the number of connecting passengers (indirect flight capacity) by calculating the number of passengers (p i,j ) arriving at airport j from airport i, and then estimating the number of passengers (p j,k ) going from airport j to airport k, based on all flights reported in the database. we limited the potential connections (trip jrk) to flights that departed no sooner than one hour after the first trip (irj), and no later than six hours after the arrival of the first trip. we also disallowed return of passengers to mexico once they left the country, and the return of passengers to north america once they left that region. we thus obtained a quantity, x i,j,k , that estimates the total potential connections to airport k available to passengers from the first trip (irj). setting constant the fraction of all passengers that connect (x), we obtained an estimate of the number of passengers with two leg itineraries for each potential destination (irk; eq. ): we summarized these connections at the country scale, thereby estimating connectivity for nearly every country on the globe with mexico through either direct or indirect flights; the only countries excluded would require an overnight stay in a hub airport, or three or more connecting flights. we validated our algorithm (eq. ) for connections within the contintental u.s.a. (the only data on actual itineraries, including connecting flight information, to which we had access). we randomly chose connecting itineraries within the u.s.a. and compared our predictions to the actual routes. our predictions were statistically significant, using a simple proportional model with log-normal errors, and explained over % of the variance in actual routes (f = . , p, . on , d.f, adjusted r = . ). we determined the date a country reported its first whoconfirmed a/h n case through may th , . we chose this date in order to limit the analysis, as much as possible, to initial spread from mexico, because it served as a natural breakpoint in the distributions of reporting dates, as well as being the date our initial analysis. we performed a survival analysis using r [ ] , and used an accelerated life time model using a log-logistic distribution. we also examined using a scale-free exponential distribution, as opposed to a log-logistic distribution, which requires a scale parameter, but these models did not fit nearly as well, as measured by aic. we followed burnham and anderson [ ] , in using akaike information criterion (aic) to choose the model that best explains the data (i.e., the one with the lowest aic, or equivalently daic, score). additionally we provided the akaike weights, which estimate the likelihood that a specific model is the true model, assuming that the true model is in the set of examined models [ ] . using this methodology, we choose to evaluate models that made mechanistic sense including a null model for a reference. we did not include any models with only the indirect flight data, and without the direct flight data, because we feel that this does not make mechanistic sense. to reduce multicollinearity we included at most two socio-economic indicators. we evaluated four independent predictors for the date of first confirmed a/h n case: the volume of ( ) direct and ( ) indirect passengers on international flights, ( ) the country-specific gross domestic product and ( ) healthcare spending per capita, by both private and public entities, from (the most recent year with all data available) from world bank estimates [ ] . we also examined alternate socio-economic metrics as compiled by the world bank [ ] , such as the number of physicians, and average population density. however models including these predictors did not perform as well (as measured by aic) and often had many more missing values if limited to most recent information. for all analyses, dates were transformed to julian day since february th , and all predictor variables were standardized (mean subtracted, then divided by standard deviation) in order make possible the direct comparison of coefficients. this standardization has the added advantage of canceling out the x factor in equation for the statistical analysis; thus, our analyses do not require any assumptions about the number of passengers who make connecting flights. these statistical models were used to predict the expected time of detection for all countries in our database that had gdp, population density, healthcare, and flight data. confidence intervals were constructed from the best model fit based on the variance of the data, using the ''predict'' functions in r [ ] . we obtained united nations food and agriculture organization data on trade in live swine (commodity code hs :s ) and live poultry (s ) from the u.n. comtrade data portal [ ] . we analyzed data from the last ten years (the approximate time since a/h n diverged from the nearest sampled virus) [ ] , and focused on trade to north america (mexico, canada and united states) from outside this region, as well as trade to mexico within the north american region. figure s model predictions compared with actual case arrival dates. dates of case arrivals (black diamonds) for cases that were reported before our cut off of may th. grey whisker plots represent % confidence intervals for predicted arrival date, with interior grey bar as expected (mean) date of arrival from survival analysis. found at: doi: . /journal.pone. .s ( . mb pdf) figure s forward prediction of future case arrival dates. dates of case arrivals (black diamonds) for cases that were reported after our cut off of may th, but before may th. grey whisker plots represent % confidence intervals for predicted arrival date, with interior grey bar as expected (mean) date of arrival from survival analysis. found at: doi: . /journal.pone. .s ( . mb pdf) figure s forward prediction of future case arrival dates. grey whisker plots represent % confidence intervals for predicted arrival date, with interior grey bar as expected (mean) date of arrival from survival analysis. found at: doi: . /journal.pone. .s ( . mb pdf) microbial threats to health: emergence, detection, and response global trends in emerging infectious diseases isolation and characterization of viruses related to the sars coronavirus from animals in southern china factors that make an infectious disease outbreak controllable strategies for containing an emerging influenza pandemic in southeast asia strategies for mitigating an influenza pandemic pandemic potential of a strain of influenza a (h n ): early findings antigenic and genetic characteristics of swine-origin a(h n ) influenza viruses circulating in humans emergence and pandemic potential of swine-origin h n influenza virus origins and evolutionary genomics of the swine-origin h n influenza a epidemic income and inequality as determinants of mortality -international cross-section analysis social inequalities and emerging infectious diseases social scientists and the new tuberculosis united nations department of economic and social affairs --statistics division the scaling laws of human travel modeling the worldwide spread of pandemic influenza: baseline case and containment interventions forecast and control of epidemics in a globalized world global traffic and disease vector dispersal perspectives for artificial insemination and genomics to improve global swine populations a/h n influenza, canada. oie weekly disease information preliminary outbreak assessment.reference: vitt /h n influenza a in argentina pigs ecology of avian influenza viruses in a changing world global epidemiology of influenza: past and present world health organization ( ) global alert and response demographic and spatial analysis of west nile virus and st the social and economic context and determinants of schistosomiasis japonica predicting the global spread of h n avian influenza the economic impact of pandemic influenza in the united states: priorities for intervention r: a language and environment for statistical computing model selection and multimodel inference: a practical information-theoretic approach world development indicators online (wdi) database we acknowledge aleksei a. chmura, jon epstein, alonso a. aguirre, barry nickel, and evan girvetz for assistance. conceived and designed the experiments: prh pd. analyzed the data: prh shs kjv amk. contributed reagents/materials/analysis tools: amk. wrote the paper: prh shs amk pd. key: cord- -b lg authors: athreye, suma; piscitello, lucia; shadlen, kenneth c. title: twenty-five years since trips: patent policy and international business date: - - journal: j int bus policy doi: . /s - - - sha: doc_id: cord_uid: b lg in this introduction to the special issue, we take stock of the impact of the trips agreement on international business in the hyper-globalised world of the late twentieth and early twenty-first century. we begin by providing a brief background on trips, putting it in the historical context of international agreements on intellectual property (ip) and then looking at the logic of national patent policies, examining how policies may vary across countries, in theory, and reviewing literature that discusses the factors driving historical variation, in practice. we review the key issues in the domestic politics of implementation as the new rules migrate from the international to national levels. lastly, we consider the implications of trips for the governance of innovations in industries based on ict and where ict has enabled global value chains (gvcs), where the speed and distributed nature of innovation makes ipr simultaneously less effective and more necessary. the uruguay round of trade negotiations, which began in and concluded in with the signing of the marrakesh agreement by all negotiating countries, was notable for numerous reasons, including the formal integration of intellectual property rights into international trade rules. when the world trade organization (wto) was launched in , a product of the uruguay round, one of its main pillars would be the agreement on trade-related aspects of intellectual property rights (trips). trips is not the first international agreement on intellectual property (ip); the paris convention (patents), madrid system (trademarks), and berne convention (copyright) have existed since the late s.yet trips can be understood as marking a fundamental break in a variety of ways. trips is much deeper and more granular, placing external constraints on many more dimensions of national ip policy than previous agreements had. beyond establishing shared commitments to basic principles, as previous international accords had done, trips, in a detailed set of articles, includes specific prescriptions and proscriptions for national policy. notwithstanding its title, trips addresses national ip measures regardless of whether these are ''traderelated.'' trips is also stronger and more binding than previous agreements, as the costs of noncompliance are substantial. because the inclusion of trips in the wto means that it is subject to the wto's dispute settlement system, which authorizes trade sanctions as a penalty against countries judged to be in violation of its rules, failure to abide by the rules can have economically painful consequences. the establishment of extensive and binding rules on national ip policy marks a shift from ''international'' to ''global'' ip governance (maskus, ; drahos, ) and, importantly, a major step toward global harmonization of national policies and practices for establishing and protecting intellectual property rights. this special issue presents papers examining years since trips came into effect, in january . in these two and a half decades, much has changed in the global innovation landscape. technology trade has flourished and more technology has been transferred to subsidiaries by mnes (branstetter et al., ) . although ib theories emphasize the role of innovation and technological change in originating and strengthening the competitive advantages of the mne, ib scholarship has focused mostly on considering ipr regulations as a location advantage/disadvantage (e.g., ivus, park & saggi, ) , or an institutional factor (e.g., peng, ahlstrom, carraher, & shi, ; peng, ) interacting with mne strategies. through this special issue, our aim is to champion research analysing the contribution of ip harmonization to processes of technology transfer, policy-making, capability building and challenges to governance. assessing the trips experience to highlight what has worked well and what has not can offer new insights and lessons. in this introduction, we take stock of the impact of trips on international business in the hyperglobalised world of the late twentieth and early twenty-first century. we begin by providing a brief background on trips, putting it in the historical context of international agreements on ip. we then look at the logic of national patent policies, examining how policies may vary across countries, in theory, and reviewing literature that discusses the factors driving historical variation, in practice. the following section discusses the international campaign that produced the trips agreement and considers key issues in the domestic politics of implementation as the new rules migrate from the international to national levels. we then look more closely at the implications of trips for industries based on icts and where governance of gvcs feature prominently. the final section introduces the papers in the special issue, placing each of them in the broader debates and themes discussed in this introduction. a brief primer on trips one of the remarkable aspects of trips is how it expanded over time during the course of the uruguay round. what was originally advanced as a global accord against counterfeiting after years of negotiation ended up being a comprehensive agreement covering a wide range of ip policies. as the content expanded, the axes of political conflict shifted as well. although, at the time of the uruguay round's launch, divisions over whether to include ip on the agenda were largely of a ''north-south'' nature, once this hurdle was cleared, subsequent negotiations on substantive issues revealed ''north-north'' divisions as well. this dynamic was notable, for instance, in the area of ip for pharmaceuticals. many developing countries tried to block the inclusion of ip on the uruguay round negotiating agenda, maintaining that ip and trade rules should be kept separate, and having failed to keep ip off the agenda they mobilized their efforts to resist the inclusion of the provision that would require countries to allow patents on pharmaceuticals products. after all, prior to the s, few developing countries did so. though developing countries lost this fight too, the specifics of this requirement (for example, transition periods and whether this should be done retroactively), and more generally the rules about how countries should treat ip in pharmaceuticals, were produced by extensive negotiations and compromise, not only between north and south, the original antagonists, but also among countries in the north. most european countries, for example, had only recently (since the late s) begun to allow patents on pharmaceuticals, and they too were grappling with the consequences of this change and were resistant to some of the proposals made by countries where pharmaceutical patenting was longer established (taubmann & watal, ; reichman, ; matthews, ) . as much as the content of trips expanded during the uruguay round, the world's changes outpaced it. the establishment of the european common market in altered (or reflected ongoing shifts in) the political and economic strategies of many european countries, and the balance of power within international organizations. the collapse of the berlin wall and the dissolution of the soviet union (as well as that of yugoslavia), and thus the end of communism and state-planning in most of central, eastern, and south-eastern europe, meant that a large group of additional countries would now seek to attract foreign investment, participate in international trade, and, more generally, integrate into the global economy. at the same time, many developing countries abandoned industrial planning and policies of import-substituting industrialization, reduced barriers to imports and foreign investment, and also sought greater integration into the global economy. and, of course, china, the world's most populous country, also underwent a major reorientation of economic strategy in this period; though not a participant in the uruguay round negotiations, by the time the wto was launched in , china, which eventually became a wto member in , was already emerging as an industrial powerhouse. the worlds of business and technology were also markedly different by the end of the uruguay round than they had been at the start. the spread of new technologies of ict began to gather steam and ultimately ushered in a new phase in the development of industry and global production barnett ( : ) largely dominated by increasing fragmentation of production and global value chains (gvcs). for the leading industrial countries strident in their demand for stricter ip protection, the trips provisions had few safeguards for the new technology sectors that were emerging, such as software, ai, and telecommunications. patent and copyright policies towards the new ict industries, and their relation to competition policy, remain contentious areas where consensus has yet to evolve. in some sectors marked by globalization of production and the presence of gvcs, trips has been almost redundant and supplanted by standards and cooperative agreements over essential patents as the mode of governance of innovation and appropriability. the emergence of digital commerce created new challenges and forms of conflict that trips was unable to address (azmeh, foster, & echavarri, ; haggart, ) . international labour mobility has also brought a slew of new issues to consider such as trade secrets and espionage activity. thus trips, though the most comprehensive international ip agreement, was in some ways born outdated, having to cope with new realities that were unforeseen at the start of -and even during most of -the uruguay round. and practice standard economic theory as outlined in scotchmer ( ) argues that optimal (patent) incentive polices will differ when we consider the national or international context. in a domestic context, the optimal patent policy tries to balance benefits that accrue to consumers and producers, mainly by addressing the question: how much monopoly profit should the innovator be allowed in order to maximise the social welfare that society as a whole may derive from a new invention? phrasing the question in this way recognises that pricing under patenting will be higher due to the implicit monopoly granted by the patent and as such will produce a deadweight loss to society as a whole because of the restriction of output and the higher price borne by consumers (nordhaus, ) . as a consequence, economic thinking about patents is also dominated by market share arguments and the societal lack of welfare due to the monopoly granted by patents. indeed, economic theory since schumpeter has long recognized that patents (and ip protection, more generally) can have both dynamic effects, by creating incentives for innovation, and static and deadweight losses, by allowing patent-owners to charge monopoly prices. the optimal patent policy tries to balance these two effects, and thus the benefits that accrue to producers of innovations and users of innovations. in establishing national patent systems, three levers are available to the government to strike this delicate balance between producer and social welfare interests. these are the scope of patentability, which defines the boundaries of what types of knowledge are eligible for private ownership; the exemptions to property rights, which define the relative rights of owners versus users; and the duration of patents, which establishes the time when privately owned knowledge enters the public domain. in the paragraphs that follow we briefly discuss each of the three levers, though before doing so it is worth noting simply that the first lever, which affects the establishment of the ipr, is the most important of the three in a gatekeeper sense, as the abilities of owners to exercise such rights and how long they may do so are relevant only in the context of there being a property right. regarding ''scope,'' patents are available for inventions and not available for products of nature, but countries may differ in their determinations of what knowledge fits within each of these categories. more concretely (and less philosophically), countries may declare that certain types of knowledge, even if ''inventions,'' are nevertheless ineligible for patent protection. as noted above, the area of pharmaceuticals provides an example: new molecules and compounds are ''inventions,'' but until the late s only a handful of countries allowed pharmaceutical products to obtain patents (liu & lacroix, ; shadlen, sampat, & kapczynski, ) . related to the scope of patentability is the ''breadth'' of patents, which regards the number and type of claims that are allowed. broad patents allow the producer to profit from subtle product differentiation and make it more difficult for potential competitors to ''invent around the patent'' and enter the market upon achieving such differentiation (merges & nelson, ) . until the late s japan stood out among advanced economies for having a patent system that imposed narrow breadth, restricting patents on a single claim (ordover, ) . for the most part, patent breadth is determined through office practices and jurisprudence, and not a matter of policy per se. a second lever concerns exemptions to patent rights. with intellectual property, which is based on non-rivalrous material, consumers and other producers beyond the owners (i.e., ''third parties'') typically are allowed more rights to use the privately-owned knowledge than is the case with ordinary property. patent systems will always have provisions that set out and delimit such rights. some of these will be established as automatic exemptions that do not depend on permission from the rights-holder or the state, such as research use, or preparing products for commercial launch upon expiration of the patent. other exemptions, which are non-automatic, require the state to grant permission to private or public actors to use patented knowledge without the owner's consent, as is the case with a compulsory license. although pharmaceuticals is the area where we observe the most amount of action with regard to compulsory licensing, as discussed by ramani and urias in this si, other sectors where such exemptions play an important part include semiconductors (chip manufacturers need to experiment with various chips to create their own) and seed producers (they need to experiment with seeds in order to create new hybrids). the final lever of national policies, the duration of patents, is also the clearest: longer-lasting patents allow producers to charge monopoly prices (and thus earn greater profits) for a longer time, while consumers in the economy pay higher prices for longer periods of time. note, however, that in sectors with rapid technological change, the length of the patent is less consequential than it might seem if inventions become obsolete well before their patents expire. the discussion of the three levers allows us to conclude that countries' ip systems afford ''stronger'' protection when they allow more types of knowledge to be patented, the exemptions to owners' private rights of exclusion are fewer, and they last longer. indeed, we could, at least theoretically (subject to data constraints), use these dimensions to compare the strength of all countries' patent systems across time and space. having explained how patent policies may differ in theory, the next question is what factors account for variation in practice. scholars have argued that ip institutions are endogenous to the growth process and acquire prominence with the growth of technological capacity, and strong ipr in earlier stages of development can prove to be barriers to the development of technological capability and innovation, rather than act as incentives. as countries acquire more innovative capabilities and their scientific and industrial sectors expand, and as their firms move closer to the technological frontier, the case for stronger ip protection often follows (sweet & eterovic, ; sweet & maggio, ; kalaycı & pamukçu, ; acemoglu, aghion, & zilibotti, ) . accordingly, a substantial body of research has shown that countries' choices of how strong to set the level of protection in their ip systems have, historically, been a function of domestic conditions, such as levels of income, industrial structure, and scientific-technological capabilities. in general, countries seeking to catch-up with wealthier and more technologically advanced countries tended to offer weaker ip protection to facilitate the use of foreign knowledge and information, and subsequent strengthening of ip tended to reflect changes in these same characteristics. indeed, the close relationship between national conditions and ip policies has long been demonstrated (chen & puttitanun, ; lerner, ; lacroix & liu, ; maskus, maskus, , may & sell, ) . the netherlands and switzerland had no patent systems in the th and much of the th centuries (schiff, ) ; the german patent system was only established in . and even as countries had patent systems, some areas of knowledge remained off limits, and the rights of exclusion were moderated. in the usa, although a patent system to protect inventions was mandated in the first article of the constitution, throughout much of the th century, protection for inventions originating abroad remained weak (peng et al., ; mowery, ; khan, ) . as noted, not until the late s did japan offer stronger patent protection, rather it was designed to maximize the diffusion of knowledge and maximize opportunities for local actors to develop technological capabilities (ordover, ) . for many late-developing countries, ip policies featuring weak patent protection were fundamental to their industrialization strategies (kim et al., ; odagiri, goto, sunami, & nelson, ; kumar, ) . this scenario of national variation in patent policies was a function of a permissive international environment. that is, prior to trips, international rules were based on the principle that different approaches to ip made sense in different countries depending on national conditions. indeed, international rules on patents, which established a framework for an international patent system (e.g., rules on priority dates) but imposed few substantive obligations on countries, explicitly accommodated cross-national diversity. in the next section, again focusing on patents, we explain the major shift in global governance, from the paris convention to trips. of harmonization: from paris convention to trips the most important provision of the paris convention regards ''national treatment,'' which requires countries to afford foreign inventors the same opportunities and rights as those available to national inventors. but this is extremely limited. national treatment equalizes treatment at whatever level the country chooses, but it does not address the level of treatment. that is, in the language of the three levers of policy discussed above, national treatment does not say that countries should allow patents over given types of knowledge, or limit exemptions in particular ways, or have longerlasting patents, but rather that if they do grant patents in particular technological classes, with particular rights of exclusion attached for a given period of time, they must treat foreign inventors the same as they treat national inventors. if a country does not offer strong patent protection, national treatment simply means that no one receives strong patent protection in that country. from the perspective of firms in information-and knowledge-intensive industries which sought stronger protection on a global scale, the paris convention was clearly inadequate. they wanted to raise the bar across the globe, establishing international arrangements that would encourage harmonization at a higher level of ip protection. starting in the late s and early s, these firms, both on their own and through their sectoral associations, mobilized intensively in the us and europe to create a new international arrangement, with the key step being to link ip rules to international trade (sell, (sell, , ryan, ; drahos, ) . in doing so, they made achieving stronger ip protection a key feature of american and european foreign economic policy in this period. the usa first linked ip practices to trade in , with a reform of the trade act that defined ''unfair'' trade to include ip practices that did not meet us standards. the punishments attached to transgressions could range from trade sanctions imposed under section to withdrawal of preferential market access provided by the general system of preferences. then, in , just as the uruguay round discussions on ip were picking up pace, the us trade act underwent a further amendment, this time creating a new mechanism that was specifically about ip. starting in , the united states trade representative (ustr) began issuing an annual ''special '' report, essentially a global report card that evaluated all countries' ip practices and placed those judged to be problematic on the ''watch list'' or ''priority watch list.'' as countries were placed on the watch list and then escalated to the priority watch list, the threat of penalties increased, and when a country was identified as a ''priority foreign country,'' the ustr was obligated to initiate proceedings to apply sanctions. not surprisingly, many countries that were most resistant to ip negotiations in the uruguay round were targeted directly by the ustr. unilateral pressures of this sort not only brought many hesitant countries to the negotiating table, but made agreement on a multilateral set of rules more attractive too (odell, ; drahos, ; bayard & elliott, ; bhagwati & patrick, ) . when the wto was launched in , the agreement on ip, trips, was included. trips took international ip rules to an entirely new level, by calling for harmonization at a level closer to what was available in wealthier countries. its aims extended far beyond reciprocal national treatment of foreign inventions to the harmonization and strengthening of ip systems in the world. in the quest for stronger protection, trips addressed each of the levers of national policy. it called for wider scope, requiring patents to be granted in all fields of technology; it tried to restrict the range of allowable exemptions to patent rights; and it established longer terms for patents, requiring terms of years from the date of application. this new approach to ip did not respect where particular countries were in their national evolution, but sought to construct a uniform system of protection that could support a global market for trade in technology goods. low and middle-income countries who were net buyers of technology, were fearful that stronger protection at home would increase profit flows to foreigners. international profit flows depended upon the relative size of domestic markets and the relative sizes of country innovative capacities. thus, countries with smaller national markets and countries with stronger innovative capacities (most high-income countries) generally favoured stronger protection, but countries with larger markets and weak innovative capacities resisted. middle and low-income countries who opposed trips were in the latter group. it is important to underscore that the wto was concluded as a ''single undertaking,'' meaning that all members were subject to all of its agreements. as a result, even countries that resisted trips ended up as parties to -and bound by -it. thus, once the uruguay round was concluded and the new wto's rules came into effect in , countries began revising their national laws to come into conformity with trips (and other wto agreements). in other words, wto member states moved from a period of trips negotiation to trips implementation (shadlen, ; deere, ) . in this context, with participation in the international trading system conditioned on being in compliance with trips, the question that countries faced was not if but how they would comply with the new international agreement. although trips established harmonization, it did not create a world of uniform patent policies and levels of patent protection. that is, a set of countries could all be in compliance with trips yet all demonstrate differences in the details of their national ip systems. the reasons for this are twofold. first, trips is not a self-executing body of law, but rather an agreement that prescribes and proscribes different practices, leaving matters of implementation to countries. for example, trips establishes a set of conditions that should be met in granting compulsory licenses, but how these conditions are operationalized in national patent systems (what sort of behaviour by patent owners constitute grounds for compulsory licenses? can the ministry of health act on its own? does there need to be a health emergency, and, if so, how is it determined and who declares it?) was left to be determined locally. this means that trips left countries with policy options (commission on intellectual property rights, ; correa, ) , and countries could -and did -comply with trips differently. second, trips for the most part addressed laws, not so much enforcement practices. that means that not only may countries differ de jure (e.g., the three policy levers, or the details of the compulsory licensing rules), but also de facto due to the enforcement of their new laws. and evidence suggests substantial gaps between de jure and de facto levels of ip protection (maskus, ; shadlen, schrank, & kurtz, ) . one recent study (papageorgiadis & mcdonald, ) shows that de jure ip protection departs significantly from the de facto ip protection for several middle-and low-income countries. figure is from their paper and shows the two dimensions of de jure and de facto ipr on the two axes. although attention on lax enforcement has often focussed on china, china is not alone. figure reveals similar gaps between laws on the books and laws in practice in many other emerging economies, such as argentina, mexico, the philippines, and turkey, as well as india, russia and brazil (many of these countries initially opposed the trips agreement). indeed, as pointed out in athreye, martelli and piscitello ( ), one can discern two groups of countries -those for whom de jure and de facto ipr move in the same direction (a positive relation) and a smaller group of middle income countries for whom the two are compensatory (a negative relation). as we examine the dynamics of trips implementation at the national level, both introducing and enforcing new laws, it is worth underscoring how the new international agreement altered the nature of domestic politics by imbuing technologyintensive sectors with new authority and importance. this happened in much the same way as baldwin ( ) argues the reciprocity principle in gatt helped shift political interests to create a juggernaut of tariff cutting behaviour across nations. prior to trips, national patent policies were shaped largely by strong consumer groups and import substituting industrial sectors. innovators (actual, fledgling, and aspiring) rarely had large and direct say in the drawing up of national ip policies, which in many developing countries were not designed to encourage innovation so much as to assure that knowledge, information, and technologically-intensive goods were accessible to consumers and as inputs to local industry. by forcing shifts in national policies toward stronger ip protections, trips served as an exogenous shock that changed the distribution of incomes between innovative and non-innovative business groups. once stronger ip protection was implemented, innovative businesses/sectors gained from the new arrangements while businesses that relied on the previous arrangements experienced shrinking margins and some even left non-innovative lines of business. this changed the balance of political power with the two groups in ways that became self-reinforcing, as in subsequent political conflicts over ip, it was now the more innovation-focused sets of actors in business (and also within the state) that hold the upper hand. and the preferences of actors changed too. faced with a new status quo, some actors that opposed trips adjusted to the new environment and began to see opportunities where they previously felt only threats. when this happened, they revised their political strategies and were likely to seek alliances with actors that had supported the introduction of new arrangements (sinha, ; shadlen, ) . governance and trips in the spectrum of goods to which the provision of trips could apply, scholarly attention has focussed sharply on goods with externalities, such as access to medicines and climate change technologies where the stronger monopoly enabled by trips was obviously to the detriment of many poorer nations and poor consumer in richer nations. the adoption of trips, however, came before the full impact of the newly emerging icts was felt. consequently, the ict sectors themselves and the ict-mediated global value chains faced challenging governance issues shaped by the uncertainty of ip rights and in some cases, these were sorted out through sectoral innovations in the governance of ip rights. improvements in icts and rapid globalisation created unprecedented opportunities for the fragmentation of global value chains by reducing the transaction costs of exchanging information and communication across different stages of production. the best example of the changing industrial organization of production is the car industry, which moved from being a monolithic fordist assembly line to gradual vertical disintegration along component lines. today the car we drive has engine and components sourced from different parts of the world and includes improvements due to r&d conducted in different countries. ghemawat ( ) ascribes this development to the globalization of markets being accompanied by the globalization of production. thus, in many sectors of industrial activity, firms today select the best location for every value chain activity, either at home or abroad, and whether inside or outside organizational boundaries (alcacer, cantwell, & piscitello, ) . as icts allow higher-quality information to be more readily accessed through a greater diversity of potential channels (rangan & sengul, ); market-based transactions and outsourcing are favoured and the use of ict tends to reduce the extent to which facilities are owned by the mne (zaheer & manrakhan, ) . thanks to it-enabled integration capabilities, the fragmentation of processes across units allows firms to exploit complementarities between dispersed fragments, to vary their information-protection approach according to the specific institutional context of each host country, and to (selectively) develop a differentiated use of internal controls over activities performed abroad (gooris & peeters, ) . on the other hand, better quality of ipr institutions in host countries facilitates intra-firm knowledge transmission by mnes to their affiliates (branstetter et al., ) , and shifts the organisational mode towards outsourcing by reducing the need for integration to hedge against knowledge dissipation and opportunistic behaviour by the supplier/local unit. one important consequence of the new possibilities opened up by gvcs is that attention has shifted from market share arguments (based on the economic efficiency of ip policies) toward propertybased arguments that highlight the role of ip in facilitating technology trade and the emergence of disintegrated, specialized technology markets (spulber, ; barnett, ; arora, fosfuri & gambardella, ; athreye, ) . the greater is the use of specialized markets, the greater the need for ip to enable transactions across them. this is shown in figure , adapted from barnett ( ) , which illustrates the different ip requirements of the integrated and disintegrated industrial organization models. the first model in figure represents the classical case of r&d-based innovation to produce a technology product (as in the case of big pharma). but the next two models represent different realities of subcontracting and vertically disintegrated supply chain models, with the second and the third being representations of sectors like semiconductors or the new biopharma. what is interesting is the more ip-intensive nature of the second and third models shown by the shaded boxes, which involve ip-based technology transfer activities. the more points at which ip transactions occur as technology is handed over for further processing to create the final product, the more patent-intensive is the final product. having patents protecting these stages reduces transactions costs. the higher the division of labour in r&d, the more the scope for such ip transactions. however, this ip is for the most part protecting very small market shares as each stage involves a number of different operators. icts, due to the higher use of patents in more fragmented value chains, increased the scope for trips-like provisions. this is the case even in those sectors like telecommunications where it is not immediately obvious that patents are always the most effective means for protection as technology is changing so rapidly. widespread patent ownership created other issues -such as the difficulty of new innovations in the presence of fragmented patent ownership (patent thickets) and blockage to innovation that is cumulative. in these instances, sectors have come up with their own institutional innovations such as patent pooling to permit cross -licensing of fragmented patent ownership into a single contract in ict and the use of fair, reasonable, and non-discriminatory licensing of essential patents (frand) to allow scaled up manufacturing in telecommunications. the effect of these institutional innovations in the governance of ip on globalization of r&d and production is sadly an understudied but important subject. although figure does not distinguish between domestic and foreign operations, we can speculate that mnes' strategic choices also influenced the effects and trajectories of ip policies in different countries (bessen & meurer, ) . the global fragmentation of value chains is associated with multidirectional flows of information and knowledge across the entities involved in the international network of mnes (markus, sia, & soh, ) and weak ipr protection increases the risk of information leakage and misappropriation (e.g., martinez-noya & garcia-canal, ). successful gvc integration requires a dense circulation of information flows to communicate specifications, standards and technical know-how in addition to costs and other items (gereffi, humphrey, & sturgeon, ) . within this context, lead firms need to weigh the advantages of disaggregating the production process and the cost reduction this can bring against the risk of losing control over some of their proprietary intangible assets. thus, lead firms engaged in gvc trade are interested in stricter iprs in trade agreements to contain the risk of ip appropriation resulting from the international fragmentation of production. however, in order to circumvent the difficulty of using formal ip protection channels and to find other ways to enforce iprs without limiting the scope of gvc activity, other mechanisms for the management of ip are increasingly emerging, mainly based on the attempt to move beyond legal procedures. strategies such as a finer slicing of the processes (gooris & peters, ) , or a sort of holistic approach using corporate social responsibility to enforce stricter ipr standards along the chains (gillai, rammohan, & lee, ) , or the actions aiming at fostering ''a culture of ip protection and compliance'' throughout the global supply chain are all becoming mainstream (wipo, ) . on the flip side, many middle-income countries that aspired to move up the technological ladder and build their own domestic capabilities, could see a new path to growth through participation in gvcs if they were willing to embrace the tougher ip demands in trips. for example, as mnes became willing to locate their production in different countries, industrialists in these countries (hoping to become part of a global value chain) were also willing to conform to the ip standards required by the mne -often with more stringent enforcement (brandl et al., ) . in fact, the tightening of ip regulations and the deeper integration between countries through regulatory standards convergence (rodrik, ) goes in parallel with the expansion of gvc trade (timmer et al., ) . this has led authors like chang ( ) to protest that the stronger and better institutions for development demanded of developing countries today was not fair but an attempt to ''kick away the ladder'' to prevent developing countries from joining the elite club of developed nations. however, china's rise shows us that if the government/firms were prepared to make the r&d investments, then strong ip need not be a deterrent to technological growth in lower income countries. indeed, china's rapid growth today and the effect of its prosperity on the growth of other middle and low-income countries is testament to the success of such strategies, although as gomory and baumol ( ) predict, such a strategy can create conflicts when the incumbent countries feel that their market share is threatened. the growing role of intangible assets (technology, design and branding) in production is increasingly reflected in the growing share of intangible assets in the value of final products in international trade (durand & milberg, ; wipo, ; timmer et al., ) . hsieh and rossi-hansberg ( ) attribute this to a second industrial revolution in services sectors due to which productivity in services has been raised by icts in a manner similar to what machines and mechanical engineering did during the first industrial revolution. furthermore, lead firms in gvcs are increasingly focussing on the intangibles, while outsourcing the tangibles to their partners in middle and low-income countries. as a consequence, more protection of intangibles is being demanded under the ambit of trips such as protection for data, trademarks and copyrights. sectors that have greater intangible capitalwhether because of technological knowledge or consumer goodwill (brands) -are also able to earn more by judiciously choosing their location strategies. of the special issue papers there is a growing recognition in the ib literature that institutions are not always exogenous and instead co-evolve with firms: as the behaviour of firms starts changing, institutions start adapting as well (athreye, ; cantwell, dunning, & lundan, ; peng et al., ) . however, the imposition of trips and the acceptance of seemingly stringent agreements and the shift to stronger ip for middle and low-income countries was exogenously driven. once the status quo changed and the new institutions were in place, actors did change their strategies and new political possibilities emerged (as was discussed earlier). the papers in this special issue in one way or another describe the various strategies used to drive policy in the national implementation stage of the trips agreement. one way in which a more nuanced use of harmonised ipr could emerge is through the drafting of more detailed ip chapters in preferential trade agreements (ptas) between countries. the paper by christoph mödlhamer argues that the innovative capacity of states that are members of a preferential agreement shapes demand for iprs in the pta. innovative economies that rely on ip generation favour iprs because ipreliant industries press for ipr inclusion when governments negotiate ptas with less innovative economies. by contrast, ptas between non-innovators remain sparse in ipr provisions because few industries on either side demand ipr. analyzing novel data on ipr provisions in ptas signed between and , he shows that heterogeneity in pta members' innovativeness indeed increases the inclusion of ipr clauses in ptas. his findings help to understand preferences towards iprs in pta negotiations and shed light on reasons for varying numbers of ipr inclusions, while offering a refinement of the conventional wisdom that adds to our understanding of pta design. in general, these findings on ip chapters of ptas are consistent with gamso and grosse ( ) . they find that deep ptas with provisions such as investor-state dispute settlement mechanisms and property rights protections provide signals that are especially important to investors in countries where property rights are weak, as the extra protections provided by a deeper agreement can substitute for those that are missing at the domestic level. empirically, they find that pta depth is positively associated with fdi between member countries, but the association weakens as property rights laws in host countries increase in strength. thus, they conclude that governments can attract higher levels of fdi through comprehensive trade agreements, as opposed to shallow ptas, when domestic policies are not sufficient. however, shallow agreements suffice where domestic policy already protects property rights. for many countries, another obvious way to prioritize national interest is to weaken the 'national treatment' principle in enforcement. a growing body of work has demonstrated anti-foreign bias in patent grants by offices around the world such as the jpo (helfgott, ) , epo (kotabe, ) and sipo (brander, cui & vertinsky, ) . though most of this evidence shows correlation rather than causation, if true it is a repudiation of the 'national treatment' principle, which as we noted earlier was a central pillar of the paris convention and trips. the paper by rassenfosse and hosseini, using data for the uspto, shows that inventions of foreign origin are about ten percentage points less likely to be granted a patent than domestic inventions, which suggests discrimination against foreigners. why does such discrimination exist? they distinguish between intentional and unintentional discrimination. intentional discrimination relates to disparate treatment of a specific group of applicants, whereas unintentional discrimination arises when policies, practices, and rules have disparate impacts on a specific group of applicants. their analysis shows that the bias against foreigners is largely the result of unintentional discrimination and can be explained by differences in patent agents used by foreigners and locals, the financial resources of the applicants, and the level of effort that applicants put into the prosecution process. thus, the story they tell is about disparate impact (due to better financial resources) rather than disparate treatment. the paper by petit, van pottelsberghe de la potterie and gimeno-fabra disagrees with the results presented by rassenfosse and hosseini and argues that tests of the national treatment argument should be conducted not on grant rates (which may be influenced by more adverse market conditions facing the foreign applicant) but on the examination process. the examination process is defined as the work carried out by the patent examination office (to assess if an application fulfils the legal patentability conditions), which is assumed to be (mostly) independent from economic forces. testing for national bias within the examination process relies on the fact that patent offices are legally required to justify each decision they publish through concrete and transparent evidence. as a result, discriminatory behaviours from patent offices should show up in the way applications are processed. using this alternative empirical approach to test for national bias at the epo, the jpo, and the uspto, and through a unique database that quantifies the key patent examination processes and find no evidence of national bias throughout the work of three patent offices (wipo, epo and uspto). the paper by ramani and urias reviews the use of the much-publicized trips flexibility -compulsory licensing for public health -in middle and lowincome countries. compulsory licensing is considered an important policy instrument to make medicines affordable in countries where a pharmaceutical industry does not exist or where stronger trips provisions on product patents are likely to increase the prices of medicines placing then out of the reach of a large segment of the population in many low and middle income countries. based on a systematic review of the existing evidence on the impact of compulsory licensing on drug prices, ramani and urias identify instances of compulsory licensing in countries -which is a very limited use of this much touted flexibility. they attribute this limited use to the very restrictive scope for the use of compulsory licensing in the trips provisions. comparing pre-and post-compulsory licensing prices, their paper finds that a compulsory licensing event is likely to reduce the price of a patented drug, although public knowledge of the extent of price drop is poor. further, they find compulsory licensing procurement from the international market is likely to be more effective in reducing drug prices than contracts to local companies. interestingly, their findings are reconfirmed in the race to improve access to the antiviral medication remdesivir for hospitalized covid- patients, based on information that is publicly available. clearly, the future incidence and impact of compulsory licensing will depend on further possible procedural refinements to ease its implementation, the development of technological and manufacturing capabilities in developing countries, and the importance of biologics among life-saving drugs. covid- could prove a pivotal moment in redefining this flexibility and enabling its wider use. finally, abinader's in-depth analysis of pharmaceutical patenting in the dominican republic, a country that does not ordinarily receive much attention in the literature on ip, sheds light on what conformity with trips looks like in practice. the paper allows us to observe patent prosecution in a developing country where substantive examination is new. the finding of low grant rates, not just for more questionable ''secondary'' patents but also for ''primary'' patents covering active ingredients suggests that, trips-driven harmonization notwithstanding, domestic politics and state institutions continue to cast a substantial influence over de facto levels of patent protection. although the papers in this issue do not cover all aspects of international business since trips, we hope some of the issues noted in this introduction and in the included papers will create a rich menu of future options for research on trips and patent policy by ib scholars. trips is also wider in that it covers more areas of ip. in addition to patents, trademarks, and copyright, trips also addresses geographical indications, industrial designs, integrated circuits, and plant varieties. watal and taubam ( ) provide a fascinating account of the process of negotiation and its twists and turns. trips article , on ''patentable subject matter,'' in its first paragraph states that ''patents shall be available for any inventions, whether products or processes, in all fields of technology….'' many of the post-communist countries eventually joined the european union, contributing to its expansion from , at the time the wto was founded, to by the mid- s (and after the united kingdom's departure in ). it is also widely acknowledged that patents are not the only way to spur innovative r&d, and that complements include government funding and prizes. governments have supplemented national patent policies with prizes in areas where solutions are needed e.g., the longitude prize in by the uk government to solve the problem of determining the precise longitude of a ship, as this was causing deaths at sea. the longitude prize has recently been re-established in around six challenge areas. see scotchmer ( ) and david ( ) for more discussion of the array of incentives. while conceptually these are three distinct policy levers, they are related to each other in their effects. for example, a patent system that, in terms of scope, allows multiple versions of similar inventions to be eligible for protection, may de facto offer longer periods of patent protection if the multiple patents are filed sequentially. examples of indices along these lines include park ( ) as a general measure, campi and nuvolari ( ) for agricultural technologies, liu and la croix ( ) for pharmaceuticals. a prominent example of this was not recognising the bessemer patent for steel production, granted in the uk. although priority foreign country designation is meant to trigger the process leading to trade sanctions, countries can be sanctioned without ever being labelled as such. the paris convention continues to be the reference for coordinating procedures on how patents are applied for and the respect of priority dates, for example. the axes in figure are better thought of as ''strength'' of patent systems, following the earlier discussion in this paper, than ''quality.'' after all, for poorer countries with minimal innovative capabilities, a patent system that provides extensive rights of exclusion over a wide array of knowledge may not be of high ''quality. '' while the assumption in the literature is that weak enforcement will lead to ip protection being weaker ''in practice'' than what's promised ''on the books,'' the inverse can also be true. some countries have patent provisions that, though designed to reduce the level of protection (within the constraints imposed by trips), are under-enforced, yielding levels of ''in practice'' that are greater that what's ''on the books.'' see shadlen ( , ) . rodrik ( ) makes a similar point. applications made through international bureau at the world intellectual property office (wipo), based in geneva, switzerland take place through the patent cooperation treaty route. the pct application is published by the wipo in one of the ten ''languages of publication'': arabic, chinese, english, french, german, japanese, korean, portuguese, russian, and spanish. distance to frontier, selection, and economic growth internationalization in the information age: a new era for places, firms, and international 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secondary pharmaceutical patenting in brazil and india indian pharmaceutical patent prosecution: the changing role of section (d) industrialization without national patents: the netherlands the political economy of intellectual property treaties private power, public law: the globalization of intellectual property rights the rise and rule of a trade-based strategy: historical institutionalism and the international regulation of intellectual property the political contradictions of incremental innovation: lessons from pharmaceutical patent examination in brazil coalitions and compliance: the political economy of pharmaceutical patents in latin america the political economy of intellectual property protection: the case of software patents, trade and medicines: past, present and future globalizing india: how global rules and markets are shaping india's rise to power the case for patents do stronger intellectual property rights increase innovation? world development do patent rights matter? years of innovation, complexity and productivity the making of the trips agreement: personal insights from the uruguay round negotiations an anatomy of the global trade slowdown based on the wiod slicing up global value chains the making of the trips agreement: personal insights from the uruguay round negotiations intangible capital in global value chains concentration and dispersion in global industries: remote electronic access and the location of economic activities about the authors suma athreye is professor of technology strategy at essex business school. her main research interests lie in the fields of economics of innovation and international business and cover issues such as intellectual property management and policy, r&d management and the study of emerging market multinationals where she is also co-director of the john h. dunning center for international business, and professor of international business at politecnico di milano in italy. her research interests cover the economics and management of mnes, the international aspects of technological change, the geography of innovation his main areas of research include the global and cross-national politics of intellectual property (ip), the politics of pharmaceutical assistance and health regulation key: cord- -ppn yd authors: abbott, frederick m; reichman, jerome h title: facilitating access to cross-border supplies of patented pharmaceuticals: the case of the covid- pandemic date: - - journal: nan doi: . /jiel/jgaa sha: doc_id: cord_uid: ppn yd the covid- pandemic has brought into stark relief the gaps in global preparedness to address widespread outbreaks of deadly viral infections. this article proposes legal mechanisms for addressing critical issues facing the international community in terms of providing equitable access to vaccines, treatments, diagnostics, and medical equipment. on the supply side, the authors propose the establishment of mandatory patent pools (‘licensing facilities’) on a global or regional, or even national basis, depending upon the degree of cooperation that may be achieved. the authors also discuss the importance of creating shared production facilities. on the demand side, the authors propose the establishment of regional pharmaceutical supply centers (rpscs) for the collective procurement of products, and the need to coordinate the issuance of necessary compulsory licenses for production and/or importation, depending on relevant circumstances. the authors envisage that centralized coordination by rpscs should assist in overcoming difficulties individual countries may encounter in addressing administrative and technical issues in procuring supplies, as well as creating improved bargaining leverage with potential suppliers. the authors finally address the problem created by the decision of various high-income countries to ‘opt out’ as eligible importing countries under the world trade organization trips agreement article bis amendment that addresses the predominant export of pharmaceutical products under compulsory licenses. the covid- pandemic has brought into stark relief the gaps in global preparedness to address widespread outbreaks of deadly viral infections. these gaps reflect a general problem with preparing for low-probability, high-risk events. government budgets are constrained, and establishing priority for 'unlikely' events inevitably elicits resistance from more immediate demands. as for private sector enterprises, the prospect that a new vaccine, treatment, or diagnostic to address a 'contingent' outbreak ultimately may not be needed, or needed in sufficient quantity, makes investment in research and development (r&d) potentially problematic for shareholders. in consequence, private sector r&d on pharmaceutical products to address new pathogens, including a pandemic virus, often must be subsidized through one of several mechanisms. the gaps in preparedness for covid- (or its pathogen equivalent) had been repeatedly identified by the scientific community for years. those gaps might have been filled by substantially increased investment in the platform technologies needed to accelerate development and introduction of needed vaccines and treatments. the lack of adequate investment in manufacturing facilities needed to respond on demand was well known, as was the general withdrawal of the major pharmaceutical companies from the vaccine sector. as a result, the response has been an historically unprecedented ramp-up in the amount of government subsidization flowing to the pharmaceutical industry. as of june , there were no vaccines available that appear capable of preventing the spread of covid- , although promising research results have been announced. some treatments may effect modest improvement, but nothing approaching a 'cure' has so far been developed. nevertheless, ongoing studies suggest that covid- may be addressable by known pharmaceutical technologies and that the development of efficacious vaccines and treatments appears likely within the next to months, although the ultimate degree of effectiveness remains uncertain. whenever these new vaccines or drugs are ready to be used by a reasonably wide public, their manufacture and distribution will take priority. in the short run, however, constraints due to manufacturing capacity shortfalls are likely, particularly for vaccines. these constraints may be exacerbated if the technologies needed to address the pandemic are closely held by individual private enterprises with decision-making authority over how, where, and when to produce and distribute vaccines and treatments that will typically have been developed with large-scale government subsidization. these private sector controls will be grounded in intellectual property rights (iprs), including patents and regulatory-based market exclusivity regimes. in the past years, public-health specialists, pharmaceutical companies, nongovernmental organizations, and intellectual property experts have struggled over the terms and conditions under which access to medicines (including vaccines) could be facilitated. the human immunodeficiency virus-acquired immunodeficiency syndrome (hiv-aids) pandemic precipitated a wide-ranging debate about the role played by patents and other forms of market exclusivity for drugs needed to treat significant parts of the global population, especially in poorer countries where personal incomes are low. the united nations (un) secretary-general convened a high-level panel on access to medicines that conducted an in-depth study, with inputs from a wide range of interested groups, and issued a report that encapsulates the different sides of this debate without proposing major new solutions. companies that invest in r&d on new treatments and vaccines argued that high prices enabled by patents and regulatory market exclusivity were necessary to provide capital for the investigation of new treatments. public-health specialists and advocacy groups concerned with access countered that innovative treatments are not useful unless they are reasonably affordable. legislators and other government officials lined up on different sides of the issues. in retrospect there is considerable evidence that the current system underlying the development and distribution of medicines is 'suboptimal' . a range of proposals for retooling that system already exists. for example, several highly articulated 'delinkage' proposals to separate r&d activities from manufacturing and distribution have sought to ensure that companies would be well compensated for successfully developing new treatments-through subsidies or prizes (i.e. push and pull mechanisms) -without selling medicines at high prices. thus, manufacturing and distribution would become 'generic', while the r&d elements would be separately compensated. given a worldwide emergency, it seems a good time for reflecting on such proposals to reorganize the basic system. we cannot accurately predict when a pharmaceutical company, academic researchers, a teaching hospital, or biotech startup will develop a successful treatment for covid- , or an efficacious vaccine. almost certainly there will be more than one of each since this is being worked on by so many. nevertheless, it is fairly certain that various new treatments and vaccines will be patented. absent government intervention, the patent owners will enjoy the exclusive rights to make, use, and sell the covered treatments and vaccines for a minimum term of years. innovators could thus prevent any third parties from making and selling the same drugs or vaccines. in ordinary practice, innovators would possess monopoly pricing power enabling them to charge what the market will bear, especially in a country like the usa where the government largely abstains from pricing decisions. the private sector innovator industry has not hesitated to fully exercise this pricing power. at the time of writing, a number of pharmaceutical companies that are receiving substantial government subsidies to develop vaccines and treatments to address covid- have declared that they intend to provide them on a 'not-for-profit' basis, although nothing in their grant arrangements appears to require specific pricing commitments, and there is limited public transparency on this account. several factors may underlie a commitment to not-for-profit supply. first, because government subsidies involve paying companies for their r&d expenses, they may already be profiting from the amounts paid by the government for such work without further need to profit from the sales. that posits an 'accounting question' . second, the recipients of federal subsidies are already under scrutiny by legislators and the public, and they lack a 'reservoir of goodwill' . a not-for-profit approach to the pandemic may thus be a way to improve the image of the industry and forestall future price regulation. third, once any specific medicine becomes the standard treatment, it may enhance the prospects of a company in competing for future opportunities, including additional subsidies and/or product sales. fourth, one cannot entirely discount charitable tendencies within the pharmaceutical industry even though it may appear to be more the exception than the rule. moreover, price-however important-is not the only factor to be considered. because innovators file patent applications in countries around the world, and especially in countries where pharmaceutical products may be manufactured, monopoly control effectively becomes worldwide. left to their own devices, a few major originator pharmaceutical companies will end up controlling the global supply of treatments and vaccines for covid- and thereby set the conditions for public access to them. given a predictably large-scale demand for vaccines and treatments, their production and distribution should be maximized, a task best accomplished by allowing effectively open-access to the technologies needed to attain this objective. clearly, innovators should be paid well for their efforts. nevertheless, steps should be taken now to ensure reasonable pricing and wide distribution of covid- treatments, vaccines, diagnostics, and medical equipment (including personal protective equipment (ppe)) so that appropriate measures are ready when the need arises. vaccines, treatments, and diagnostics may also be developed by entities that are not profit oriented. while these entities are also likely to secure patents (at least for defensive purposes), they may elect to pursue manufacturing and distribution on a nonprofit basis as a matter of institutional preference. their participation in wider efforts to make technologies available on an equitable basis should not raise concerns. the treaties administered by the world intellectual property organization (wipo) and the world trade organization (wto) clearly allow for the grant by governments of compulsory patent licenses, that is, licenses granted without consent of patent owners. such licenses can be issued to private enterprises or directly to governments under 'government-use' licenses. the legitimacy of all such licenses, although never seriously in doubt, was expressly reconfirmed by the doha declaration on the trips agreement and public health in . their availability to address national public health needs was then further amplified by an amendment to the trips agreement, in the form of article bis, which was initially adopted by a waiver in and finally ratified in . nevertheless, the pharmaceutical innovator or 'originator' companies have stridently contended-for many years-that the use of compulsory licensing should be strictly limited (if allowed at all) because overriding patents would destabilize investor expectations and reduce future investment in the development of new drugs. industry has also argued that countries issuing compulsory licenses will fail to attract foreign direct investment, even though they have not provided evidence to support that implicit threat. when the arguments concerning the alleged threats from invoking compulsory licensing are viewed from the perspective of equitable access to medicines, they have some substantial flaws. first, a very small portion of global r&d is contributed from drug purchases in countries and by populations with limited incomes. very little would accordingly be lost by overriding patents in their favor. second, a rather substantial portion of the funding for r&d in the current crisis has been provided by governments and private foundations. in this context, questions about the stability of investor expectations are secondary at best. the private sector pharmaceutical companies have not significantly invested in vaccines and treatments for addressing unknown viruses and pathogens because the returns on such investments were inherently speculative. making new pharmaceuticals available under compulsory licensing should do little to affect investor expectations, since investors had modest expectations to begin with. third, even crediting the originator industry perspective that government-use or compulsory licensing of patents may have a long-run adverse effect on capital aggregation, there are cases where we must be more concerned with immediate public health needs than with the long-term financial prospects. this was starkly illustrated during the emergence of the hiv-aids pandemic in the s. it took a surprising amount of struggle to force accommodations that eventually allowed the hiv-aids pandemic to be addressed in low-and middle-income countries (lmics) by means of generic versions of antiretroviral treatments, not to mention the role of the usa (president's emergency plan for aids relief [pepfar]) and international financing for such solutions. these struggles continue in many countries, including the usa, where prices of antiretroviral treatment remain high. whether patents and other forms of market exclusivity are necessary or useful in the context of addressing the covid- pandemic remains an open question. much depends, inter alia, on how the development of individual products is financed. it seems clear, however, that such exclusive rights in technologies should not be allowed to stand as obstacles to production and distribution of vaccines, treatments, diagnostics, and medical equipment to address global public health needs. the next two sections of this article set out proposals addressing both the supply and demand sides of the problems regarding access to essential health technologies. the potential interconnection between these proposals is discussed later in this article. there was recognition early on that government intervention would be necessary to address the gaps in r&d, production and distribution of vaccines, treatments, diagnostics, and medical equipment pertaining to the covid- pandemic. that iprs in emerging technologies might constrain equitable access to them was also foreseen. in march , the government of costa rica submitted a proposal to the world health organization (who) director general for the creation of a voluntary technology sharing pool. that proposal resulted in the launch by the who of a voluntary pooling arrangement, as well as a decision by unitaid to expand the operational scope of the voluntary medicines patent pool (mpp). g- leaders also issued a statement supporting what appeared to be progressive access policies, although without regard to how patents and other forms of exclusive rights were to be addressed, and without specifying how the objectives would be attained. other governments have made proposals for funding r&d, procurement, and the distribution of vaccines and treatments with respect to covid- , including a european-led initiative-the access to covid- tools (act) accelerator-that promises to make vaccines and treatments 'accessible and affordable to all' . the act proposal expressly refers to several institutions with substantial experience creating 'push' and 'pull' mechanisms designed to promote wide access to needed medical supplies. in early days, it was unclear how the who, g- , european union, or other governments and institutions were preparing to organize vaccine and treatment there are few specific details about how it will deal with claims of exclusive rights to existing technologies, though eu officials have said that while companies will not be asked to forgo intellectual property (ip) rights, production, or to address distribution and access issues from a practical standpoint. national governments, at least, have announced plans for various arrangements with private sector companies. nevertheless, there are reasonable grounds for concern that, in the midst of a pandemic, national governments will hoard medical supplies in defense of the local population, and there is reason to believe this will prove to be the case in the current pandemic. already there are controversial plans for special 'national priorities' being granted to governments that have financed r&d and production facilities. more generally, there is evidence of a stunning deterioration in international relations that might be characterized as a 'psycho-pathology' . although a more general trend toward nationalism was clearly in evidence before the pandemic outbreak, political relations between the usa and china subsequently have become reminiscent of the cold war, and it is difficult to foresee where the 'off switch' for this deterioration might lie. b. establishing global, regional, or national licensing facilities for essential medicines maximizing the supply of vaccines, treatments, diagnostics, and medical equipment can best be accomplished by allowing open access to the underlying technologies. this does not equate to eliminating patents. as previously noted, patents remain useful in various contexts, representing identifiable public interests in specific technologies that innovators have been spurred to develop. innovators should accordingly be compensated by measures that recognize contributions to the public interest, but not necessarily through elevated sales prices. with specific regard to treatment and prevention of covid- infection, governments should agree that owners of patents must place their patents into a 'pool' from which licenses may be freely taken and used by manufacturing companies in return for specified compensation. to the extent that regulatory marketing exclusivity grants might otherwise interfere with use of the patents, these restrictions should also be they should commit to making vaccines and treatments available worldwide at affordable prices. see emmott, above n . see, e.g. reuters, ' astrazeneca agrees to supply europe with million doses of covid- vaccine', june , https://www.reuters.com/article/us-health-coronavirus-vaccines/astrazeneca-agrees-to-supplyeurope-with- -million-doses-of-covid- -vaccine-iduskbn k hw (visited june waived and compensated by means of the relevant public interest license. in other words, a system of compulsory patent pooling and licensing should include express suspension of any regulatory marketing exclusivity while ensuring that actual production remains dependent on demonstrating compliance with good manufacturing practice. conceptually, it might be ideal to anchor the licensing facility within the who global architecture. however, there are significant political obstacles to negotiations within the ambit of the who. these problems are further exacerbated by the current targeting of the who as a scapegoat for the failures of national leaders to react to covid- . moreover, because the proposed licensing facility implies concrete action to address potential obstacles to access inherent in intellectual property rights (iprs), it would likely be resisted by some who members on behalf of perceived industry interests. hence, one should consider alternatives to global arrangements that might more realistically be possible. one such alternative is for licensing facilities to be established by countries party to existing regional agreements, or simply by groups of like-minded countries. one should not assume that like-minded countries would be limited to lmics, given that there are a number of organisation for economic co-operation and development (oecd) countries that have either issued compulsory patent licenses with respect to covid- technologies or that have proposals to do so on the table. there are various reasons why governments may consider it in their best interest to override exclusive rights in favor of wider access to medicines. moreover, a country would not need to become a party to the licensing facility in order to take advantage of imports from countries that are parties to it, although they may nonetheless need to take certain legal steps to comply with international treaties. the technical and legal details of such arrangements should not constitute a significant obstacle, and it is reasonable to foresee that other countries might gradually join existing arrangements once they became operational. patent pools are a relatively common mechanism used in the private sector to accomplish different objectives, and competition authorities have accordingly prescribed guidelines for these types of arrangements. while various institutional frameworks are feasible, the licensing facility(ies) should be constituted by government national or regional regulatory approvals as required for marketing of generic products would remain but should be facilitated by mutual recognition of approval of bioequivalence. parties through some form of international agreement. if that agreement was part of an existing multilateral or regional arrangement, the institutional structure could generally be incorporated within that multilateral or regional arrangement. otherwise, a sui generis agreement would confer standing on the licensing facility as an international legal institution. that agreement would prescribe the customary governance features, such as an executive director and decision-making mechanisms, along with specified functions and obligations of the parties, including dispute settlement and other specific duties as appropriate. the principal obligation of all the parties would be to contribute rights to patents granted within their territories to the licensing facility and to ensure that licensees from the facility would be authorized to distribute pooled products within their territorial jurisdictions. the innovator patent owners should be compensated for use of their technology through the payment of royalties and by other means of remuneration. various options for determining, collecting and distributing remuneration exist, and any specific mechanism may depend on the country parties involved and on their choice of institutional structure. for example, royalties could be paid by producer/user licensees-through the pool-to the government entities involved in the facility, which entities might then allocate royalty payments (or other forms of compensation) to patent owners within their jurisdictions. the royalty entitlements of each such entity might be based on the expenditures within that country for r&d on the products used to address covid- . countries that had more heavily subsidized r&d would also be entitled to higher aggregate distributions reflecting that subsidization, and private sector investments would be taken into account. moreover, countries participating in the pool could establish an allocation formula that varied over time based on changing developments. governments that granted the compulsory licenses would be responsible for distributing the remuneration to patent owners within their jurisdictions. the level of royalties payable by producer/user licensees would vary depending on the country where the licensee supplies specific products (e.g. taking account of such factors as population and per capita gross domestic product (gdp)). least developed countries regarding methodology for determining the cost of a new pharmaceutical product, and a reasonable profit increment, see abbott, excessive prices, above n . this is not so different from any number of cooperative international endeavors in which there are multiple contributions from different governments, for example, with respect to development and sale of military equipment. potential claims by patent owners with respect to royalty compensation would lie within the jurisdiction or jurisdictions where their investments were made. such compensation might be based on the cost to the patent owners of developing the new drugs or vaccines, plus a fair profit under the circumstances. although innovators may be reluctant to disclose their r&d costs, it would be reasonable for them to make an exception in this case, particularly if compensation becomes dependent on disclosure. to provide an additional incentive for investment in r&d, there might be a supplementary fund established to add a social benefit premium that reflects a specific contribution a pharmaceutical product makes to addressing the pandemic. guidelines or milestones could be established for allocating such premium payments, and it is foreseeable that there may be disputes regarding what costs might be allocated or attributable to a particular drug or vaccine. (ldcs) should remain exempt from financially contributing to the global r&d effort, recognizing their budgets continue to be constrained. the proposed licensing facility also envisages a patent royalty board to assist member governments in establishing entitlements to royalties. in principle, the burden of financing subsidization should be shared reasonably among governments and populations that stand to benefit from the resulting technologies. one must also recognize that longer-term benefits accrue from investing in r&d. this may disproportionately benefit countries where r&d is undertaken in terms of developing their own knowledge base and infrastructure. given that diverse contribution and royalty payment options are available and that different licensing facilities might elect to approach this task in different ways, a specific formula is not prescribed in this article. the point is to emphasize that there are viable mechanisms for recognizing financial and scientific contributions in keeping with overall incentivizing objectives. the wto trips agreement does not pose an obstacle to establishment of the proposed licensing facility. as earlier noted, the trips agreement in article makes provision for the grant and exercise of compulsory licenses, both in the private commercial and government-use contexts. the inherent authority of governments to grant compulsory licenses was confirmed by the doha declaration on the trips agreement and public health in . in cases of emergency or government-use (i.e. public noncommercial use), licensing is further facilitated by article (b), which allows grant of licenses without prior negotiation with or even prior notification to the patent owner. the requirement that authorization be based on the individual merits of the licenses can be addressed by identifying categories of products meeting urgent public health needs. the establishment of a royalty mechanism under the licensing facility satisfies the requirement for payment of adequate remuneration as the circumstances require. the authors will in section iv address a related issue regarding the opt-out by certain high-income countries (hics) as eligible importing countries under the article bis mechanism and explain why this does not pose an obstacle to any given pooling and regional supply arrangements. moreover, wto rules provide a mechanism this is consistent with the approach that wto members have taken in authorizing exemption for ldcs from obligations to grant and enforce patents that are otherwise the mechanism used to return profits to the patent owners that may be reinvested in r&d. ldcs are not required to grant pharmaceutical patent protection or to enforce existing patents at least until january . for the waiver of otherwise applicable rules when needed, and one would expect that the necessary three-fourths of wto members would accommodate a trips agreement waiver to address a pandemic. wto members also have the right to invoke article of the trips agreement, which establishes a national security exception to address emergencies in international relations, and members are understood to have substantial discretion in making use of that provision. in general, national and/or regional patent legislation should provide adequate flexibility for the grant of compulsory and/or government-use licenses. typically, use by the government is expressly facilitated. for purposes of establishing and implementing licensing facilities intended to meet urgent global public health needs, such facilitated government-use licensing may suffice to accomplish most objectives, although some commercial use licensing may also be needed. implementation of an internationally agreed compulsory pooling arrangement (whether global, regional, or like-minded) could nonetheless require implementing legislation at the national (or regional) level with some modifications to existing domestic rules. so long as participating governments have agreed to such arrangements, legislative modifications should be achievable. if the ambitious licensing facility was to demand too much international cooperation in a short span of time, the establishment of needed pools could be left to individual governments with their own licensing policies. for example, the usa could form its own covid- licensing pool to be administered by the department of health and human services or another suitable agency. while such a pool would only cover patents granted in the usa, r&d enterprises across the world normally apply for patents in this country. already the federal court of claims determines the appropriate amount of royalties when the us government, pursuant to existing statutory authority ( usc § ), makes use of patents without the consent of patent owners. private companies may also want to take advantage of licenses not covered by specific government programs, and a federal pool would accommodate a private option. there will likely be many relevant patents covering drug and vaccine candidates, and it would seem advisable to organize a comprehensive response from the outset. one model for a kind of licensing arrangement similar to that discussed above is the medicines patent pool to which originator companies contributed patent licenses on hiv-aids, tuberculosis, and hepatitis c treatments that are sublicensed to generic drug manufacturers for distribution of pharmaceutical products in lmics. as noted earlier, the mpp has already expanded its scope to cover covid- related treatments. the licensing facility proposed in this article would differ from the mpp model in that companies (and other patent owners) would be required to contribute their patents under mandatory participation rules. voluntary patent licensing arrangements, such as the mpp, do not generate the same political or legal pushback associated with compulsory licensing. under ordinary circumstances, a patent owning pharmaceutical company faced with the prospect of a compulsory license (e.g. an application by a generic producer) will challenge the potential grant in administrative proceedings and/or a court, which may delay the grant for a substantial period of time, or block it altogether. such delay is less likely to occur under a 'government-use' license because national statutes typically restrict options for patent owners to block the issuance of such licenses, even if subsequent challenges concerning remuneration remain available. the mere possibility that a government intends to grant a compulsory (including government-use) license almost invariably triggers a political reaction from the home-base government of the patent owner, combined with threats of financial retaliation in one form or another. for these reasons, it may seem 'easier' to rely more on voluntary licensing than compulsory licensing, especially since voluntary licensing arrangements, such as the mpp, have successfully facilitated the supply of low-price medicines. thus, it may seem imprudent to forgo this faster and easier path and instead to pursue compulsory licensing. on closer inspection, however, the mpp and other voluntary pools have significant limitations. first, private sector companies determine what patents and related products are made available to such entities. there is accordingly no assurance whatsoever that the most successful and/or most needed treatments would be made available under voluntary pooling arrangements. second, private sector companies establish limits on the countries allowed to receive their licensed products. with respect to covid- , this option may exclude countries for which access is vitally important. brazil, for example, has previously been excluded from receiving products under mpp licenses, and brazil is among those most seriously affected by covid- . moreover, all hics are typically excluded from benefits under the mpp, while the proposal envisioned here is definitely intended to also address the needs of hics. third, the mpp relies on individual companies to grant licenses for specific products on a case-by-case basis. with respect to covid- , patents on relevant technologies will likely be held by a wide variety of entities, including foundations, teaching hospitals, and government laboratories, and case-by-case licensing could both be difficult and problematic. fourth, governments should not refrain from pursuing arrangements that rely on compulsory licensing because this would antagonize pharmaceutical companies that may protest to their home governments. to do so would imply that the refraining governments have surrendered their sovereign authority. this article, in contrast to voluntary mechanisms, is proposing potentially largescale compulsory licensing programs involving multiple countries, preferably operating under a global regime. in the past, compulsory licensing has been controversial in the sense of provoking adverse political reaction and civil litigation. from a broader perspective, however, the world community has not witnessed a crisis on the scale precipitated by the covid- pandemic since the second world war. armed conflict has the perhaps surprising characteristic of promoting innovation. necessity is the mother of invention. if only because of that, we do not think that national governments faced with the prospect of a public health emergency that threatens significant parts of local populations should or would refuse to undertake reasonable measures because pharmaceutical industry executives, or their home governments, consider such action inconvenient. even if governments might yet be dissuaded from taking appropriate measures to address covid- , the proposals in this article may provide useful-and workable-suggestions to address future public health exigencies. current manufacturing capacity for supply of covid- vaccines is almost certainly not adequate to address global demand. a substantial ramp-up in the construction of vaccine manufacturing facilities is thus required. in the case of pharmaceutical treatments (i.e. drugs), there is more substantial worldwide manufacturing capacity, although existing facilities (including for active pharmaceutical ingredients) may need to be repurposed. nonetheless, there is not likely to be the same scale of manufacturing shortfall for pharmaceutical treatments as for vaccines. just as governments should pool patents and other technology resources, they should also be planning investments in manufacturing facilities that could efficiently serve substantially larger populations than in the past. particularly for countries with smaller populations, it may be useful to plan and invest in jointly owned and operated vaccine production facilities. agreement on the geographic location of such facilities may well prove difficult, given that the distribution of economic opportunities has traditionally challenged countries engaging in regional cooperation efforts. because the availability of vaccines may determine life or death outcomes, the immediate stakes are raised during a pandemic when supplies prove inadequate. which among a group of countries will be the better location to house manufacturing facilities depends on a variety of factors, including the state of infrastructure in any given location (e.g. transport, electric grid, etc.) and the availability of technically trained staff. because funding is an equally important factor in some cases, an external funding source, like the world bank, could play an important role in facilitating agreement on location, priority of access to output, and other issues. the authors of this article witnessed or participated in projects under the auspices of international and regional organizations directed toward enhancing national and regional production and distribution of pharmaceutical products and are well aware of the possible obstacles. there is no easy solution to the problems of regional coordination that have impeded diverse economic integration efforts for generations. but it is important that governments quickly begin to work on solving manufacturing gaps and distribution issues, and obstacles they have confronted in the past are not a good reason for failing to pursue new efforts. the urgency of addressing the covid- pandemic should provide the stimulus to action. sufficiently robust solutions to the problems of manufacturing and distributing vaccines, treatments, diagnostics, and medical equipment might overcome potential obstacles that governments and the public are likely to face when attempting to access them. there is, however, substantial risk that supply-side initiatives will not be sufficiently comprehensive to address aggregate global demand. therefore demand-side initiatives are also proposed. in an earlier work, the authors of this article have already proposed that developing countries seeking access to patented medicines should establish regional pharmaceutical supply centers in order to strengthen their respective bargaining positions. such centers would enable participating governments to pool their procurements of patented medicines, which in and of itself would give them greater bargaining power with respect to both originator pharmaceutical companies and generic suppliers than if each country operated on its own. a pooled procurement strategy could also stimulate more local production of pharmaceuticals in developing countries, in part by affording potential investors more advantageous revenue prospects than those offered to purveyors of imports alone. for present purposes, we emphasize that a pooled procurement strategy along these lines would also greatly strengthen the inherent power of governments in developing countries to threaten and, when needed, to issue compulsory licenses for patented pharmaceuticals under articles and bis of the trips agreement. as explained below, article bis already addresses the lack of pharmaceutical production capacity in most developing countries. at the same time, it should be noted that very few countries, including hics, maintain the capacity to produce all of the important pharmaceutical products that are required to meet the needs of their national populations. these inherent limitations may require governments considering the use of compulsory licenses to seek assistance from other provider countries that do possess the requisite manufacturing capacity as well as access to the key active ingredients. however, even when the latter governments were inclined to consider helping by issuing a second compulsory license for exports of needed drugs, they were potentially stymied by article (f) of the trips agreement. this provision requires that medicines produced under a compulsory license must be 'predominantly for the supply of the domestic market of the member authorizing such use' and thus not produced principally for export to other countries. to alleviate this obstacle, the amended article bis now expressly allows a country willing to assist other countries needing pharmaceuticals at affordable prices to produce them entirely for export, typically under back-to-back compulsory licenses. in other words, article bis authorizes countries inclined to issue compulsory licenses for patented pharmaceuticals to seek assistance from other countries willing and able to provide the drugs in question and to export them in special packaging formats under supplementary compulsory licenses issued for that purpose. under article bis, none of the goods in question need be sold in the markets of the exporting countries, notwithstanding the language of the trips article (f) as originally drafted. adequate compensation of the patentee in question need only be paid in the country of exportation, taking into account the economic circumstances of the importing country where they will be sold and distributed at more affordable prices. despite the carefully elaborated terms of article bis, or perhaps because of them, there remains a widely held belief that its provisions fail in practice to make compulsory licensing of pharmaceuticals a viable option for most developing countries. the prevailing view, in other words, is that the various requirements set out in article bis remain too complicated or too onerous to be of practical value to the countries that would most need to invoke them for access to medicines. the authors of this article have elsewhere explained why this belief in excessive complexity of the article bis system is not well founded, and do not repeat the analysis here. it is true that, to effectuate these provisions, wto members willing to supply other countries without manufacturing capacity must have some form of enabling mechanism in their domestic legal system. these mechanisms may, in turn, be more or less complicated depending on the specific national legal system in question. moreover, a compulsory license for export (or import) may well be granted under a wto member's general compulsory licensing or government-use provisions, so that specific legislation implementing this new provision of the trips agreement is not required. alternatively, the procedural rules of article bis can be followed without the necessity of express domestic legislation that establishes the national roadmap, though such enabling legislation may be useful. all ldcs are automatically eligible to invoke article bis. see generally abbott and reichman , above n , at - . para , trips agreement, article bis, above n . see further abbott and reichman , above n , at - (covering all aspects of article bis and citing authorities). pursuant to article bis( ), there is a specific accommodation in favor of developing and ldc parties to regional trade agreements. the subject agreements must be comprised of at least half ldcs. it permits re-exports of pharmaceutical products produced or imported under compulsory license by one member to other members of the regional trade agreement without restriction regarding whether the re-exports are a predominant or non-predominant part of the compulsory license production. the government of canada has adopted enabling legislation that some have considered unnecessarily complicated, and it was invoked in the criticized case of rwanda's seeking aids drugs from that country. however, canada's legislation also includes some positive elements, such as short fixed timelines for seeking voluntary licenses, well-considered royalty rates, and express recognition of the right to supply non-wto members. many other governments, including the european union, have now enacted implementing statutes and have also expressed their willingness to collaborate in supplying needed medicines under article bis. that said, the very act of issuing compulsory licenses against patented inventions remains controversial, especially in the usa where, however, they are nonetheless widely used for other purposes. these political costs cannot be dismissed as readily as the alleged administrative complexities. disregarding political costs, if the persistent view that using compulsory licenses under article bis is technically 'complicated' will not withstand legal analysis, there are nevertheless problems of coordination that deserve more careful analysis. this problem begins with the internal domestic difficulties of aligning all the government agencies and departments whose inputs and approvals of such action are prerequisites. once these hurdles are overcome, moreover, there remain the difficulties of negotiating and coordinating affirmative action by two or more governments involved in any pooled procurement strategy, as well as the further need to negotiate licenses for actual production and distribution of the pharmaceuticals in the manner prescribed by articles and bis of the trips agreement. these problems would be present in almost any situation in which a number of countries were pursuing the procurement of medicines under some form of international arrangement. to address these coordination problems more efficiently, the authors proposed establishing rpscs, which would be tasked with implementing the pooled procurement strategies of different participating governments over time. to the extent that compulsory licenses-actual or threatened-were needed for this purpose, the regional centers, acting as trusted intermediaries, would possess the expertise to assist government agencies in organizing and completing the relevant administrative actions and practical arrangements. procedures that might otherwise seem complicated to government agencies taking their first steps to trigger any given compulsory licenses would thus be routinely pursued by agents well versed in all the legal and technical requirements applicable under the trips agreement. the centers could also assist ldcs in profiting from provisions in article bis intended to reduce the quantity of licenses needed to be issued when operating within certain regional arrangements, including several in africa. reliance on rpscs should thus amplify the bargaining power of any countries needing to invoke articles and bis of trips when seeking access to medicines. on the one hand, the legal powers emanating from article bis should give originator pharmaceutical companies a greater incentive to supply the products in question at lower prices, in order to maintain their patents and trademarks in a number of small countries that coordinate their access efforts to obtain substantial discounts on a regional basis. on the other hand, a systematically organized strategy for pooled procurements of needed drugs in a number of different countries could stimulate greater interest in generic producers wherever situated. it could serve their interests, in other words, to respond positively to offers from rpscs empowered to implement a number of compulsory licenses, if and when needed. here we refer to the marrakesh treaty to facilitate access to published works for persons who are blind, visually impaired, or otherwise print disabled, of , which entered into force on september . under this treaty, copyrighted literary and artistic works normally subject to the amended berne convention of , may be made available in 'accessible format copies' to 'beneficiary persons' by 'authorized entities' who serve the interests of the blind and visually impaired. the marrakesh treaty does not expressly trigger a compulsory license provision in the manner of the trips agreement. instead, signatory governments agree to enact limitations and exceptions in their copyright laws that facilitate cross-border exchanges of accessible format copies in order to meet the needs of the visibly impaired in different countries. for this purpose, article imposes a duty on contracting parties to allow importation and exportation of accessible format copies through 'cross-border exchanges' , without the consent of the copyright owners themselves. in other words, authorized entities are entitled 'to distribute [or "make available"] format copies to beneficiary persons in the territories of other contracting parties' . article then expressly allows the authorized makers of accessible format copies in one country to import such copies as needed from other countries. from a policy perspective, the marrakesh treaty endows a trusted intermediarynamely the world union of the blind (wub)-with the marketing power that representatives of a print-disabled community might not otherwise possess. this follows because there are few countries, apart perhaps from india, in which the visibly impaired constitute a substantial market for literary works on their own. the fact that the wub can thus, in principle, supply the global market for such artifacts endows them with much greater clout than would otherwise be the case under the territoriality principle of the berne convention, which normally would require them to negotiate licenses with publishers on a country by country basis. medicines what the marrakesh model should teach us is that the cross-border supply of essential knowledge goods requires both a suspension of any conflicting requirement of territorial iprs and the services of some coordinating supply agency operating under public international law. providing such services is perhaps the single most important task of the rpscs discussed earlier in connection with the compulsory licenses now available under the trips agreement. the primary goal of any rpscs is to provide access to medicines at prices people in relatively poor countries can afford. phrased differently, their goal should be to redress the inequities attendant upon current marketing practices that ration access to patented pharmaceuticals for most of the world's population in order to exploit the buying power of more affluent customers. in so doing, the centers-like 'authorized entities' under the marrakesh treaty -would be implementing the larger goals of public international law embedded in the human right to health. once established by agreement of the participating governments, the regional supply centers could become the most efficient organizers of any given pooled procurement strategies authorized by those same governments. to the extent that compulsory licenses-threatened or imposed under articles and bis of the trips agreement-became potentially important tools in carrying out this assignment, the centers would find themselves in the best position to effectuate any such licensing strategies needed to provide cross-border supplies of essential medicines. with specific regard to compulsory licensing of pharmaceuticals in a cross-border context, the rpscs should play a role analogous to that of the wub under the treaty. in both cases, the coordination problems arise in the first instance from the territorial nature of intellectual property laws, which vary the barriers to be overcome in the cross-border supply of the products in question. under the marrakesh treaty, the wub must coordinate the supply of specialized books and articles from different publishers to the visibly impaired in different countries. under the trips agreement, the rpscs would have to coordinate the purchase or procurement of specified pharmaceuticals needed in diverse countries as authorized by the relevant participating governments. these governments, in turn, must be ready, willing, and able to threaten to issue compulsory licenses, when needed, to bolster the bargaining power of the supply centers. like 'authorized entities' under the marrakesh treaty discussed above, the rpscs should operate as agents of the participating governments. in this capacity, they would-when necessary-obtain an exemption from the territorial intellectual property regimes otherwise applicable to the pharmaceutical products in question. they would thereby also help fulfill the objectives underlying the human right to health and related human rights treaties. governments needing essential medicines at affordable prices would delegate the centers, as 'authorized entities' , to provide them in a manner consistent with the trips flexibilities. however, it is well to ask how often compulsory licenses would actually be needed if such a scheme were to be set in place and rendered operational. once empowered to bargain on behalf of all the participating governments, the rpscs could probably obtain the needed price concessions through centralized bargaining power without actually having to issue back-to-back compulsory licenses. this conclusion follows because the originator suppliers have long-term interests in dealing with the developing countries with whom they are already accustomed to applying differing tiered pricing mechanisms. the ability to preserve their patents and trademarks and their influence by directly supplying their products in greater quantities under pooled procurement arrangements could itself be an incentive to cooperate with the supply centers and to avoid the conflicts inherent in the triggering of compulsory licenses. as the brazilian experience suggests, it is not always necessary to issue compulsory licenses when bargaining for the supply of products to a potentially large and growing market, once potential suppliers understand that the procuring government is ready, willing, and able to do so. in any event, the regional centers-like 'authorized entities' under the marrakesh treaty-would then distribute the exported medicines to 'beneficiaries' in participating countries that had initially requested them and whose governments had agreed to issue compulsory licenses for that purpose, if needed. special packaging would be required as well as restrictions on re-exports from the importing countries. the fact that a relatively large-scale demand for such pharmaceutical products could be generated via a pooled procurement strategy should in and of itself encourage both originator and generic manufacturers to participate whenever feasible (i.e. when technical capacity exists and safety requirements are met). authorized entities operating with the threat of article bis should be able to provide large quantities of patented drugs at affordable prices to most countries. moreover, this scheme-once implementedcould further encourage originator companies to adopt more realistic tiered pricing strategies in order to avoid conflicts with the authorized entities. by the same token, these authorized entities could eventually find themselves in a position to encourage, and even help to fund, the production of bioequivalents and biosimilars at affordable prices for developing countries and ldcs. the rpscs would logically pool their respective procurement requests for purposes of bargaining directly with the originator pharmaceutical companies and/or potential suppliers of generics. if these negotiations were successful, the centers would also distribute the needed medicines directly to the participating governments or their agents at agreed prices. if negotiations with originators proved unsuccessful, the centers, as authorized entities, would seek to obtain production in countries with manufacturing capacity for purposes of exporting end products to requesting countries lacking such capacity under compulsory licenses when necessary. in effect, willing producers would thus supply the authorized entities with products for purposes of redistribution to participating governments. to this end, governments in producer countries must be willing to issue compulsory licenses solely for the export of such pharmaceuticals to agents acting on behalf of requesting countries. legal authority is grounded in article bis of the trips agreement, as supplemented by human rights law and treaties. the rpscs should thus be created with a view to finally achieving the goal proclaimed by the doha declaration of , namely 'access to medicines for all' . in so doing, the centers would not be limited in the time or circumstances needed only to address covid- . we propose these entities as durable institutions. in the long run, successful implementation of pooled procurement strategies might ultimately persuade the innovator pharmaceutical industry to market its life-saving products in a manner more consistent with the global public interest. the creation of global supply and demand solutions for the production and distribution of vaccines and treatments, including licensing facilities and rpscs, might encounter a 'peculiar' obstacle arising from a decision made by the usa, the european union, and a number of other hics at the tail end of the paragraph negotiations that resulted in the article bis amendment to the trips agreement. these hic governments decided to forgo the right to import pharmaceutical products manufactured under compulsory license abroad (when such exports are a predominant part of production) by explicitly incorporating an 'opt-out' in the annex to article bis. not be available to them even in an emergency. but the potential problems are larger than this specific situation. when the usa, european union, japan, canada, australia, switzerland, among others, took themselves out of the equation as eligible importing countries under article bis, they eliminated a large part of the potential global demand for pharmaceutical products originating from countries exporting under compulsory licenses. as a result, for example, if india were asked by countries in africa and latin america to manufacture drugs under compulsory license and export to them, the indian producers might not be able to supply the hics with the same products. the efficiencies in production that might otherwise be achieved by indian manufacturing facilities when addressing a global market would be reduced. giving effect to requested compulsory licenses would thus become less cost-efficient and might result in higher selling prices for purchasers everywhere. it is difficult to foresee all the various scenarios in which the opt-out might have a material effect on prospective exporters and how it might influence the global supply situation. but it is at least worth bearing in mind that the creation of truly global pooling arrangements may ultimately run into some obstacles raised by the article bis opt-outs. there are various legal approaches under which formerly opted-out countries may consider opting back in or otherwise making use of the article bis system to import needed pharmaceutical products. these include: ( ) relying on an interpretation of the text of paragraph (b) of the annex which provides that 'a member may notify at any time that it will use the system in whole or in a limited way' as qualifying the express opt-out in footnote ; ( ) seeking a waiver pursuant to article ix ( ) and ( ) of the wto agreement; ( ) collectively opting-in through a consensus decision incorporated as a trips council approved interpretation or amendment of the annex text; ( ) acting without wto preapproval and going before the dispute settlement body, with the potential for withdrawal of trade concessions by a (hypothetically) successful complainant (including with arbitration on the justified amount of concession are the following: hong kong, china; israel; korea; kuwait; macao china; mexico; qatar; singapore; the separate customs territory of taiwan, penghu, kinmen and matsu; turkey and the united arab emirates' .) whether a fully opted-out country can change course and opt-in can be addressed more facilely than through argument about textual interpretation of the annex, thereby avoiding a lengthy struggle over the interpretative issue. while the wto attempts to achieve consensus among its members in decision-making, the waiver mechanism expressly contemplates that a waiver decision can be taken by three-fourths of the members. the opt out was not a bargained-for concession in favor of the lmics. this was an action by the hics pursued for their own reasons. if the hic members collectively decided to opt back in, they would not have rebalancing of concessions claims against each other. in other words, there should be nothing to prevent all the formerly opting-out countries collectively to announce to wto members that they had decided to opt back in since they have no reciprocity commitment to other countries not to do so. withdrawal) ; and ( ) invoking article of the trips agreement ('security exceptions'), which provides substantial deference to members protecting essential security interests through measures taken in times of emergency in international relations. there appears to be a widespread assumption among trade and intellectual property experts that whatever the wto may say on the matter, hics are not going to forgo importing pharmaceutical products under compulsory licenses regardless of the technical legal obligations. nevertheless, from the standpoint of maintaining the integrity of a rule-based system, it would be preferable to identify an appropriate legal justification. the opt-out by hics was a misguided effort to protect the commercial interests of their pharmaceutical companies notwithstanding the most severe public health emergencies. wto rules and practices should provide feasible options for reversing that short-sighted initial decision. this article has proposed several models for addressing access to essential medicines under the trips agreement of rather than one globally integrated proposal. given a fractured global political environment in which the prospects for cooperation are constrained, one may expect that various solutions will be adopted to address the problem of developing and supplying vaccines, treatments, diagnostics, and medical devices to address the covid- pandemic. these solutions should include patent and other technology pools on the supply side (including joint manufacturing facilities), as well as regional procurement systems on the demand side. such proposals may well work in tandem, but they may also function independently if necessary. global implementation of a licensing facility, on the supply side, might obviate the need for full implementation of rpscs, on the demand side, if it proves unnecessary for the latter to coordinate requests for compulsory licenses in exporting countries. similarly, on the demand side, if rpscs were made operational and able to coordinate compulsory licensing for imports from countries that agree to supply under compulsory licenses for export (under article and article bis of the trips agreement), then the needs for a compulsory patent pool on the supply side would be limited (since the exporting countries would have agreed to issue compulsory licenses for this purpose). a 'middle ground' combination of the two proposals might arise. to illustrate, using article bis of the trips agreement, a rpsc could coordinate compulsory licenses for importation among a group of countries and seek exports to fulfill those licenses for importation. there may be a group of countries on the supply side that has established a patent licensing pool to satisfy the demand for pharmaceutical products within the group, and that also expects to have export capacity. rpsc compulsory licenses for importation could then be addressed to the group that has created the patent pool even if the wto system was functioning, the case would take from beginning to end approximately years, at which point the complainant might (assuming it was successful) be able to claim compensation in the form of rebalancing from the hic importing and the exporting country. this would entail addressing the level of compensation (or rebalancing) due to the complainant. see n , above. with capacity for export. this would help to reduce coordination issues and facilitate production 'at scale' . the current world political situation suggests that the possibilities for truly 'global' solutions may be limited. nevertheless, there are likely to be a variety of solutions developed and implemented as time passes and as the needs for pharmaceuticals become more evident. hence, this article has proposed potential solutions on both the supply and demand sides of the equitable access equation as models to aid policy planning in both developed and developing countries. federal drug price negotiation: implications for medicare part d excessive pharmaceutical prices and competition law: doctrinal development to protect public health johnson announces a lead vaccine candidate for covid- ; landmark new partnership with u.s. department of health & human services; and commitment to supply one billion vaccines worldwide for emergency pandemic use a not-for-profit vaccine from johnson & johnson? not so fast, press release' , patients for affordable drugs new health tools for covid- see also kevin outterson, 'patent buy-outs for global disease innovations for low and middle income countries article and bis article (f) trips agreement article bis the change of packaging reinforces the obligation to not re-export the drugs in question beyond the market specified in the initial compulsory licenses cooperation to facilitate cross-border exchanges of accessible format copies. see also, ibid article ( ) ('without the authorization of the rightholders') cooperation to facilitate cross-border exchanges) and ('general principles of implementation'). see generally india is said to have nearly five million visibly impaired inhabitants see also trips agreement the / divide see above n and accompanying text see references to human right to health and rights of the disabled in world blind union guide regarding special packaging, and annex para regarding antidiversion measures. in effect, the centers would thus become 'procurement agents' for specified medicines at 'reasonably affordable prices in the countries in question' . governments would also commit to endowing these authorized entities with the legal tools allowed by trips flexibilities for this purpose, including the power to implement requisite compulsory licenses when issued and pool them when needed for bulk purchasing. the centers would also have to coordinate the special packaging and notification procedures required whenever back a. an ill-considered decision the hic governments were not opting out because of a demand from lmics. this was their own self-initiated action. several other countries did not fully opt-out of the regime, but indicated their intention to use compulsory licensing for imports only in cases of emergency, circumstances of extreme urgency, and/or for public noncommercial use. the hic opt-out could become a problem for the people of the usa and other hics that chose this option because the relevant pharmaceutical products would key: cord- - jk mp r authors: zhang, cheng; qian, li-xian; hu, jian-qiang title: covid- pandemic with human mobility across countries date: - - journal: j doi: . /s - - - sha: doc_id: cord_uid: jk mp r this study develops a holistic view of the novel coronavirus (covid- ) spread worldwide through a spatial–temporal model with network dynamics. by using a unique human mobility dataset containing flights with a total capacity of passengers from january to april , , we analyze the epidemic correlations across countries in six continents and particularly the changes in such correlations before and after implementing the international travel restriction policies targeting different countries. results show that policymakers should move away from the previous practices that focus only on restricting hotspot areas with high infection rates. instead, they should develop a new holistic view of global human mobility to impose the international movement restriction. the study further highlights potential correlations between international human mobility and focal countries’ epidemic situations in the global network of covid- pandemic. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. although countries worldwide have gradually restricted nonessential international travel, particularly those from high-infection areas, it does not seem to have had the desired effect of stopping the spread of the novel coronavirus in the past few weeks. the epidemic continues to be severe in the european and north american regions. it has even gradually spread to more areas, such as africa and south america, leading to controversy over the pathway of the epidemic transmission [ , ] . the urgent situation needs a better assessment of the covid- spread under global human mobility [ , ] . besides non-pharmaceutical interventions within each country [ ] , restrictions on nonessential international travel from epidemic areas are proposed as a critical strategy to slow the spread [ ] . it intends to cut off people's outbound movement from a country when it becomes a hot spot of the epidemic. this approach may not be as effective as policymakers expect if they ignore the current reality of global human mobility. another important decision-making factor that has been overlooked is how to impose internal movement control policies, such as curfew or other forms of travel restriction, in the infected areas. these issues are particularly important in designing a global strategy to respond to the covid- dynamics and to recover social and economic activities. figure summarizes three different views on understanding the role of human mobility in the pandemic. the first view is a focal view that addresses the role of internal mobility and movement controls in tackling epidemic in a single country while ignoring the influence of inbound and outbound mobility [ ] [ ] [ ] [ ] . the second one is a dyadic view that explores the role of international mobility and travel restriction between a centric country (usually a hotspot area in the epidemic) and some other countries [ ] [ ] [ ] . this approach usually does not take into account the impact of population movements other than those of the centric country, and in addition, only the one-way impact of the centric country on other countries. the third one is a holistic view that simultaneously analyzes the multiple paths of international mobility and travel restrictions in a global network and thus allows for the correlation of each path in the network. in this way, the networked approach allows the study of simultaneous and asymmetric effects between multiple countries through different mobility pathways. global network-based analysis is now more urgently needed than the previous focal view approach [ ] [ ] [ ] [ ] or the dyadic view approach [ ] [ ] [ ] , that is, investigating epidemic developments between countries in the global network where each country is a node and the inter-country human mobility between two countries is represented by an edge. in this way, scholars and policymakers can gain the holistic insights on the virus' spread across the globe and develop effective and worldwide-coordinated measures to contain the pandemic [ ] . this study responds to this urgent call by developing a spatial-temporal model with network dynamics [ , ] to understand the correlation between the covid- epidemics in different countries accounting for the inter-country human mobility and international travel restrictions targeting different countries. our analysis of the covid- pandemic starts from january , , when the epidemic was officially reported by the world health organization (who), to april , , when the number three views on the role of human mobility in the pandemic. note: the solid and dashed lines indicate unrestricted human mobility before public interventions and restricted mobility after public interventions, respectively. a (solid or dotted) line with the arrow from country a to country b stands for the correlation between the epidemics in these two countries accounting for (restricted or unrestricted) international mobility. an arrow connector on a country itself represents the correlation between the internal spread and (controlled or unrestricted) internal movement of covid- infections exceeded . million worldwide. based on the timing of the outbreak and the scale in terms of the accumulated confirmed infection numbers in the covid- pandemic, we selected countries from six continents, which accounted for . % of total infection amount worldwide as of april , . detailed information of the countries is provided in table s in supplementary materials. we collected the daily number of confirmed covid- infections in every country from the who. we also use a unique dataset containing flights with a total capacity of passengers among the countries from january to april , . in the follow-up analyses, the information is aggregated to the countryday level, resulting in daily pairs of international travel movement across six continents. figure s illustrates a clear decreasing trend since early march regarding the capacity and number of international flights among these countries. we also compile data from multiple sources containing international travel restriction and internal movement control policies (such as curfew and other forms of domestic travel restriction), as summarized in table s . by treating each country as a node in the global network and the international human mobility as the connections between countries, we model the dynamic process of the epidemic. the unit of analysis in this study is the number of confirmed infections in country i on day t. at the beginning of the epidemic, every country had zero infection and human mobility was unrestricted between countries. likewise, there were neither non-pharmaceutical interventions within countries nor international mobility restriction between countries. therefore, countries around the world had formed a fully connected human mobility network. during the pandemic period, however, travel restrictions were introduced by countries gradually and applied to travelers from different countries at different time points, which led to a dynamically changing global human mobility network. the restriction reduces the human mobility between countries. if the action, saying the travel restriction from a hotspot country a to another country b, was introduced in time and did take effect, we would expect to see a weaker association between the epidemic in country a and the daily new cases in country b in the controlled international travel period than in the pre-controlled period, which is equivalent to a positive effect of such correlation before the introduction of international travel restriction with reference in the restricted period. this would effectively imply a decreasing association of epidemic situations from country a to country b with the introduction of international travel restriction, largely due to the fewer number of travelers from country a to country b. however, if the international travel restriction is not effectively implemented by country b regarding timing and targeting countries, we might even observe a stronger association between the daily new cases in country b and the epidemic in country a after country b bans the entry of international travelers from country a, which is equivalent to a negative association between the daily increment in country b and the epidemic in country a in the pre-controlled period for international travel with reference in the controlled period. in addition, reducing the spread of the epidemic does not solely depend on the international travel restriction and would also rely on the effective internal movement control within each country. specifically, even if country b reduces international movement from the hotspot country a, the virus may still have the chance to spread within country b (e.g., via internal spread or from the third country), so that the impact of the epidemic in country b cannot be reduced without effective internal movement control policies. therefore, if country b effectively implements internal movement control, we would also expect the control to work with international mobility restriction and observe a decreasing epidemic trend in country b, after a certain lagged period. this idea is applied to all the countries in the network, taking into account the multiple paths of international mobility and travel restrictions between any two of them simultaneously. through such a global network perspective, we aim to examine the correlations of covid- epidemics in respective countries and the extent to which the human mobility and the introduction of international travel restriction targeting hotspot countries influence the pandemic. we collected multi-sourced datasets in this study. the daily numbers of confirmed infections of all countries were collected from the who covid- dashboard. based on the timing of the outbreak occurred and the scale in terms of their accumulated confirmed infection numbers during the outbreak, we selected countries from six continents: countries from asia (china, iran, india, japan, south korea, and turkey), countries from europa (belgium, france, germany, italy, netherlands, portugal, russian federation, uk, spain, and switzerland), countries from north america (canada and usa), countries from south america (brazil, ecuador), country from africa (south africa), and country from oceania (australia). these countries accounted for . % of the total infection amount worldwide as of april , . in addition to the who data, we also collected data from and the covid- data repository by the center for systems science and engineering (csse) at johns hopkins university [ ] to replicate the analysis. we further use a unique human mobility dataset containing daily global commercial flights among the selected countries between january , , and april , , from a leading data consulting company in the civil aviation industry, variflight. the dataset contains information on the origin country, destination country, date, the number of flights, and total capacity in terms of the maximum available seats. in summary, this dataset provides information on flights between pairs of origin and destination countries that covers a total capacity of passengers during the period. moreover, we collected data on the international travel restriction between countries and the internal movement control within every country from oxford covid- government response tracker and gardaworld crisis global portal, which timely document epidemic prevention policies in countries around the world. in a global network, the path connection from country a to country b is set by value at day , representing the availability of international movement from a to b. such connection is disabled on day t, due to either the internal movement control in country a or the entry ban for travelers from country a into b. thus, on day t onward, the connection from a to b is set to be to represent such disconnection. table s summarizes the timing and scale of the outbreak, as well as travel restriction policies by the countries. the unit of our analysis is the number of confirmed infections in country i on day t. given the spatial nature of this research, we develop a dynamic network model based on the spatial-temporal features [ , ] to examine the extent to which the number of newly confirmed infections in each country is correlated with the cumulative number of infections in each of the remaining countries, by taking into account ( ) the mobility volume between countries, ( ) the introduction of inter-country travel restriction policies targeting different countries at different time point, and ( ) internal movement restriction within each country. specifically, the number of newly confirmed infections in the country i (i to ) on day t (t to , starting at january till april ), nci i,t , is given by where ε it is the error term, the coefficient α i measures the τ -day lagged effect of new infections in the same country (nci i,t−τ ), and α i captures the ω-day lagged effect related to internal movement restriction in the same country (preir i,t−ω ), such as social distancing and home-stay orders, where specifically, the significantly positive value of α i represents the positive association between fully allowed internal movement (with reference to the restriction) and the new infections in the same country i after ω days. this effectively means that there was the less severe epidemic in the controlled period (preir i,t−ω ) than in the pre-controlled period for internal movement (preir i,t−ω ) and thus implies the effectiveness of internal movement control policy in country i. on contrary, the significantly negative value of α i would suggest the more severe epidemic in the controlled period (preir i,t−ω ) than in the pre-controlled period (preir i,t−ω ), while the insignificant value of α i means there is no statistical difference on the epidemic in country i before and after introducing the internal movement control policy. furthermore, c i jt is the number of cumulative confirmed infections in each of the rest of countries other than country i by day t ( j i) and fcap i jt stands for the human mobility from country j to i, such as the number of direct flights or maximum flight seats in the direct flights from country j to i on date t, which might be further restricted by the international travel control policies introduced by country i targeting different countries on different days. to capture such dynamic international travel controls, w t is the time-dependent spatial weight matrix of the international mobility network between all considered countries on day t, with its element w i jt defined as specifically, the travel from country j to i on day t might be restricted due to the respective policies in the origin or destination countries. in the origin country j, its internal movement restriction on day t might make regular travelers difficult or even impossible to leave country j. the destination country i may also ban the entry of travelers from country j. therefore, α i j (i.e., the coefficient of the term fcap i j,t−θ w t−θ c i j,t−θ ) measures the θ -day lagged correlation between the epidemic in country j and the daily new cases in country i, accounting for international mobility capacity and the international travel restrictions, where the θ -day lag can be largely attributed to the incubation period. the significantly positive value of α i j means that the correlation between the cumulative epidemic in country j and the θday lagged new infections in country i is stronger in the pre-controlled period for the international mobility (w i jt ) than in the international mobility controlled period (w i jt ). in other words, the positive value of α i j suggests the weaker correlation effect in the international mobility controlled period and thus implies the effectiveness of introducing international mobility control policies on containing the covid- epidemic in country i. conversely, the significantly negative effects of α i j means that the stronger correlation between the cumulative epidemic in country j and the θ -day lag new infections in country i in the international mobility controlled period (w i jt ) than in the pre-controlled period (w i jt ), which might be due to the delayed implementation of international travel restriction or the myopia of only banning international travelers from the existing hotspot but ignoring the other countries with emerging epidemics. in addition, the insignificant value of α i j means the intercountry correlation of epidemics remains largely unchanged with the introduction of international travel restrictions from country j to i. the econometric model we develop above has a system of simultaneous equations with the time-dependent spatial weight matrix w t . this unique feature makes our model differs from the conventional spatial models, including the dynamic spatial panel model, which typically use the time-invariant spatial weight matrix based on the geographical characteristics [ ] . therefore, we follow the process below to estimate the model. organize the data into a time series format, with each row representing the date and each column for the different data variables on that date, such as the coded elements of the spatial weight matrix, the number of infection cases in every country and the numbers of flights and maximum available seats in every pair of international mobility route. . create time-lagged variables where necessary. in the empirical analysis, we take τ to one-day lagged effect of new infections, ω to check the effect of internal movement restriction within each country, and θ to capture the influence of -day incubation period of the covid- on its international spread. . construct an interdependent system of linear regression equations, and use seemingly unrelated regression (sur) [ ] [ ] [ ] to estimate the parameters as specified in eq. ( ). the sur is also known as joint generalized least squares (jgls), and it is a generalization of ols for multi-equation systems by allowing for the correlation of the error term of every equation. in an m-equation system for t-period observations, the variance-covariance matrix for the error term vector e can be written as where ⊗ is the kronecker multiplication operator, Σ is an m* m positive definite symmetric matrix with σ as the variance of the error in the first equation and σ i j as the covariance between the errors of the ith and jth equations, and i is the identity matrix. the estimation process of sur is as follows: a. first apply ols to every equation and obtain the residual of every equation, e i (i , , · · · , m). b. since Σ is typically unknown, the elements of Σ can then be estimated usinĝ c. flexible generalized least square (fgls) estimators are used to estimate the coefficientsβ where x v − x − is the variance-covariance matrix of the estimated coefficients. the model is implemented using the sur estimator in the syslin procedure in sas. the sas code is available in supplementary materials. table presents the estimation results, where the red and blue colors highlight the positive and negative effects, respectively, both significant at % level. overall, the -day lagged internal movement control policy is found to have significant negative effects (i.e., α i < ) in countries, which suggests the epidemics became more severe in these countries in spite of the introduction of movement control policies such as stay-at-home order. the correlations (and the changes of correlations) between the epidemics across different countries are presented in the * matrix under the coefficients α i j in table . first, the usa, south africa, switzerland, the netherlands, and brazil are positively correlated (i.e., in red cells) with the epidemics in three or more countries, which means such correlations (with -day lag) have been weaker after introducing international travel restriction across these countries. at the same time, the daily new cases in each of these five countries are also negatively correlated (i.e., in blue cells) with the epidemics in at least three other countries, which implies the -day lagged epidemic became more severe in these five countries even after introducing the international travel restriction in respective countries. overall, there were significantly positive inter-country correlations and significantly negative inter-country correlations as presented in table , which indicates that in a global network the effect of international travel restriction on containing covid- pandemic is not as straightforward as normally expected. the full estimation results are summarized in table s . as shown in table , the international travel restriction for the travelers from china is found to have insignificant effect on the changes in the association between the epidemic in china and the outbreaks in the remaining countries. that is, all the associations between china's cumulative infection number and the daily new infection numbers in other countries with direct flights are insignificant (note that china has no direct flights to brazil and ecuador). the main reason may be due to china's early and immediate restriction not only on internal movement but also on nonessential international travel outbound from china in late january . what is more, the number of new infections in china is not significantly correlated with the cumulative infections in other countries except italy (α ita→chn . , p < . ), which means that the correlation between the epidemic in italy and daily new cases in china has been weaker after restricting foreigners entering china and such correlation between other countries (except italy) and china has not changed significantly. other similar cases are south korea and iran, in which the inter-country epidemic correlations have not changed significantly before and after the international travel restriction, given the insignificant correlations ( ) between their cumulative infection numbers and table estimation results the abbreviations for country names are provided in table s other countries' lagged daily new cases and ( ) between other countries cumulative infections and their own lagged daily new cases. however, other asian countries such as japan and india experienced a different situation as they have more changes in their connections with other countries. the correlation between the cumulative cases in japan and other countries' outbreaks has not changed significantly, but we find negative effects on the correlations between the lagged number of daily new cases in japan and the cumulative infection numbers in the usa ( α usa→jpn − . , p < . ) and russia (α rus→jpn − . , p < . ). this means the correlation between these two countries' epidemic and the daily increment in japan has been stronger, even after the international travel restrictions imposed on american and russian travelers to visit japan. although the outbreak of covid- in india was quite late, its epidemic size (i.e., cumulative number of infections) has a significant association with the numbers of daily new cases in european countries, such as italy in the pre-controlled period for international travel (α ind→ita . , p < . ), which suggests the inter-country correlations between these countries epidemic and the daily new cases in the usa have been weaker after introducing international travel restrictions to the usa in march . in comparison, even after the usa introduced the restriction for foreigners to enter, its lagged number of new infections is found to have stronger correlation with the cumulative infection sizes in several other countries than in the pre-controlled period, as indicated by the negative correlation coefficients with spain (α esp→usa the uk (α gbr→esp . , p < . ) in the pre-controlled period, and italy (α ita→esp − . , p < . ) in the controlled international travel period. furthermore, the negative correlations between the epidemic in spain and the numbers of new cases in the netherlands and the usa indicate such association becomes stronger even after the international travel has been restricted from spain to these two countries. similarly, the number of new cases in germany is significantly associated with the epidemics in the uk and the netherlands as well as the usa and south africa. meanwhile, the epidemic in germany also has strong correlations with the daily increment in belgium, switzerland, the usa, brazil, and south africa. importantly, the correlations related to germany are mostly positive, except with the netherlands and south africa, which implies most associations became weaker after imposing international travel restriction to/from germany. our analysis also reveals the third-wave epidemics differ in west asia (e.g., turkey), east europe (e.g., russia), south america (e.g., brazil and ecuador), and africa (e.g., south africa). specifically, the correlation between the lagged number of daily new cases in turkey and the canadian cumulative epidemic size became stronger in the controlled international mobility period than in the pre-controlled period (α can→tur − . , p < . ); the turkish correlation between its cumulative infection number and the daily increment of south africa was weaker with the international travel restriction, but its correlation with the daily increments in france, switzerland, usa, and brazil is stronger in the controlled international travel period than in the pre-controlled period. the cumulative epidemic in russia is significantly associated with the recent upsurge of the covid- new cases in japan (α rus→jpn − . , p < . ). in comparison, the number of daily new cases in brazil is strongly correlated with the cumulative epidemics in the usa, germany, and south africa in the pre-controlled international travel period, and with the netherlands, france, and turkey in the controlled period. in addition, the cumulative infection in south africa has stronger correlation with the daily increment in the usa in the precontrolled period, but the daily new cases in south africa are more correlated with the epidemic size in the usa in the controlled period. in addition, the daily increment in south africa is more correlated with the cumulative infection numbers in germany and brazil in the controlled period, and with that of uk, the netherlands, switzerland, and turkey in the pre-controlled period. in summary, our analysis provides insightful findings on the changes in correlations of the covid- pandemic across countries with the introduction of international travel restrictions, by taking into account the international human mobility. as illustrated in fig. , the size of each node represents the total infection numbers in the corresponding country by april , . a red (blue) line represents the positive (negative) correlation between each pair of countries with the strength of the line representing the absolute value of the standardized correlation coefficient. to check the robustness of our results, we repeat our analysis by using the number of international flights instead of flight capacity for international mobility volume (i.e., fcap i jt ) in the model. the results are consistent with that in the main analysis and summarized in table s . we further consider the situation without flight information available but keeping the time-dependent spatial weight matrix (w t ) to indicate whether a country implemented international travel restriction with another country table s show that the correlation patterns we observe are largely held unchanged and may simulate the situation of international travels with transitions in third countries. finally, we replicate the analysis by using another covid- dataset maintained by the center for systems science and engineering (csse) at johns hopkins university [ ] which contains more sources of information from cdc and online media sources in many countries. results show largely consistent pattern of the correlation on the covid- epidemics across countries and continents, although country-specific impact coefficients vary in the global network. for instance, china is still found to be fully independent from the epidemics in all other countries. also, the usa is found to be consistently correlated with the european countries regarding their respective epidemics. the results based on the data from johns hopkins university are presented in tables s to s , corresponding to three models with the international flight capacity, the number of international flights and without flight information. the significant associations presented in table s are also illustrated in figure s . considering potential collinearities between the estimated coefficients, we conduct a stepwise approach that adds countries' variables continent by continent. using the usa as an example, the stepwise analysis in table s shows the consistent effects, that is, the correlations between other countries' epidemics and the daily new infections in the usa, remain largely same and robust regarding the effect sizes and significance levels. by using the global human mobility data, this study provides the first comprehensive insights into the correlation between the epidemics across a number of countries with the introduction of international travel restrictions during the first months of the covid- pandemic. specifically, although the epidemic started in asia first, the study finds that the epidemics in asian countries have diverse degrees of associations with countries in other continents. china, for example, was one of the first countries to face an outbreak and severely affected, but introducing international travel restriction targeting travelers from china is found to have little change on the correlation between the early epidemic in china and the outbreak later in other countries. in contrast, the lagged daily infection in japan shows more correlations with other counties' epidemics even with the international travel restriction. the study further reveals intensive correlations between the epidemics across north american and european countries either before or after the banning of trans-atlantic travel. among many european countries, we also find a close circle of mutual correlations in different periods of covid- epidemics. the first important takeaway from the study is the importance of a holistic view of the covid- transmission. restrictions on nonessential international human mobility between countries are one critical strategy to fight against epidemic outbreaks [ ] ; however, little was known before regarding the proper ways to implement the strategy. as such, policymakers might focus only on the hotspot areas with a high transmission rate (which is not wrong) but overlook the pathway effect beyond the epidemic areas in the global network. unfortunately, over the past months, we have observed such a narrow perspective repeatedly occurring in many countries, focusing only on cutting off hotspot outbreak areas. new york governor andrew cuomo recently start to question where the coronavirus that hit new york state came from: "…we closed the front door with the china travel ban, which was right…but we left the back door open because the virus had left china by the time we did the china travel ban" [ ] . through this study, we show that the establishment of a new holistic and networked view of pandemic transmission on a global scale is imperative, with the following important implications. first of all, it cannot be simply assumed that the international travel ban from highrisk areas will be sufficient to control the epidemic once and for all while ignoring the dynamic spread of the epidemic in the global network. policymakers in every country should keep abreast of population movements between countries and, through scientifically rigorous analysis, and foresee the pattern of epidemic transmission in the network. accordingly, they should dynamically adjust the corresponding international restriction strategy promptly. second, the global perspective should also take into account the domestic movement restriction already implemented and its effects. despite the early outbreak in asian countries, their impact on other countries is not the same. because of strict national and international restrictions imposed by china, the epidemic in china was developing in isolation: it did not affect other countries or was affected by other countries' epidemics. in contrast, the lack of strict and timely domestic restriction in some other countries, combined with their lack of global view on timely international restriction, contributed to the pandemic, which means these countries were subsequently affected by the epidemic in the second and third waves. by the same token, as epidemics are gradually brought under control in the coming months, the effects and extent of national and international movement restriction should both be taken into account when countries decide to resume international economic and social activities. at the same time, it's also important to remain vigilant about the third-wave outbreak that may appear in latin america and africa. the holistic view should be applied promptly to guide the internal and international movement restriction policies in the areas. finally, our analysis also shows that there may exist factors outside the epidemic that are influencing countries' decisions on international travel restrictions. for instance, when the usa started to ban non-us citizens or permanent residents who had been in china in the past days to enter the usa on february , , there were infected patients in china with the infection rate of . per million people. in comparison, when the usa banned the entry of european people on march , italy itself had patients with an infection rate of . per million people. therefore, this also adds another dimension of restriction timing that future research should be aware of. as one of the first few studies to focus on a holistic view of the epidemic, the paper cannot avoid its limitations. first, our estimation model captures how potential infections spread as people move out of their destinations by multiplying the flight numbers and the number of cumulative infections in the destination countries. since there is no reported infection number of china, either by who or jhu before january , the potential spread values from china to any other countries remain zero. it means that the study cannot estimate the spread situation before january and the findings of the study are limited to the situation after january . since the flight dataset shows continuous outbound flights from china to other countries after january (albeit with a decrease in number), potential infection transmission from china to other countries can still be well captured by the mobility data. second, all the restrictions were still in effect at the time of writing; therefore, we mainly focused on the short-term effects rather than a longitudinal examination. we recommend that scholars exercise caution when extrapolating our conclusions to longer periods. third, some reliability concerns still exist related to the confirmed number reported and policy implementation; however, we could analyze only the available data. furthermore, examining the restriction implementation process and efforts of the actions in a more detailed manner would increase the rigor and power of the initial analysis presented in this paper. models that can predict the dynamic future is also the focus of the next steps. phylogenetic network analysis of sars-cov- genomes introductions and early spread of sars-cov- in the new york city area. medrxiv using social and behavioural science to support covid- pandemic response applying principles of behaviour change to reduce sars-cov- transmission evolving epidemiology and impact of non-pharmaceutical interventions on the outbreak of coronavirus disease coronavirus infections-more than just the common cold modelling the covid- epidemic and implementation of population-wide interventions in italy clinical characteristics of coronavirus disease in china clinical features of patients infected with novel coronavirus in population flow drives spatio-temporal distribution of covid- in china the effect of human mobility and control measures on the covid- epidemic in china substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov ) nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study lancet: covid- : too little, too late? spatial panel data models using stata spatial econometrics: from cross-sectional data to spatial panels an interactive web-based dashboard to track covid- in real time applied econometrics using the sas system econometric analysis an efficient method of estimating seemingly unrelated regressions and tests for aggregation bias cuomo: the coronavirus that came to new york "did not come from china, it came from europe key: cord- -trshrh f authors: notari, alessio title: temperature dependence of covid- transmission date: - - journal: nan doi: nan sha: doc_id: cord_uid: trshrh f the recent coronavirus pandemic follows in its early stages an almost exponential growth, with the number of cases quite well fit in time by $n(t)propto e^{alpha t}$, in many countries. we analyze the rate $alpha$ for each country, starting from a threshold of total cases and using the next days, capturing thus the early growth homogeneously. we look for a link between $alpha$ and the average temperature $t$ of each country, in the month of the epidemic growth. we analyze a {it base} set of countries, which developed the epidemic earlier, an {it intermediate} set of countries and an {it extended} set of countries, which developed the epidemic more recently. applying a linear fit $alpha(t)$, we find increasing evidence for a decreasing $alpha$ as a function of $t$, at $ . %$c.l., $ . %$c.l. and $ . %$ c.l. ($p$-value $ cdot ^{- }$, or $sigma$ detection) in the {it base}, {it intermediate} and {it extended} dataset, respectively. the doubling time is expected to increase by $ %sim %$, going from $ ^circ$ c to $ ^circ$ c. in the {it base} set, going beyond a linear model, a peak at $( . pm . )^circ c$ seems to be present, but its evidence disappears for the larger datasets. we also analyzed a possible bias: poor countries, often located in warm regions, might have less intense testing. by excluding countries below a given gdp per capita, we find that our conclusions are only slightly affected and only for the {it extended} dataset. the significance remains high, with a $p$-value of $ ^{- }- ^{- }$ or less. our findings give hope that, for northern hemisphere countries, the growth rate should significantly decrease as a result of both warmer weather and lockdown policies. in general the propagation should be hopefully stopped by strong lockdown, testing and tracking policies, before the arrival of the cold season. the recent coronavirus (covid- ) pandemic is having a major effect in many countries, which needs to be faced with the highest degree of scrutiny. an important piece of information is whether the growth rate of the confirmed cases among the population could decrease with increasing temperature. experimental research on related viruses found indeed a decrease at high temperature and humidity [ ] . we try to address this question using available epidemiological data. a similar analysis for the data from january to february , , among different chinese cities, was performed in [ ] and similar studies were recently performed in [ ] [ ] [ ] [ ] [ ] . the paper is organized as follows. in section ii we explain our methods, in section iii we show the results of our analysis and in section iv we draw our conclusions. we start our analysis from the empirical observation that the data for the coronavirus disease in many different countries follow a common pattern: once the number of confirmed cases reaches order there is a very rapid subsequent growth, which is well fit by an exponential behavior. the latter is typically a good approximation for the following couple of weeks and, after this stage of free propagation, the exponential growth typically gradually slows down, probably due to other effects, such as: lockdown policies from governments, a higher degree of awareness in the population or the tracking and isolation of the positive cases. our aim is to see whether the temperature of the environment has an effect, and for this purpose we choose to analyze the first stage of free propagation in a selected sample of countries. we choose our sample using the following rules: • we start analyzing data from the first day in which the number of cases in a given country reaches a reference number n i , which we choose to be n i = [ ] ; • we include only countries with at least days of data, after this starting point. the data were collected from [ ]. we then fit the data for each country with a simple exponential curve n (t) = n e αt , with parameters, n and α; here t is in units of days. in the fit we used poissonian errors, given by √ n , on the daily counting of cases. we associated then to each country an average temperature t , for the relevant weeks, which we took from [ ]. more precisely: if for a given country the average t is tabulated only for its capital city, we directly used such a value. if, instead, more cities are present for a given country, we used an average of the temperatures of the main cities, weighted by their population [ ] . for most countries we used the average temperature for the month of march, with a few exceptions [ ] . we analyzed three datasets. a first list of countries was selected on march th. finally an extended set has been studied on april th [ ] , adding the following countries to the previous dataset: belarus, bolivia, cameroon, congo, cote d'ivoire, cuba, democratic republic of congo, djibouti, el salvador, georgia, ghana, guatemala, guinea, honduras, jamaica, kenya, kosovo, kyrgyzstan, madagascar, mali, mauritius, montenegro, niger, nigeria, paraguay, puerto rico, rwanda, sri lanka, togo, trinidad and tobago , uganda, uzbekistan, venezuela, zambia. using such datasets for α and t for each country, we fit with two functions α(t ), as explained in the next section. note that the statistical errors on the α parameters, considering poissonian errors on the daily counting of cases, are typically much smaller than the spread of the values of α among the various countries. this is due to systematic effects, which are dominant, as we will discuss later on. for this reason we disregarded statistical errors on α. the analysis was done using the software mathematica, from wolfram research, inc.. we first fit the base dataset, with a simple linear function α(t ) = α + β t , to look for an overall decreasing behavior. results for the best fit, together with our data points, are shown in fig. . the estimate, standard deviation, confidence intervals for the parameters, together with the significance and the explained variance, r , are shown in table i . from such results a clear decreasing trend is visible, and indeed the slope β is negative, at . % c.l. (p-value . ). however, the linear fit is able to explain only a small part of the variance of the data, with r = . , and its adjusted value r adjusted = . , clearly due to the presence of many more factors. in addition, a decreasing trend is also visible in this dataset, below about • c. for this reason we also fit with a quadratic function results for the quadratic best table ii . from such results a peak is visible at around t m ≈ • c. the quadratic model is able to explain a slightly larger part of the variance of the data, since r ≈ . [ ] . moreover, despite the presence of an extra parameter, one may quantify the improvement of the fit, using for instance the akaike information criterion (aic) for model comparison, ∆aic ≡ ∆k − ∆ ln(l), where ∆k is the increase in the number of parameters, compared to the simple linear model, and ∆ ln(l) is the change in the maximum log-likelihood between the two models. this gives ∆aic = − . , slightly in favor of the quadratic model. we table ii: in the left panel: best-estimate, standard deviation (σ) and % c.l. intervals for the parameters of the quadratic interpolation, for the base set of countries. in the right panel: r for the best-estimate and p−value of a non-zero β. in fig. and in table iii . the slope β is smaller in absolute value, but the significance actually slightly increases, since a zero slope is excluded at . % c.l. (p-value . ). now r = . and r adjusted = . . in this sample the quadratic trend is not visible anymore, and indeed the aic does not prefer the quadratic fit: ∆aic = + . compared to the linear fit, in disfavor of the quadratic model. the r is also practically the same as in the linear fit. for the extended sample results of the linear fit are shown in fig. and in table iv . the slope β becomes larger and, most importantly, the significance highly increases, since a zero slope is now excluded at . % c.l. (p-value · − , or σ detection, translated in the language of a gaussian distribution). now r = . and r adjusted = . . in this dataset, which extends to april th, a few anomalies are however present: in the case of bangladesh and thailand it is possible to see that the exponential growth became much faster after the initial days. we have checked what happens by using a different interval of time for these cases, instead of the standard days. namely we have used days for thailand and days for bangladesh, which give the maximal value of α in both cases. the results for the linear fits using such corrected values is shown in table v . the significance is lower, but still very high: p-value . · − , or . σ detection, translated in the language of a gaussian distribution. finally we have tested the existence of a possible bias on the data: the fact that poor countries v: in the left panel: best-estimate, standard deviation (σ) and % c.l. intervals for the parameters of the linear interpolation, for the extended set of countries. here thailand and bangladesh have been corrected for, as explained in the text. in the right panel: r for the best-estimate and p−value of a non-zero β. have less intense testing. this could in principle be a source of major bias, since many countries with low income are located in warm regions. in order to discard such a bias we have analyzed the existence of a nonzero linear correlation β on subsamples of the extended dataset, by excluding countries with low income. more specifically we have set a threshold on the gdp per capita [ ] , and checked whether the correlation is still there, excluding countries below such a threshold from the analysis. we show in fig. our results: we find a correlation to exist, rather independently on the threshold that we applied. the significance of a nonzero beta (p-value) is plotted in fig. and remains always between · − and · − . in addition, we have also checked for a correlation between the growth rate α and the gdp per capita, shortly gdp . we find no significant correlation in the base and intermediate datasets, while we find a negative correlation in the extended dataset, with p-value = . . this is not so surprising, since the extended dataset contains many low-income countries, where the disease has arrived later, and where most likely testing is not intense enough. for this dataset we performed thus a linear fit with two variables, gdp and t . results are shown in table vi . the dependence on t is still highly significant, with p-value . and the best-estimate is β − . . as expected, t also has non-negligible correlation with the gdp per capita. table vi: in the top panel: best-estimate, standard error (σ), t−statistic and p−value for the parameters of the linear interpolation in two-variables, temperature (t) and gdp per capita (gdp ), for the extended set of countries. in the bottom panel: r and correlation coefficient (i.e. normalized off-diagonal element of the covariance matrix) between t and gdp . we have collected data for countries that had at least days of data after a starting point, which we fixed to be at the threshold of confirmed cases. we considered three datates: a base dataset with countries, collected on march th, an intermediate dataset with a total of countries, collected on april st, and an extended dataset with a total of countries, collected on april th. we have fit the data for each country with an exponential and extracted the exponents α, for each country. then we have analyzed such exponents as a function of the temperature t , using the average temperature for the month of march (or slightly earlier in some cases), for each of the selected countries. for the base dataset we have shown that the growth rate of the transmission of the covid- has a decreasing trend, as a function of t , at . % c.l. (p-value . ). in this fit r = . . in addition, using a quadratic fit, we have shown that a peak of maximal transmission seems to be present in this dataset at around ( . ± . ) • c. such findings are in good agreement with a similar study, performed for chinese cities [ ] , which also finds the existence of an analogous peak and an overall decreasing trend. other similar recent studies [ ] [ ] [ ] [ ] find results which seem to be also in qualitative agreement. for the intermediate dataset we also found a decreasing slope β. this is smaller in absolute value, but the significance remains high, since a zero slope is excluded at . % c.l. (p-value . ). for this fit we found r = . . finally for the extended dataset we found a very highly significance for a negative β, p-value · − ∼ · − (depending on the treatment of some anomalous cases), which would translate in a . σ ∼ σ detection, in the language of gaussian distributions. here r = . ∼ . . for all datasets we also tested the influence of a possible large bias: the fact that poorer countries have less intense testing, which might be in principle partially degenerate with effects of temperature. our analysis indicate that this should not be a major issue: by excluding countries with low income from the analysis we find small variations on the best-fit value of β, and the significance of the correlation β remains very high, with p-value · − or less. we have also checked for a correlation between the gdp per capita and α: we find a significant correlation only in the extended dataset. this should be probably interpreted as the fact that poorer countries do not have enough testing capabilities. however, after taking into account of this variable, the dependence on t remains highly significant. the decrease at high temperatures is expected, since the same happens also for other coronaviruses [ ] . it is unclear instead how to interpret the decrease at low temperature (less than • c), present in the base dataset. this could be a statistical fluctuation, since it is not present in the intermediate and extended datasets. one possible reason for this decrease, if real, could be the lower degree of interaction among people in countries with very low temperatures, which could slow down the propagation of the virus. a general observation is also that a large scatter in the residual data is present, clearly due to many other systematic factors, such as variations in the methods and resources used for collecting data and variations in the amount of social interactions, due to cultural reasons. further study is required to assess the existence and the relevance of such factors. as a final remark, our findings can be very useful for policy makers, since they support the expectation that with growing temperatures the coronavirus crisis should become milder in the coming few months, for countries in the northern hemisphere. as an example the estimated doubling time, with the quadratic fit, at the peak temperature of . • c is of . days, while at • c is expected to go to about . days. the linear fit implies an increase in the doubling time by % (or %), going from • c to • c., using the estimate from the extended dataset (or the extended dataset, taking into account of the gdp per capita, at a reference value of thousand dollars). for countries with seasonal variations in the southern hemisphere, instead, this should give motivation to implement strong lockdown policies before the arrival of the cold season. we stress that, in general, it is important to fully stop the propagation, using strong lockdown, testing and tracking policies, taking also advantage of the warmer season, and before the arrival of the next cold season. the effects of temperature and relative humidity on the viability of the sars coronavirus temperature significant change covid- transmission in cities spread of sars-cov- coronavirus likely to be constrained by climate will coronavirus pandemic diminish by summer? high temperature and high humidity reduce the transmission of 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 the one in which the number of cases ni is closest to . in some countries, such a number ni is repeated for several days; in such cases we choose the last of such days as the starting point. for the particular case of china for japan we have subdivided into three regions: hokkaido, okinawa and the rest of the country, using respectively the temperatures of sapporo, naha and tokio. for the u.s.a. we used the national average of about japan we considered an interpolating function of the temperature for the months of january, february and march and we took an average of such function in the relevant days of the epidemic only countries with at least . inhabitants have been considered in this dataset where ssr is the residual sum of squares and sst is the sum of the squared differences between the α values and their mean value we would like to acknowledge viviana acquaviva, alberto belloni, Ángel j. gómez peláez, jordi miralda and giorgio torrieri, for useful discussions and comments. key: cord- -xzfo jjq authors: todd, ewen c. d. title: foodborne disease in the middle east date: - - journal: water, energy & food sustainability in the middle east doi: . / - - - - _ sha: doc_id: cord_uid: xzfo jjq food safety is a concern worldwide and according to the world health organization, developing countries are probably more at risk of foodborne illness because many of these, including those in the middle east, have limited disease surveillance and prevention and control strategies. specifically, the middle east and north africa (mena) region has the third highest estimated burden of foodborne diseases per population, after the african and south-east asia regions. however, it is difficult to determine what the burden is since little is published in peer-reviewed journals or government reports for public access. this chapter reviews autonomous nations, namely, afghanistan, bahrain, egypt, iran, iraq, israel, palestine, kuwait, lebanon, oman, pakistan, qatar, saudi arabia (ksa), syrian arab republic (syria), united arab emirates (uae) and yemen. countries range in size from bahrain with . million inhabitants to pakistan with a population of million. agriculture and local food production is much influenced by water availability for irrigation. water shortages are most severe in the gulf countries which rely on aquifers, desalination, and recycled waste water for most of their water supplies. this means that most food is imported which is expensive if not subsidized through petrodollars. this impacts food security which is a particular concern in countries under conflict, particularly, syria, yemen and iraq. gastrointestinal infections are frequent in this region from salmonella typhi and other salmonella spp., shigella spp., campylobacter jejuni and c. coli, rotavirus, hepatitis a virus, parasites, and more rarely from aeromonas, yersinia enterocolitica, brucella spp., and middle east respiratory syndrome coronavirus (mers-cov). reports indicate that children are the most susceptible and that many isolates are multidrug resistant. chemical contamination of water supplies and crops are probably more of a concern than published reports indicate, because of widespread indiscriminate use of fertilizers, antibiotics, and pesticides, coupled with increased industrial pollution affecting the water supplies. like many other parts of the developing world, foodborne disease surveillance is limited and outbreaks are most often reported through the press but with insufficient detail to determine the etiological agents and the factors contributing to the outbreaks, leading to speculation to the cause by those interested or responsible for food prevention and control. however, there are some well investigated outbreaks in the region that have those details, and reveal where the shortcomings of both the establishments and the inspection systems have been. where the causative agents are known, the kinds of pathogens are generally similar to those found in the west, e.g., salmonella, but many outbreaks seem to have short incubation periods that point to a toxin of some kind of chemical or biological origin, but these are almost never identified. because of sectarian warfare, residents and refugees have been given food that has made them sick and solders? have been deliberately poisoned. research has been focused on microbial contamination of locally-sold foodstuffs and manager and employee knowledge of food safety and hygienic conditions in food preparation establishments. an innovative pilot project in qatar is to use seawater and sunlight for raising crops through the sahara forest project. all countries have some kind of food establishment inspection system, but they tend to be punitive if faults are found in management or employees on the premises rather than being used for their education for improving food safety. restaurants may be closed down and owners and employees fined for often unspecified infringements. however, some food control agents are moving towards employee training through seminars and courses before problems occur, which is a good disease prevention strategy. unfortunately, many of the food handlers are from asian countries with languages other than arabic and english, which makes effective food safety communication and training difficult. tourists visiting popular resorts in turkey and egypt have suffered from foodborne illnesses, usually of unknown origin but poor hygienic conditions are blamed with law suits following, and the adverse publicity affects the long-term viability of some of these resorts. food exports, important for local economies, have occasionally been contaminated resulting in recalls and sometimes illnesses and deaths, notably fenugreek seeds from egypt (e. coli o :h ), pomegranate arils from turkey (hepatitis a virus), and tahini from lebanon (salmonella). overall, in recent decades, the middle east has made strides towards improving food safety for both residents and foreign visitors or ex-pat workers. however, within the countries there are large discrepancies in the extent of effective public health oversight including food safety and food security. currently, almost all of the countries are involved to a greater or lesser extent in the civil wars in syria and yemen, or are affected through political tensions and strife in egypt, iraq, iran, israel, palestine, lebanon and turkey. in addition, the current overproduction of oil on a world-wide scale has led to a rapid decrease in revenues to most gulf states. all this points to a severe setback, and an uncertain foreseeable future for improvements in obtaining both sufficient and safe food for residents in this region. the world health organization (who) eastern mediterranean region, comprising countries in the middle east and north africa (mena), has the third highest estimated burden of foodborne diseases per population, after the african and south-east asia regions. according to the who ( a), more than million people living in this region are estimated to become ill with a foodborne disease every year and million of those affected are children under years. diarrheal diseases caused by e. coli, norovirus, campylobacter and nontyphoidal salmonella account for % of the burden of foodborne disease. an estimated people die each year from unsafe food, caused primarily by diarrheal diseases, typhoid fever, hepatitis a, and brucellosis. both typhoid fever and hepatitis a are contracted from food contaminated by the feces of an infected person and the source of brucellosis is typically unpasteurized milk or cheese from infected goats or sheep. half of the global cases of brucellosis are in people living in this region, with more than , people infected every year, causing fever, muscle pain or more severe arthritis, chronic fatigue, neurologic symptoms and depression. cholera, which after a short incubation period of - days causing severe diarrhea and dehydration, is returning to those countries with limited public health infrastructure caused by conflict, such as iraq (agence france-presse ). the list of countries covered by this chapter is similar to that of who but leaving out north african countries except egypt (which has territory in eastern asia) and adding turkey which is not always considered in the region because it is not arabic, but has interesting food safety data. therefore, the countries under review are afghanistan, bahrain, egypt, iran, iraq, israel and palestine, kuwait, lebanon, oman, pakistan, qatar, saudi arabia (ksa), syrian arab republic (syria), united arab emirates (uae) and yemen. gulf countries bahrain, kuwait, oman, qatar, ksa and the uae have similar social, political, economic, culture, religion, language and ancestry with several similarities in their food control systems and food safety programs (al-kandari and jukes ). a food and agriculture organization (fao) report covering international investments in agriculture in the near east (not identical to the countries chosen for this chapter, but many of the findings apply) states that this region is characterized by a mix of very different countries' resources and incomes (tanyeri-abur and elamin ). the wealth in the richer countries of the region is primarily dependent on oil revenues and the past economic growth has been closely linked to the oil market; about % of regional gross domestic product (gdp) is concentrated in the high income countries (qatar, kuwait, uae, saudi arabia, and bahrain) which are home to only . % of the population in the region, and many of these are expatriates working in these countries. the report indicates that food insecurity varies sharply in the region but overall the percent of the undernourished population does not exceed % in most countries of the region, except for sudan, mauritania, djibouti and yemen where the proportion of undernourished exceeds %; however, in these percentages will be totally out of date for countries like syria and iraq and in neighboring countries where refugees have reached because civil war and jihadi terrorist groups have put considerable stress on public health facilities and food availability. the countries in the region however, are largely similar when it comes to the challenges in achieving sustainable agriculture and food security. for most of these countries, the overwhelming concern is to secure adequate and stable supplies of food at the national level, making food security a concern for both rich and poor countries of the region (tanyeri-abur and elamin ). the three major problems affecting most of the countries are (i) limited water availability; (ii) population growth; and (iii) heavy dependence on food imports. water scarcity in particular, is the most critical development problem in the region and the single most important factor in limiting agricultural growth, and water availability has been declining steadily since the late s. the region as a whole has % less availability of renewable water per person in - than in - . lack of water for irrigating crops but also for potable water supplies affects many of the countries, particularly in the gulf region. it is important to note that the wealthiest countries are also those with the highest water depletion record, namely, the uae and qatar. the unprecedented growth in investment in agriculture is in large part a result of the food crisis of , which brought about a rethinking of agricultural support policies, mostly in countries of the gulf and particularly saudi arabia, which has invested heavily in the last years in large-scale agricultural production using up valuable water resources. saudi arabia announced in january that it would phase out wheat and agricultural production in the course of the next years. in july , qatar and uae took similar policy decisions (tanyeri-abur and elamin ). crops grown in the region may serve as fresh food sources for the population, but much of the food is imported with limited locally processed products, and if the policies of ksa, qatar and uae expand to other countries, more will be imported in the future (tanyeri-abur and elamin ). thus, the main foodborne disease issues are with homemade, restaurant and street food, where isolated claims of illness are followed up by inspections and possible punitive action by public health agencies responsible for food safety. those countries that rely on tourism for their main source of gdp have sometimes been damaged by adverse publicity, e.g., egypt, and to a lesser extent, turkey and lebanon. according to the food and agriculture organization, less than % of the world agricultural trade is conducted in the region. even though by tradition many of these countries relied on growing their own food, today some of these countries import almost % of their food; . % of the food in the world alone was imported to saudi arabia and united arab emirates in , and the food trade balance in food in middle east is negative, estimated at over us $ billion dollars (tajkarimi et al. ). there are specific restrictions prevalent in the arab-speaking countries related to islam and judaism with the prohibition of eating pork and blood, the drinking of alcohol, and mixing dairy foods and meat under halal and kosher food laws. therefore, parasites related to pigs, e.g., trichinella and taenia spp., are unlikely to be prevalent in these populations. however, there are many muslim and jewish feast occasions with large gatherings such as eid linked to ramadan and particularly the muslim hajj, which put a strain on food preparation, distribution and storage. good health conditions for travelers to saudi arabia for the pilgrimage to mecca (hajj) are critical and any incident that occurs has to be quickly contained to prevent extensive infectious disease outbreaks (memish and al rabeeah ) . traditional middle eastern foods are mainly related to legumes, leafy greens, fruit, dairy products and meat on special occasions; details can be found in brittin ( ) . in urban areas today, grocery stores and supermarkets can supply most of the food requirements of a family but imported foods tend to be expensive. also, some fruit and vegetable items are seasonal and are only available once or twice a year such as local plums, almonds and bananas, which tend to be cheaper than imported varieties. quality of raw produce in stores varies but they often have short shelf lives and can spoil quickly because of harvesting ripe products, bruising, and high storage temperatures. traditional rural foods include aromatic stews, stuffed vegetables, wild leaves, pulses and cracked wheat, and occasional goat or lamb meat. a typical middle eastern meal starts with a variety of cold and hot mezze (appetizers), salads and pastries, especially in greece, turkey and lebanon. many contain herbs, cheese, pickles, nuts, seeds, and parsley and lettuce are widely eaten in salads or traditional mezzes. most mezzes are vegetarian and fresh fruits and vegetables are an integral and important part of the cuisine when they are in season. tabbouleh, a salad where parsley is a major ingredient with small pieces of tomato, and some bulgur (ground wheat) in it, is often served in leaves of romaine lettuce or raw cabbage. almost as popular is fattoush, a mixed bowl of lettuce, tomatoes, cucumbers, and fried or toasted pita chips, typically seasoned with a dusting of sumac and pomegranate molasses. since leafy greens do not have a final decontamination step, they are at risk from environmental fecal contamination as reported in lebanon by faour-klingbeil et al. ( ) . hummus, a smooth chickpea paste made with tahini/tehineh, lemon juice or citric acid, garlic and salt, and often served with olive oil, is the most ubiquitous mezze. since tahini and hummus are major exported products from the region, particularly lebanon, they are prone to salmonella contamination, and are sometimes recalled from other countries, which is damaging to the local economies. dairy products are also served regularly at meals and these are locally made or imported. labneh, strained yogurt, very similar to greek yogurts, is widely used as a base for mezze which might have olive oil, pine nuts or za'atar (a mixture of thyme, sumac, and sesame seeds) added. cheeses including the popular haloumi are frequently served in restaurants. shawarma/ shwarma is frozen or refrigerated raw or marinated meat (lamb, beef or chicken) cooked on a vertical rotisserie popular throughout mena countries and now frequently seen in western nations. higher fish consumption tends to be close to where these are locally caught, either sea or river netted. one example from iraq is masquf (split large fish cooked on stakes over a fire, and eaten outdoors by a river, served with slices of tomato and onion and arab bread. crustaceans are less frequently eaten but can be obtained from imports. cosmopolitan foods are widely available in the larger cities, as are multinational fast-food chains. foodborne illnesses have been sporadically reported throughout the region over the past decades and global assessments of the kinds of problems encountered reviewed, e.g., todd ( ) and al-mazrou ( ) and more recently by tajkarimi et al. ( ) . these last authors indicate that reporting foodborne disease is functioning well in jordan, kuwait, oman, saudi arabia and uae, compared to other countries in the region. however, the foodborne outbreak surveillance systems in middle eastern developing countries are still limited with reporting of less than % of the actual outbreaks; one reason is that many foodborne illnesses occur in homes and those ill may not visit medical care facilities. in addition, available laboratory analytical support for public health agencies is often minimal or lacking, even though some research institutions may have up-to-date equipment and technical expertize. change is gradually coming and a food and drug authority has been established in both saudi arabia and jordan (al-kandari and jukes ). also, new food legislation has been initiated by egypt, lebanon and syria (tajkarimi et al. ) , but is currently stalled in last two countries. improvements in inspection service, hand held computers, customized software and improved surveillance systems are some examples of developments in food safety systems in the region. jordan, saudi arabia and bahrain have been developing unified food safety activities from farm to fork (al-kandari and jukes ). however, there is a need for substantive food safety education for all foodservice staff. increasing quality and quantity of the food safety training and human resources in governmental agencies in the region will improve the public health infrastructure. for example, the municipality of dubai has established an international annual food safety conference to improve the food safety education system of those in the region, now in its th year ( ). the following sections of the chapter focus on five aspects: gastrointestinal infections; foodborne disease outbreaks in specific countries; food safety related research and surveys; issues relating to tourism and exported food; and government oversight of the food industry, with specific examples from countries in the region. gastrointestinal diseases are frequently encountered in the middle east and many etiological agents have been identified where specific studies have been carried out to look for bacterial, viral and parasitic pathogens. the average annual incidence of culture-proven shigellosis in israel was / , from to , but each reported case was considered to represent cases indicating the high burden of the disease in the country (cohen et al. ) . orthodox jewish communities, living in highly crowded conditions and with a high number of children aged < years were the epicenter of country-wide biennial propagated epidemics of s. sonnei shigellosis. s. flexneri was the leading shigella serogroup in israeli arabs. isolates showed high rates of resistance to ampicillin and trimethoprim/sulfamethoxazole, but very low rates to quinolones and third-generation cephalosporins. there is no indication if foods or water were vehicles of these shigellosis cases. also, in israel a study of pregnancy-related listeriosis cases from to , identified cases, resulting in a yearly incidence of - cases per , births (elinav et al. ). there were fetal deaths, two neonate deaths and one maternal mortality. the incidence of israeli pregnancy-associated listeriosis has a high yearly variability and is one of the highest worldwide. the geographical distribution varied greatly between years and had a different epidemiological pattern compared with nonpregnancy-related listeriosis. the sources of the infections were not studied but all listeriosis cases have a foodborne link. this has to be further researched as to diet, and the unawareness of the israeli public of the risk for certain food products contributing to the extremely high incidence in israel, in both general and pregnancy-associated listeriosis, as occurs in other countries. a total of stool samples were collected from palestinian patients with acute diarrhea from which ( . %) yielded enteropathogenic bacteria. salmonella, campylobacter coli/ jejuni, and aeromonas hydrophilia were isolated in equal numbers from samples / ( % each), shigella boydii / ( . %), yersinia enterocolytica / ( . %) (abdelateef ) . many strains were antibiotic-resistant. children younger than years old were more susceptible to infectious diarrhea; in addition, diarrhea was more frequent in those living in crowded houses, and in houses rearing poultry, including pigeons. salmonella enterica serovar typhi continues to be an important public health problem in kuwait. analysis of the isolates from patients, collected between and , showed that the majority were from patients from the indian sub-continent, and many strains were drug resistant (dashti et al. ) . typhoid fever in kuwait is predominantly associated with those who have traveled from endemic areas to work in kuwait. the circulation of enteric viruses among the population of cairo, egypt, between march and february was studied by kamel et al. ( ) . at least one type of virus was detected in % of fecal samples, . % of which were positive for rotavirus, % for norovirus, . % for adenovirus, and . % for astrovirus. over % of infections were mixed infections. among the noroviruses, half belonged to the predominant ggii. cluster which were similar to those circulating elsewhere, but there were also new ggii. variants that were not associated with any previously known ggii. isolate. although norovirus is rarely implicated in foodborne outbreaks compared with the us and other western countries, it is clearly present in egypt. further studies are required to assess the disease burden of enteric viruses in egypt and the impact of atypical strains. the disease burden of hepatitis a and e in egypt is one of the heaviest worldwide, based on serological analysis, with hav infections occurring very early in life, with almost % seropositivity after the first years of life (kamel et al. ) . to determine the actual contamination levels in the environment, these authors conducted a survey of hav and hepatitis e virus (hev) in sewage in cairo. hav was detected by rt-pcr in of ( %) sewage samples. in addition, all the hav-positive samples were also positive for enteroviruses. that only one stool sample was hev-positive might be explained by the lower level of excretion of the virus in stools, the fragility of the virion in the environment, and technical difficulties in concentrating and amplifying the virus with standard methods. bacterial etiology was found in . % of cases of childhood diarrhea in dhahira, oman, mostly shigella sonnei and to a lesser extent salmonella (patel et al. ) . antibiotics were prescribed in . % of cases and the resistance to the common antibiotics tested was low. one reason for the low pathogen isolation rate could be that many cases had viral etiology. rotavirus was detected in stool specimens from ( %) of children, who were admitted to regional public hospitals in oman for a median of days with severe diarrhea (al awaidy et al. ) . a diverse rotavirus strain pattern in oman was identified with g ( %), g ( %), and g ( %) accounting for most of typeable strains. the authors estimated the burden for the omani government at us$ , and us $ . million annually to treat rotavirus-associated diarrhea in the outpatient and hospital settings, respectively. they recommended a rotavirus vaccination program that would substantially reduce the burden of severe diarrhea among children in the country. unlike the above countries where the health care system functions for most residents, though not always to western standards, the same cannot be said for pakistan, particularly in rural areas. poor nutrition combined with diarrheal and other foodborne diseases puts the population at risk for serious illness and death, especially among infant and children in pakistan (akhtar ) . cholera, campylobacteriosis, e. coli gastroenteritis, salmonellosis, shigellosis, typhoid, and brucellosis have been demonstrated to be the major foodborne illnesses in the country as well as infectious diseases caused by viral and parasitic agents. many fatalities have been associated with food poisoning but the actual agent has rarely been determined. many health experts believe that rapid spread of gastrointestinal diseases cannot be controlled if the public has no awareness of prevention and control measures against cholera and other forms of gastroenteritis, and that in most parts of the country, sewage is continuously contaminating streams, lakes, springs, wells, and other drinking water sources (qasim ). in may , an epidemic of diarrhea and gastroenteritis occurred in kamalia, toba tek singh, with over children and others being admitted to hospitals which had few medical supplies. apart from lack of potable drinking water, the main reason given for the rise in cases was the heat of summer when there were frequent power cuts so that food "rots" or becomes "stale" (islam ) . in remote areas of pakistan, cholera has been responsible for many outbreaks. two examples in july and august of , both in areas of conflict near afghanistan, give an idea of local but severe outbreaks. in one case authorities seemed not to want to be involved and in the other vaccinations are carried out. although water is the primary vehicle of the vibrio cholerae pathogen, it can easily contaminate prepared foods through poor hygienic practices. in july , five deaths from cholera occurred in pashtoon kot area, balochistan region of pakistan (federally administered tribal areas) along the afghan border (staff ), some km from quetta, in the absence of any emergency medical aid. the condition of an additional people suffering from the disease was said to be critical. a local tribal elder expressed the fear that outbreak of cholera might cause loss of life at large scale. he complained that the doctor and paramedics deployed at the basic health center in panjpai live in quetta and are rarely seen at the center. officials of the provincial health department appeared to be unaware about the cholera outbreak and loss of lives (or ignored these), as they sent no medical teams to the affected area. in fact, pakistani government rebuffed international media's claims, and did not respond to requests to dispatch healthcare professionals to the balochistan area. it was assumed the outbreak would continue without medical aid. in , cholera outbreaks killed hundreds of people, mostly children, in flood-hit districts of nasirabad, jaffarabad and jhal magsi where waterborne diseases were reported at a large scale because of consumption of contaminated water by local people. in august , two people died and others had fallen ill, following a cholera outbreak in kurram tribal agency near afghanistan (hussain ) . dhand and kudiad khel were the worsthit areas but vaccinations were carried out amid tight security, and tribesmen were instructed not to drink water directly from the well and boil it first instead since the wells had been contaminated from the rain water. around people were shifted to parachinar headquarters hospital, while others were discharged after medical aid. sometimes diseases kept at bay by functioning public health systems come back when these break down as is occurring in a few of the countries embroiled in internal strife and outside attacks. for instance, in iraq in october, , > cases and deaths of cholera occurred which started along the euphrates valley in september with the governorates of baghdad and babil, south of the capital, being the worst affected with more than cases each. the epidemic then spread to the northern autonomous kurdish region, which hosts hundreds of thousands of people displaced by conflict from other parts of iraq (agence france-presse ). a previous outbreak killed four people in the kurdistan region in . the united nations says the number of people displaced by conflict in iraq since the start of has topped . million which would exacerbate the spread of the disease. authorities blamed the cholera outbreak mostly on the poor quality of water caused by the low level of the euphrates. limited vaccination programs are in place in areas of conflict. in october, , two persons arriving in kuwait from iraq tested positive for cholera and both were provided proper treatment and recovered. the ministry of health recognized that further cases could be discovered among people arriving from iraq, but because kuwait has a well-structured health infrastructure with water and sewers grids, and a supply of healthy and safe food, the disease should not spread into the kuwaiti population (anonymous a) . probably there are some cases in yemen and syria, countries also with limited public health infrastructures, but have yet to be identified. in saudi arabia, a country with a well-maintained health system, the main infectious disease concern today are the infections and deaths arising from exposure to the middle east respiratory syndrome corona virus (mers-cov), which has reservoirs in camels and bats (todd and greig ) . a potential food source for this virus and other pathogens is from unpasteurized camel milk, as camel farmers drink the milk as well as being exposed through other aspects of camel contact. this brief review indicates that diarrheal diseases, caused by cholera, dysentery, hepatitis a, salmonellosis, shigellosis, typhoid fever, and other enteric diseases through water and food are major contributors to ill health in the region in agreement with the who ( b) report on global estimates of foodborne diseases. in the region, not very many outbreaks of foodborne disease tend to be investigated, or at least reported publically, and those that are tend to have fatalities or are very large. for instance, in june, , two children and one adult were brought to a hospital in dubai, uae, with suspected food poisoning (vomiting) after they ate take-away food (the father was out of town). although the mother eventually recovered, the two young children ( and years old) died, one on arrival and the other the next day. the cause was not determined (saberi and scott ) . it is not known if the family or restaurant was primarily responsible for the deadly gastrointestinal attack as bacteria can multiply quickly in the hot summer months, and the public had been recently warned to minimize eating out at this time of year, especially at smaller eateries where hygiene levels are often of lower standard. a toxin was likely involved to cause fatalities so rapidly, but it could have been an accidental contamination of the food with a chemical such as a pesticide, as much as it could have been with an enterotoxin produced by staphylococcus aureus or bacillus cereus through careless ambient temperature storage. unfortunately, this was one episode in a string of incidents, most of them with fatalities, in the county. in april, , a -year-old died of suspected food poisoning in sharjah, and in august, a -year-old girl died of food poisoning in abu dhabi. in march, , six people fell ill after eating buffet food at a restaurant in the large ibn battuta mall, dubai; in november of the same year, employees at a cement factory were hospitalized after consuming what was considered rotten food prepared at the factory kitchen in another emirate, ras al khaimah. in may, , a -year-old girl died of suspected food poisoning in sharjah. the indian family of four rushed to the hospital after series of vomiting but were too late to save the girl. dubai has been reporting foodborne outbreaks and cases through its foodborne disease investigation and surveillance system since ; in that year there were cases reported in the first nine months (saseendran ) . in , suspected cases of foodborne illnesses were reported but only cases were confirmed. no deaths were reported since the surveillance system was in place. egypt has had a particular problem with foodborne illnesses in universities and schools, mostly without a confirmed etiology, which seem to be related to poor food quality. food poisoning is not uncommon in egyptian university dormitories, where basic hygiene standards are often not observed, but the following outbreak was one of the largest. on april , hundreds of egyptian students angered by a mass outbreak of food poisoning at a cairo university stormed the offices of the country's top muslim cleric and university president, ahmed el-tayeb, because of the students who were hospitalized after a meal served at the university dormitories in the nasr city district of cairo (associated press ). the university is affiliated with al-azhar mosque, the world's foremost seat of sunni muslim learning, and awards degrees in sciences and humanities, as well as in religious studies. in the protest, thousands of al-azhar students blocked roads, broke into el-tayeb's offices by the main campus, and chanted slogans against the university's management. the causative agent was unknown, and only with the incubation period, types of symptoms and their duration would it be possible to consider the potential etiologies of this illness. because of their poor quality, campus meals were not very popular before they were being blamed for the current food poisoning outbreak. although investigators were not able to find a specific cause, the university suspended its food services director and some other staff members. within a few weeks food poisoning affected students on april , at the same university, al-azhar (masriya ) . investigations were initiated within the university and by the ministry of health, and apparently "bad tuna" had been served at the campus cafeteria; no further details were given. if tuna was the vehicle of the outbreak, scombroid poisoning was the likely cause of the illnesses. the allergic-like symptoms generally begin - minutes after ingestion and usually resolve in a few hours. scombroid fish poisoning occurs after fish, most frequently tuna, with high levels of accumulated histamine or other biogenic amines, is eaten. but "bad tuna' could equally be contaminated with bacterial or viral enteric pathogens with a longer incubation period. a month later there was another outbreak. because at least three outbreaks of food poisoning occurred at al-azhar university between april and may with over cases of food poisoning detected in the university's male dorms, the dorm's director, the university's kitchen manager and eight chefs were sentenced in november, , to years in prison with a financial bail. in a similar situation, egypt's top prosecutor ordered a swift investigation into the cases of food poisoning reported in two primary schools in october, , in suez (masriya ). an official of the ministry of education indicated that the poisoning was caused by the consumption of milk provided by the schools. the distribution of milk to all schools in the governorate was halted until the milk's validity was ensured. if milk was responsible, the etiological agent could be bacillus cereus enterotoxin if the onset time was short, or less likely an infectious disease pathogen such as salmonella or e. coli o :h . on january , , female students were diagnosed with food poisoning at al-azhar university in upper egypt's assiut/ asyut governorate, by the banks of the nile, and were briefly hospitalized in an assiut city (anonymous b) . this follows a similar incident which occurred in april when students, also in the girls' dormitories, contracted food poisoning on the university campus in luxor. this report also flags two major poisoning incidents involving at least students ill consecutively at its campuses in cairo in (probably the ones already discussed). the reason given for these repeated mass foodborne illnesses among university students is the quality of the food served them. apparently cheap, subsidized food is poorly stored, cooked and distributed to the poorer university students. in most cases the attorney general would open a criminal investigation that would be closed without knowing the microbiological cause of these outbreaks. the promed-mena editor speculated that enterotoxins of staphylococcus aureus were the most probable cause of such communal food poisoning, as a toxic dose of less than . microgram in contaminated food is sufficient to produce symptoms of staphylococcal intoxication. this toxin level is reached when s. aureus populations exceed , /g, a condition likely to be present in these university kitchens because of intense pressure on them to feed a huge number of students in a short time, taking into consideration that most of these kitchens lack basic hygienic measures with regard to safe food handling. the editor also considered shigella, with its low infective dose ( - depending on the species) as another possible agent. however, the incubation period and symptoms of s. aureus intoxication and shigellosis or dysentery are quite different. pakistan is similar to egypt in that much of the country is rural but with very large cities with high populations (total population is million in egypt and million in pakistan, the most populous of all middle eastern countries). in september, , more than of the flood victims at a relief camp in bengali boys sindhi section school in ibrahim hyderi vomited after eating cooked food and then fell unconscious; of them had to be taken to a nearby hospital (aligi ) . a local philanthropist had been providing cooked food to the flood victims but by the time the food arrived at the relief camp, the cooked rice had turned "stale". since the rice did not show any sign of spoilage, it was served to the flood victims. a similar incident had taken place days earlier at another town where more than flood affectees had fallen unconscious after consuming "stale" food and were hospitalized. none was seriously affected. during the investigation, it was noticed that the sanitary situation in and around the relief camps was very poor. even though the reason for the illness was not determined, the police took action against the donor and two caterers. in fact, based on the information of the vehicle and the symptoms, bacillus cereus enterotoxin which is known to be produced in boiled rice, was the most likely agent. in the following two outbreaks yoghurt is blamed for the serious illness and deaths though details of the symptoms are not given. rapid onset of symptoms indicates the presence of a toxin of some kind, although yoghurt is not a food known to be frequently contaminated with pathogens because of its high acidity. either the yoghurt was made under very unhygienic condition with the source of the milk perhaps being spoiled (possibly containing bacillus cereus enterotoxin), or a chemical had been added accidently such as a pesticide, or deliberately and illegally to enhance the flavor. however, it is possible other foods were involved and yoghurt was not the contaminated vehicle. in january , in lahore, a hospital employee died and two other employees became critically ill after eating contaminated yoghurt. the three employees ate rice with yoghurt at a local restaurant (ians ) . action was taken against the restaurant owner and manager. no further details are known. in early april, , a rawalpindi family of ten became seriously ill after eating a home-prepared evening meal where yoghurt was suspected to have been the contaminated food, and they were taken to a hospital, where a teenage boy and -year-old girl died (asghar ) . the surviving family members remained in critical condition for some time but eventually recovered; the cause of the illnesses was not discovered, although it was postulated by a relative who had eaten the yogurt with the meal that it was possibly poisonous or, strangely he thought a lizard might have fallen into it. in february , at least four people died and another seven were hospitalized in a critical state after eating home-cooked biryani (a dish made with spices, rice and meat or vegetables) in a suburb of karachi (mahmood ) . the owner of a grocery shop, who provided the ingredients, was arrested, and a sample taken for analysis. it is not known if any toxin was found. a month later in march, in faisalabad, more than children and women were ill after eating contaminated aalo-chanay (potatoes, chick peas, onions, tomatoes and spices) purchased from an unidentified vender (anonymous c) . as soon as the children ate the aalochaney, they felt ill and started vomiting. although they were immediately rushed to a rural health center, one boy died. a medical opinion was given that the eaters suffered from "diarrhea and cholera". however, the onset was too rapid for anything but a toxin of some kind, most likely heat-resistant since the aalo-chanay was cooked. also, in march , as many as student nurses and eight staff nurses were hospitalized with acute food poisoning at a hospital in rawalpindi after eating food at the nursing hostel, but none was critically ill (anonymous d). the nurses residing in the hostel started reporting complaints of vomiting and diarrhea along with high-grade fever at an undisclosed time after a meal. the hospital administration was criticized for failing to provide safe food and drinking water to its employees and demanded immediate inquiry into the case, but none was reported on. the illnesses are consistent with an enteric infection such as salmonella or norovirus. in april , at least constables suffered from diarrhea and were admitted to hospitals when they ate food during the sehat ka insaf program, which is a blanket method of administering the polio vaccine along with eight other vaccines, hygiene kits and vitamin a drops in order to circumvent polio-specific terrorist attacks in pakistan. local administration purchased packed food, including piece of chicken and juices from a local supporter (mayar ) . no further details are given but the chicken could have been undercooked or cross-contaminated with enteric pathogens such as salmonella and campylobacter; if the packs had been left at ambient temperatures for some time, these pathogens could have multiplied on the chicken to large numbers. over thirty children in faisalabad were hospitalized over days because of diarrhea and gastroenteritis, three seriously, and other children were expected to be ill. undetermined contaminated food was postulated as the cause, more than usual because of the extreme seasonal heat combined with frequent power outages to allow rapid bacterial growth in contaminated food. the unavailability of clean drinking water was mentioned as a contributing factor to the increasing number of gastrointestinal disease cases. hospital administrators complained that vaccines and medications were required but were not forthcoming from the health department. probably many family meals were contaminated because of the lack of potable water and any unspecified enteric bacterial pathogens present could grow rapidly in the heat. children are more vulnerable than healthy adults to infections which might explain the high proportion of sick children seeking medical help. botulism outbreaks occur periodically in iran. in a study of stool and serum specimens of patients with clinical symptoms of botulism, who were at inpatient and outpatient medical centers in tehran and other areas of iran, between april to august , specimens of patients showed the toxin and spores of c. botulinum (modarres ) . type e was the most common causative agent found in this study, being responsible for . % in all specimens; other etiologic types, in order of frequency were types a ( . %) and b ( . %). type e strains are typically associated with fish and freshwater and marine sediments. the results of this study indicate that the cases had consumed salted fish, smoked fish and canned fish, along with cans of green beans and cucumbers. a similar result over a decade later confirms that c. botulinum type e is a major pathogen in iran. in gilan province, of fish samples collected in , % of processed fish and . % of non-processed fish contained clostridium botulinum, mainly type e (tavakoli and imani fooladi ) . the processing is insufficient to kill the spores or reduce much of toxin produced because the fish tend to be partly cooked with the intestines kept intact. a total of traditional food product samples ( cheese, kashk [a type of dried yoghurt or thick cream], and salted fish) were examined using a bioassay method for detection of clostridium botulinum toxin (hosseini et al. ) . standard monovalent antitoxins were used to determine the toxin types. c. botulinum toxins were detected in . % of examined samples ( . % of cheese samples and . % of salted fish samples). none was found in kashk samples. c. botulinum types a and e were dominant in cheese and salted fish samples, respectively. consumption of these traditional foods either raw or processed may contribute to foodborne toxicity in iranian populations. in may , a quickthinking mother immediately brought her -month old boy to an israeli hospital when she saw he was suffering from vomiting, difficulty in breathing, listlessness, glassy-eyed, apathetic, and an inability to nurse or eat (bender ) . a doctor at the hospital diagnosed the child as suffering from infant botulism. he decided to treat the baby with the antitoxin stored in the emergency stocks, even before they got back the lab test results. the hospital like all israeli medical facilities keep ample supplies of biological and chemical warfare antidotes on hand in case of war or terrorist attacks, and staffers are regularly drilled in dealing with the symptoms of various chemical, neural and blister agents. the infant started recovering soon after the administration of the antidote. in the rare disease of infant botulism, spores of clostridium botulinum are ingested and the infant's flora is not mature enough to prevent germination and slow growth of the toxigenic pathogen. it is entirely possible that infant botulism occurs more frequently in the region but is not diagnosed. foodborne disease surveillance depends on an infrastructure of reporting and diagnosis in hospitals, epidemiologists, and food testing laboratories. lebanon is an example of a country where modernization in public health seems to occur at a glacial pace. however, diseases including those of foodborne and waterborne origin, are documented and published. the law of december , regarding communicable diseases in lebanon mandates all physicians, from private or public sectors, in hospitals or ambulatory services, to declare to the epidemiologic surveillance unit of the moph all diseases considered a risk to public health. the data available at the ministry of public health (moph) are compiled from different sources, and the declaration of cases remains irregular and insufficient (moph ) . in , foodborne and waterborne diseases were the most frequently reported in lebanon at a rate of . ‰ (total of cases), with the highest rate in the bekaa ( . ‰) and the lowest in the south ( . ‰). the most common infection was viral hepatitis a, which represented . % of the total food and waterborne diseases with cases. there were also cases of typhoid ( . %), cases of food poisoning (unspecified, . %), cases of dysentery ( . %), cases of brucellosis ( . %, cases of parasitic worms ( . %) and cases of hydiatic cyst ( . %). no cases of cholera and trichinosis were declared. hydiatic cyst (cystic echinococcosisis) caused by echinococcosis (typically e. granulosis) is acquired by contact with animal feces contaminated with tapeworm eggs. sources include contaminated food (meat), water, and animal fur. cysts containing tapeworm larvae may grow in the body for years before symptoms appear. when cysts become large, they may cause nausea, weakness, coughing, and belly or chest pain. occasionally, well-investigated outbreaks are published; the following two examples are from lebanon and neighboring jordan. in may , employees suffered from diarrhea, fever, and abdominal pains . - . h (mean, . h) after eating chicken noodles au gratin at a catered lunch served at a bank cafeteria (hanna et al. ). a few cases had systemic infections. salmonella enteritidis (se) was confirmed in stool and blood cultures within - h after hospital admission of the first cases, and also in leftovers of the suspect food. the same dish had been served at the bank in the past with no apparent health problems. preparation normally started in the evening prior to the day the dish is served. however, in this instance, some of the constituents had been prepared days ahead, because the dish was to be served on a monday, immediately after the week-end closure. no salmonella was found in rectal and nasal mucosal swabs taken from all kitchen workers, or in the tanker water supply (although it had high fecal coliform counts), but se was found in a frozen batch of the same raw chicken breast consignment that had been used for the chicken noodles. the batch of chicken came from a large producer of poultry and eggs in lebanon, who was advised of its potential involvement in a major foodborne outbreak. however, the investigators were refused access to the poultry-producing facility. it is highly likely that contaminated chicken carcasses had been, and would continue to be, shipped to many parts of lebanon. that the same se strain occurred in the patients, the raw chicken, and the leftover food was confirmed through random amplified polymorphic dna polymerase chain reaction (rapd-pcr). it would appear the -day delay in the chicken noodle preparation was significant in allowing the salmonella present in the ingredients not only to survive but probably to grow; undercooking, cross-contamination, inadequate storage and reheating all may have played a role in the outbreak, but no more information was available to determine which of these were the key factors in the outbreak. the bank management decided to sue the caterer and because they were aware of apparently inefficient way that public authorities were conducting the procedure, they took the initiative to call upon an independent investigative team to obtain solid evidence to win any court action. the caterers, concerned that they would be the only party blamed for the salmonella outbreak, had succeeded in concealing some raw and cooked items from destruction by the public health authorities, which was their normal practice after a complaint. these items were central to establishing contamination upstream from the caterer's kitchen. no action seems to have been taken against the poultry producer who was the source of the se, a pathogen that is invasive of flocks and difficult to eradicate. the authors complained about the obsolete lebanese laws dating back to the s that still governed what should be done following a report of "food poisoning". public health officers are mandated to stop the spread by destroying allegedly contaminated food items and closing down incriminated facilities. hanna et al. ( ) stated that this kind of action is generally lauded by the public but does not help determine the cause to develop appropriate prevention and control strategies. they also complained that because no investigation is typically done, many non-implicated foods and ingredients are wastefully discarded. the jordanian example is over two decades old, but is worth noting in detail. in september , a -case outbreak of salmonellosis occurred in a university hospital in amman after employees, patients and visitors ate in the cafeteria. the incubation period ranged from to h. symptoms included diarrhea ( %), fever ( %), abdominal pain ( %), dehydration ( %), and bloody stool ( %); were hospitalized (khuri-bulos et al. ) . cultures of eight food items were negative, but stool culture on of patients and of kitchen employees yielded salmonella enteritidis (se) group d . a cohort study revealed a foodspecific attack rate of % for the steak and potato meal and % for the rice and meat meal. stratified analysis of the steak and potato meal revealed that the potatoes were implicated most strongly. cultures were obtained from all kitchen employees, who showed no symptoms of illness, but of grew se group d . one asymptomatic, culture-positive employee had prepared the mashed potatoes on september , h before the first case presented at the hospital emergency with severe gastroenteritis symptoms. all of the food workers had negative stool cultures months earlier. the potatoes were mashed by machine, but peeled after boiling and mixed with milk by hand, using a ladle but no gloves. two different batches, the first of which was served exclusively to hospitalized patients and the second to a few remaining patients and employees, were prepared and served within to minutes of preparation. from the epidemiological data it can be assumed that the infected handler fecally contaminated only the second batch of potatoes, thus sparing most of the highly susceptible inpatients from exposure. furthermore, while potatoes clearly were implicated, individuals who ate steak only had an elevated risk of being attacked. this probably was due to surface contamination of foods being served on the same plate. kitchen employees harboring salmonella were excluded from work until they had three negative stool cultures taken week apart; it took weeks for them to return to work. stool surveillance that was routinely carried out in the hospital was ineffective in detecting infected employees to prevent this outbreak and the investigators recommended that employees adhere to proper hygienic practices including thorough washing of hands, especially when preparing food. today, salmonella is only one of many of the pathogens that can be encountered in foodborne illness. one of the newer pathogens, well established in the west is norovirus (nov), which causes more cases of foodborne disease in the u.s. than any other agent (scallan et al. ). in may , a significant increase in acute gastroenteritis (age) cases was noted in the american health clinic at incirlik air base (iab) in adana, turkey. this increased rate of age led to discussions with local turkish military public health authorities, which confirmed that the turkish military community and the residents of adana were also experiencing an anecdotal increase in age illnesses (ahmed et al. ). an epidemiologic investigation was launched to attempt to identify the cause and possible source of this age outbreak at iab from may to june with the peak incidence of cases during the week of may -june , with a total of patients seeking medical care at the clinic. of the total infected persons, patients completed the case survey, % reported diarrhea, % reported vomiting, and % reported fever. the median number of days between symptom onset and clinic visit was days. during the days prior to symptoms, % of respondents reported travelling off base, % reported eating off base, and % reported using an outdoor pool. this outbreak had a significant negative operational impact, degrading mission readiness with nearly % of the american population in a -month period affected. initiation of a clinic case-based investigation yielded stool specimens in which nov was detected in %, with % of the positive nov specimens identified without a copathogen. dna sequencing data demonstrated that several relatively rare genotypes of nov contributed to this outbreak; four different genotypes were isolated from positive specimens. two of the nov strains were previously reported in iraq and only from deployed troops, while the other two genotypes were reported in south africa and in the us. in turkey, little systematic data on circulating nov genotypes exist. however, giib/gii. strains have been frequently identified in turkish children with gastroenteritis; strains belonging to this genotype have been found in europe and mainly in children. previous reports from british troops deployed to iraq indicated that two nov strains isolated were responsible for cases of gastroenteritis there. similar mixed nov outbreaks have been previously observed and are often attributed to systematic failure of cooking/cleaning/drinking water supplies (ahmed et al. ) . one limitation of this investigation was that the survey was not used to capture data from a control group, those without recent age, preventing carrying out a risk factor analysis. another limitation was the lack of environmental samples that could be tested for nov in order to track the source of outbreak. from anecdotal information, it is likely many in the local population and the turkish military base were ill, but a formal outbreak investigation in the turkish population was never performed. from the multiple genetic types involved, one specific contaminated food or water source seems unlikely. the largest turkish nov outbreak was in keçiborlu province of isparta county between april and , , with patients seeking medical help from the healthcare centers, after suffering from nausea, vomiting and abdominal pain (more frequent than diarrhea) (s€ ozen et al. ) . because of underreporting, the number of affected people was estimated to be higher. municipal water was the suspected source but no samples tested positive. as a cautionary note, the authors suggest that nov may not be the only causative agent of gastroenteritis outbreaks, especially from an undetermined fecal source, and bacterial, viral and parasitic agents should be examined together with the nov. in saudi arabia, a national policy for reporting, notifying, and recording incidents of bacterial food poisoning was established in (al-joudy et al. ). since then salmonella food poisoning outbreaks have been reported from different regions of ksa, exhibiting seasonal and regional variations, with chicken, meat, and rice being commonly incriminated food items, and frequently reported in the saudi epidemiological bulletin. al-mazrou ( ) reviewed the history of foodborne outbreaks in ksa and saw an increase over the last few decades, especially those caused by salmonella, with the main food vehicles being chicken, meat and eggs, and s. enteritidis being the most frequent salmonella serovar responsible. according to promed editorials, restaurants and communal feasts and institutional feeding (such as in school cafeterias, hospitals, nursing homes, prisons, etc.) where large quantities of food are prepared several hours before serving are the most common settings in which foodborne illness incidents occur (http://www.promedmail.org). for instance, in , a hospital in the jizan region received suspected food poisoning cases that were ill after taking meals from a restaurant, including a woman who suffered from severe diarrhea, abdominal pain, vomiting and dizziness (fagbo ) . the restaurant was closed down and three of its workers were detained pending the results of laboratory tests. the report of an investigative committee could not find a specific cause, but noted that the restaurant had earlier been responsible for some hygienic violations. in , cases suspected of foodborne illness after eating a meal at a restaurant were admitted to various hospitals in the najran region (alhayat ) . most of the cases were not seriously ill. no report was given on the samples that were taken from the suspected restaurant, which was closed temporarily. there is an interesting observation related to variant creutzfeldt-jakob disease (vcjd); four cases have occurred in the us since the disease was first diagnosed in the united kingdom in linked to consumption of cow meat suffering from bovine spongiform encephalopathy (bse); two of these were associated with the united kingdom (where bse was first reported), but one came from saudi arabia and the most recent case in had extensive travel to the middle east and europe (cdc ) . this may indicate some source of vcjd in the middle east including saudi arabia. one of the big concerns for ksa is the annual hajj with millions of muslims from around the world converging on mecca, in saudi arabia, each year. no other mass gathering can compare with the hajj, either in scale or in regularity, and various communicable disease outbreaks of various infectious diseases have been reported repeatedly, during and following the hajj (memish ) . in , an outbreak during the hajj occurred where all the cases came from one tent occupied by soldiers located in a government camp in mina, makkah province, near mecca (al-joudi ). the camp was served by a catering company that prepared and distributed three meals daily (breakfast, lunch, and dinner). a case was defined as any individual who developed diarrhea with or without abdominal pain after eating at the camp in mina in january, . of the soldiers who were interviewed, ( %) had developed gastroenteritis, most commonly manifested by diarrhea ( %), and abdominal pains ( . %). the mean incubation period was . ae . h and the epidemic curve suggested a common point source outbreak. out of three served meals, lunch with a rice dish was found to have a statistically significant association with illness. unfortunately, no food remnants were found for sampling, and the results of stool cultures of all diarrhea patients, and rectal swabs from all food handlers were inconclusive. temperature abuse was cited as a contributory factor in this outbreak. based on the incubation period and symptomatology, bacillus cereus would be the most likely etiological agent. another example of a foodborne illnesses associated with the hajj occurred in when bangladeshi pilgrims were taken to hospitals in madina (medina) after eating a meal prepared by an unlicensed caterer (promed-mena ). they suffered from abdominal pains associated with diarrhea and vomiting. the pilgrims were all treated and discharged, except for one who remained hospitalized. samples of the food they had eaten were sent for analysis but the results are not known. considering the mass of people converging on this small part of the middle east, it is surprising there are not more foodborne disease outbreaks. this may mean excellent food control by the authorities or some illnesses are simply not recognized and reported. at least bahrainis suffered from food poisoning after eating catered sandwiches served during a wedding celebration, the biggest mass poisoning outbreak in the country's history (promed-mena ) . the wedding took place in the safala village, near the eastern island of sitra. all eventually recovered after treatment but one man who had sickle cell disease, died. teams were formed to investigate the outbreak, and blood specimens from all workers at the bakery who prepared the egg, cheese, and mayonnaise sandwiches along with leftover sandwiches and their ingredients on the caterer's premises were sent for bacteriological analysis. the bakery which supplied the sandwiches was closed by the public health directorate at the ministry pending the investigation's results. unfortunately, no final report was released to the public. the promed editor considered the etiological agent could be salmonella or staphylococcus aureus enterotoxin, depending on the length of the unstated incubation period. the region experiences some unusual type of illnesses relating to on-going hostilities. for instance, the united nations has been sending aid to reach besieged towns in syria, close to the lebanese border, but in october, , it sent hundreds of boxes of "moldy" high-energy biscuits past their 'sell-by' date in september ( of the boxes transported) to zabadani and madaya, apparently causing food poisoning (afanasieva et al. ; muhkalalati and kieke ) . officials stated these could be the only cause of an outbreak of food poisoning among almost residents who came to makeshift hospitals, mainly children who had vomiting, diarrhea and abdominal swelling almost immediately after eating the biscuits. the biscuits were described as "moldy and rotten and had been poorly stored". apparently, when the last aid order that was sent was filled, there was a shortage of food. the red crescent, who was filling the order, took some of the expired goods to complete it. however, these biscuits had only just expired and normally would not have posed any health risks to those eating them. nevertheless, the words poorly stored suggest that moisture may have encouraged microbial growth (visible mold more likely than bacteria because fungi can grow aerobically in the presence of the presumably elevated sugar content in the high energy biscuits). also, contributing to the symptoms, the residents of zabadani and madaya had been blockaded for consecutive days, and their immune systems were extremely weak. refugees are also at risk of gastrointestinal diseases from contaminated water or food. up to two million syrian migrants fleeing syria due to the civil war were living in turkey, and supplying them with safe and secure food supplies is a challenge for any host country. one incident, no doubt, one among many indicates the risk of contaminated food. in april, , five security forces were injured after syrian migrants in a tent city in turkey's southeastern province of mardin reportedly attacked guards over allegedly being poisoned from the lunch at the camp (anadolu agency ). some syrian migrants were detained after the incident; syrian migrants out of the currently residing in the temporary sheltering center in mardin's derik district applied to the center's hospital with symptoms of food poisoning, dizziness, and vomiting. after treatment they were discharged, none of them in a critical condition. although an investigation was conducted and samples from the lunch sent to the lab for analysis, no further information was available on the outbreak. promed speculated that if the lunch food was the vehicle, it would be a short incubation illness likely caused by staphylococcus aureus, bacillus cereus, clostridium perfringens, or possibly a non-biological toxin. these illnesses may cause vomiting, diarrhea, or both, and are usually short in duration (less than h), and are not associated with prominent fever. in iraq, no recent foodborne disease outbreaks have been published, but no doubt many have occurred in the last decades with so much public health infrastructure dismantled. only the most newsworthy of outbreaks are being covered by the press today. iraq and other middle eastern countries are in sectarian turmoil and on two occasions islamic state (isis/is/isil) fighters (jihadis) were likely poisoned by cooks who infiltrated their camps. in november, , a group of defected syrian soldiers (free syrian army men) who posed as cooks reportedly poisoned isis militants after they ate a contaminated lunch at the fath el-sahel camp, where of them were based (gee ). apparently about a dozen of the jihadis were killed and taken to nearby field hospitals. the 'cooks' immediately fled, along with their families, with the help of fellow revolutionaries. seven months later, in july , jihadis died after ingesting an iftar meal eaten by isis militants (akbar ; variyar ) . it remains unclear whether the jihadis, who were breaking their ramadan fast in mosul, iraq, died of accidental food poisoning or intentional poisoning, but it is likely a repeat attack of the earlier incident described above. the nature of the poison or details of the illnesses in either episode are not known. however, in both episodes, onset and severity of the attack were rapid, probably caused by a relatively tasteless chemical in lethal doses added to one or more foods. targeting the military by any means including poisoning food has always been a strategy of opposing forces. in february , a deliberate attack was foiled when afghan border police detected a significant amount of bleach in fruit and coffee stored at their main border checkpoint between afghanistan and pakistan, a likely attempt to poison the afghan security forces (tucker ) . the police decided that although none of this food had been consumed, the level of contamination was high enough to cause serious injury, and it must have been done intentionally. there had been previous incidents of intentional food poisoning aimed at afghanistan's civil defense forces, including an episode in kabul in when several people were sickened. in , in southern helmand province militants killed four afghan policemen and two civilians inside a police checkpoint by poisoning their yoghurt coordinated with an attack (anonymous a). there had been several recent poisoning incidents involving members of the afghan national police, as part of attempts by the taliban to infiltrate the security forces; three police officers were reported missing, along with their weapons and a police vehicle, following that attack in helmand province. taliban militants had first poisoned the police officers' yoghurt before launching a full scale attack on the checkpoint. similar tactics had been used by insurgents in helmand before. the same thing happened again in january when a rogue policeman collaborating with insurgents in southern province of uruzgan shot dead colleagues after first poisoning their food, but no further details are given (reuters ). turkey does have food laws that are supposed to limit food contamination and resultant foodborne illnesses. the turkish food code stipulates that all turkish food businesses have to provide food hygiene training commensurate with the work activities of their staff. to see what progress had been made in this area baş et al. ( ) evaluated knowledge, attitudes, and practices concerning food safety issues among food handlers in ankara, conducting face to face interviews and administrating questionnaires. the majority of the food handlers who responded ( . %) had not taken a basic food safety training (and probably most of non-respondents had not either). the mean food safety knowledge score was . ae . of possible points. the self-reported hygienic practices showed that only . % of those who were involved in touching or distributing unwrapped foods always used protective gloves during their working activity. of those food handlers who used gloves, only . % and . % always washed their hands before putting them on and after removing them, respectively. in addition, there was a difference handlers' scores depending on where they worked. scores were higher for food handlers in catering establishments ( . ae . ), school food services ( . ae . ) and hospital food services ( . ae . ) than restaurants ( . ae . ), hotels ( . ae . ), takeaways ( . ae . ) and kebab houses ( . ae . ). these scores may also be biased upwards since they were self-reported and not observed practices. the study demonstrated that food handlers in turkish food businesses often have lack of knowledge regarding the basic food hygiene, e.g., critical temperatures of hot or cold ready-to-eat foods, acceptable refrigerator temperature ranges, and cross-contamination. those who were trained scored better, and the authors stated there was an immediate need for education and increasing awareness among food handlers regarding safe food handling practices. in istanbul from / , thermophilic campylobacter was isolated from . %, . %, and . % of beef, mutton, and chicken samples tested, respectively (bostan et al. ). there was no significant seasonal variation in the prevalence of the pathogen. c. jejuni was the species most commonly isolated from chicken meat, while c. coli was the most common in beef ( . %) and mutton ( . %) carcasses. campylobacter isolates were most often resistant to tetracycline ( . %), followed by trimethoprim-sulfamethoxazole ( . %), nalidixic acid ( . %), erythromycin ( . %), enrofloxacin ( . %), ciprofloxacin ( . %), chloramphenicol ( . %), and gentamicin ( . %). the results of this study suggest that a high proportion of meat samples, particularly chicken carcasses, are contaminated by campylobacters, most of which are antimicrobial-resistant strains. in yemen, the prevalence of salmonella in food was determined in sana'a city from april to april by ahmed ( ) . of the different food samples collected from local markets, salmonella spp. were isolated from ( . %). the highest prevalences were in red meat ( . %), chicken ( . %), eggs ( . %), cooked foods ( . %), raw milk and milk products ( %), juices ( . %), vegetables ( . %), sandwiches ( %), and pastries ( . %). serogroups identified were b, c , c -c , d , e , and e , and some foods contained more than one isolate with different serogroups, especially red meat. because handlers in foodservice facilities play a major role in transmission of foodborne diseases (greig et al. ) , studies have been carried out to demonstrate their knowledge of practices related to food safety. in jordan, osaili et al. ( ) measured food safety knowledge of food handlers working in fast food restaurants in the cities of amman and irbid. a total of food handlers in fast food restaurants participated in this question survey study. the overall knowledge of food handlers on food safety concepts was considered to be fair ( . %). the food safety aspect with the highest percentage of correct answers was "knowledge of symptoms of foodborne illnesses" ( . %) and "personal hygiene" ( . %), while the lowest percentage of correct answers was for "safe storage, thawing, cooking and reheating of the foods" ( . %), critical practices to prevent the survival and growth of pathogens. the mean knowledge score of "personal hygiene" reported in the study was much higher than . % and . % reported by martins et al. ( ) and baş et al. ( ) , for the food handlers in portugal and turkey, respectively. also, only . % of respondents considered the duration of hand washing to be ! s. when they were asked how they check that the poultry is sufficiently cooked, only % knew "when the meat has the correct thermometer reading", although % of the respondents had thermometers in their restaurants. about % of them answered that poultry is cooked "when it has been cooked for the stated time" ( %) and "when it looks cooked" ( %). about % of them would store leftovers on the steam table ( %) and in the refrigerator ( %) while about % of the correspondents would store leftovers at room temperature in kitchen or in the oven. a low percentage of the respondents ( %) reheated leftovers to the appropriate temperature ( c). about % and % of the respondents had heard about salmonella and hepatitis a virus, respectively, but % of the respondents knew about listeria monocytogenes, staphylococcus aureus, bacillus cereus, escherichia coli o :h , clostridium perfringens, campylobacter jejuni, or shigella. food workers who had enrolled in a food safety training course had significantly higher total food safety knowledge score than those who did not take any training. there was no association between the experience or any other characteristic of food workers and total food safety knowledge score. this study suggests adopting proper food safety education training courses to food handlers, periodic evaluation of food handlers' knowledge and food safety training course materials. also, the authors considered that better pay for food handlers would improve the food safety status in foodservice institutions. similar concerns over practices that could lead to food contamination and foodborne illnesses were demonstrated in lebanon. a survey was conducted in beirut to evaluate the knowledge, attitudes and practices related to food safety issues of food handlers (n ¼ ) in foodservice establishments (n ¼ ), and to assess the influence of management type on enactment of safe practices on food premises (faour-klingbeil et al. ) . the data suggest that while respondents do have some knowledge of food safety aspects, substantial gaps in their knowledge and self-reported practices associated with critical temperature of foods and cross contamination remain, therefore posing health risks to consumer health. food handlers in corporate managed food outlets showed a significantly higher awareness on food safety practices. it is concluded that the management type is an integral element of the theory of planned behavior that influence food handlers' practices and substantiate the need for more research work on safe food handling in the context of food safety culture framework in food businesses. as in many other mena countries, there is a critical need for food safety education interventions and technical guidance fostered by synergistic participation of the private and public sector to support food handlers in smes (small and medium sized enterprises). parasites are not often looked for in middle eastern countries but they are frequent, and one of the ones of most concern for pregnant women is toxoplasma gondii which is transmitted through undercooked meat and cat feces. since stray cats are common in some localities, of fecal samples of stray cats examined in kuwait, ( . %) were found to be infected with oocysts of coccidian protozoa (abdou et al. ) . toxoplasma gondii was found in . %, and cats < months old had higher infection rate with oocyst of enteric protozoa than older cats. a serosurvey of the stray cats revealed that . % were positive to t. gondii igg. toxoplasma sero-positivity was observed in a higher number of adult cats compared to younger ones suggesting that with age the risk of exposure to t. gondii increases. thus, pregnant women handling cats and particularly kittens or cleaning out sand boxes have a chance of infecting their fetuses and eating raw meat. in pakistan, enteric pathogens are present not only in water but also foods contaminated from the environment or through human actions. mishandling of foods allows these pathogens to contaminate and multiply in them. for example, street-vended fruit salads, locally called fruit chats, offered for sale at high ambient temperatures without coverings, and khoya and burfi, two indigenous sweet dairy products, and locally produced ice cream are often heavily contaminated with enterobacter, e. coli, klebsiella, salmonella and s. aureus (akhtar ) . these contamination scenarios have led to outbreaks with cases severe enough to be hospitalized. bus and train stations where pulses (edible seeds of various crops as peas, beans, or lentils), ground meat dishes, and chickpeas are sold to passengers, and are also heavily contaminated with bacteria including clostridium perfringens. sweet dishes and home-prepared foods in small communities are commonly contaminated with s. aureus, c. perfringens, and bacillus cereus leading to rapid intoxications. one study confirmed campylobacters to be present in % of tested samples of milk and meats and . % of vegetables in three major cities of pakistan (akhtar ) . a wide array of vegetables is routinely consumed in this country and serve as a rich source of vitamins, minerals, bioactive compounds, and fiber but these can be sources of enteric infections if they are consumed contaminated. shigella spp. has been shown to develop resistance and is generally thought to be a major cause of foodborne illnesses, especially among the poor where health care facilities are minimal; shigellosis is associated with poor sanitary conditions and unsafe water for drinking and preparing foods. possible etiologies can be postulated in the following outbreaks. unfortunately, it is not only pathogens that give rise to food-associated disease. soomro et al. ( ) highlighted the indiscreet use of pesticides in agriculture and its impact on environmental pollution. despite the increased production cost associated with extensive use of pesticides, their use is common in developing countries. numerous studies have demonstrated substantial levels of pesticide residues in various foodstuffs in pakistan, and the groundwater has been observed to be considerably polluted in many parts of punjab and sindh provinces of pakistan (akhtar ) . commonly used open rural wells in the punjab were polluted with six pesticides: bifenthrin, λ-cyhalothrin, carbofuran, endosulfan, methyl parathion, and monocrotophos. in the hyderabad region % of the tested samples of eight vegetables (cauliflower, green chili, eggplant, tomato, peas, bitter gourd, spinach, and apple gourd) were found to be contaminated with pesticide residues exceeding maximum recommended limits (mrls) (tariq et al. ; anwar et al. ) . heavy metals such as cadmium (cd), copper (cu), lead (pb), and zinc (zn) arising from increased industrialization can contaminate agricultural soils and these can be found in fruits (including widely-consumed mangoes), fruit juices, vegetables directly from soil uptake or from the processing and packaging (akhtar ) . for instance, spinach, coriander, and peppermint, grown in sindh province contained . - . mg/kg of arsenic resulting in a total ingestion of arsenic . - . μg/kg body weight/day in diet (arain et al. ; khan et al. ) . aluminum concentration in branded and nonbranded biscuit samples from hyderabad were found to range . - . and . - . mg/kg, respectively (jalbani et al. ) . similarly, javed et al. ( ) detected higher concentrations of cd, cr, ni, and pb residues (mg/l) in bovine and goat milk. pakistani foods are more prone to aflatoxin contamination because of the warm and humid climate, and the situation is exacerbated by malpractices during handling and storage of edible commodities (mobeen et al. ) . samples of broken rice, wheat, maize, barley, and sorghum ranged - % with the highest aflatoxin concentration ( . μg/kg), in wheat samples (akhtar ) . chilies are widely eaten and exported, but aflatoxin levels can be eightfold higher than the eu permissible limits to pose a potential health risk to pakistani consumers; concentrations can be reduced by more appropriate care and handling of the chilies at pre-and postharvest stages. nuts and dried fruits in pakistan are cultivated and processed in the northern areas and have been shown to have aflatoxin levels above the eu limit of μg/kg in up to % of samples (ahmad et al. ; luttfullah and hussain ) . aflatoxin m in milk and milk products requires regular monitoring in pakistan since % of the total tested samples of milk were found to exceed the us tolerance limit of . μg/l (hussain and anwar ; hussain et al. ) , and buffalo milk had higher levels of aflatoxin compared with cow's milk. intentional deception of consumers by blending low cost and inferior quality ingredients to make more profit of food intended for sale is prevalent in pakistan, where families are exposed toxic dyes, sawdust, soapstone, and harmful chemicals in beverages, oil or ghee, bakery products, spices, tea, sweets, bottled water, and especially milk and milk products where more than % of samples tested have had adulterants added (akhtar ) . one of the more innovative research projects to provide more home-grown food is in qatar. the sahara forest pilot (sfp) pilot study demonstrated that there are significant comparative advantages using saltwater for the integration of food production, revegetation and renewable processes: ( ) seawater cooling system for greenhouses supports production of high-quality vegetables throughout the qatari summer, and reduces freshwater usage to less than half that of comparable greenhouses in the region; ( ) solar and desalination technologies were successfully integrated as designed into the sfp system, such as the greenhouse and evaporative hedges providing wet-cooling efficiencies without cooling towers; ( ) the external evaporative hedges provide cooling of up to c for agricultural crops and desert revegetation with vegetable and grain crops growing outdoors throughout the year; ( ) commercially interesting algae showed good tolerance to heat and high evaporation rates in the leftover salty water (miss ; clery ). the concentrated solar power plant uses mirrors in the shape of a parabolic trough to heat a fluid flowing through a pipe at its focus. the heated fluid then boils water, and the steam drives a turbine to generate power. hence, the plant has electricity to run its control systems and pumps, and can use any excess to desalinate water for irrigating the plants. in summary, sfp allows food production in all months of the year ( crops) with half the fresh water usage than in comparable greenhouses. on the basis of the pilot success, sfp is now engaged in studies aimed at building a -hectare test facility near aqaba in jordan, large enough from the -hectare operation in qatar to demonstrate a commercial enterprise. tourism is popular in several middle eastern countries, particularly beach and coastal resorts in egypt and turkey. tourism has been the major economy in egypt for many years but can be threatened not only by civil unrest and terrorism but also by foodborne illness (costa ). tourists might not stop coming to egypt due to a few reports of diarrhea; however, widespread reporting of severe cases, and lawsuits, will make tour operators much more selective, and bring pressure on the egyptian hospitality industry to improve its hygienic standards. the greater challenge is for egypt to ensure that it has the capacity to sustain a safe food supply for its own people. in doing so, it provides safe food for those who want to explore its rich history and seaside resort areas. multiple reports of illness have been reported from nile river cruises and a resort town on the coast. from september to november, , cases of hepatitis a imported from egypt were reported to the german public health authorities (bernard and frank ) . investigations pointed to a continuing common source of infection, most likely linked to nile river cruises. in addition, eight cases from france had been travelling on a nile cruise and one on a red sea diving safari (couturier et al. ). one specific cruise ship was mentioned by six of ten belgian cases (robesyn et al. ). those who took a nile cruise had typically done this in combination with a hotel stay. at least three different ships and three different hotel accommodations were mentioned in the travel histories of the french cases. the patients affected had not been vaccinated, which emphasized the need for more effective travel advice before trips to hepatitis a endemic countries (sane et al. ) . possible sources of infection might have been contaminated food obtained from a common food catering company consumed onboard, contaminated tap water supplies for the ships' bunkers, or a common exposure on shore (e.g., a restaurant where tourist groups from various ships were taken during day trips). as all of these ships continuously traveled up and down a short stretch of the river (aswan to luxor and back) with standard mustsee stops along the way, the cases possibly shared an exposure on land. both the long incubation period of hepatitis a ( - days) and long delays in collecting information on the individual cases precluded any rapid intervention on location. no specific food source was identified but it could have been juices as recognized in an earlier major outbreak. in , tourists returning from egypt included hepatitis a case-patients from european countries who were infected with a single hav strain (genotype b) (frank et al. ). the case-control study identified orange juice most likely contaminated during the manufacturing process, e.g., by an infected worker with inadequate hand hygiene or by contact of fruit or machinery with sewage-contaminated water. citrus fruit and citrus juices have occasionally been implicated as vehicles of hav and salmonella infections, with contamination typically occurring during production, or preparation just before consumption. as hav is resistant to acid, it likely can survive for prolonged periods in orange juice. it is also possible that leafy greens could contribute to foodborne illness in egypt. an international study of contamination of leafy green lettuce and spinach samples taken between and from open-field farms in belgium, brazil, egypt, norway, and spain showed that the egyptian samples were the most contaminated at . % (liu et al. ) . these authors claimed that temperature had a stronger influence than did management practices on e. coli presence and concentration. region was a variable that masked many management variables, including rainwater, surface water, manure, inorganic fertilizer, and spray irrigation. temperature, irrigation water type, fertilizer type, and irrigation method should be systematically considered in future studies of fresh produce safety. also in the spring of , a young couple was ill with vomiting and abdominal cramps after their first meal at a sharm el sheikh -star hotel in the egyptian coastal resort area, and they remained there in their bedrooms for the rest of their week (this is staffordshire ). both continued to have ongoing issues months later, with one of them suffering from reactive arthritis. other guests also complained about diarrhea. they stated that the food was disgusting; the meat was undercooked, the buffet was left out for long periods of time, with new food being piled on top of the old food, and there were flies landing on food items. in august , a family stayed at a resort hotel, also in sharm el sheikh, and all suffered severe symptoms including diarrhea, stomach cramps, and vomiting. they were put into the hotel clinic given antibiotics and intravenous drips but had not completely recovered after they returned home (galley ) . at the time other guests were also ill. they noticed that the food including chicken and beef, appeared to be undercooked a couple of times, and that one of the chefs touched raw meat and then touched cooked meat without changing gloves. the booking company confirmed that "a very small number" of guests staying at the resort in reported that they had been unwell, "with symptoms similar to a virus". the company said that guests were offered the appropriate support and advice by their overseas holiday advisors. it claimed that all of its hotels were subject to stringent monitoring and audits and this hotel achieved an extremely high score in its audit carried out in the summer of . however, high audit scores do not necessarily correlate with day-to-day safe hygienic practices (powell et al. ) . the popular beach resort of sarigerme, turkey, on the aegean sea also has had a reputation for gastroenteritis, with repeat problems of foodborne illness with british tourists on vacations organized by tour companies, although the actual hotels were different. in , an outbreak of gastric illness at this resort led to £ . m paid out in compensation, with people suffering from infections including salmonella, cryptosporidium, campylobacter and e. coli (hutchison ) . in september, , hundreds of british holidaymakers suffered from salmonellosis after returning from a hotel complex in sarigerme (disley ) . final figures may have been close to , and several were hospitalized. in october , the swannell family had booked a week's stay at the first choice holiday village resort in sarigerme, when mark swannell, , fell seriously ill a few days into the break with diarrhea, abdominal pain, nausea and lethargy (hutchison ) . he said that some of the food he was served at the hotel had been undercooked, with some chicken bloody in the middle, food was not served at the correct temperature, food was left uncovered for prolonged periods of time, and the same food had been served more than once. the family stated that cutlery, crockery and table linen used in the restaurant was not up to standard, and they saw cats in the public areas of the hotel and in the restaurant. legal action was taken. in addition to ill tourists in middle eastern countries, contaminated exported food can affect those abroad, as illustrated in the following u.s. outbreak. from march to august , of patients identified with hepatitis a in ten states, ( %) were admitted to hospital, two developed fulminant hepatitis, and one needed a liver transplant, but none died (collier et al. ) . almost all cases reported consuming pomegranate arils (seeds) from one retail chain. hepatitis a virus genotype ib, uncommon in the americas, was recovered from specimens from people with hepatitis a virus illness. pomegranate frozen arils imported from turkey were identified as the vehicle early in the investigation by combining epidemiology, genetic analysis of patient samples, and product tracing. the product was then removed from store shelves, the public warned not to eat the seeds, recalls took place, and post-exposure prophylaxis with both hepatitis a virus vaccine and immunoglobulin was provided. this investigation showed that modern public health actions can help rapidly detect and control hepatitis a virus illness caused by imported food. egyptian trade has also been adversely affected by exports. in , there were three outbreaks of hepatitis a sickening persons in -european countries. in the first report in april, persons in four scandinavian countries were infected with hepatitis a (andrews ) . epidemiological investigations traced those cases to frozen strawberries grown in egypt and morocco, though no strawberries were found to be positive for hav. the second outbreak in april was larger in extent with ill in countries, all having recently visited egypt, and the outbreak strain of the virus had the same subgenotype as the first outbreak associated with strawberries. an epidemiological investigation into the second outbreak suggested the likely source was strawberries or another fruit distributed to hotels in egypt. the third outbreak was reported in germany in may, after nine germans were infected with hepatitis a after traveling to italy. this third outbreak infected about italian residents, as well as nine germans, one dutch traveler and five polish travelers; irish residents with no travel history to italy were infected by the same strain of the virus. separate investigations in italy and ireland both implicated imported frozen mixed berries as the source, with most of those berries coming from eastern europe. it is not known if these berries came from other regions, such as egypt, or were local to eastern europe. contributing factors to the larger number ill was lack of vaccination. because hav infections were declining in europe over the last few decades, fewer people had developed antibodies to repel the virus. couple that with the fact that hepatitis a was not on the vaccination schedule for citizens of many of the countries affected, and the result was a highly susceptible population. also, most of the european travelers to egypt were not advised to get hepatitis a vaccinations when staying in all-inclusive resorts, which were attracting an increasing number of europeans traveling to egypt. further, the investigators believe contamination of the berries occurred early in the food production chain. investigators suspect that irrigation water contaminated with sewage water likely contaminated the strawberries in the two outbreaks connected to egypt. but the contamination might have also been caused by infected workers in the field or the processing facility, or by contaminated water sprayed on the berries sometime before distribution. the outbreaks indicate that fresh and frozen berries are efficient vehicles of hav infection, as previously demonstrated in the us and elsewhere (palumbo et al. ) . european authorities agreed that "the experience demonstrated the absolute necessity for extensive collaboration between countries and between the public health and food sectors to identify as quickly as possible the vehicle of infection and, ideally, to control the outbreak in a timely fashion." a more serious outbreak damaged egypt's food export trade. in july , the european union (eu) banned the import of certain egyptian seeds and beans till at least october following an official report that a single batch of egyptian fenugreek seeds probably caused two european outbreaks of e. coli infections responsible for ill persons and at least deaths. a task force of health officials set up by the european food safety authority (efsa) reported that one lot of fenugreek seeds imported from egypt was the most likely common link between the two outbreaks in northern germany and in bordeaux, france (anderson ) . both were traced back a year and a half to a shipment of , pounds ( , kg) of fenugreek seeds, that was loaded onto a ship at the egyptian port of damietta on november , . on the ship's arrival at antwerp, belgium, the seeds were barged to rotterdam to clear customs. the sealed container was trucked into germany to an unidentified importer, who resold most of the lot. an unidentified german company then resold about pounds of the seeds to the german sprouter, which is believed to be the source of the sprouts that caused the extensive german outbreak. the german importer also sold about pounds of sprout seed to the english company thompson & morgan, which repackaged the seeds into . -ounce ( grams) packages. those packages were shipped to a french distributor, who resold the seeds to about garden centers around france. investigators believe that one of those packets was the source of the second european outbreak with cases in the bordeaux area. because the seeds were likely contaminated with e. coli o :h at some point before leaving the importer, and more contaminated seeds could be in circulation, it was deemed appropriate to consider all lots of fenugreek from the egyptian exporter as suspect. soil contact or animal or human fecal contamination of the seeds likely occurred during their production or distribution in egypt. even a negative laboratory test of those seeds could not be interpreted as proof that a batch was not contaminated. trace-forward findings indicate the german importer sold seeds from the suspected lot to companies, and the shelf life of the seed can be up to years. by mid-october, , the european commission (ec) lifted import restrictions on fresh and chilled podded peas and green beans and other fresh produce from egypt, but the ban on egyptian seeds and sprouts, scheduled to expire on october , was to be extended until the end of march, , following an "unsatisfactory audit" of seed producers in egypt (news desk ). the extended ban involved arugula sprouts, leguminous vegetable sprouts (fresh or chilled), soy bean sprouts, dried (shelled) leguminous vegetables, fenugreek seeds, soy beans and mustard seeds. the ec audit showed that measures taken by the egyptian authorities to address shortcomings in the production of seeds that may be sprouted for human consumption were not sufficient "to tackle the identified risks." those shortcomings were not seen in the growing and processing sites for fresh peas and beans, and therefore those vegetables were no longer considered a food safety risk. there is no need for actual illnesses to occur to affect trade. recalls, seizures, and bans can be employed by importing countries if standards are not met, and force exporting countries like egypt to take action. for instance, in the ec suspended the import of peanuts from egypt due to the presence of aflatoxin in concentrations in excess of maximum levels specified in eu regulations (technical cooperation department ) . egypt is a major peanut exporting country and the european markets then accounted for % of its peanut exports. this decision was repealed on december and was replaced by another decision, which imposed a requirement for certification to accompany every consignment and required systematic analysis of consignments and documentation by the importing member state. under this system only egyptian exporters were allowed to ship to the eu. in august , the decision was replaced by another decision that required the competent authorities in eu member states to undertake random sampling and analysis of % only of peanut consignments from egypt for aflatoxin b and total aflatoxins. this improvement came as a result of the efforts that the egyptian government put in complying with the requirements of the eu. to this end, the egyptian ministries of agriculture and land reclamation (malr) and ministry of foreign trade (moft) issued ministerial decree no. / , which covered all stages of production, processing, sampling and exporting of peanuts. the main provisions of the decree were: exported peanuts must be produced, inspected and prepared according to set scientific procedures; and exporters who violate the rules would be suspended for year; the decree also established the legal limit for aflatoxin in peanuts in both the domestic and eu export markets. in the egyptian domestic market, the legal limit was mg/kg aflatoxin b and mg/kg total aflatoxin content. for the eu market, the legal limits were mg/kg aflatoxin b and mg/kg total aflatoxin content. in addition, the decree specified the sampling procedures that must be followed for export certification. in september of the food and veterinary office sent a mission to egypt to assess egypt's compliance with its certification system requirements. a number of recommendations on steps egypt should take to improve the control system of foodstuffs intended for export to the eu were made. in response, the egyptian authorities declared that they were taking actions to address the mission's recommendation. but to achieve that there was a need to coordinate among a number of egyptian agencies involved in the production and export of peanuts and aflatoxin control: malr, the central administration for plant quarantine (capq), the agricultural research center (arc), the ministry of foreign trade (moft), and the customs service. also a laboratory capable of testing for mycotoxins was necessary. alongside this; egypt had technical assistance from international organizations in order to build human and physical capacities necessary for achieving compliance. the action by the eu forces egypt to improve the safety of its peanut production which would be beneficial both to europeans and to all who eat products made from egyptian peanuts, including the domestic consumers. lebanon used to be a tourist haven but is less today because of a seemingly dysfunctional government following a civil war. the country produces food for both the domestic and overseas markets. unfortunately, some exported food has caused illnesses and recalls. twenty-three cases of salmonella bovismorbificans in eight states and in the district of columbia (washington, d. c.) from august to november, were linked epidemiologically to hummus eaten at three mediterranean-style restaurants in the d. c. area, all owned by the same individual (goetz ) . although samples collected from all ingredients used to make the hummus tested negative for any salmonella, the hummus was recalled and the outbreak ceased. during its investigation of the restaurants, the d.c. department of health discovered multiple food safety violations at the establishments, including inadequate food temperature control, insufficient hand washing, and the presence of pests and insects, which had to be corrected. it is not clear if any abusive temperature conditions could have allowed growth of the salmonella in the hummus. the public was not notified because by the time the hummus had been withdrawn from the market, there were no further cases. however, the contaminated ingredient in the hummus was not discovered until may, , when a traceback by the u.s. food and drug administration (fda) revealed that the tahini used to make the hummus in one of the restaurants had recently been associated with recalls in canada for contamination with s. cubana (september ) and s. senftenberg (february ). all tahini linked to these outbreaks had been imported from the same company in lebanon. the fda then mandated that all tahini products coming from this lebanese company be tested for salmonella before entering the u.s. and has recommended that u.s. and canadian officials partner to inspect the tahini manufacturing plant. this was the first time s. bovismorbificans had been implicated in a tahini outbreak in the u.s. as a result of this outbreak, the author stated it is important for public health officials and consumers to be informed that products made with imported sesame paste have been shown to be associated with salmonella outbreaks and that they should be considered as possible sources for foodborne illness in the future. in fact, contaminated sesame seed paste was in the news a few days before a cdc report on the outbreak was made public, after a supply of contaminated tahini was stolen from a california importer's warehouse, where it was being stored because a sample had tested positive for salmonella. the tahini, which had also been imported from lebanon but from a different manufacturer, was awaiting destruction, and the fda warned the public that the stolen, potentially contaminated tahini may be on the market. lebanese tahini has been implicated in several outbreaks in the past and subject to recalls (harris et al. ) . government oversight of the food industry is variable across the region with many regulations stemming back to colonial days, but modernization changes are gradually being considered or implemented. unfortunately, where some middle eastern countries are slowly moving forward to improve food safety, others are slipping back in their oversight because of conflict and lower public health priorities. there are relatively few large food processing operations except those managed by multinational companies, and most of the government oversight is on smes particularly small foodservice outlets. the states in the gulf cooperation council (gcc), each have an aggressive food safety policy but do not always follow identical approaches, some of which are well-established and some of which are innovative. the ksa has had a food inspection system in place for many years with reports of outbreaks published regularly, though no doubt it could be improved with more cooperation between the ministry of health, the municipalities and the saudi food and drug authority (sfda). the sfda was established under the council of ministers resolution no ( ) dated january , , as an independent body that directly reports to the prime minister (el sheikha ). the sfda is responsible to regulate, oversee, and control food, drug, medical devices, as well as set mandatory standard specifications thereof, whether they are imported or locally manufactured. the control and/or testing activities can be conducted at the sfda or any other agency's laboratories. moreover, the sfda is in charge of consumers' awareness on all matters related to food, drug and medical devices and associated other products and supplies. the sfda has to negotiate with the moh their mutual responsibilities following specific foodborne disease instances or consumer complaints. bahrain claims to have one of the more advanced food control systems in the region. in july , as ambient temperatures heated up, the ministry of heath urged people to make sure the food they consume is properly stored during the summer months to avoid microbial growth and risk of food poisoning, e.g., keeping meat and fish at c and to cook food thoroughly (haider ) . the ministry was aware that both visitors and locals want to eat safe food, especially as bahrain is moving towards more tourism with people are eating out more often. the ministry ordered shops to provide appropriate storage facilities, e.g., coolers and refrigerators, for food as part of its efforts to protect the public's health. inspectors were checking food stalls, ice-cream parlors and vegetable shops to ensure that customers were not being sold contaminated or rotten products. the ministry claimed to thoroughly investigate any complaints it receives, and to facilitate this a new hotline number was launched by the ministry for general public to report food contamination complaints against supermarkets, restaurants, coffee shops and hotels. specific advice for consumers included: being careful when buying salads; fruits and vegetables should be washed thoroughly before they are consumed; and dairy products such as milk, cheese and eggs, should always be refrigerated, since microorganisms grow faster in these products. the ministry claimed that bahrain has one of the best food control methods and food safety records in the region, and could even act in the future as a consultant in this field for other countries, including other gcc states. by , government oversight had stepped up. in april, the ministry of health warned people against buying food advertised on social media or sold on the street by unlicensed retailers in bahrain, either made in people's homes or by street hawkers (anonymous c) . the ministry stated that control of these home operations is difficult if someone suffers from food poisoning since inspectors are not allowed to go into homes. many homes sell food without a license and some would-be entrepreneurs even have barns where they slaughter livestock and market the meat illegally. there were , inspection visits conducted in by inspectors from the food safety and licenses group, which closed of around registered outlets. inspections cover imported food from ports right up to where it reaches restaurants and food outlets; , visits revealed around , tonnes of imported food were permitted for consumption, but tonnes were considered as non-consumable (rejected), during the same period. one of the more recent important programs is the smart inspection project launched in april . inspectors, many with masters and phd degrees, visit restaurants and coffee shops to take food samples, as well as explain to staff how to store food and ensure its safety (anonymous c) . it includes awarding food outlets that achieve a % food safety standard a blue sticker, while those meeting % of standards get a green sticker. outlets that fail to achieve basic standards are warned with a red sticker. the total number of outlets assessed between august and february was ; were presented with blue stickers, with green stickers and with red stickers. this project features daily inspections and is focused on small food outlets, some of which have caused food poisoning in the past. inspection visits depend on the hygiene of each outlet and the complaints received about them; some require two or more visits annually. high-level restaurants already have certified inspectors for evaluation and most of them require only one visit per year. the ministry's ultimate goal through this project is to decrease cases of foodborne disease, particularly important as bahrain is increasing its tourism efforts and, thus, ensuring food safety is essential. to support the ministry's initiatives, live demonstrations on food safety practices were promoted in kitchens in hypermarkets. however, if red sticker facilities fail to take advantage of educational material, they may be punished for neglecting food safety standards and guidelines though public prosecution. in a bid to improve standards of hygiene in restaurants, qatar's supreme council of health (sch) increased the number of spot checks on food outlets and has launched a hotline for residents to report food poisoning (walker ). the council is responsible for monitoring food establishments and implementing qatar's food laws along with the ministry of municipality and urban planning (mmup/baladiya). the sch embarked on an intensive inspection campaign, collecting food samples from all restaurants and food outlets in the country including suppliers. the inspection teams, which include specialized doctors from the sch's communicable diseases department and the environmental health inspection department, also medically check workers responsible for preparing food to ensure they are not carrying infections. those found to be handling food in an unhygienic way would be immediately dismissed. following a hotline complaint call, a report is filed, a team from the sch visits the affected people, then inspects the related food outlet and collects samples for laboratory examination. the latest crackdown was in response to the illness of a family of four which suffered food poisoning after eating chicken, rice and salad at a popular turkish restaurant which was closed down because a medical report prepared by the sch's environmental health section confirmed that the outlet served contaminated food and violated health regulations. tests conducted in the central food laboratory at sch found three types of bacteria causing diseases in food served by the restaurant. medical tests on the victims also showed that they were infected by the same bacteria, as well as one of the restaurant workers. another popular turkish restaurant was closed for months after it was found that several customers were treated in the hospital for food poisoning symptoms including intense nausea, vomiting and diarrhea. as part of the sch's new campaign, experts would undertake community awareness drives, and organize seminars and training sessions about food contamination to improve understanding among owners and workers in food establishments. other closures occurred because of serving food with moldy ingredients, rotten vegetables in the kitchen, insects in pasta, and generally violating the provisions of the food law. the mmup increased the number of spot-checks and naming and shaming erring establishments on its website in arabic. the amendments to the food law gave greater powers to authorities to fine and close down venues that break the law including temporarily closing down establishments if it has violated food safety and hygiene regulations, and also has the power to recommend severe penalties. a follow up to one of these closed doha turkish restaurants was after a trial when five staff were each been handed fines, jail sentences and deportation orders after they were found guilty of causing food poisoning to approximately customers ill with vomiting, nausea and diarrhea (santacruz ) . the restaurant was accused of serving spoiled and unsafe food on october, . an affected pregnant woman gave birth to her baby months prematurely. the manager of the restaurant was fined approximately $ and sentenced to spend months in jail while three other staff members were each fined approximately $ and sentenced to month in jail. during an inspection it was found that another staff member did not hold the necessary health certificate and was subsequently fined approximately $ and also sentenced to month in jail. as well as the staff members being sentenced to jail and fined, the court of environmental misdemeanours also found that the restaurant itself was guilty of causing the food poisoning outbreak, and issued the restaurant with approximately $ in fines and ordered it closed for a further months. in other parts of the world these penalties would seem unduly harsh, as it would be difficult for this restaurant ever to recover financially. coupled with education, there has been recent enforcement blitzes on food establishments such as hotels, restaurants and bakeries by oman municipalities, and a leading bakery in muscat was closed down because of rats in the premises in late december, (staff . this led food safety experts and the public to call for stricter rules and heftier fines to be imposed after surprise checks conducted by the muscat municipality, especially when it was disclosed that nearly half the restaurants in the bausher area were not following food safety standards. surprise inspections by the muscat municipality at restaurants in bausher found that around restaurants did not meet food safety standards and were violating rules formulated by the municipality. also, in the same time frame, ibri municipality officials were forced to shut down commercial shops and they destroyed more than km of outdated food in . according to the municipality's officials, health violation letters were issued throughout the year, as well as warnings were issued to different institutions operating in the wilayat of ibri. there are no easily-accessible reports on government oversight in pakistan and inspection actions are more likely to be released to the public through the press. in , the islamabad capital territory (ict), administration conducted a drive against adulterated food items with unannounced inspections of food outlets in different markets and imposed fines amounting to rs , (about us$ ) on owners for unhygienic conditions at their premises including restaurants, cafes, bakers, candy (sweet) stores, and a hotel was sealed (app ) . cleanliness conditions at the outlets' kitchens were found unsatisfactory and unhygienic while workers had not been vaccinated against viral diseases. some business owners were also paying less to their workers in contravention of the minimum wages act. business owners were directed to improve cleanliness conditions and ensure food safety standards failing which strict action would be taken against them. a cattle market was also ordered to "beef up" its security. punjab, pakistan's most populous province, has a population that is more than double that of california, and lahore, the provincial capital, has a vast array of food outlets. from the available press reports, the punjab food authority (pfa) has a mixed record of oversight of food operations. a pfa team visited the polo ground restaurant at the race ground park and found expired food, blocked sinks and unhygienic conditions in the kitchen and food storage area in contrast to the claimed high quality standards by the management of the supposedly high-class restaurant (raza ) . the team faced resistance from the management but it managed to enter the kitchen for inspection. pfa officials said the kitchen condition was similar to that of an ordinary road-side eatery, dispelling general perception that restaurants serving the elite follow higher standards of hygiene and food safety. however, the pfa in lahore had received a complaint that an assistant food safety officer had received rs , (about us$ ) bribe from the restaurant owner so he could keep his restaurant open (anonymous d) . another restaurant on peco road sealed by the pfa for poor hygiene and unsanitary conditions of its workers in the second week of march, was opened for business the very next day. typically, according to the pfa's standard operating procedure (sop), a restaurant sealed for the first time may resume business after a week. at the end of the week, the proprietor has to submit an affidavit assuring the authority that all problems pointed out by the food safety officer had been taken care of prior to reopening it for business. the pfa director general (dg) had constituted a three-member committee to probe the complaint of bribery but it was later shelved. similar situations occurred when restaurants that had reopened before the stipulated period for closure had expired. in the first week of , a restaurant was fined rs , (about us$ ) for unhygienic conditions and lack of soaps in the workers' washrooms, instead of following the pfa sops of sealing the premises. the sops regarding duration of closure and required permission from the pfa dg were stated to be flouted openly. however, a pfa spokesperson denied any wrongdoing, and the sop was being observed to the letter. she said a written permission from the dg used to be mandatory in order to de-seal restaurants, but now an operations deputy director can also issue permission for it. she also stated that the restaurant on peco road had not reopened on orders of the pfa; its owner had de-sealed it illegally. these reports indicate that there may be some illegal activities including bribery by inspectors but miscommunication on how much leeway inspection staff have on prevention and control practices may be more of the issue. in mid- ayesha mumtaz became the new operations director of the pfa, tasked with ensuring food in punjab is unadulterated and safe (reeves ) . her self-declared war on unhygienic food generated so much publicity in the last months that she became a household name in pakistan. mumtaz says many food producers know nothing about hygiene but are willing to learn. there's also a hardened mafia who are only interested in profit, she says. everyone in the street seems to know about mumtaz. storekeepers begin shooing away customers, hauling down the shutters, and heading into the shadows in the hope that mumtaz's scrutinizing eye will not fall on them. these traders would sooner lose business than risk a visit from a woman whose campaign to clean up the kitchens and food factories of pakistan has made her a national celebrity. she declared that the pfa cannot allow them to get away with their "perverse" activities and to "play havoc" with the lives of the people. consumers are unaware that the cakes and sweets that they buy over the counter are produced amid unhygienic conditions. she has found spoons encrusted with filth, fly-blown cans of gooey liquid lying around haphazardly, dirty containers, grimy rags and rusty tin cans, moldy scraps of cake, all involved in making cakes and sweets to be sold to the public. civil servants in pakistan are often accused of being lazy and corrupt. mumtaz is being feted as a rare example of a government official who actually champions the public's rights. she and her inspectors have so far raided more than , businesses, and pakistanis seem to approve. her fans call mumtaz the fearless one. hundreds of thousands have clicked like on the pfa's facebook page in appreciation of her work. there was a very famous hotel in the heart of lahore that she inspected and found the chiller where they keep all the foods together (vegetables with chicken, meat), but also a big rat; this became big news for the public. however, there are complaints that she does her raids with police and cameras to be broadcast nationally even before the owners are convicted, according to the lahore restaurant association. in , the abu dhabi food control authority (adfca) planned to check all food handlers by . the authority's emirate food safety training (efst) program, started in , provides basic training in food hygiene and safety to those who work in food outlets (olarte ) . according to the adfca, small catering businesses in most countries have the lowest standards of food safety, and most workers in abu dhabi's small restaurants are illiterate and do not speak fluent arabic or english, making it a challenge for them to understand and follow safety guidelines and regulations; % of managers and % food handlers in the capital speak south asian languages such as urdu, hindi and malayalam (pennington ) . the training is now offered in four languages -english, arabic, urdu and malayalam -which the majority of food service personnel speak, and covers basic food hygiene issues including staff hygiene, food temperature, cross-contamination, cleaning and sterilization. to help them understand and follow food-safety rules, the adfca is using photographs to teach employees how to handle food safely according to international standards. the scheme is an extension of a pilot involving small restaurants carried out in - . as part of the efforts to ensure retention of their learning, the adfca conducted spot checks at food outlets in marina and khalidiya malls, and gave guidance and advice to staff for those with violations, rather than just penalizing them, the normal practice in most middle eastern countries. the field operations manager at the adfca noted that the differing cultures, education and languages are the barriers that sometimes hinder food handlers from carrying out what they are trained to do. he recommends that supervisors should quiz them on hygienic and safety issues so that they know how to properly prepare and serve food. those who have learning difficulty or are illiterate are given assistance through illustrations, in order to make it through the lessons and pass the examination. one of the critical elements of food safety that the adfca has to monitor and ensure, is that food handlers are aware of cold ready-to-eat food being kept at c, while hot food should be kept and served very hot > c. the adfca categorizes the food premises and carries out inspections based on their risk factors -high, medium and low. restaurants and hypermarkets belong to the high-risk group; warehouses to the medium risk; while groceries, honey shops and vegetable and fruit outlets are considered low risk. recently, the establishment of the egyptian food safety authority was initiated by the minister of trade and industry, with the support of the ministry of health and the ministry of agriculture. it would be responsible for food safety and consumer protection through the provision of sound data and guidance to deal with processed or genetically modified food in accordance with food safety standards (anonymous b) . the strategic plan for the new draft law includes a revision of all egyptian laws and legislation that deal with food safety since , including around other legislations. the authority would need to apply food safety standards on imported food the same way it does for locally produced foodstuffs. adopting the draft law would in effect cancel all existing laws and create one food safety law for the country. the food safety authority plans to monitor the foods consumed by egyptians of different age groups as a basis for where to put resources. another issue to be faced is that studies in egypt based on us statistics have revealed that the cost of food spoilage costs the country million egyptian pounds annually. the chamber of food industries indicated that a unified body for food safety to apply international quality specifications and unite regulators was lacking. this reduced the competitiveness of local products, especially since most foreign countries do not recognize egyptian regulations. it was hoped that investors in food industries would bring in new investments to the sector in the upcoming period if a food safety authority were to be established, as per a ministerial decision issued in . the food safety authority has received several approvals from governments that ruled during the -year period following the revolution, but apparently nothing has been yet finalized until recently (mefreh and saeed ) . in a similar way to egypt, the lebanese government has been debating a new law on food safety for many years but unlike egypt, it has yet to make much progress. lack of agreement at the parliamentary level has resulted in different ministries (health, agriculture, industry, environment, tourism) taking action as they see fit. the latest was in november , when the minister of health conducted an extensive campaign of inspections in lebanese establishments and naming of facilities that did not meet the ministry's expectations (naylor ) . the minister personally revealed that numerous supermarkets, bakeries, butchers and restaurants had been violating food safety and sanitation standards. they shut down slaughterhouses, restaurants, supermarkets and other retailers selling contaminated food. for instance, changes needed to be made for the slaughterhouse to conform to health standards; the report said livestock must be hanged during slaughter and not laid on the ground and that the abattoir should also be equipped with refrigerators and storage units for separate types of meat and their cuts. however, discord among ministries is apparent with the tourism minister trying play down the publicity of the health minister's food safety blitzes by saying "we are in favor of full transparency, but we feel like we were 'deceived' because the food safety situation in lebanon is good and better than other countries. we apologize to tourists, but more importantly, any of the ministry of health staff is ready to apologize to the lebanese citizens for the public sector's failures throughout the years?" (yaliban ) . foodborne disease surveillance is limited in lebanon and cannot be used to indicate the actual level of foodborne illnesses in the country. lebanese food exports are also being required to conform to international standards. tahini made from sesame seed paste is a major food export to the west, but recalls of tahini manufactured in lebanon because of salmonella contamination are more frequent than they should be; one recent example was a health hazard alert for certain clic, al nakhil and al koura brand tahina products that may have contained salmonella, recall/advisory dated august , posted from canadian food inspection agency [also see tahini/hummus linked illnesses under foodborne disease in specific countries]. under the new us food and drug administration food safety modernization act, foreign companies importing foods to the us must demonstrate that they have the operational plans and facilities sufficient to produce safe food before they can ship any product to the us (fda ), which is causing some concern among lebanese tahini manufacturers and government agencies. thus, although there is knowledge about foodborne disease and other food safety issues within government, industry and academia, the political inertia means that many foodborne illnesses will continue to occur but not be properly reported or know what factors were present to cause the outbreaks. industry currently is taking the lead; apart from companies promoting food safety like boecker and gwr food safety, mena food safety associates (mefosa) (http://www.mefosa.com/), based in beirut, assists mena companies hone their competitive edge by establishing and verifying procedures and practices that ensure quality, wholesome and safe products through consulting, auditing and training services in haccp, gmps, and hygienic practices. however, lebanon's lack of a coordinated system of government oversight of the food industry pales into insignificance compared to that in syria. prior to the war, syria's healthcare system had hospital and doctor levels equivalent to other middle-income countries such as brazil, turkey and china, with life expectancy of years, and most of the disease burden being similar to that in the west with non-communicable diseases, but four years of violence have changed all of that. child vaccination levels dropped from % pre-conflict to % in march (templeton ) . as a result, outbreaks of diseases that had long been under control have spread across the land and into neighboring countries: hepatitis, measles, leishmaniasis, multi-drug-resistant tuberculosis, typhoid and even polio, which had not been seen in the middle east for years. life expectancy has dropped by two decades. medical personnel are clearly targeted because they are seen as potential enemies helping the opposite side. the majority of syria's doctors have been killed or fled the country (> medical workers have been killed since ). the situation has been called the worst humanitarian catastrophe this century, and the worst concerted attack on healthcare in living memory. at least , syrians have been killed and more than million others have been forced from their homes since the conflict began on march , , with over four million people in areas that are hard to reach for humanitarian aid, and Á million have fled mostly to neighboring turkey, lebanon, jordan, and northern iraq, while others have sought safety in europe, provoking a political crisis in the -member bloc (devi ) . another middle eastern country under stress but with less publicity is yemen. currently there is little government oversight into food as there is little to be had. the situation in yemen is characterized by large-scale displacement, civil conflict, food insecurity, high food prices, endemic poverty, diminishing resources, and movement of refugees and migrants (wfp ). the un world food programme (wfp) has been in yemen since . in , wfp conducted a comprehensive food security survey which found that % of the people ( . million) were food insecure, of which some five million were severely food insecure, meaning they were unable to buy or produce the food they need to survive. the organization's protracted relief and recovery operation (prro), aims to reach six million people between mid- and mid- with , metric tons of food and us$ . million in cash and vouchers at an overall cost of us$ million. if the conflict continues, this goal is unlikely to be met in time since both the airport and shipping port are areas being fought over. the wfp has been attempting to bring in relief supplies but cannot do so under fire, which means that only small amounts are occasionally delivered to the country (mukhashaf and miles ) . one example of this occurred in aden on july , when a ship docked after waiting a month to unload enough u.n. food aid to feed , people for a month. previous repeated attempts to send ships to aden were been blocked due to severe fighting in the port area. the prro is aligning wfp's activities with moves to increase the government's capacity to respond to the crisis and will promote recovery and resilience to enable food insecure households and communities to better withstand and recover from the effects of conflict and shocks. there are many similarities as well as substantial differences in the descriptions of issues concerning food safety and foodborne disease of each country in the region. gastrointestinal diseases are frequent throughout the middle east with some countries identifying their etiologies, such as egypt, kuwait, israel, pakistan, turkey, yemen. these include bacteria and parasites, e.g., salmonella, shigella, campylobacter, enterotoxigenic e. coli (etec), giardia, entamoeba, and occasionally enteric viruses such as hav and norovirus. however, none of the countries has a well-functioning foodborne disease surveillance system, but a few report on a regular basis like ksa, and starting recently, lebanon with pulsenet. mostly it seems that only large outbreaks or ones with fatalities that are reported on, and mainly through the press. these outbreaks are often related to point sources which are in most cases communal foods prepared for a large number of individuals as in feasts, student hostels, schools, campuses, or military camps. however, the actual etiological agents and the factors contributing to outbreaks are only rarely determined. one example is a very large outbreak in bahrain in with at least people suffering from foodborne illness after eating contaminated egg-andmayonnaise sandwiches served at a wedding party, but the etiology was not determined, even though clinical specimens and food samples were analyzed, at least in a publically-released report (promed-mena ) . based on the type of preparation including the length of time taken for preparation of the implicated food and the time from consumption to the appearance of symptoms of foodborne illness, the types of symptoms, and what has already occurred historically in foodborne disease outbreaks, possible agents can be surmised, such as bacillus cereus and staphylococcal enterotoxins, and salmonella, shigella, or norovirus infections, but promed is continually asking for more information once an outbreak is announced, and hardly ever receiving it (promed-mena ). all this indicates that even if clinical specimens or food samples are taken and analyzed, laboratories are only rarely able to determine an etiologic agent, or at least report on their results. most agents described with the little information available seem similar in all the mena countries and to those encountered in the west. however, a few pathogens are more likely to be restricted to a few nations, such polio in pakistan, cholera in iraq, mers-cov in ksa, and botulism in egypt and iran where river fish are often eaten (one case of infant botulism was diagnosed in israel but it is a rare disease anywhere); the first two are more likely transmitted though water or poor hygienic conditions, the third by camels, and only botulism exclusively through food. brucellosis is widespread in the middle east but only a few country studies indicate its link to meat or dairy products. much of the middle east is in the throes of conflict which results in unique situations in specific countries to exacerbate foodborne disease or food poisonings; these include relief agencies supplying "stale" food to those trapped and starving by the syrian civil war, almost lack of food at all in yemen, deliberate poisonings of enemies in afghanistan, syria and iraq, accidental pesticide poisonings in iran, preventing unsafe food being sold to those on the hajj in ksa, improperly prepared catered food for foreign troops in bases in afghanistan, iraq, kuwait, ksa, and turkey. countries where tourism is a major source of income can be adversely affected by bad publicity over complaints over food served in resorts, such as in egypt and turkey. also, gulf countries tend to employ workers from india and other surrounding territories, and these are typically housed in camps or separate communities from citizens and visitors, and are transported to work sites and back; conditions are not always conducive to safe food, and outbreaks are occasionally reported either from their work sites or their overnight residences where meals are prepared or catered. most food to many of these countries is imported, especially those with limited agricultural land and adequate water supplies; fruits and fresh vegetables, tend to be grown in rural or peri-urban settings for local consumption and these can be contaminated at source through polluted river or well water, such as in the bekaa valley of lebanon and mountain communities in pakistan, and the nile, tigris and euphrates fluvial plains. on one occasion, iranian watermelons were recalled and future sales banned in ksa, qatar, and uae because they were suspected of being poisoned or were injected with pesticides (nobody claimed to be ill after eating the melons), because holes were found in a few of them. however, the rationale of iranian farmers deliberately losing money seems to counter this argument, and it is more likely a sectarian economic barrier (abdullah ) . in fact, with the temporary ban the price of watermelons went up in the countries that had banned them. random tests carried out on the fruit confirmed they were free from any chemical substances, insecticides or other pollutants. the holes were most likely caused by emerging insect pupae. countries outside the gulf region reported no problems with the imported iranian melons. where some processed foods are exported, there is a risk of the importing countries recalling these if they cause foodborne illnesses or contaminants are found in them. this has happened in egypt with hepatitis a virus in strawberries and e. coli o :h in fenugreek seeds causing serious illnesses in europe and restricting further trade for an extended period. the same issue affected turkish pomegranate arils and lebanese tahini (made from imported ground sesame seeds), both containing salmonella, exported to the us. large to medium operations for broiler chickens and egg layers in ksa, kuwait, lebanon and other countries try and meet national standards or international guidelines for salmonella but are not always achieved, resulting in recalls and fines. governments are also aware of increasing concern over campylobacter in chickens, as widely-eaten poultry is a major source of this pathogen, but campylobacteriosis is not often cited as causing foodborne disease. raw milk (cow, sheep and camel) and raw milk cheese are still widely consumed in the middle east at the local level, though not usually obtained through supermarkets, and the risk of infections is high, as it is in other parts of the world, but with the added concern of brucella spp. and mers cov (the latter in the gulf countries where camels are bred and milked), both serious pathogens. yoghurt, surprisingly since it is acidic and is a source of gut beneficial lactobacilli, apparently was the foodborne vehicle to cause illnesses and deaths in afghanistan, israel, and pakistan. no agent was found in any of the samples. in the afghani example, the yoghurt was claimed to be deliberately poisoned; in the israeli one, it was apparently "stale" given to palestinian prisoners; there were two episodes in pakistan, one was from a home-prepared meal and the other from a restaurant which served rice and yoghurt. for prevention and controls strategies, most countries seem to rely on local authorities (municipalities) to do inspection of food facilities, more typically restaurants than processing plants as there are far more of them. illegal sales for unapproved products by local entrepreneurs are sometimes an issue, e.g., homeslaughtered meat in bahrain, and palestinians shipping food to israel. these illegal operations probably occur more often in porous borders within the region, and are only recognized when authorities decide to become vigilant in this area. some countries have conducted research and surveys much more than others based on the publication record, e.g., egypt, israel, palestine, ksa, turkey, and to a lesser extent, iran, lebanon, pakistan, uae, and yemen, but some research may occur without formal publication in recognized journals, making it difficult to have a true picture of how food safety problems are recognized and controlled. a few surveys have shown that home makers and food employees have limited knowledge of food safety, as in other regions. thus, some agencies or industry associations, sometimes in collaboration with outside organizations like fao or who, have attempted to train food employees in basic haccp principles, including best hand hygiene practices, and speakers give the latest food safety issues at the annual dubai international food safety conference, now in its th year. a few governments have established food safety agencies that have broad powers to inspect and control without overlapping responsibilities; these include jordan and ksa with food and drug administrations, uae with abu dhabi and dubai food control authorities, oman with its national food quality and safety centre, and pakistan with a punjab food authority. egypt and lebanon are initiating food safety authorities. israel, palestine and jordan have a cross-border agreement to collaborate on food safety issues. typical of many food control agencies in developing countries, periodic campaigns are launched to "crack down" on foodservice operations and sometimes processing plants. these are usually stimulated by complaints of the public, or the need for the responsible ministry to be seen doing something to justify its existence in compliance with regulations (if they exist). this has occurred recently in lebanon, qatar and pakistan. one issue is that poorly constructed or out-of-date regulations may be interpreted in different ways by the owners and the agencies (kullab ) . if a violation is found, the facility may be fined and/or temporarily closed down until it has satisfied the inspectors at the next visit. in one extreme instance in qatar, the owners and employees, were fined, imprisoned and deported. unfortunately, although the names of those at fault are often publicized by the media, their specific violations and how they relate to the regulations are not usually documented or at least publically released. another issue is that whether illnesses are suspected or not following a complaint, inspectors often insist that all food be discarded as soon as a sufficient violation, which may be unrelated to the complaint, has been determined; this prevents any samples being taken for outbreak investigations (hanna et al. ), as well as using the outbreak for a teaching tool for the owner and other similar operations. in conclusion, some progress has been made in the surveillance of foodborne disease in the middle east, but the disease's health and economic burden is barely being considered in many countries for future decision-making policies, an issue that is being tackled at the global level (who b). food control agencies seem to be trying to stop apparent abuses but have limited resources to do much more. this region, in particular, is severely strained because of sectarian distrust, on-going civil wars, and terrorist attacks, with refugees from iraq seeking shelter toward europe but stalled in turkey and lebanon for long periods of time. the crisis in syria is considered the greatest humanitarian disaster of the twenty first century, or even since world war ii, and it looks like the on-going fighting including outside armed forces will make food insecurity in the affected countries even worse in the foreseeable future. less public attention has been directed to yemen where food insecurity is a major concern. this coupled with gulf countries losing their wealth over low oil prices and a resultant stagnant global economy means a focus on food safety will likely become lower in priority for many of these countries. since secure food has to be safe, as illustrated by "stale" food being issued to besieged syrian residents and prisoners, it is important that relief agencies and countries themselves be aware of the risk of foodborne diseases associated with immunocompromised persons, particularly children. however, even in countries where the food supply is acceptable, inadequate hygienic practices put the local and tourist population at risk of illness and exported foods jeopardize industry profits and a poor reputation for future trade. as demonstrated by ksa, jordan and uae, single agencies or multiple agencies with clear-cut roles responsible for food safety, should be pursued by governments in consultation with industry and academia. duplication creates ambiguities for enforcement and education strategies as well as being unnecessarily costly. water supplies are also critical and some governments are weaning away farmers from depleted groundwater aquifers, and making irrigation more efficient where there are sustainable supplies. water for irrigation and processing has to be both free of pathogens and unacceptable levels of chemicals, and effectively treated waste water can substitute for groundwater. the sahara forest project in qatar is one example of a very dry country using seawater resources effectively; an even larger project is being considered from the -hectare in qatar to a -hectare test facility in jordan (clery ) . all these issues are being compounded by climate change and expected higher temperatures in already arid lands, which will make the region all the more dependent on more expensive imported foods. gulf counties have enough petro-dollars to afford these, but other countries are struggling to be self-sufficient for the near future even if the fighting ceases. the repair to destroyed infrastructure will be immense, coupled with the lack of trained personnel to create a restored food system at all levels from primary production through food processing, foodservice, and retail to the home. antimicrobial resistance for enteric pathogens isolated from acute gastroenteritis patients in gaza strip enteric protozoan parasites in stray cats in kuwait with special references to toxoplasmosis and risk factors affecting its occurrence sale of watermelons with holes stopped in uae. khaleej times u.n. causes food-poisoning with deliveries of old, 'moldy' biscuits to syria, says rights body iraq cholera cases grow, spread to kurdish region. relief web presence of aflatoxin b in the shelled peanuts in karachi incidence and distribution of salmonella serogroups in some local food in sana'a -yemen viral gastroenteritis associated with genogroup ii norovirus among u.s. military personnel in turkey isis fighters killed by poisoned ramadan meal. daily mail online food safety challenges-a pakistan's perspective considerations for introduction of a rotavirus vaccine in oman: rotavirus disease and economic burden foodborne illness -saudi arabia: (najran) restaurant. archive number: . . promed-mena flood victims suffer food poisoning. the daily times an outbreak of foodborne diarrheal illness among soldiers in mina during hajj: the role of consumer food handling behaviors outbreak of food borne salmonella among guests of a wedding ceremony: the role of cultural factors a situation analysis of the food control systems in arab gulf cooperation council (gcc) countries food poisoning in saudi arabia. potential for prevention? syrian migrants attack gendarmerie in southeastern turkish tent city, five injured one egyptian seed shipment: two outbreaks. food safety news what can we learn? food safety news afghanistan: militants 'kill police by poisoning food'. bbc news pakistan-minor dies of food poisoning. the news international accessed pakistan -over nurses hospitalized after food poisoning. the news moh on cholera alert; two patients detected 'food poisoning' cases at al-azhar dorms in egypt's assiut new guidelines: punjab food authority giving 'unsanitary' restaurants an easy time of it determination of pesticide residues in fruits of nawabshah district surprise inspections: pakistan officials fine food outlets, seal hotel. express tribune determination of arsenic levels in lake water, sediment, and foodstuff from selected area of sindh, pakistan: estimation of daily dietary intake teenage boy, sister die of food poisoning egypt students storm office of top al-azhar cleric. the record the evaluation of food hygiene knowledge, attitudes, and practices of food handlers in food businesses in turkey israeli doctor's bio-warfare serum saves infant from botulism death cluster of hepatitis a cases among travellers returning from egypt prevalence and antibiotic susceptibility of thermophilic campylobacter species on beef, mutton, and chicken carcasses in istanbul the food and agriculture around the world handbook confirmed variant creutzfeldt-jakob disease (variant cjd) case in texas desert farming experiment yields first results recent trends in the epidemiology of shigellosis in israel a middle east subregional laboratory-based surveillance network on foodborne diseases established by jordan, israel, and the palestinian authority outbreak of hepatitis a in the usa associated with frozen pomegranate arils imported from turkey: an epidemiological case study food-borne illness and its effect on tourism in egypt. food safety and environmental health blog cluster of cases of hepatitis a with a travel history to egypt salmonella enterica serotype typhi in kuwait and its reduced susceptibility to ciprofloxacin syria's health crisis: years on british holidaymakers in turkey hit by salmonella food safety issues in saudi arabia pregnancy-associated listeriosis: clinical characteristics and geospatial analysis of a -year period in israel food poisoning -saudi arabia (jizan): request for information investigating a link of two different types of food business management to the food safety knowledge, attitudes and practices of food handlers in beirut understanding the routes of contamination of ready-to-eat vegetables in the middle east making certain imported foods meet u.s. standards under fda food safety modernization act. u.s. food and drug administration major outbreak of hepatitis a associated with orange juice among tourists dream five-star holiday 'ruined' after family struck down by vomiting bug a dozen isis fighters killed after chefs infiltrate camp and poison terrorists' lunch. daily mirror cdc: salmonella from tahini sickened last year. food safety news outbreaks where food workers have been implicated in the spread of foodborne disease. part . description of the problem, methods and agents involved poisoning alert over improper food storage food-borne salmonella outbreak at a bank cafeteria: an investigation in an arab country in transition. la revue de santé de la mé diterranée orientale outbreaks of foodborne illness associated with the consumption of tree nuts, peanuts, and sesame seeds. in outbreaks from tree nuts, peanuts, and sesame seeds survey of clostridium botulinum toxins in iranian traditional food products deadly disease: two dead, over affected in kurram's cholera outbreak. express tribune a study on contamination of aflatoxin m in raw milk in the punjab province of pakistan aflatoxin m contamination in milk from five dairy species in pakistan blood in the chicken and cats around food': father-of-three hospitalised with severe gastric illness at same turkish holiday resort where fell ill in man dies after eating contaminated yoghurt. gaea times gastro epidemic: rising temperatures turn stomachs. express tribune evaluation of aluminum contents in different bakery foods by electrothermal atomic absorption spectrometer heavy metal residues in the milk of cattle and goats during winter season predominance and circulation of enteric viruses in the region of greater cairo presence of enteric hepatitis viruses in the sewage and population of greater cairo soil and vegetables enrichment with heavy metals from geological sources in gilgit foodhandler-associated salmonella outbreak in a university hospital despite routine surveillance cultures of kitchen employees experts emphasize need for food safety measures after scandals. daily star impacts of climate and management variables on the contamination of preharvest leafy greens with escherichia coli studies on contamination level of aflatoxins in some dried fruits and nuts of pakistan pakistan-food poisoning claims four lives. pakistan observer food handlers' knowledge on food hygiene: the case of a catering company in portugal egypt: azhar's food poisoning cases rise to -moh egypt: cases of food poisoning in two suez primary schools cops suffered from diarrhea during sehat ka insaaf drive. the nation establishment of food safety authority will allow investments in food industries the hajj: communicable and non-communicable health hazards and current guidance for pilgrims. eurosurveillance ( ) global perspectives for prevention of infectious diseases associated with mass gatherings qatar pursues water and food security aflatoxins b and b contamination of peanut and peanut products and subsequent microwave detoxification a survey of clostridium botulinum in food poisoning in iran outlook/srq m / _moph_national_health_statistics_report_in_lebanon.pdf. accessed december ) hepatitis a spreading because of lack of awareness aid delivers food poisoning as residents' immunity 'extremely weak u.n. ship brings food aid to yemen's aden as fighting rages in food-crazed lebanon, a war over tainted chicken and messedup meze eu ban on egyptian fenugreek seeds extended. food safety news % of food handlers complete hygiene and safety training food safety knowledge among food workers in restaurants in jordan survival of foodborne pathogens on berries. fshn - , food science and human nutrition department, uf/ifas extension, gainesville factors associated with acute diarrhoea in children in dhahira, oman: a hospital-based study abu dhabi food authority provides clearer picture of safety rules in restaurants. the national uae audits and inspections are never enough: a critique to enhance food safety mass poisoning in bahrain foodborne illness -saudi arabia foodborne illness -egypt: (suez) school children, milk susp nih confirms cholera case in capital polo ground eatery fined for expired food, lack of hygiene. the news international pakistan's food safety czar declares 'war' on unhygienic food after poisoning, rogue cop shoots dead policemen in afghanistan. hindustani times cluster of hepatitis a cases among travellers returning from egypt dubai siblings die of suspected food poisoning. gulf news multistate foodborne hepatitis a outbreak among european tourists returning from egypt-need for reinforced vaccination recommendations jail sentences and deportation for qatar food poisoning cases of food borne diseases recorded in dubai foodborne illness acquired in the united states-major pathogens insecticides in the blood samples of spray-workers at agriculture environment: the toxicological evaluation an outbreak of norovirus gastroenteritis in a county in turkey cholera claims five lives muscat municipality shuts down leading bakery in ruwi food safety challenges associated with traditional foods in arabic speaking countries in the middle east an overview of international investments in agriculture in the near east pesticides in shallow groundwater of bahawalnagar, muzafargarh determination of contamination with clostridium botulinum in two species of processed and non-processed fish regional programmes for food security in the near east: towards sustainable food security and poverty alleviation couple may take action on holiday nightmare sickness. the sentinel foodborne and waterborne disease in developing countries -africa and the middle east. dairy food and environmental sanitation viruses of foodborne origin: a review. virus adaptation and treatment afghan cops; food poisoning at border post isis fighters die in 'iftar poisoning'; more ill after eating ramadan meals in mosul. international business times, india edition amid growing complaints, sch launches food poisoning hotline in qatar yemen: current issues and what the world food programme is doing who's first ever global estimates of foodborne diseases find children under account for almost one third of deaths. world health organization who estimates of the global burden of foodborne diseases. foodborne diseases burden epidemiology reference group - . world health organization food scandal: food poisoning rate in lebanon lowest, says tourism minister key: cord- -ug ler e authors: ramos-rincón, josé m.; pinargote-celorio, héctor; belinchón-romero, isabel; gonzález-alcaide, gregorio title: a snapshot of pneumonia research activity and collaboration patterns ( – ): a global bibliometric analysis date: - - journal: bmc med res methodol doi: . /s - - - sha: doc_id: cord_uid: ug ler e background: this article describes a bibliometric review of the scientific production, geographical distribution, collaboration, impact, and subject area focus of pneumonia research indexed on the web of science over a -year period. methods: we searched the web of science database using the medical subject heading (mesh) of “pneumonia” from january , to december , . the only document types we studied were original articles and reviews, analyzing descriptive indicators by five-year periods and the scientific production by country, adjusting for population, economic, and research-related parameters. results: a total of , references were retrieved. the number of publications increased steadily over time, from publications in to in (r( ) = . ). the most productive country was the usa ( . %), followed by the uk ( . %) and japan ( . %). research production from china increased by more than %. by geographical area, north america ( . %) and europe ( . %) were most dominant. scientific production in low- and middle-income countries more than tripled, although their overall contribution to the field remained limited (< %). overall, . % of papers were the result of an international collaboration, although this proportion was much higher in sub-saharan africa ( . %) and south asia ( . %). according to the specific mesh terms used, articles focused mainly on “pneumonia, bacterial” ( . %), followed by “pneumonia, pneumococcal” ( . %) and “pneumonia, ventilator-associated” ( . %). conclusions: pneumonia research increased steadily over the -year study period, with europe and north america leading scientific production. about a fifth of all papers reflected international collaborations, and these were most evident in papers from sub-saharan africa and south asia. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. acquired pneumonia (cap) remains the primary cause of death from infectious disease globally, and its high impact on morbidity and mortality is especially concentrated in children under five and the elderly [ , [ ] [ ] [ ] . the world health organization (who) predicted that deaths from lower respiratory tract infections would remain among the top four causes of deaths up to at least [ ] . antibiotic-resistant strains have also been on the rise, although resistance does not appear to be related to mortality. however, pneumonia is associated with high rates of hospitalization and length of hospital stay. moreover, it has considerable long-term effects on quality of life, and long-term prognosis is worse in patients with pneumococcal pneumonia [ ] . despite the public health importance of the disease, few studies have evaluated research in the area using bibliometric methods. indeed, only head et al. ( ) have analyzed publications on pneumonia, and their work was limited in geographical scope to the uk [ , ] . in this study, by analyzing scientific papers on pneumonia published in the main international scientific journals, we aimed to identify the scientific contribution of different countries to the worldwide research effort, the most cited landmark articles, the degree and nature of scientific collaboration, and the topics addressed. this bibliometric description can provide relevant information for researchers in the field, particularly new scientists, giving a snapshot of strong research areas in pneumonia and global health as well as possible gaps requiring additional investments [ ] [ ] [ ] . the paper also provides clues for addressing the weaknesses observed, such as the need to promote north-south collaborations and other research initiatives with countries that have relatively little scientific development on the topic [ , ] . the aim of the present study is to assess the scientific literature on pneumonia that is indexed in the web of science (wos). specifically, we will analyze: ( ) the evolution of scientific production; ( ) its distribution by countries and regions; ( ) the impact of the research papers; and ( ) the degree of international collaboration. finally, we will present details on the subject area focus of different publications according to the medical subject headings (mesh). for the performance of the study, we opted to identify documents about pneumonia by means of the mesh thesaurus in the medline database because this is a detailed instrument for controlled terminology. the thesaurus employs both a human team of specialist indexers to analyze each article and assign medical subject headings to it, plus automated processes to improve indexing; the result is a highly consistent system of classification for research topics [ ] [ ] [ ] . the pneumonia descriptor was introduced in as a disease of the respiratory tract and the lung, and it was defined as "infection of the lung often accompanied by inflammation" [ ] . synonyms of this descriptor (and therefore also included in search results) are "lung inflammation" and "pulmonary inflammation". additional file : table s shows the mesh tree structure for "pneumonia". the next step was to identify the documents assigned with the medline descriptor of "pneumonia" indexed in the wos. this body of research constitutes the population of documents for the present study. conceived by eugene garfield but now maintained by clarivate analytics, wos is the top scientific citation search and analytical information platform worldwide, serving both as a multidisciplinary research tool supporting a variety of scientific tasks and as a dataset for large, dataintensive studies [ ] . the use of the wos databases enables the analysis of all institutional affiliations reported in the documents and the calculation of citation indicators. the wos brings together the most visible literature at a global level. these qualities justify its choice as the database platform used in this study despite some limitations related to covering non-english biomedical journals [ ] . although initially no limitations were imposed on our search, to calculate the bibliometric indicators we considered only two types of documents, articles and reviews, as these are the primary references for researchers. the study period was limited to - , as delays associated with assigning mesh descriptors to documents mean that information on the most recent articles on pneumonia is not updated. the searches took place on the clarivate analytics wos platform, which includes medline database, on march , . for each of the retrieved documents, data on the following bibliographic characteristics were extracted: year of publication, journal of publication and wos subject category, document type, authorship, citations, institutional affiliation(s), and mesh descriptors. data were then standardized: institutional affiliations corresponding to england, northern ireland, scotland and wales were grouped together under "united kingdom," while affiliations in overseas france, british overseas territories, and island dependencies were also assigned to their ruling countries (for example, the documents signed by authors from french polynesia, guadeloupe, martinique, new caledonia, and reunion were assigned to france), although regional designations correspond to geographical rather than political criteria. scientific production from taiwan, which in wos is considered independently from the democratic republic of china (china) but whose status is disputed at an international level, was analyzed separately. countries responsible for publications were categorized according to their world bank classification by income level: low-income (< usd ), lower-middleincome (usd to usd ), upper-middle-income (usd to usd , ) , and high-income (≥ usd , ) countries. each of the countries identified was assigned to a macro geographical (continental) region according to the groups established by the world bank based on geopolitical and economic criteria and reflected in the world bank country and lending groups (see additional file : tables s and s ) [ ] . two kinds of indicators were obtained: descriptive indicators for the evolution of scientific production production by country, adjusted for demographic and economic parameters as well as for human resources dedicated to research activities we determined standardized indicators for each country's productivity with respect to: -population: number of publications per million inhabitants (population index). data were obtained from world development indicators in the world bank online databases [ ] . we calculated a mean value for each indicator based on available data from the study period. the analysis was limited to countries participating in the top articles in the field of pneumonia in order to facilitate comparison between countries' scientific production, demographic indicators, and economic development. results for the top articles are shown in the main text, while those for the top are provided in additional file . we calculated the following citation indicators by journal, country, and geographic region: -citation of the publications. absolute number of citations received. -citation rate (cr). number of citations divided by number of publications. -hirsch index (h-index). the h-index is a semiqualitative proxy measure to assess the impact of an author's or country's research output on the scientific community [ ] . an h-index of indicates that out of published papers have been cited at least times. in order to assess the differences in the distributions of the publications according to the prestige of the journals, we performed a specific analysis of a sub-sample of publications in journals occupying the top % in the impact factor ranking in their respective subject categories in the journal citation reports ( edition). we analyzed participation in these "prestigious journals" according to geographical location (regions and countries), collaboration level and number of citations. we calculated the percentage of documents produced in international collaboration and the evolution by quinquennium in order to estimate the scope of cooperative practices at a global level, considering the whole population of documents analyzed (research field) by country and geographic region. to specifically analyze collaboration between countries, collaboration networks were generated for each of the three quinquenniums using pajek software. to specifically analyze collaboration between countries, collaboration networks were generated for each of the three quinquenniums using pajek software. the collaboration network is a graphic representation (graph), wherein the nodes represent authors' countries (as determined from their institutional affiliations) and links between the nodes represent coauthorships between countries, that is, an international collaboration in published research. the more intense the collaboration, the thicker the links between the nodes. the spatial distribution of the nodes responds to the execution of the kamada-kawai algorithm in pajek, which places the most prominent nodes (those with a greater number of documents and collaboration links) in the center of the map, and the nodes with a smaller number of publications and degree of collaboration towards the periphery. based on an analysis of mesh terms, we identified the main research focus of the studies in the area, generating density maps using the vosviewer program with a spatial description of the main mesh terms for each type of pneumonia [ ] : (a) "pneumonia, aspiration" (b) "pneumonia, bacterial," (c) "pneumonia, ventilator-associated," (d) "pneumonia, viral," and (e) "pneumonia, pneumocystis"). the process of generating and interpreting the maps proceeded as follows: -determination of the co-occurrence of the descriptors assigned to the documents and generation of a matrix of absolute values. the joint assignment of two descriptors in a single document implies a thematic affinity, as both aspects are addressed simultaneously in the same paper. this affinity will be more intense as it is repeated a greater number of times in the collection of documents analyzed. -elimination of generic descriptors. in order to facilitate the analysis, we eliminated some excessively generic descriptors (like "humans" or "animals"), along with geographical descriptors and those related to age groups. these descriptors showed very high-density relationships, complicating the analysis and the interpretation of the results, so we analyzed their frequency more specifically. -visual representation of the network. to establish the main topics that exist for each type of pneumonia and to represent them visually, we used a clustering algorithm in the vosviewer program, which helps to detect the communities (clusters) within a network, made up of groups of homogeneous items that are strongly related to each other. the different groupings, in the form of "islands" in red tones, represent the main clusters of the thematic networks, while the chromatic gradation illustrates the areas with a lower density of relations between the mesh in yellow and green tones. the spatial distribution of the mesh and their proximity to each other responds to the intensity of co-occurrence between them. all data used to perform the study, including the information downloaded from the database as well as that derived from the treatment of the bibliographic entries, are available in the dataverse project, an open access public repository [ ] (https://dataverse.harvard.edu/, doi: https://doi.org/ . /dvn/ bune). due to the nature of the study and dataset, it was not necessary to obtain informed consent or approval from an institutional ethics committee. the search yielded a total of , documents published between and and assigned with the descriptor "pneumonia" in the medline database. of these, , ( . %) were indexed in the wos core collection databases; , ( . %) of them were classified as articles and ( . %) as reviews. thus, the population of study documents was a dataset of , articles and reviews, which we used to calculate the indicators presented below. letters (n = ; . %), editorials (n = , ; . %), news (n = ; . %), proceedings (n = ; . %) and other document types (n = , . %) were excluded from the analysis. the number of publications rose from in to in .the evolution of scientific production by year was fitted to a linear growth model, showing an r value of . . overall, the study period saw a two-fold increase in scientific production (additional file : figure s ). the country with the greatest number of documents was the usa ( . %), followed at some distance by the uk ( . %), japan ( . %), germany ( . %) and france ( . %). table shows the number of documents and the evolution of scientific production in the most productive countries by quinquennium (see additional file : table s for results on the top countries). although the usa ranks first in all periods, its relative contributions have declined, from . % of all documents in - to . % in - . on the other hand, china's emergence is highly notable, with a . % share of total scientific production in the first period (rank = ), compared to a . % share in the third (rank = ). south korea has also seen considerable growth, contributing just . % to total research production in - (rank = ) but . % in - (rank = ). likewise, taiwan and brazil have increased their production from . and . %, respectively, to . and . %. scientific production in different countries and geographic regions, and its evolution by quinquennium, is concentrated in north america and europe & central asia; together these regions are responsible for . table ) (see additional file : figure s for a visual representation of density equalizing mapping projections). table ranks the production of the top countries, adjusted for demographic and economic indicators (see additional file : table s for results on the top countries). when normalized by population, the most productive countries were switzerland, the netherlands, iceland, and denmark. adjusted for the gdp index, the most productive lmics were the gambia, malawi, uganda, and guinea bissau. if we calculate the ratio of pneumonia publications to gni per capita index, the usa, china, india, malawi y brazil were the most productive. adjusting by r&d expenditure index, the usa ranked first, followed by spain, the uk, china, and italy. in relation to the researchers in r&d index, the usa also leads the ranking, followed by india, uganda, and china. (see additional file figure s and figure s for a visual representation of density equalizing mapping projections of the number of documents and world development indicators, by gni per capita index, gdp index and population index plus r&d expenditure index). figure shows the collaboration networks between different countries by quinquennium. the most prominent countries in all time periods, occupying central positions in the networks with multiple cooperative links, are the usa, canada, the uk, germany, france, and the netherlands. the presence of south american and african countries is scarce in all periods. only south africa has a notable presence in the third quinquennium (fig. a) . a few other countries also "emerge" with a high degree of collaborative links in the second period, like spain, greece, italy, australia, china, and japan, although the latter two countries are not fully integrated in global networks, showing collaborative ties only with the usa (fig. b) . finally, other european countries, while present throughout all three periods, stand out to a greater degree in the third period. this is the case of sweden, switzerland, belgium, and austria. at the same time, china and japan seem more implicated in the network in this third period, while india and south korea also gain relevance (fig. c) . the documents we analyzed were published in scientific journals. twelve journals accounted for . % of the pneumonia literature table table s for results on the top journals with highest absolute and relative citations). the comparative analysis of the scientific production and crs of different journals is noteworthy in that some journals (such as the american journal of respiratory and critical care, critical care medicine, and intensive care medicine) present a very high cr in relation to their total scientific production (additional file : figure s for the top journals producing the most research on pneumonia, plus citation rates). with regard to the subject categories to which the journals are assigned, the most prominent are "infectious diseases" ( . % of the documents), "respiratory system" ( . %), "immunology" ( . %), "microbiology" ( . %), and "critical care medicine" ( . %) table . many of the most productive journals in pneumonia also fall into these subject categories. moreover, over the course of the three study periods, nearly all of the subject categories saw a moderate decrease in their relative contribution, as research articles became more dispersed and made headway into different disciplines producing less research on pneumonia table . the analysis of the documents published in the top % of prestigious journals shows a higher participation from the usa ( . %, compared to . % in the overall body of documents) and from some other european countries like the uk or spain. in contrast, the weight of asian countries, particularly japan and china, is much lower (table ) . overall, international collaboration in these journals (n = , . %) was sensibly higher than in the overall body of documents ( . %), and the greater degree of collaboration was much more pronounced for countries like brazil, japan, china, and even european countries like italy and germany ( table ). the high degree of collaboration was also confirmed between regions in the publications appearing in these journals (table ). with regard to the degree of citation, we observed notable increases in the citation rate of the usa and the european countries; these were even more significant for countries in the middle east & north africa, and for sub-saharan africa when they participated in these journals ( table ). with regard to types of pneumonia studied, the mesh terms to appear most frequently were "pneumonia, bacterial" ( . %), followed by "pneumonia, pneumococcal" ( . %), and "pneumonia, ventilator-associated" ( . %). table shows the number of documents assigned to each term describing the different types of pneumonia (additional file : table s for the top general mesh). table ranks the top countries in crude numbers of retrieved articles, stratified by types of pneumonia (additional file : table s for information on the most productive countries). for "pneumonia, aspiration", the main countries were the usa, japan, and germany; for "pneumonia, bacterial", the usa, france, and spain; for "pneumonia, pneumocystis", the usa, france, and the uk; for "pneumonia, ventilator-associated", the usa, france, and spain; and for "pneumonia, viral", the usa, china, and japan. table shows the relationship between mesh terms referring to age groups with those corresponding to different types of pneumonia. the closest associations for "aged, and over" and "aged" were with "pneumonia, aspiration" ( . and . %, respectively), while "pneumonia, viral" was the most frequent topic for studies in pre-adults ("infant", "child", "child, preschool" and "adolescent"). the one exception to this was "infant, newborn", where the highest proportion of articles was about "pneumonia, pneumocystis." in "adult" and "middle aged" people, studies most frequently focused on "pneumonia, bacterial" and "pneumonia, ventilator-associated." figure shows the subject area maps with the main mesh terms in the documents on (a) "pneumonia, aspiration"; (b) "pneumonia, bacterial"; (c) "pneumonia, ventilator-associated"; (d) "pneumonia, viral"; and (e) "pneumonia, pneumocystis." the principal mesh term related to "pneumonia, aspiration" is "deglutition disorder", but research is linked to a broad array of topics, including epidemiological aspects ("incidence", "risk factor", "retrospective studies"), treatment approaches in intensive care, and surgical techniques procedures facilitating breathing, swallowing, and feeding (fig. a) . the two main mesh terms that appear most frequently with "pneumonia, bacterial" are "community-acquired infections" and "anti-bacterial agents", reflecting the central focus that research has taken to identify risk factors and test different therapeutic approaches. mesh terms related to specific bacteria and infections, such as streptococcus, chlamydia, acinetobacter, and haemophilus influenzae, are also prominent (fig. b) . for its part, research on "pneumonia, ventilatorassociated" seems more disperse, although three areas of interest can clearly be differentiated: (a) epidemiological studies, clinical protocols, and treatment in intensive care units (the term "intensive care unit" is the most prominent in this area); (b) treatment outcomes ("treatment outcome" and "anti-bacterial agents"); and (c) cross infections ("cross infection") (fig. c) . research on "pneumonia, viral" also shows a disperse nature, with different areas of interest. epidemiological aspects are covered under terms such as "communityacquired infections" and "hospitalization", while at a researcher level, interests reside in the virus "influenza, human" and "orthomyxoviridae infections" (fig. d) . with regard to "pneumonia, pneumocystis", one prominent subject focus is on "aids-related opportunistic infections" and another is on "pneumocystis jirovecii" (fig. e ). our analysis shows that the number of publications on pneumonia increased notably over the study period, with annual research outputs doubling from to . different factors may have contributed to this. the first of these is the growing research relevance of pneumonia as a clinical entity, as this disease is one of the community-acquired infections with the highest incidence and is an important cause of hospital admissions. it is also associated with a high global burden of morbidity and mortality in both children and adults [ ] [ ] [ ] ] . the second potential factor relates to advances in basic immunological and microbiological research along with deepening knowledge on the pathogenesis of the disease with regard to aspects like microbiological resistance and preventive interventions (e.g. vaccines) [ ] . thirdly, increased funding has been directed toward research and particularly "proactive investments for emerging infectious threats" [ , ] , and finally, the increase in scientific production could be related to scientific development and international dissemination of scientific research in the wos databases. this is particularly the case of china and other emerging economies like brazil, where the rates of growth were highest relative to their respective regions [ ] [ ] [ ] . we observed a substantial increase in research worldwide, but particularly in some geographical regions and countries of south asia, east asia & the pacific, latin america & and the caribbean, and sub-saharan africa. to a great extent, this increase is simply a reflection of the limited contribution to global research that these countries made in the first period analyzed ( ) ( ) ( ) ( ) ( ) . the bulk of scientific production continues to come from countries with more economic and scientific development in europe and north america (together, these countries participated in % of all publications). despite the striking increase in scientific production across lmics, the relative contribution to pneumonia research remains very modest, and the fact that some countries rank highest in demographic and economic indicators may not be a positive feature, but rather a reflection of the scant development in their scientific systems. furthermore, the increase in international collaboration could have played a role in these indicators, multiplying the assignment of articles to different countries and possibly inflating some values, masking the real contribution of countries with less scientific development in research activities [ ] . the usa is undoubtedly the main reference for pneumonia researchers in quantitative terms, as it produces by far the largest volume of publications-four times that of the next most productive country in the last period. other european countries with important scientific systems (e.g. the uk, germany, france, and spain), along with other countries like japan, canada, china, india, and brazil, also stand out in relation to some of the indicators of scientific production and economic development (gni per capita index, and r&d expenditure index). the other significant aspect in the analysis of how scientific production evolved over the study period is the emergence of china, which in the last period of study ( ) ( ) ( ) ( ) ( ) trailed only the usa in research output. this growth has come about in large part from the investments and scientific policies to foster openness that have been implemented over the past several decades to promote internationalization [ , ] . the level of international scientific collaboration that we have observed in the field of pneumonia ( %) is below that seen in other areas of knowledge [ , , , [ ] [ ] [ ] [ ] . thus, even though the trend is toward increased international cooperation, rising from to % over the study period, implementing new strategies that favor collaboration is still necessary [ ] . initiatives promoting research could include those launched by international organizations, such as the world health organization (who) and the bill & melinda gates foundation, which have both invested considerable resources to investigate the etiology of childhood pneumonia in low-income countries [ ] [ ] [ ] . however, these initiatives [ ] are also collaborating in different projects related to hiv, tuberculosis, and malaria, and these organizations are largely responsible for the important degree of collaboration between european and sub-saharan african countries [ ] . research for operational health services is necessary to improve the distribution and accessibility of pneumonia treatments, including antibiotics in primary healthcare centers and oxygen in hospitals. likewise, new vaccines still need to be developed for strains of pneumococcus that current multivalent conjugate vaccines do not protect against [ ] . in addition to programs focused on financing and implementing collaborative north-south and south-south projects, other efforts could be directed toward reducing obstacles associated with publication processes fig. subject area maps with the main mesh terms associated with different types of pneumonia-(a) "pneumonia, aspiration" (b) "pneumonia, bacterial, " (c) "pneumonia, ventilator-associated, " (d) "pneumonia, viral, " and (e) "pneumonia, pneumocystis" groupings in the form of "islands" in red tones represent the main clusters of the thematic networks, while the chromatic gradation in yellow and green tones illustrates the areas with a lower density of relations between the mesh. the spatial distribution of the mesh and their proximity to each other responds to the intensity of co-occurrence between them that limit the dissemination of lmics through the main international scientific journals. the literature has described obstacles related to linguistic skills and methodological deficiencies, which highlights the need to improve these areas in particular [ , ] . other authors have pointed to the costs associated with publishing in open access journals, so it is worth assessing whether the programs to support open access publishing implemented at an institutional level and by publishers such as plos, biomed central, or the lancet journals, are sufficient [ ] [ ] [ ] . with regard to the impact of research, although europe and north america are balanced in terms of the absolute number of citations, north america holds an advantage in terms of the citation rate. research from sub-saharan africa also has a very high citation rate, which almost reaches that achieved in europe. the fact that these african countries present a high degree of collaboration with researchers in the usa and europe, who represent the "mainstream" international research interests, could help explain the high citation rates seen in this region. on the other hand, latin america & caribbean, south asia, and east asia & pacific are all regions with generally lower citation rates, although this difference is not so pronounced in the case of papers produced in collaboration, as reported elsewhere [ ] . by country, the hegemony of the usa and several european countries in terms of the number of citations received was evident, as was the lower ranking of some asian countries, such as japan and china, in relation to their scientific production. the positioning of china as a reference for scientific production and participation in international research networks does not correspond to its ranking with regard to citation indicators, despite their improved standing over the past several years [ ] . on these indicators, china still lags behind the usa as well as the leading european countries, canada, australia and even nearby countries such as japan. for now at least, the countries that have traditionally occupied the "mainstream" of scientific research still maintain their hegemony [ ] . as with the relative indicators of scientific production adjusted for economic and demographic parameters, some countries surpass the major scientific systems with regard to the citation rate, which links the degree of citation with the volume of scientific production [ ] . these countries may have participated in certain highly relevant contributions, or they may be small countries with highly developed scientific systems, such as vietnam, switzerland, south africa, new zealand, and saudi arabia. these countries also stand out for their high levels of international collaboration, which is a factor associated with more citations. the high mean citations received by publications produced in sub-saharan africa, and the participation of different emerging countries like vietnam and south africa in some of the highest cited papers we identified, underlines the capacity of these countries to contribute to high-impact and excellent-quality scientific studies. this result is consistent with previous studies that have also demonstrated these countries' capacity to participate in emerging research topics [ ] . these specialists therefore represent an excellent asset, strengthening the human capital from high-income countries and enabling the advancement of research [ , ] . in general, the most prestigious journals show a greater concentration of research from the usa and europe, with greater collaboration and impact when countries from other geographical regions also participate [ ] . bacterial pneumonia is the main branch for the multidisciplinary and multipathological mesh of "pneumonia", with the main areas of interest ("community-acquired infections", "anti-bacterial agents" and "treatment outcome") reflecting the focus of research on identifying risk factors and assessing different treatments and their outcomes. in publications pertaining to the mesh "pneumonia, ventilator-associated," the main axes of the subject content according to the mesh terms were the group of epidemiological studies and clinical and treatment protocols in intensive care. "pneumonia pneumocystis," is closely related to infection due to hiv and immunodepression. the main areas of research interest for "pneumonia, viral," were the epidemiological aspects related to the setting for the infection ("community-acquired infections" and "hospitalization") along with the viruses responsible ("influenza, human" and "orthomyxoviridae infections"). finally, for the mesh "pneumonia, aspiration" the main research focus is "deglutition disorder". the main limitation of this present study is its analysis of only the documents included in the wos databases and medline ( % of the documents). thus, a number of papers were excluded from the study, particularly those written in languages other than english, as well as the proceedings included in wos, as our searches were based on the journals included in medline. on the other hand, our approach also allowed us to precisely characterize collaboration in the area, as only recently has medline begun to include all the institutional affiliations of the authors. we were also able to analyze the citations of the publications, with a focus on the journals with the highest impact and dissemination at an international level [ ] . in conclusion, pneumonia research increased steadily over the -year study period, with europe and north america leading scientific production. about a fifth of all papers reflected international collaborations, and these were most evident in papers from sub-saharan africa and south asia. additional file : table s . descriptors included under the mesh "pneumonia" in pubmed. table s . top countries in crude numbers of retrieved articles in "pneumonia, aspiration", "pneumonia, bacterial", "pneumonia pneumocystis", "pneumonia, ventilator-associated", and "pneumonia, viral" mesh. figure s . evolution of scientific production on pneumonia ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . clinical and economic burden of communityacquired pneumonia among adults in europe 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virus (htlv- ): geographical research trends and collaboration networks density equalizing mapping of the global tuberculosis research architecture the pneumonia etiology research for child health project: a st century childhood pneumonia etiology study gates annual letter. our big bet for the future gatenotes background paper -priority diseases and reasons for inclusion. bp . -depression. who the bill &amp melinda gates foundation's grant-making programme for global health european and developing countries clinical trials partnership (edctp): the path towards a true partnership bibliometric assessment of european and sub-saharan african research output on poverty-related and neglected infectious diseases from publication bias -a reason for the decreased research output in developing countries geography of africa biomedical publications: an analysis of - pubmed papers bmc: apc waivers and discounts secondary instructions for authors nassi-calò l. articles by latin american authors in prestigious journals have fewer citations bibliometrics evaluation of research performance in pharmacology/pharmacy: china relative to ten representative countries scientometric research assessment in the developing world: a tribute to michael j. moravcsik from the perspective of the twentyfirst century experiences and perceptions of south--south and north--south scientific collaboration of mathematicians, physicists and chemists from five southern african universities the impact of african science: a bibliometric analysis differences in citation rates by country of origin for papers published in top-ranked medical journals: do they reflect inequalities in access to publication? publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we gratefully acknowledge the assistance of meggan harris in translating our manuscript from spanish.authors' contributions jmrr: study conception, study, design, data analysis, manuscript writing and final manuscript approval; hpc: data collection, data analysis, manuscript writing and final manuscript approval; ibr: study conception, manuscript writing and final manuscript approval; gga: study conception, study design, data collection, data analysis, manuscript writing and final manuscript approval no funding was received for this work. all data used to perform the study, including the information downloaded from the database as well as that derived from the treatment of the bibliographic entries, are available in the dataverse project, an open access public repository [ ] (https://dataverse.harvard.edu/, doi: https://doi.org/ . /dvn/ bune). due to the nature of the study and dataset, it was not necessary to obtain informed consent or approval from an institutional ethics committee. the authors give consent to publish the manuscript. the authors declare that they have no competing interests. key: cord- -y w hjy authors: loeffler-wirth, h.; schmidt, m.; binder, h. title: covid- trajectories: monitoring pandemic in the worldwide context date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: y w hjy background: covid- pandemic is developing worldwide with common dynamics but also with partly marked differences between regions and countries. they are not completely understood, but presumably, provide one clue to find ways to mitigate epidemics until exit strategies to its eradication become available. method: we provide a monitoring tool available at www.izbi.de. it enables inspection of the dynamic state of the epidemic in countries using trajectories. they visualize transmission and removal rates of the epidemic and this way bridge epi-curve tracking with modelling approaches. results: examples were provided which characterize state of epidemic in different regions of the world in terms of fast and slow growing and decaying regimes and estimate associated rate factors. basic spread of the disease associates with transmission between two individuals every two-three days on the average. non-pharmaceutical interventions decrease this value to up to ten days where complete lock down measures are required to stop the epidemic. comparison of trajectories revealed marked differences between the countries regarding efficiency of measures taken against the epidemic. trajectories also reveal marked country-specific dynamics of recovery and death rates. conclusions: the results presented refer to the pandemic state in may and can serve as working instruction for timely monitoring using the interactive monitoring tool as a sort of seismometer for the evaluation of the state of epidemic, e.g., the possible effect of measures taken in both, lock-down and lock-up directions. comparison of trajectories between countries and regions will support developing hypotheses and models to better understand regional differences of dynamics of covid- . coronavirus disease arrived in countries with . mio infections and more than , deaths worldwide so far ( th may ). the disease affects almost all spheres of life, especially public health, economics and well-being. present situation and near future lasting from months to one-two years (in worst-case more, in best-case less) will require coexistence with the virus until effective pharmaceutical countermeasures (medication, vaccine) are available and applicable [ ] . this coexistence requires adjustment of a balance between a controllable low level of infections and maximum-possible levels of public life and economics. controlling the infection requires feedback loops sensitive to early and robust indications of secondary outbreak waves. this includes permanent surveillance of epidemiologic and medical indicators by testing programs, monitoring of case numbers and symptoms and forecasting methods on one hand, and suited 'no-pharmacological intervention' (npis) strategies on the other hand, to held the case numbers low (ideally further decreasing) to prevent secondary outbreaks. various 'number-tracker' tools are active (e.g., [ ] [ ] [ ] [ ] ). they mostly plot case numbers (infected, recovered, death) over time, usually on a country-by-country (or region-by-region) basis. as an illustration, we show the number of current infections and of covid- related deaths as a function of time in selected countries ( figure ). these 'epi-curves' reveal how the epidemic was expanding in time and space from china (end of and january ) via other asian countries (south korea, iran) and western europe towards eastern europe, amerika, and other parts of the world (february to april ). they also reveal different phases of epidemic, namely, an initial 'take-off stage', an 'exponential growing stage' followed by 'slowed growth', 'turning into a decline' and 'decline' [ ] . charting the outbreak day by day in each country and comparing them, e.g. by setting an arbitrary starting threshold of, for example, infections, illustrates the succession of events as a global story [ ] . for a straightforward evaluation simple measures are typically used such as doubling time of cases, reproduction numbers (mean number of people infected by a typical case) or the number of new infections per , citizens in a certain region, which all provide a limited snapshot-view with pro's and con's in different states of epidemic. as a next, more elaborated level, standard epidemic models provide a theoretically well-founded description of dynamics of disease incidence in terms of rate constants for transmission and recovery of covid- and detailed infection-transmission 'serial interval' functions. different models, mostly assuming a series of diseases states such as the 'susceptible-infected-removed' (sir) types (see below) have been used to describe 'epi-curves' of selected countries and regions under consideration of i) spatial heterogeneous outbreak and transmission scenarios, and ii) the effect of npis [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . in case of the latter, models have been applied not only in retro-perspective but also to forecast epidemic in dependence on measures taken. because of still limited knowledge about disease mechanisms and detailed data about its spread in the population forecasting either provides short-term extrapolations or hypothetical predictions of possible future scenarios as the result of different model assumptions. we here provide the covid- viewer, a monitoring tool which aims at bridging the temporal 'epicurve' and the modelling levels. our monitoring substitute the time-coordinate used in the epi-curves by infected cases (cumulative or current ones). the obtained trajectories then enable to visually estimate the dynamic state of epidemic in terms of simple shape characteristics such as slope, parallel shifts or turning points with direct relations to transmission and removal rates of the disease. comparative analysis between trajectories of different countries enables to judge different scenarios of npis, population size, and social factors. daily actualized data and interactive web-functionalities enable monitoring pandemic based on newest data. our trajectory-approach is complemented by a series of simple model calculation which visualize the obtained trajectories for comparison with real ones. the paper is organized as follows: in the results section we introduce and illustrate the different trajectories and plots available in the monitoring tool by showing examples from different countries of the world, which are thought to serve as worked examples referring to the actual state of pandemic in the second half of may . the majority of plots shown in the publication were directly taken from the web-tool. the interested reader thus can actualize the data and/or chose countries of interest for similar views. we address the effect of nips in europe, the spread of epidemic in germany and compare mortalities between selected countries. the materials and methods section shortly explains the major functionalities. details of the methods, model simulations and fits as well as supplementary figures were provided in the supplement (appendix). figure : covid- cases (left plot: currently infected, right plot: died individuals) in different countries as a function of date. the ' -cases per country' threshold is crossed between end of february and end of march for the countries shown (except china). the time courses reflect growing (e.g., us, rus, nl), slightly decaying (e.g., i, d, tk), strongly decaying (e.g., ch, rok) regimes of epidemic or indications of bi-or multiphasic growth (e.g. am, ir). the courses of the dead toll as a function of time reflect country-specific percentages of covid- victims. the plots were generated in the corona-viewer on a daily actualization-basis as described in the text. the trajectory-monitoring tool ('covid- viewer') was programmed as web application using the rpackage 'shiny' [ ] . it processes the number of newly infected and of removed (sum of recovered and died) individuals from countries (and of diamond princess cruise liner with cases) as provided by the corona virus resource center of johns hopkins medical university ('world data': https://systems.jhu.edu/research/public-health/ncov/) and from robert-koch-institut ('germancountry' data: https://www.rki.de/de/content/infaz/n/neuartiges_coronavirus/fallzahlen.html). data are daily updated. the tool is available via the websites of izbi (www.izbi.de) and the leipzig health atlas (https://www.health-atlas.de/models/ ). the 'covid- viewer' is an interactive tool to monitor the development of the pandemic in countries and in the german states using simple and intuitive plots ( figure , appendix i). the tool is interactive and enables the user to select different presentations of data. the so-called 'rise-fall' trajectory was chosen as 'standard visualization'. it shows the newly confirmed covid- cases per country and per day (averaged over the past -days) as a function of accumulated total cases per country in double-logarithmic scale. the 'rise-fall' trajectory typically divides into a 'rising' exponential growth part reflecting growth of epidemic and a 'falling' decay regime due to counter measures and/or progressive immunization in the population. it allows estimating transmission and removal rates and reproduction numbers (appendix i). the time range can be chosen and, as an illustration, pressing the 'start animation' button generates a movie of the dynamics of epidemic in the selected countries in terms of progressing rise-fall trajectories. the user can chose 'custom' trajectories to combine different numbers (infected or removed cases, deaths, daily or cumulative counts, figure ) along the coordinate axes for alternative views (use the hoover window for curve assignment and details such as date, numbers). trajectories can be generated for all countries, groups of countries (use left-handed table for selection) or single countries. german states can be selected by choosing 'germany-state codes'. in addition to the standard plot, conventional time series plots show the different numbers (infected, removed, recovered, died as cumulative or per-day) as a function of date. the viewer offers standard browsing functionalities (zooming in and out, image download). . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint figure : covid- viewer: screenshot with major functionalities indicated (above) and example plots (below). the sir (susceptible-infected -removed) model provides a simple, adequate and straightforward interpretation of the data (see figure for illustration and appendix ii). it describes the disease as a sequence of three states, s (susceptible), i (infected) and r (removed), where infection proceeds via interactions between s and i individuals. recovered individuals are assumed to get immunized. the respective numbers were reported by census systems, which can differ between countries, e.g. by counting only hospitalized individuals, counting died covid- positive cases as not covid- caused and/or referring to different test-frequencies. all case numbers must therefore be understood as 'visible', i.e. reported ones. the rise-fall trajectories enables classification of the type of the growth and identification of the epidemic threshold (no growth). custom trajectories allow to estimate time-dependent sir model parameters such as the effective transmission and removal rate factors, c e (t) and k(t), respectively. time courses of the rate factors were extracted from the local slopes of the trajectories (appendix i and ii). the ratio of the rate factors estimates the effective reproduction number r e (t) defined as the number of individuals who get contaminated by one infected person on the average. the timedependent rate factors depend, in addition to the intrinsic properties of covid- on a series of external factors such as public health measures (non-pharmaceutic interventions, npis) to slow down transmission of epidemics (affecting c e ) and effective medical services after infection (affecting k). in addition to the estimation of sir parameters as described above, we performed least-squared fits of the trajectories where the daily numbers of newly infected and removed cases were calculated as a function of the cumulative number as predicted by the sir model (appendix ii). the fits provide estimates of n max , the maximum cumulative number of infected cases, and of the rate constants. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint monitoring the state of epidemic using 'rise-fall' trajectories the 'rise-fall' trajectory plots the newly confirmed covid- cases (averaged over a running day windows) as a function of accumulated total cases per country in double-logarithmic scale. the 'select all' function shows the trajectories of all countries considered (figure a ). overall, these doublelogarithmic trajectories reveal two basic features: an initially linear increase with a slope of unity indicates exponential growth of epidemic. this linear regime is followed for many countries by a downwards turn which indicates slowing down of growth owing to npis 'locking down' infections and/or possibly also to progressing immunization of the population in later phases of epidemic leading to the depletion of the reservoir of susceptible individuals and/or other factors. the 'rise-fall' plots use the cumulative number of cases n as a robust measure of progressing epidemic in a population. naturally, it is larger for countries with larger population sizes providing a larger overall reservoir for covid- infections compared with smaller countries. shape of the 'rise-fall' trajectories are however virtually independent of country size. the trajectories thus reflect intrinsic properties of epidemic in terms of its transmission and removal potential. the two sets of trajectories shown in the left and right part of figure a refer to situation at april th and about six weeks later, respectively. for most countries, among them france, italy, spain and germany, the trajectories turn into falling courses during this time and/or the falling parts further drop and intersects the ' . -slope' line referring to a more than tenfold reduction of the transmission rate of epidemic (see below). these trends thus indicate decay of pandemic after the npis taken in most of countries. on the other hand, brazil and russia emerged to the countries with most cumulative cases after usa, with still growing case numbers. most western european countries of larger and medium size reached the decaying part in the first week of april (except sweden and great britain) roughly two-three weeks after npis were taken in these countries. countries from different parts of the world such as austria, iceland, south korea, australia, new zealand and china reached low levels of new infections as indicated by strong vertical decays. larger countries (e.g. russia, india, brazil, pakistan) were in the rising part. some countries show a two-phasic growth as indicated by the parallel right shift of linear regions in their growing part (e.g. sweden, denmark, iran, ukraine, armenia) indicating that fast exponential growths are followed by slower phases due to reduced transmission rates (see below). singapore and japan show relatively slow growing phases with reduced rates and late turns into falling regimes while south korea's turn is very sharp presumably because of the 'crash down' measures taken there. is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . hence, the 'rise-fall' trajectories illustrate the current state of the epidemic and its developmental course with country-wise resolution. they enable monitoring the state in terms of differences and similarities between the countries and geographic regions revealing specifics and commons of epidemic spread: (i) a unique linear slope of most of the trajectories in the intermediate abscissa range is indicative for exponential growth in early phases of the outbreak of the pandemic (low level of immunity in the population). the nearly identical position of these lines refers to covid- typical pandemic spread rate and maximum basic reproduction numbers r (appendix ii). (ii) parallel, downshifted lines suggest still exponential growth, however with reduced rates reflecting reduced effective reproduction numbers < r e < r . in these countries (e.g., sweden, iran), the epidemic is not stopped. (iii) the 'flattening' of slope and downwards curvature seen, e.g. for most european countries such as italy, spain or germany reflects slowing down growth owing to efficiency of npis and, possibly to a minor degree of progressive and significant immunization in the population. (iv) the sharp, virtually vertical drop of trajectories reflects the stop of epidemic observed, e.g. for china and south korea, and after may st for new zealand, australia, and also part of european countries. (v) the different qualitative features of the trajectories are virtually independent of (population) size of the countries. 'smaller' countries like island, cyprus, armenia or georgia show overall similar features such as linear rise, parallel shifts (armenia), a maximum and steep falling parts (e.g., island). . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint the 'rise-fall' trajectory uses cumulative cases n along the abscissa as a robust measure of the extent of the epidemic. this number doesn't consider the degree of recovery and thus it doesn't reflect the current amount of infected cases (i). custom trajectories make use of the independent number of removed cases (r) reported and plot cumulative, current and differential (per day) numbers in different combinations (appendix ii). using the current number of infected cases (i= n -r) as x-axis one sees whether the extent of infection increases or it decays. while the rise-fall trajectory, n-vs-n, tends asymptotically towards a maximum cumulative number of infections (n max ) for each country, which reached the falling regime, the n-vs-i trajectory turns from a growing i into a decaying branch at i max , the maximum number of infected individuals. these trajectories turn in clock-wise directions for most countries meaning that the rate factor of transmission of epidemic, c e (t), strongly decays (appendix i and ii). for example, austria and japan show full turns while the turns of sweden and usa remain incomplete leading to less pronounced decays of the respective c e (t)-courses (figure a, b) . in contrast, the r-vs-i trajectories turn typically in counter-clockwise direction referring to an increase of the removal rate factor as explicitly seen in the respective k(t) plots. the ratio of the effective transmission and of the removal rates then estimates the effective reproduction number as a function of time, r e (t) (figure b ). the trajectories of the countries selected for illustration reflect different types of trends such as strong and straight repression and stop of epidemic via reduction of transmission in austria, reduced growth but still expanding epidemic in usa and sweden or indications of a second wave of expanding epidemic in iran. here, the respective trajectories and plots of rate factors and of r e (t) show different aspects of the dynamic of the epidemic. for example, s and j are characterized by relatively low levels of rate factors compared with a and ir, a difference seen also in the parallel shifts of the respective trajectories. in appendix ii we find analogous differences between western and south european countries (e, f, i, figure s ) compared with middle european ones (d, a, ch), which suggest differences in the spread mechanism of covid- and, possibly, also in the recovery dynamics. the removal rate obtained depends on the time-delay between infection and recovery, which is neglected our simple trajectory-approach (see also epicurves in figure a ). 'cumulative balance' and 'current case' custom trajectories complete the visualization options: lower levels of transmission and removal rates associate with such trajectories running closer to the diagonal. overall, the trajectories enable tracing an epidemic in terms of case numbers reported directly be the census agencies of the respective countries. derived numbers such as the rate factors and reproduction numbers 'translate' these numbers into features more directly describing the dynamics of the epidemic. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint effective reproduction numbers as shown in figure b provide suited summary measures of the case numbers with a well-defined epidemiological meaning. their value defines the transmission potential in the population in terms of the mean number of individuals who are infected by one infectious person on the average. for the comparison of all or a selection of the countries available, the monitoring tool generates a ranked boxplot of their actual reproduction numbers. presently, the epidemic is not stopped in roughly % of all countries because their r e is still larger than unity ( figure ). the tool also generates the respective plot for r e -values obtained two and four weeks before. at the latter date about % of countries show r e > , which demonstrates the presently decaying trend. time courses of a selection of countries illustrate different types of decays which eventually relate to the type of npis taken. for example, early, consequent eradication of epidemic in island and croatia result in fast and steep decays. slower but monotonous decays were observed in russia, spain and portugal. also wave-like changes before the final decay (japan, singapore) or even worsening of situation (armenia, sweden until middle of may) were found. presently (may, th ) sweden shows the highest reproduction numbers among all countries studied. note, that r e is a relative measure considering daily changes and current numbers of infections and recoveries (appendix i), meaning that restricted outbreak clusters affecting only relatively small numbers of individuals suggest spread of epidemic in a larger, not affected population. hence, a combination of charcteristic numbers should be used to characterize dynamic of epidemic, namely transmission rate factor (or doubling time of cases) more at the beginning, effective reproduction numbers more in the phase of vast spread of epidemic and absolute numbers of new cases in the phase of mitigation and near eradication. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint next, we asked how the npis taken in middle and western europe and scandinavia in the first three weeks of march affected the dynamics of the epidemic. the rise-fall trajectories of countries selected from [ ] reveal that they now are mostly in the falling regime however with modifications such as parallel downwards shifts, wave-like decays and even lacking decays as already discussed above (figure fehler! verweisquelle konnte nicht gefunden werden.a) . in figure fehler ! verweisquelle konnte nicht gefunden werden.b we re-plot the trajectories separately for each country together with marks indicating which measure was taken when along the trajectories. in most cases, trajectories start turning downwards about two weeks after a complete lockdown in the respective country. before this, one often finds slowing down of the exponential growth as indicated by small differences compared with the trajectory of us referring to exponential growth. in norway, denmark, and also sweden one observes a relatively strong first slowing down as indicated by the parallel downwards shift of the trajectories which roughly refers to a reduction of the transmission rate constant by about % (figure d ). sweden, without complete lockdown measures, but also great britain show weakest decay of the trajectories and largest values of the effective reproduction numbers r e > in contrast to all other countries except belgium (figure c ). comparison of the reproduction numbers two and four weeks earlier indicates consistent high values in britain and sweden and also a delayed decay in italy, spain and france, the european countries, which were heavily hit by covid- in february and march. the time courses of the reproduction numbers r e (t) respond nearly immediately on the measures in many cases showing, at least, small drops in support of a recent study [ ] which assumes that the reproductive number -a measure of transmissionimmediately responds to interventions being implemented ( figure d , the first measure and complete lockdown were indicated). consistent decays to values r e < after about two weeks were seen in scandinavia (except sweden) and austria, switzerland and germany while in belgium, france, italy and spain the decays last roughly four weeks until they fall below the epidemic threshold. in sweden and great britain, virtually unchanged levels of r e above the et were observed. a recent model analysis of the effect of npis in germany applies a sir model with changed rate constants at so-called 'change points' which are assumed to take place when measures were applied [ ] . we found a decay of the transmission rate during the time when measures were applied which drops overall by - % in rough agreement with [ ] (figure d , right part). interestingly, japan showed a similar resonse to npis as the european countries, namely a slow, but instantaneous growth of epidemic turned into the falling regime at the beginningf may ( figure ), two-three weeks after npi measures were intensified at april th . overall, our simple analysis reveals that npis were followed by drops of the reproduction number mainly due to a decay of the transmission rate factor and by halt of epidemic after two to four weeks after complete lock down. sweden (and partly gb) shows also a drop of r e and the transmission rate which however overall are insufficient until end of may to stop epidemic. both, the time-course of reproduction number and the rise-fall trajectory are sensitive to detect the slowing down and the halt of epidemic. the available country-wise numbers used do not allow to analyse the observed effect assuming heterogeneous effects of npi on different subpopulations which, in principle, could explain steps and wavelike changes in the courses of the trajectories as an alternative to alterations of the rate factors in a homogeneous population assumed here. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint figure : the effect of non-pharmaceutical interventions across ten european countries selected in analogy with [ ] . the trajectory of us is shown for comparison. a) rise-fall trajectories of selected countries mostly decay thus indicating marked decrease of epidemic in most cases. b.) country-by-country plots of the rise-fall trajectories together with marks assigning the nips (dates and assignments were taken from [ ] ) show that the trajectories turn downwards about two weeks after lockdown in most cases (the grey box refers to the 'two weeks after the last measure' date). exceptions are sweden (no complete lockdown) and united kingdom. the two green boxes indicate the data obtained at march th (mostly before measures) and may th. c) the effective reproduction numbers are still clearly above the critical value of r e = for sweden and great britain. italy and france show the strongest decay of re over the last weeks. d) courses of the effective reproduction number as a function of time indicate a marked drop of re(t) immediately after the lock down in most countries. also the first measure taken is indicated. for germany all measures were indicated together with the courses of the rate factors. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint countries across the world differ in many factors related to covid- epidemic such as the particular npi measures, social behaviour, family structure and education systems with differing school rules, population densities, urban structure, transport system and also age distribution. the heterogeneity of these factors is assumed to be smaller inside each of the countries than between them. for germany, the covid- viewer provides 'rise-fall' trajectories for all sixteen german states, which cover population sizes between about . mio (bremen) up to mio inhabitants (nordrhein-westfalen). they include three city-states (hamburg, bremen, berlin), while the other states are 'area'-states include countryside regions and towns of different sizes. the trajectories overall express very similar courses of the epidemic across germany (figure a) , which suggest relatively similar dynamics of the epidemic in different parts of the country and, particularly, that germany-wide npis 'locked-down' epidemics in the different states in a similar way. analysis of the maximum cumulative number of infected individuals, n max , using fits of the 'rise-fall' trajectories however reveals considerable differences especially between the south and west of germany and its east and north (figure b ). in bavaria, which is located in the south of germany, roughly eight-times more people are infected on relative scale than in mecklenburg-vorpommern located in the north-east. in general, 'area' states from the west and south of germany were more affected by epidemic than states in the east and north. this difference associates with an earlier outbreak in the former states with higher amounts of infected individuals (figure c ). npis were taken germany-wide at the same time between th and th of march, which suggests that delayed measures with respect to the outbreak will increase the burden of infections. in summary, germany-wide the trajectories reflect similar dynamics of epidemic where however earlier outbreaks especially in the west and south and in larger cities gives rise to increased numbers of infected persons, possibly because of the delay of npi. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint figure : covid- in germany: a) 'rise-fall' trajectories across german states: the trajectories of german states resemble that of whole germany indicating similar dynamics of covid- across germany. trajectory of us is shown for comparison. b) the relative maximum cumulative number of infected cases (per , residents of the respective states divides clearly into states from west and south germany and states in the east and north of germany. city states (be, hh, hb) are found in the former group. c) epi-curves (cumulative case numbers as a function of time) reveal that epidemic arrived earlier in western and southern states mostly by a few days compared with the eastern and northern ones. the curve of the city state bremen (hb) slightly differs from that of the other ones. mortality is an important endpoint of covid- epidemic related to a series of factors such as the intrinsic severity of the virus [ ] in first instance, but also age, sex, genetic and immunological predisposition [ ] , disease history and also co-morbidities of the patients [ ] , as well as the effectivity of medical measures such as icu services [ ] , the capacity of health care systems and also socio-economic factors. censing of deaths, e.g. by counting covid- positively tested deaths as covid- caused or not, is another factor affecting the reported numbers. so far we subsumed the numbers of death cases together with recovered individuals as removed ones. separate counting shows that, overall, the dead toll of covid- ranges from less than % up to more than % of counted infections, depending on country and time, when the data were registered (see below). the 'custom trajectory' page provides 'mortality trajectories' in terms of cumulative death cases versus cumulative infections . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint (alternatively one can choose daily cases). constant percentages refer to parallel diagonal lines as indicated ('iso-percentage' lines). for illustration we selected groups of countries in figure for comparison with part of the 'rise-fall' trajectories in figure b . larger-size west-european countries (great britain, france, spain, italy) all show similar mortality trajectories referring to about % of the (visible) infected individuals. mortality of germany and austria is smaller (about %), possibly due to the smaller mean age of infected persons at the beginning of epidemic. the respective mortalitytrajectories however slowly grow in direction of the level of the other european countries with increasing number of infections. note that the slopes of the trajectories of the latter countries (e.g. france, italy, spain) is slightly steeper than that of the iso-percentage lines which indicates slowly growing mortalities across in these countries. presently, mortality in europe is largest in sweden, belgium, netherlands and great britain with further increasing trends. relative small mortality is found in russia and belarus possibly caused by governmental-control about covid- related death-census. mortalities in ukraine and estonia and in east asia (china, japan) are comparable with mortality in us, where the latter asian countries and also south korea show an increasing trend of mortality. in south america, one finds higher mortalities than in us with further increasing trends. overall, comparison of the mortality trajectories reveals systematic differences and trends, which need further analysis for interpretation. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint we here presented the 'covid- trajectory viewer', which generates a series of trajectories and plots based on public available covid data. it enables the comparison between epidemic development with country-wise resolution worldwide. trajectories are based on two types of counts, namely the number of infected and of removed (recovered and died) individuals. plots use either these counts directly, their cumulative values or increments per day and combine them in different ways, which allows to inspect the actual state of the epidemic from different perspectives. in addition, the monitoring tool enables calculation and visualization of derived parameters, namely the effective transmission and recovery rate factors and the effective reproduction number. they estimate the transmission and removal 'power' as basic characteristics showing whether epidemic growths or declines. changes of these parameters during epidemic development reflect different factors affecting the dynamic of epidemic, namely (i) the possible consequences npis, (ii) eventually growing immunity due to decaying numbers of susceptible individuals, and, (iii) also differences in the methods of counting and reporting data between different countries. our monitoring metric is sensitive for subtle alterations of the dynamics of the epidemic making it suitable to estimate the effectivity of npis and to serve as 'seismometer' for secondary outbreaks to early indicate such events ( figure ). three possible future pandemic scenarios for covid- dynamics have been suggested based on previos influenca courses [ ] , firstly, 'peaks and valleys' where the first big wave in spring is followed by repetetive smaller waves with geographic specifics depending on local npis; secondly, the 'fall peak' suggesting a large secondary peak in fall, winter ; and, third, a 'slow burn' of ongoing transmission and case occurrence, but without a clear wave pattern, again with geographic variations affected by the degree of mitigation measures in place in various areas. one or none of them, or even all three in parallel in different countries will be possible, where trajectories and rate factor curves will provide an instrument to distinguish the different scenarios. thereby, one has to keep in mind that these are data on visible, symptomatic covid cases. unsymptomatic cases remain usually undetected and can exceed the number of symptomatic ones considerably. a recent publication shows that more than % of all positively tested covid- cases on a cruise liner did not show any symptoms, raising questions about the true prevalence of "silent" infections [ ] with possible consequences for the immunization dynamics in a population. moreover, our simple monitoring does not explicitly consider heterogeneities of the spread of the epidemic in a population (e.g. cities versus countryside, elderly versus younger, hospitalized versus non-hospitalized, symptomatic versus asymptomatic, highly exposed professions versus less exposed ones, etc.). such effects are hidden in the data and can be considered in terms of the trajectory approach by using more detailed data, e.g. by stratifying populations geographically, with respect to professions, age, symptoms etc. and/or by applying more elaborated models. our visualization in terms of trajectories and derived rate factors and their interpretation is based on the simple sir model dividing the visible population into three types of individuals. such three-state models have been widely and successfully used in many areas of sciences to describe different kinds of dynamics, ranging from elementary reaction kinetics in chemistry to photo-physics, molecular transformations in biology and many other fields. the basic assumption behind the sir model is the mass action law, claiming that changes of the population of a state directly relates to its population number. the different trajectories visualize this relationship by plotting changes of newly infected or . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint removed individuals as functions of the number of cumulative or currently infected individuals. the double logarithmic scaling of the axes accounts for the fact that the solution of the ordinary differential equations behind the sir model predicts exponential dynamics in important limiting regimes such as the early or late outbreak limits, which in turn, suggest linear courses of the trajectories. this way the obtained trajectories reflect a virtually common maximum transmission rate in the exponential growth phase in many countries suggesting that each infected individual infects another one every two-three days (figure a ). the initial growth is followed by down-steps and parallel shifted lines indicative for exponential growth with reduced transmission rate (e.g., transfer of infection between two individuals every five days). downturns of different sharpness indicate markedly reduced spread dynamics, and also halt of the epidemic in terms of falling courses if transmission frequency reaches a level of more than one per ten days. the close temporal relatedness between slowing down of the transmission dynamics and the dates when measures of the npi-type were taken suggests causal relations and shows that an associated 'falling' regime can be monitored using the trajectory approach. the npi result in dropping transmission rates and reproduction numbers where the steepness of decay in europe is larger for countries such as austria and germany, which were hit by the main infection wave a few weeks later than italy, france and spain showing slower decays. early nips on a relative time scale with respect to growth dynamics obviously facilitate faster slowing down afterwards. so-called 'complete lockdown' measures seems to be an essential measure for stopping epidemic despite considerable differences between countries, e.g. in handling go-out restrictions ('ausgangssperre', relatively moderate rules in germany versus strong ones in italy, spain and france). the swedish model seems to fail regarding transmission dynamics conceding further expanding epidemic and high death toll (figure a ). our trajectories show that lowering a of transmission rates by more than - % compared with its maximum, intrinsic value, is required to stop epidemic and to turn it into the decaying regime. joint plotting of trajectories using the covid- viewer shows that at present majority of east asian (china, south korea, singapore) and european countries are in the falling regime, while most american countries are in the exponential growth phase. epidemic seems virtually eradicated in the island states new zealand, iceland but also other small countries such as croatia in a similar way as observed at 'diamond princess' cruise liner held under isolation (figure b ). it shows that isolation in combination with strong npis effectively stop epidemic. on the contrary, slowing down but still exponential growth are seen in other small and relatively isolated countries such as armenia (surrounded by mountains and closed borders to part of neighbouring countries) reflecting inefficiency of measures taken. wavelike up and down as seen for iran indicate repeated waves of growing epidemic (figure c ). new outbreak clusters become evident as spiked upturns in the falling regime as indicated presently for south korea (figure d ). the removal rate factor is a second, important characteristic of covid- dynamics, which additively composes of recovery and death rates, where the former number is dominating. removal rates can differ by a factor of two-to-ten between different countries (e.g. germany and austria versus spain and france, figure s ) by unknown reasons. possible explanations are specifics of the recovery process due to healthcare measures applied and/or epidemiological factors such as age-and/or health-risk of the respective populations. also counting criteria of recovered individuals are another, possibly more relevant factor, which can differ between countries. often census agencies apply recovery counting algorithms (e.g. by assuming recovery two weeks after infection if no other information is available in germany) presumably biasing estimation of removal rate factors. moreover, also counting of deaths is census-dependent. on the other hand, the initially low but afterwards increasing mortality rates in austria and germany can be rationalized by the increasing age of infected individuals (disease was initially spread in communities of younger persons). thus, comparing trajectories supports detection . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint of differences of recovery and mortality rates between countries for subsequent analysis of the possible reasons. figure : example trajectories indicating different dynamic regimes of covid- : a) basic rise and falling regimes refer to transmission intervals of - and more than days, respectively. they were observed in european countries under complete lock down such as austria. incomplete lock down as applied in sweden only slowed down spread of epidemic. it associates with roughly two times more infections and a more than four-fold deathtoll. b) eradication of epidemic can be expected in island states (iceland, new zealand) and other relatively small countries (e.g. croatia) showing disappearance of new cases two to three months after the outbreak (see epicurves in the insertion). another example of eradication is covid- spread at the princess diamond cruise liner with about infections. c) wave-like up and downs of epidemic were observed in armenia and iran. the trajectories transform into wave-like oscillations of the effective reproduction number (insertion). d) a new spike of cases is seen in the trajectory of south korea. the trajectory for us is shown for comparison. covid- pandemic develops in different phases around the world ranging from exponential growth to decaying regimes and even eradication from region to region and from country to country. it is characterized by high dynamics, which necessitate prompt monitoring to evaluate the outcome of npi measures in either, 'lockdown' or 'lock up' direction to indicate improvement or worsening in terms of suited metrics such as increasing or decreasing numbers of cases, rate factors or reproduction numbers. the covid- viewer provides this information in the worldwide context on a daily actualized basis. we understand our report as a worked example reflecting aspects of the pandemic in may , which supports future monitoring using the covid- viewer as a sort of working instruction. many aspects of the covid- pandemic are not completely understood. this includes dark figures of infections, detailed spreading mechanisms and associated socio-economic, politic and health factors. here more studies reasoning differences between regions and countries are required. the trajectory approach complements epi-curve reporting by bridging the gap to modelling methods. inspection and comparison of the trajectories and of the time courses of rate factors extracted are expected to inspire development of substantiated hypotheses and elaboration of improved models to better understand mechanisms of epidemic spread and decay and theirs specific in different countries and regions. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . covid- : the cidrap viewpoint: part : the future of the covid- pandemic: lessons learned from pandemic influenza coronavirus pandemic (covid- ) coronavirus tracked: the latest figures as countries fight to contain the pandemic the covid tracking project mitigation and herd immunity strategy for covid- is likely to fail a first study on the impact of current and future control measures on the spread of covid- in germany projecting the spread of covid for germany imperial college covid- response team estimate of the development of the epidemic reproduction number rt from coronavirus sars-cov- case data and implications for political measures based on prognostics quantifying the effect of quarantine control in covid- infectious spread using machine learning covid- spread: reproduction of data and prediction using a sir model on euclidean network sequential data assimilation of the stochastic seir epidemic model for regional covid- dynamics effective containment explains subexponential growth in recent confirmed covid- cases in china estimating effects of physical distancing on the covid- pandemic using an urban mobility index a time-dependent sir model for covid- with undetectable infected persons. eprint arxiv viola priesemann: inferring change points in the covid- spreading reveals the effectiveness of interventions autocatalytic model for covid- progression in a country using phenomenological models for forecasting the extended sir prediction of the epidemics trend of covid- in italy and compared with hunan evaluation of the secondary transmission pattern and epidemic prediction of covid- in the four metropolitan areas of china shiny: web application framework for r. r package version inferring change points in the spread of covid- reveals the effectiveness of interventions sars-cov- (covid- ) by the numbers a global effort to define the human genetics of protective immunity to sars-cov- infection factors associated with hospitalization and critical illness among , patients with covid- disease features of , hospitalised uk patients with covid- using the isaric who clinical characterisation protocol covid- : in the footsteps of ernest shackleton estimating epidemic exponential growth rate and basic reproduction number the disease-induced herd immunity level for covid- is substantially lower than the classical herd immunity level estimating individual and household reproduction numbers in an emerging epidemic time-dependent sir model for covid- with undetectable infected persons. arxivorg key: cord- -a i vnjz authors: nason, guy p. title: rapidly evaluating lockdown strategies using spectral analysis: the cycles behind new daily covid- cases and what happens after lockdown date: - - journal: nan doi: nan sha: doc_id: cord_uid: a i vnjz spectral analysis characterises oscillatory time series behaviours such as cycles, but accurate estimation requires reasonable numbers of observations. current covid- time series for many countries are short: pre- and post-lockdown series are shorter still. accurate estimation of potentially interesting cycles within such series seems beyond reach. we solve the problem of obtaining accurate estimates from short time series by using recent bayesian spectral fusion methods. here we show that transformed new daily covid- cases for many countries generally contain three cycles operating at wavelengths of around . , . and . days (weekly). we show that the shorter cycles are suppressed after lockdown. the pre- and post lockdown differences suggest that the weekly effect is at least partly due to non-epidemic factors, whereas the two shorter cycles seem intrinsic to the epidemic. unconstrained, new cases grow exponentially, but the internal cyclic structure causes periodic falls in cases. this suggests that lockdown success might only be indicated by four or more daily falls in cases. spectral learning for epidemic time series contributes to the understanding of the epidemic process, helping evaluate interventions and assists with forecasting. spectral fusion is a general technique that is able to fuse spectra recorded at different sampling rates, which can be applied to a wide range of time series from many disciplines. what the impact of measures that came in on march will be". the measures that professor mclean referred to were the widespread uk social distancing and lockdown interventions made in the face of the covid- threat. at the time of writing, few countries have experienced in excess of days of covid- cases and most only have around days. professor mclean is correct in that many scientific inferences require longer time series than those currently available. however, we show that there are considerable and useful similarities in the underlying cyclic (spectral) behaviours of the numbers of new daily covid- cases for a range of different countries (see extended data figures). we use recent bayesian spectral fusion methods [ ] (regspec) to pool spectral information across countries, which provides significantly more accurate estimates of cyclic behaviour than provided by a typical spectral analysis of a single country alone. the bayesian principles underlying our fusion method handle mean that uncertainty is treated coherently, producing rational uncertainy assessment for our cycle (spectral) estimates. our methods produce cycle estimates using the equivalent of over nine hundred daily observations, compared to the fifty or so that a typical standard spectral analysis might use. using data [ ] from all of the countries we considered, our results show that transformed new daily covid- cases have three underlying cycles: one operating at a wavelength of . days, a second at . days and a third at . days, which we take to be a weekly effect. we conducted separate analyses for the uk and groups of countries with similar spectra and note some variation in those cycles. for some purposes it is not reasonable to compare or pool the number of new daily cases from one country to another [ ] . for example, different countries might use different definitions of the number of daily cases and they record cases through different national structures and this is even the case for countries with political, geographical or cultural similarities. however, as long as the method of recording cases is broadly unchanged over the period in question for a particular country, the spectral properties across countries are comparable. the transformed cases' spectrum quantifies the internal oscillatory structure within the series and is largely unaffected by the overall level of cases, the different start times of epidemics in different countries (phase) and country-specific internal delays due to reporting requirements (also phase). in addition, the demonstration of the presence three consistent cycles across all countries, with some variation, provides supporting evidence for the suitability of the transformed new daily cases as a target of analysis, and comparisons between and across countries, another topic of great current interest is to ascertain whether and how a lockdown will influence the number of new daily covid- cases. we consider this question for the group consisting of the uk, italy, france, germany, spain, switzerland, belgium and the netherlands. the number of days (with cases) be-fore lockdown is, on average, for this group of countries, and, after lockdown, is (except the uk, which started its lockdown later). the averages just quoted include allowance for a seven day incubation period. our analysis compares the spectral properties before and after lockdown. a spectrum based on about days worth of data would provide a very poor and highly uncertain estimate. however, our spectral fusion methods [ ] permit effective sample sizes for the group of days worth of data prior to the lockdown, and after, resulting in highly accurate spectral estimates for these periods. we learn that, after lockdown, the weekly cycle remains strong, but the cycles operating around . and . days become suppressed. this indicates that the weekly cycle is due, at least in part, to administrative recording effects, which are not effected by the lockdown, whereas the . and . day cycles might be related to virus dynamics, which is certainly affected by lockdown. the discovery of how the high-frequency cycles are disrupted by full lockdown suggests that they could be monitored during partial lockdowns. for example, if schools are reopened and the . and . day cycles do not reappear, then this might indicate the effectiveness of that strategy. given the similarity of the cycles across countries, this indicates that cases could be monitored and pooled across regions, over a short number of days to be fused into longer effective samples using the methods described here. a more difficult problem is that of forecasting transformed new daily covid- cases. such information would be of great interest, e.g., to those planning health provision over a short timescale. knowledge of the three cycles is helpful and we have had moderate success in forecasting daily cases. however, with individual country series, with smaller number of days, it is unrealistic to expect too much and, in particular, the transformed cycles experience both a degree of time-modulation and possible frequency changes. more useful perhaps, are not daily forecasts, but the knowledge that the number of cases will increase and decrease over a period of three/four days. this means that if one observes a decrease in the number of daily covid- cases after lockdown, that does not necessarily mean the peak has been reached, but is simply a manifestation of the / day cycles. hence, one might believe a lockdown strategy has been successful after a sustained decrease of at least four days. spectral analysis [ , ] of epidemics is not new, but most work has been carried out on epidemics observed over long time periods (seasons and years) using lengthy time series [ , , ] . recent work [ ] on covid- has applied popular autoregressive integrated moving average process [ , ] models to a single prevalence time series with a sample size of n = . however, conclusions derived from such analyses on a single series with such small sample sizes [ ] are questionable. for example, an autoregressive process of order one with parameter . , normally considered to be a strong signal, is only distinguishable from white noise [ ] approximately % of the time with sample size of n = ; basic simulation studies show the large number of possible different models that can fit such short series apparently well. this indicates that it is virtually impossible to tie down the correct model with such a small sample size. phenomenological sub-epidemic models [ , ] show much more promise and have been applied with some success to short-term forecasting of covid- cases in guangdong and zhejiang, china. these improve performance by using bootstrap methods on short case time series, but are still ultimately based on a parametric model of single series. our work is very different as it provides exceptionally accurate spectral estimates for a novel live epidemic that is still in its early days on short series, but reliably so by using recent bayesian spectral fusion techniques. [ ] . the nonparametric nature of our analysis also permits us to split case time series at a boundary (e.g. lockdown or other intervention) and analyse the two halves separately, still with very short series in each. this is perhaps harder to do with classical parametric models and to maintain consistency between the two halves. on the other hand, our method relies on good quality case series from different regions, which is again not always the case for all epidemics. we transformed the number of new daily covid- cases by applying a signed log transform to the first differences of the new case time series (see methods). the transformed number of new daily cases for countries are shown in figure each showing a distorted noisy, but characteristic sinusoidal trace. the estimated log-spectrum for the uk transformed new daily cases is shown in figure and for all other countries we analysed in the extended data figures. spectral estimates are commonly displayed on a logarithmic scale [ ] . spectral peaks can be observed at wavelengths of . , . and . days, respectively. although the peaks are visible, the credible intervals indicate that there is a fairly large degree of uncertainty, because this time series contains observations. a frequentist analysis, e.g. using the spectrum function in r [ ] , produces a similar result, but with even wider confidence bands. similar spectral analyses for each country indicate three similar spectral peaks, although not always as well-defined nor in precisely the same location. figure shows an estimate that is the result of coherently fusing spectra from countries, giving an an effective sample size of days. here, the clear spectral peaks have narrow credible intervals, due to the large effective number of days afforded by using countries together. the spectral peaks are located at wavelengths of . , . and . days. the peak around . days is observed in the spectral plots for individual countries and we interpret it to be a weekly effect. such a weekly effect could be produced by reporting artefacts (e.g. paperwork being delayed until monday, or carried out differently at the weekend) or due to the behaviour differences of people at weekends. all countries analysed have a + working week/weekend pattern, although not necessarily the same days of the week (the actual days for a weekend are a phase effect, which does not effect the spectrum). clustering spectra and groups of countries with similar spectra we next clustered our countries based on their spectrum, by calculating a dissimilarity between the spectra for each pair of countries, and then performing both a hierarchical cluster analysis and multidimensional scaling on the dissimilarity matrix. the scaling solution indicated that only two dimensions were required to encapsulate % of variation in the data. figure shows the resultant twodimensional solution. attaching a meaning to the scaling axes in figure is not easy. we hypothesise that axis might indicate how badly a country has been perceived to have been affected by the virus with australia, new zealand and sweden less so and those on the left of the plot considerably more so. however, germany is the obvious anomaly to this interpretation as, currently, it has perhaps been perceived to have handled the crisis well so far. table : spectral peaks for the three country groups in units of days. the peaks in the second and third rows have been arbitrarily labelled as peak a. and b. figure show the spectral estimates for the three groups of countries identified in figure , using the clustering techniques mentioned in methods. the peak frequencies for each of these groups is listed in table , which shows differences between them. however, each group possesses a possible weekly peak and higherfrequency peaks labelled a., of around three to four days, and b., around . days. many countries experiencing the covid- pandemic have instituted a lockdown procedure to dramatically reduce virus transmission. at the time of writing, these countries have observed new daily covid- cases for between and days. we assume that, on average, it takes about seven days for the virus to incubate, for a person to seek attention and then be tested positive for the sars-cov- coronavirus. for each country, the number of days prior to and after the lockdown ( , ) . for some of these countries the lockdown was applied over a period of two of three days and we took the median of these as the lockdown start date. the number of days before and after the lockdown are, in each case, too small to carry out anything other than the most simplistic time series to maintain statistical reliability. in particular, a spectral estimate in this situation would be subject to a high degree of uncertainty. however, figure shows our coherently fused spectral estimates [ ] across these countries before and after the lockdown period, making use of effective days prior to lockdown and days afterwards. the weekly peak is clearly visible in both estimates. the second and third peaks (labelled a. and b. in table ) are visible pre-lockdown, but have all but disappeared post-lockdown. the spectrum is flat in the location where peak a. was previously, and spectral power declines considerably, relatively, where peak b. was located previously. this result is particularly interesting as it suggests that peaks a. and b. have been disrupted by the lockdown. the weekly effect seems relatively unchanged by the lockdown, indicating that perhaps it was strongly driven by non-epidemic effects, such as recording/paperwork or bureaucracy caused by weekends. the post-lockdown spectrum is higher overall than the pre-lockdown spectrum, this is due to the larger variation associated with the larger number of cases identified during the progress of the epidemic. our transformation suppresses this variation, but does not remove it entirely. we have had varied success in forecasting daily cases using a sum of two timemodulated cosine waves model, described in methods, and more research is required. we used the nelder-mead [ ] optimisation routine built into r [ ] , with starting frequencies of . and . taken from our uk spectral estimate plots, and built the model on the transformed cases up to april th. after optimisation, the fitted model resulted in modified frequencies ofω = . ,ω = . , close to the starting frequencies (the other estimated parameters wereα = . ,α = . ,φ = − . ,φ = − . ,μ = . ,μ = − . ,p = . ,p = . ). figure shows transformed new daily uk cases, the model fit and forecasts. the model fit does not look too bad, many spectral peaks are being identified, but perhaps the amplitudes of them could be better matched. the untransformed forecasts for april th, th, th and th were , , and , all with approximate % confidence interval of ± . the actual number of cases for april th turned out to be . in this case, the forecast was good. however, the two-step ahead forecast of was wrongthe true value turned out to be on april th. we also used several stochastic forecasting methods based on autoregressive integrated moving average modelling and exponential smoothing, but nothing that we tried was particularly successful. the series is difficult as its amplitude/variance is not constant and we suspect that frequencies are changing over time (as, e.g., the lockdown plot figure indicated). however, rather than point forecasts, the general sinusoidal nature of the transformed cases suggests a further, perhaps more reasonable strategy. at this stage, the uk government and media are looking expectantly at the daily case numbers to try and detect a sustained downward trend in cases. excitement has been generated by a drop in cases two days in a row. this happened on april th with cases, followed by a drop to and then on april th and th and then, unfortunately, increasing to on the th. however, the general sinusoidal patten, with a wavelengths of about . and four days shows that we should only perhaps start believing that a downward turn is a downward trend after a sustained decrease of four days or more. however, caution needs to be applied here as there is no guarantee that the dynamics will remain unchanged. we analysed numbers of deaths using similar methods described here and found similar cycles. although we have not carried out a detailed analysis, if the number of deaths process can be approximated by a linear system [ , ] with the numbers of cases as input, then similar cycles are to be expected. a time series with a fixed sampling rate and length has a minimum and maximum (nyquist) frequency that can be observed. [ , ] although our spectral fusion methods [ ] provide more accurate estimates of the spectrum in the normal range (equivalent to having a larger sample size), they can not provide information on frequencies outside of the normal range. to estimate lower frequencies, we would need a genuinely longer series and, for higher frequencies, we would require cases more frequently than once a day, which are arguably not really necessary for any practical purpose. our analyses assume approximate stationarity and linearity for the transformed series, which is unlikely to be exactly true in practice. for example, in the uk transformed case series in figure , there are hints of the series oscillation speeding up over the last ten days. practically speaking, changes in the testing regime, recording practices, the lockdowns or other interventions will change the dynamics of either the pandemic itself or recording of it. ideally, it would be of interest to use methods for non-stationary time series [ , ] , but the current series available to us are far too short for such analyses. all computations were executed in r [ ] and packages that are mentioned specifically below. let y t , for t = , . . . , n c represent the number of new daily cases for n c days for country c. the spectral dynamics of the number of daily cases for different countries are all countries masked by the well-known and characteristic exponential increases (and decrease, for those countries that locked down and have now passed their peak). hence, we transform our number of daily cases series to reveal the spectral dynamics. after exploration [ ] the following transform was used for all series l t = sgn(d t ) log(|d t |), where the sign function sgn(x) is + , if x is positive or − , if x is negative, and d t = y t − y t− for t = , . . . , n c . the transform is easily inverted, which is essential for forecasting the number of daily cases. we use the regspec [ , ] bayesian spectral estimation method with a neutral white noise prior with prior variance of and all default arguments, except for a smoothing parameter of . , although the results are not sensitive to the latter. regspec straightforwardly enables the production of spectral estimates using multiple data sets, with each having different lengths and produces coherent credible intervals to properly ascertain the uncertainty inherent in the estimation process. regspec can also fuse spectra for multiple series recorded at different sampling rates, but we do not need to use this aspect of its functionality here as all our case time series are reported daily. however, if a country decided to release case numbers on some other sampling plan (e.g. every two days, or weekly) then regspec would be able to fuse the spectral estimates as described here. such a feature might be of use when dealing with reporting structures that are not equipped to provide daily reporting of cases or where weekly cases are thought to be more accurate. for example, this might apply to regions with fragile health or reporting systems or populations that are spread across widely dispersed geographical regions with poor communications. although the number of cases transformed time series show similar spectral behaviour, it is possible to observe closer similarities within certain subgroups of countries. we used unsupervised clustering and scaling techniques [ , ] to depict the relationship between different countries and suggest a clustering for them. first, for each country we produced a spectral estimate using regspec as mentioned above, and then formed a dissimilarity for each pair of countries by computing the euclidean distance between their spectral values (using the dist function in r [ ] ). classical multidimensional scaling was then used to produce an estimated configuration using the cmdscale function in r [ ] . for clustering we use hierarchical cluster analysis on the dissimilarity matrix we computed. it is well-known that dendrograms are sensitive to the input dissimilarity matrix, so we used the clusterwise cluster stability assessment by resampling method to produce a stable clustering [ ] . given the form of the transformed new daily cases we propose a model, m t , that is the sum of two time-modulated cosine waves, m t = m where i = , indexes the two waves and t = , . . . , n c . initial values for forecast model fitting we used α i = . , φ i = , µ i = . , p i = . , for i = , . for model evaluation we put more weight on getting later observations correct and use a residual weight vector w t = (t/n) where t = , . . . , n and n is the number of cases. for short term forecasting, we fit m(t) to the transformed daily cases by weighted least-squares using standard r [ ] optimisation functions and then extrapolate m(t), using recent weighted residuals to estimate the forecasting error. the number of daily covid- cases for countries can be found at the website of the european centre for disease prevention and control [ ] . spectral analysis and time series european centre for disease prevention and control, covid- cases worldwide should we sample a time series more frequently? decision support via multirate spectrum estimation (with discussion) we don't know if coronavirus deaths will peak this week spectra analysis for physical applications travelling waves and spatial hierarchies in measles epidemics seasonality and the persistence and invasion of measles the dynamics of measles in sub-saharan africa application of the arima model on the covid- epidemic dataset the analysis of time series: an introduction forecasting: principles and practice white noise testing using wavelets a novel sub-epidemic modeling framework for short-term forecasting epidemic waves short-term forecasts of the covid- epidemic in guangdong and zhejiang flexible procedures for clustering, r package version . - r: a language and environment for statistical computing (r foundation for statistical computing a simplex algorithm for function minimization locally stationary processes a test for second-order stationarity and approximate confidence intervals for localized autocovariances for locally stationary time series non-parametric bayesian spectrum estimation for multirate data an introduction to multivariate analysis the elements of statistical learning key: cord- -rncleqqy authors: ramírez, j. martín title: long-lasting solutions to the problem of migration in europe date: - - journal: a shift in the security paradigm doi: . / - - - - _ sha: doc_id: cord_uid: rncleqqy this is the following of a previous publication on the refugee crisis in europe and its security challenges. here we suggest some long-lasting solutions to the problem of migration. these may be summarize in four points: dealing with the countries of origin and of transit, adequate control of borders, and positive measures to facilitate the integration of the newcomers in their countries of destination. in a previous publication on the refugee crisis in europe and its security challenges, i concluded that a global problem like this one could not be solved without an adequate orderly, and controlled immigration policy, creating systematic and controlled arrival and integration programs, because the mental structure of european societies is not prepared to face a disorderly increase in migration flows (ramirez (ramirez , . it is thus vital to regulate the arrival of migrants if we want to achieve their real integration in our culture (espaliú berdud ) . here i will try to go forward, pinpointing the terrible damage made by the massive escape of young people from countries that desperately need them in their struggle for development; their great problem is precisely the continuous loss of human capital. besides of that, who emigrate are not the "poor among the poor", but people with certain economic means to be able to afford the trip and contacts in the place they are going to. what is more important, according to me, is to argue that the best way would be to encourage migrants to stay home, preventing massive uncontrolled displacements, is addressing the factors that drive emigration of their own origin countries. to stop unwanted migration, the developed countries must promote a profound democratic and economic stabilization and development. we must always remember that the first right of every human being -after the right to live-is the right not to emigrate and to have the opportunity of living peacefully and prospering in our own home, as pope pius xii wrote in the apostolic constitution exsul familia: "all men have the right to a family living space in their place of origin". the right to emigrate is only subsidiary to the main right to have a family living space in the place of origin, when this cannot be assured. migration has been a sensitive and contentious topic for ages. escaping violence, war, poverty and environmental disasters, more people than ever are migrating worldwide. since it is not a cyclical, but a structural phenomenon, which means that whatever the method put forward migration cannot be stopped. currently, according to the uno estimates, million people live outside their country of birth ( . % of the world's population). in , about % of the world's . billion people lived abroad (unhcr ) . this figure grows due to inequality, climate change, conflicts, and the interconnectivity that facilitates the movement of people. migration itself affects values, identities, cultures, assimilation capacities of societies, and, far from being a problem in se, it may be a solution to many problems; e.g., benefits the demographic catastrophe present in the aging western societies. but it doesn't always engender positive changes; it may also show important disadvantages. this is why immigration must be orderly, capable of duly regulating the massive arrival of people; otherwise our social protection systems will not resist. the illegal immigration requires proper vetting to identify criminals and terrorists-the crime rates of the foreign immigrant population are significantly higher than those of the natives-, and sometimes, to put in metaphorical terms, surgical excision procedure without anesthesia will frequently induce pain. no country needs a trojan horse. but we will leave this so interesting aspect for another parliament. although mass emigration to developed countries is a global phenomenon -it happens even within each country, internally displacing for instance from rural areas to urban ones: china is a clear example-, the present chapter will be focused mainly on what would be the better long-lasting solutions to its present situation in europe, one of the leading destinations in the world in terms of migratory flows, with million migrants, russia included, according to the un's department for population. immigration is an irresolvable problem at short-term. migration policies should follow a long-term vision, addressing economic, security and sociological points of view (de la cámara ), creating systematic and controlled arrival and integration programs of security, trade, development and employment issues. but, being a global problem, migration will only be solved as a consequence of a frank and sincere joint co-responsibility between all countries of origin, transit and destination, sharing the burden of dealing with both regular and irregular migration whenever possible. this was the intention of the un global compact for safe, orderly and regular migration, signed at the end of by representatives of the countries of the united nations (uno) met in marraquesh, in a non-mandatory and rather controversial document that says, in an indirect manner, that for the entry to be safe, orderly and regular, the conditions of entry must be safe and not subject to the mercy of smugglers, seekers' and workers' entry profiles should be differentiated, and entries should be legal. its "objectives" were peppered with vague declarations, platitudes and split differences, such as the fight against the mafias that deal with human beings, the defence of the rights of immigrant workers or a change in narrative about migration towards a more positive approach. partly in the spirit of other global agreements like the paris climate deal, it encouraged states to co-operate on tricky cross-border matters without forcing them to do anything, and urged governments to treat migrants properly, but also to work together on sending them home when necessary. at least, it may help build the trust between "sending" and "receiving" countries that is the foundation of any meaningful international migration policy (economist ). let us offer some recommending ways of improving migration at four different levels: going to the roots in the countries of origin, dealing with the countries of transit, having an adequate control of borders, and suggesting some measures in the countries of destination. i have critized elsewhere (ramirez ) the saving buenist attitude of a migrationist maximalism that wants to open the doors, the ports, the windows and throw all the walls, in favor of a weberian realism (the ethics of convictions versus the ethics of reason) (leguina ): even if we would welcome forty or fifty million africans a year, africa will continue to have the same population. it would be good if they start helping africans in their own countries and avoiding as much as possible the reasons why they want to emigrate (ramirez ) . we want the potential migrants to have a better future in their countries. as ousman umar repeats like a mantra, "the solution is in the country of origin, not in the destination. you have to feed minds (well); if you feed the mind you are satisfying hunger for more than a hundred years" (umar ) . some african prelates within the catholic church are calling attention to the most forgotten aspect of this debate: the terrible damage made by a massive escape of young people from countries that desperately need them in their struggle for development. in a book released recently, cardinal robert sarah, currently prefect of the congregation for divine worship and the discipline of the sacraments, declares his personal position on immigration: "all migrants arriving in europe are crammed, without work, without dignity. is this what the church wants? the church cannot cooperate in this new form of slavery into which mass immigration has become" (sarah a, b; indelicato ). the european union (eu), thus, has to structurally turn over economic resources for the development of africa (and of middle east), tackling the problems that are the main cause of migratory movements, analysing them and offering real help in their own home. consequently, their priority has to be to invest in the countries of origin, because migration control has to be paid with money: financing, companies, information, facilitating their institutional, social, political and economic conditions in order that nobody will be obliged to leave their home, and creating sources of employment in those countries of origin. some political party has proposed in its program that the eu should prepare a sort of "plan marshall" for africa, similar to the one usa did for the post-war europe. according to the spanish royal academy (rae) dictionary, buenismo is the attitude of who reduces the seriousness of conflicts, acting with excessive benevolence and tolerance. this "goodism" is a demagogy destined to hold power through emotional blackmail, quite different to a real goodness, born of charity or philanthropy (robles, ) . cardinal robert sarah is a native of guinea guinean who grew up under a harsh marxist dictatorship and became archbishop at the age of with the task of guiding the diocese of conacry, when still in his country there was the socialist regime of sekou touré. so, i think he knows what he's talking about. in the forties of the last century, america passed the economic co-operation act, better known as the marshall plan, because its inspiration from a speech at harvard university by george marshall, america's secretary of state. the marshall aid, aimed to revive europe's war-ravaged economies, encouraged the europeans to quash inflation and to narrow their deficits while eventually dismantling price controls and import barriers. these reforms had enormous benefits. before fear of inflation and taxation prompted german farmers to feed their harvests to their cattle, rather than it is not enough with assigning cooperation funds. as de la concha stresses ( ), a proper management of migration flows requires working as much as possible in cooperation with the countries of origin taking into account, as appropriate, the various causes of migration (economic, security, political prosecution, climate, etc.). thus, a more ambitious measures are required, such as generating opportunities for the local population and offering fiscal incentives to the investments of european companies in those regions that seem to be condemned to diaspora. this move will also offer new markets for european products and services, as well as opening of eu markets to exports from these countries. and, what is more important, besides of contributing to the economic development of those countries, europe has to improve their social and political quality of life, which is precisely what they try to find in europe. our main objective, therefore, has to be to strength the production base and the creation of jobs in the countries of origin, the provision of basic services (health, education) to the local populations, and the literacy, ensuring that students in their countries have the tools to decide their future and thus avoid the temptation to migrate to europe, avoiding future victims (de la cámara ). either we offer them opportunities in their own countries, or they will come to ours looking for them zalba ( ). the best practical means for achieving it are probably inter-governmental agreements with the origin countries, giving them a generous economic aid. this is the stance taken by the visegrad group (v ) (check republic, hungary, poland, and slovakia): instead of uncontrolled massive immigration, we have to act in their origin countries; instead of importing problems, exporting help in situ. this attitude would also be "much more inexpensive", as is honestly admitted by juho eerola, a finn of the nordic freedom, or by the then slovak prime minister, peter pellegrini, during his first visit to brussels: "what we have to do is to invest in the countries where the problem is originated. each euro spent in northern africa is more efficient than spent in the migrants who arrive massively to eu" (eerola, april ). but, there is need to build up conditions to create secure environment within the transit african countries bordering the mediterranean sea. the north african governments are responsible for effective and transparent governance aimed at management of emigrants flows through their territories. eu's money poured into their accounts are wasted as they do not cooperate as they can. another effort to stem the flow of migrants to europe is "to save and protect the lives of migrants and refugees", motivating "operations of urgent evacuation" returning them to their origin countries through a repatriation programme that encourages those who have made it to northern africa to go home voluntarily, rather than risk sell it to the cities for money that might be diluted by inflation or seized by the government. its true significance laid not in the cash it provided but in the market-friendly policies it encouraged. to receive aid, european governments had to commit to restore financial stability and to remove trade barriers. we have a similar problem within our own countries, migration towards big cities is up siding the living in small rural areas; we have to stop it offering them "the needed modern technology to have the best of both worlds. it is not an easy problem, but i feel a deep analysis needs to be done so we understand more of the dynamics behind the movements"! (lindhard, ). a rickety boat across the mediterranean. this is what uno, eu and african union (au) jointly agreed in abiyan ( nov. ): people who turn back get a free flight-cutting out the need for a perilous return journey across the sahara. the programme has repatriated some , migrants to various west african countries, which barely scratches the surface because it reckons there are about m of them in the african shores, waiting for their risky jump to europe (economist ). the spanish government did this unilaterally in , after . immigrants arrived to the canary islands in open boats, known as cayucos: some direct forms of operative cooperation with those countries through which migrants come or transit, sending there some specific police units for working jointly with the local security forces with the aim of restraining subsequent invasions from other western african countries. since the devolution of immigrants to their origin countries is one of the best deterrent action to avoid the "calling effect", governments have to launch adequate information campaigns in their own origin countries to discourage potential migrants. the eu member states are africa's largest donors, supplying more than half the aid the continent receives. africa exported twice the value of goods to the eu as it did to china in . but it is not just a matter of addressing the factors that drive emigration. europe and africa share something much more fundamental: a future dependent on one another. as moroccan king mohammed vi pointed out in , solidarity between europe and africa has to be "built on shared responsibility and mutual dependence." the european continent is a global player worthy of genuine partnership of equals with africa that priorities concerning mutual interests through rapid funding in education, health and infrastructure for africa's youth would contribute to global growth. europe's investment must be bolder in terms of financing, policy and governance reforms than what is currently on the table (cole ) . economic development, government reforms, institutional strengthening, will result in common prosperity. europe, poor in natural resources and in demographic decline, desperately needs to contribute to the unblocking of the future of africa. up to now, the -economically important-european efforts have to qualify as at least disappointing. the eu needs to encourage, promote opportunities in africa, move from a policy built around aid to cement our relationships on trade and investment (palacio a) . cooperation between states that produce migrants and those that receive them can help to streamline migration flows. the european union has to structurally turn over resources for the development of africa and middle east, which are the main source of migrants nowadays, through agreements with extra communitarian countries for stopping irregular immigration towards europe. and this requires patience and diplomacy, treating the partner governments as equals. the optimism of the "refugees welcome" campaign in -wir schaffen esled towards an uncontrolled flood of refugees which destroyed the perception of order and stability. in june , there was a great turn in the attitudes of the rulers regarding immigration, with a broad consensus at the european council around much more restrictive. this practical agreement intended to hand over the decision-making capacity over who enters and who does not in the "fortress europe", strengthening the policies of controlling the external borders; fighting against traffickers; and more aid in the countries of origin instead of endless aid in europe. there is a need to strengthen collaboration with transit countries. it is necessary to prevent ships from leaving their points of origin. in cases where this is not possible, the practice should be implemented that those rescued at sea should be assisted and returned to the point of origin or departure of navigation. this is the specific task of frontex, the european border and coast guard agency: provide technical assistance and support to the countries of origin and transit to help strengthen border controls, even if it cannot replace national competence; it is converted into an authentic border police, but not in charge of rescuing. i will to come back to this point later. according to the ngo african center for strategic studies, there is a migratory flows that move . million people from one place to another from and within africa in the hands of traffickers; % of them are minors, and only % of those . million, will try to reach europe; the remaining % travel between african countries. in this context, i point out at a report by the department for human rights at the un, marking the horror of criminal smuggling networks which lead to humanitarian scandals such as: enslavement; imprisonment; rape; prostitution; the sale of organs; and camps, whose living conditions are beyond imagination. what alternative do citizens of many african countries have to come to europe? if the european states renounce their ethical convictions, delegating their responsibility, mafias and some connected "heroic" ngos will occupy the scene doing the dirty work. those still determined to reach europe may have to pay large sums to people-trafficking gangs and risk their lives in the sea (we may say the same about america, substituting the word "sea" by "desert"). the more borders, bureaucratic obstacles, closed routes and prohibitions the immigrant finds, the more profitable for the trafficker. no one moves as many people on the planet as immigration traffickers, nobody determines human flows as much as their implementation in a given territory, nobody has their flexibility to change plans and adapt to changing circumstances and nobody gets so many benefits as they do. their criminal business is more lucrative nowadays than drug or arms trafficking. some of those traffickers have changed tactics. before, they put hundreds of immigrants in old overloaded wooden boats with the aim of trying to reach europe. nowadays, after cashing from them, the immigrants are taken in safe boats from african territorial waters, until they know that the ship of some ngo is a few miles away. then, once in international waters, they put on life jackets, crammed them in zodiacs, which can barely sail a few hours and warn by radio that there are shipwrecked people in the area. the more rescue boats they have, the more immigrants will try to cross the mediterranean…, and the more deaths, drowning in the sea, those claimed heroes of the goodism will provoke. a ngo director denounced on television that although he had managed to rescue people from a zodiac, another had perished. what nobody asked was if he did not realize that by telling those who leave libya that there are boats a few miles away they are contributing to the death of hundreds of people who, for one reason or another, cannot be picked up. trafficking in human beings to the european destination is more profitable than drug trafficking: it moves around the mediterranean, according to the latest un report published last year, about billion dollars. just take the account: boats for people are used for , crammed, standing, and almost unable to move for hours. at , e per head, it gives , e per trip. it is paid in two parts: the first , e to take them from their country of origin to the ports of libya and the other , to move them to european port, in an offshore mothership, and then in small boats that launch into the sea in a point located by gps where they can be picked up by the rescue boats of the ngos, or by merchants, fishing or recreational. if they do not find this type of boats in the area, they make a distress call with a satellite telephone with the coordinates. if the trip is frustrated and they are returned to their countries, they try again when they have collected the money. and several thousand have not even had that opportunity because they have lost their lives. with that turnover, there is no problem in paying the corresponding bribes in each place (fernández arribas ). "the good trafficker tries not to lose the immigrants who have been his clients. his goal is to get them to europe and earn money. if they lose, e.g., a truck with immigrants between agadez and algeria or a boat that sinks with people, is not a problem, because they have already paid; but if they lose kg of cocaine or two boxes of kalashnikov, then they do have a serious problem. that is the difference". and how are these people's traffickers? "these gangsters are criminal entrepreneurs, but entrepreneurs. they must have many contacts, be credible, creative, charismatic, with the power of conviction, knowledge of the routes, the laws, the latest news… which make them very fast, elastic and flexible. they also participate in other businesses; f. inst., when the vehicles that bring immigrants back through the sahara return, they never make them empty: they carry weapons or drugs back to take advantage of the trip" (musumeci and di nicola ) . fernández arribas ( ) offers a very detailed description of how tens of thousands of human beings are stranded in territories dominated by mafias, in their expected way towards europe. although every corner of the world retains its specificities, the human traffic mafias analyzed by the un reflect some common patterns. all of them have recruitment agents from the main groups that are victims of extortion. a second level is that of the local mafias, who know the land and generally pay the collectors. one more step is that of small-scale service providers: trucks, boats and other means of transport. the most dangerous level is that of the big international mafias, who control the entire process and also add links to large international crime groups and use immigrants as a way to earn money quickly and easily. infrastructures built for the exploitation of the mineral resources of the desert, oil in libya and uranium in niger, facilitate trips through the desert. according to reports from the spanish police, nigeria and libya are the most active and most established bases of immigration mafias in central africa, with ramifications in other countries, where sudanese mercenaries act unscrupulously. in the waiting time, they live in abysmal conditions, suffering very serious violations of the human rights, such as abuse, harassment, violence, robbery, kidnapping, extortion, common torture and rape. in north africa they have their point of convergence in agadez, a town north of niger, or in sehba, south of libya, where control is exercised by heavily armed tribal groups. from that point of confluence, they are transferred to the coastal cities of the tripolitana region, where trips are negotiated and where part of the population collaborates with their garages as a temporary shelter at an abusive but obligatory price for those who see the end of your nightmare construction, agriculture or any job in order to get the money. the boats used are manufactured in libya and the fishermen always have on board some drum of gasoline, pure gold for the weak boats of the new slaves of the st century. in libya, each link in the chain receives its commission, especially those who seek protection and security, from militias to corrupt authorities. this action-paying poorer ones to set up vast holding-pens for humans in unhuman conditions-is a big business for a few behind the misery of many others, and involves something which would not be tolerated at home, but it seems somehow acceptable in these situations because it is out of sight. stopping these traffickers, which is the solution that many politicians in europe offer to regulate immigration, is almost impossible; they are always ahead of a european immigration policy, without the necessary coordination. a clear example has been the failure of the military operation eunavfor med sophia (from to ), which ambitious goal of dismantling the mafias that traffic with people from the libyan coasts to europe has not been fulfilled, partially because the closing of the italian ports to illegal immigrants has left it out of play. due to the fact that operation sophia no longer uses ships but only unmanned aerial vehicles, it cannot continue rescuing people at sea. federica mogherini, at that time high representative of the union for foreign affairs, explored a new mission, with more modest goals: to train the libyan coast guard to control their own waters and avoid the departure of irregular immigrants; but there were also no practical results. this shows the external and humanitarian action of the eu, as it really is: "lack of criteria, commitment and agreement on immigration issues…. public opinion will continue to show ships coming from the libyan coasts and criminal organizations will increase their profits" (de ramón-laca ; see also espaliu , espaliú berdud . as accurately pinpointed by bitzewski (personal communication), though, it is not the eu administration to blame but the heads of states not being willing to take the action. they point their fingers out towards the eu but, when the eu puts proposals on the table, they get reluctant to contribute to the common effort. it starts with the frontier countries, crying but doing very little to protect their own borders, and goes to the rest of europe raising any reason not to commit themselves to the program. the eu should be tougher on the north african governments, corrupted and ineffective. a carrot and stick should be one of the ways to start discussion with them. it's their obligation to control migrants movement within their territories but they make money on it! turkey and egypt are perfect examples of the game. when they want they can stop trafficking! but, obviously, the money is the main reason for action. the north african countries are interested in this business and it is up to us to give them a signal "do not be too smart". we deal with state controlled trafficking and we are very naïve not forcing these governments to take the responsibility. we can help them but we cannot work for them. a key move to avoid the "calling effect" is to guarantee security and economic agreements -migration control has to be paid with money-, with those countries migrants transit through in their way to europe, preventing them from leaving its coasts and returning to their country of origin those people whose asylum in the eu has been denied. in november the eu established the emergency trust fund for africa (eutf for africa) with an allocation of e . million covering algeria, tunisia, morocco and egypt, aimed "to contribute to safe, secure, legal and orderly migration from, to and within the region and support an effective management of migration flows that protects human rights" turkey is the main starting point for the arrival of potential refugees from middle east to europe. there are more than millions syrian refugees, and almost another one in lebanon. the repatriation agreement signed by brussels and ankara in march -entering , million euros annually in the turkish coffers + visa free travel for some turkish citizens-has been a quite good example of efficacy, convincing them to keep refugees from europe's shores: more than , migrants-three fifths of the detainees came from afghanistan and pakistan-have been detained in turkish territory since the document entered into force (turkish directorate general of migration management ). according to gerald knaus, leader of european stability initiative (esi), the entry of refugees into greece was reduced "by % and even higher in the number of deaths". and, in a more global view, the more than one million irregular migrants (mainly refugees) who arrived in europe in have fallen to . in . turkey thus has played a leading role as a dam to contain migration outside europe. in the future, eu will have to invest more in integration and public awareness programmes in turkey. erdogan himself has proposed resettling at least some of the refugees in a safe zone he wants set up in northern syria. all of this is legally possible. syrians in turkey do not enjoy formal refugee status, which would protect them from deportation, but "temporary protection", which does not. according to the high commissaire of united nations for refugees (acnur, in french), a turkish meltdown would send economic shockwaves or new surges of migrants onto the european mainland. erdogan has encouraged such fears (july nd, ), threatening the suspension of the migration deal over the eu's sanctions. another point for the arrival of potential refugees from africa is the maghreb. those eu southern members with close ties to it have an special interest in encouraging the reform of state structures, as well as working to reduce the socioeconomic disparities and lack of opportunities that remain the public's most pressing problems in those countries. two successful cases have been the attempts of cooperation of the eu with morocco and tunisia, as well as a. very important job in the control of migratory flows and the fight against mafias, terrorism and drug trafficking is due to the creation of a coordination authority for the gibraltar strait. by way of example, there is a positive counter-terrorism cooperation carried out by several eu countries working closely with northern africa on security, providing training and equipment for counter-terrorism and conducting some joint operations. morocco might be a capable security partner as the authorities closely monitor its population and controls its religious sphere. it has been successful in preventing attacks and obtaining information that can benefit its european partners, but its counter-terrorism efforts fit within a framework of conserving rather than transforming the state's unaccountable relationship with its subjects, which relies on a repressive political system and resists outside calls for reform. nato has also awarded us$ billion to turkey. four years later, just when this book is going to press, the crisis has returned. turkey does not seem proactive anymore. tayyip erdogan has called for more european support for ending the war in syria and for receiving millions of refugees. and as a pression measure, on february , , turkey decided to open its borders for migrants to move to the european union. this has brought together more than , migrants along the border with greece. three weeks later, though, following the strategies of the other countries to avoid a further spread of covid- , ankara has announced just the opposite: the closure of the eu's borders. the spanish authorities have observed with relief a downward trend in arrivals in mid-january , with a significant reduction of a % of the figures of irregular immigration: the entries, an average of about . a month, confirm that the flows have been considerably reduced since then and that they have fallen to levels below those registered the previous year, when spain became the main european gateway for irregular immigration. this proactivity of morocco, deploying agents to reinforce the fight against the mafias, stop the exits by sea and employed its coastguard in the rescues on the high seas, has been highlighted both by spain and by an internal report of the european commission as the most effective tool to contain migrants. this change of attitude coincided with the announcement of the visit of king philip vi to rabat, which was finally held on february , . on that trip, the spanish monarch asked mohamed vi to go "beyond" in the control of irregular immigration. later, the fisheries and agriculture agreements, signed by eu and rabat with an injection of million euros to contain migratory flows, have also been key to boost moroccan collaboration. besides of that, spain has approved to add the almost million that rabat asked last year to contain the exit of immigrants; that is to purchase surveillance equipment "to combat irregular immigration, immigrant trafficking and trafficking in human beings", as well as for fuel, maintenance of patrols, diets and salaries (palacio b) . the moroccan and sub-saharan return agreements are also praised as a "deterrent factor" to avoid the "call effect". morocco moves many sub-saharan people to the south, leaving them lying in the middle of the desert, or locked in small cells inside an illegal detention center in arekmane ( km from melilla) and then deported to their countries. tunisia has also made significant advances in its security policies, but it has yet to find balanced ways to deal with its porous borders and the disproportionately large number of radicalized people. unfortunately, the attempts to solve the problem of migration with libya have been rather frustrating. libya is a too fragile state, a territory without government since a few years ago, which is key in the irregular migratory flows towards italy and, in the late times, increasingly diverting the flow of west african migrants to spain, via new algerian routes (fernández-sebastián ). nowadays it is the largest and more serious migration corridor, due to the use of mafia "facilitators", as we had previously commented. in this context, some libyan militias behind much of the people-smuggling migrants across the mediterranean claim that eu and, more specifically, italy have given them money and equipment to improve the coastguard stopping migrant boats from setting sail. this may explain the falling of the number of migrants crossing the sea. finally, the european leaders seem delighted with the cooperation with egypt, where immigrants no longer arrive due to the decision of this country to prevent them from leaving its coasts. if all the countries of the south did like egypt, there would be no immigrants at sea. a punctual example of joint collaboration of countries of both sides of the mediterranean sea is the cross-border military exercise neptune, with the strategic objectives of unifying efforts and coordinating action plans among the mediterranean countries, especially in terms of detention and combating the movement of foreign terrorists through ports on both sides of the mediterranean. thus, passenger and freight transport vessels were included in the controls and the use of interpol databases could be activated participation. this activity has been developed between several ports such as tangier med, tangier city and bni-ansar (nador). in sum, the eu should remain committed to encouraging and supporting the most significant pressing remaining security challenges faced by those countries, such as: ( ) the reduction of the social frustrations, economic inequality, lack of opportunities, and governance problems that increase the likelihood that people will join extremist groups and recruit radicalized individuals; and ( ) the reform of state structures, especially in relation to: (a) improving security governance based in an adequate culture and professionalism of the security forces (f. ins., training of police officers, courts judges and staff, customs and coast guard officials); and (b) developing systematic approaches to prevent further radicalization and addressing conditions that facilitate it, such as: exploring better ways to handle radicalized individuals than large-scale incarceration; distinguishing between committed jihadists and those who are more open to reintegration into society; and developing programmes to promote religious education and awareness, gearing them towards pupils and their families from an early age, so relevant to the treatment of radicalized individuals and the prevention of further radicalization (dworkin and el malki ). although the priority has to be focused on the countries of origin and transit, the fact is that we have to face a massive amount of irregular migrants who are arriving to our borders, because a chaotic, uncontrolled immigration cannot be allowed. the main objective of eu policy in this topic should be to encourage legal and orderly immigration and deter illegal flows. what should be the european criteria for who is welcome to europe and who is not, to avoid an uncontrolled migration into our continent? how could be accomplished the aims to become a historic leap in the consolidation of a european area of freedom of movement without internal borders? a spanish writer, de prada ( ), has recently reminded the clairvoyant solutions offered by thomas aquinas already in the middle age on the obligations and limits of hospitality, making clear that the help demanded by those who suffer should not be confused with their unconditional reception. he refers to several possible types of peaceful immigrant: who passes through our land in transit to another place; who comes to settle in it as an outsider; and who wants to fully join the nation that receives it "embracing their religion" (their culture, we would say nowadays). he always puts the notion of common good, which requires a desire to integrate into the life of the host country; and he is inclined not to admit them until examining their degree of "affinity" with the nation that receives them. and, as a measure of legitimate defense, we should reject those immigrants considered hostile, understanding as such not only those who have the purpose of perpetrating crimes or violence, but in general those who harbor intentions contrary to the common good of the nation that receives them (see also : ramirez ) . the decision on who is welcome and who is not does not belong to the humanitarian people, even less to the people-smugglers, but to each state. security and protection of the borders is competence of each state member. without borders there are no states and no one else can supplant a state's right to manage and protect them, treating migrants humanely but also firmly, swiftly returning those who arrived illegally or whose claims to asylum have failed. even if the eu lacks competence over it, it does not preclude the convenience of an europeanization of the migration management, through a joint cooperation for specific purposes, even if it means losing part of the national authority over a very sensitive area of the territory. the political leaders of the eu must improve their coordination and develop common legislation on borders and immigration, creating systematic and controlled arrival and integration programs, focused on the new scenarios, such as the solution of the migratory crisis, with a common, effective, and decisive security policy, finding a balance between the implementation of measures that guarantee the security of the states, while respecting the rights of those migrants who no longer enjoy their protection in their respective countries of origin. the eu not only lacks competence over the management of the flow of refugees, but also lack of homogeneous response, as it is shown by of the dublin regulation (eu european parliament ), which has resulted an absolute failure, inept to establish a coordinated strategy with minimal effectiveness. the eu foreign policy remains hopelessly underpowered, limited to coaxing national capitals towards agreement and supporting their ad hoc initiatives (the economist economist a, b; niño ). it is good to remind again that it is not eu to blame but the states not taking actions. the dublin regulation ( ) determines the eu member state responsible for the examination of an application for asylum seekers of international protection under the geneva convention relating to the status of refugees of july , as supplemented by the new york protocol of january (eu ). according to this legislation, the first member state in which the asylum application is submitted will be responsible for the examination of the request for international protection and the asylum seekers have to stay there. this, the so-called "one stop one shop", burden the countries situated at the entry to europe, notably those in the south, and the individual preferences -that is, where people arriving into europe actually want to go to and where do they wish to live-are bound to not be properly taken into account. consequently, if they move later to another european country -known as secondary movements-, this second receptor may return them to the first state. this secondary migration penalizes those southern countries, because most refugees arrive to the coasts just as a transit towards other northern european countries, where many of the newcomers had linguistic and cultural or family ties. or with better job opportunities and welfare provision. as a matter of fact, most of them live already in germany. in front of this, the different eu member states have rather antagonistic approaches: (a) northern countries, preferential asylum for most of the refugees, are in favour of a quotes policy imposed by brussels' "eurocrats" for the reubication of refugees, and suggest an eu budget with more funds for those regions with higher number of asylum seekers. (b) mediterranean countries, plus portugal and france, suffering a heavy migratory pressure in their borders, have the feeling of being left alone to cope with immigrants, and reject the responsibility of attending by themselves everybody who arrives to their borders, because it would mean establishing a sort of sanitarian cordon with the rest of the communitarian block. their aim is a reform of the dublin regulation and the help of the other eu countries in the sharing of the irregular immigration arriving to the outer borders. for instance, the greek government and aid agencies argue that the eu must overhaul the dublin regulation, so that asylum-seekers are distributed more evenly. the current system, they say, is unfair. five countries-greece, italy, spain, france, and germanyreceived over three-quarters of europe's asylum applications in the first half of . greece has had to deal with times as many claims as hungary, a country of comparable size and wealth. the rules are also ineffective: eu money is not an adequate replacement for relocation. southern countries are also reluctant to expand frontex because this affects their rights to the sovereignty of control of the territory, but also concerns related to better registration of migrants…. this is the key problem! (c) the visegrad countries (v ) -poland, hungary, czech republic and slovakiaplus baltics (latvia and lithuania) and some recent addings (at least, austria, and partially italy), call for reform, and refuse to consider any binding sharing in , germany received . applications, almost double that of any other eu country, requesting the return of . refugees to other eu countries, but only managed to execute % of the returns of asylum seekers requesting from the eu. based on that, the german home minister, horst seehofer, wants to send tens of thousands of migrants to italy, and, on the contrary, italian home minister, feels legitimized to send those who arrive to the northern european countries; f.ins.,"france was to welcome , immigrants, but in reality accommodated only " (france has returned to italy , people in ). following the principle of solidarity, which is included in the lisbon treaty ( ), jean-claude juncker called on the member states of the eu to share refugee quotas according to the wealth of each country and population size, but it shattered and the european policy of immigration and asylum was marked by increased sovereignism in the states of europe. out of asylum-seekers. based on their right to security, they insist that their priorities are more about controlling europe's outer borders, in order to preserve the free movement of persons within the schengen space, than about managing the burden of refugees who cross them. what should be a reasonable attitude to avoid an uncontrolled moving of illegal migrants within the schengen area? the intended distribution of the burden of refugees imposing a quota system -i.e. every eu state had to admit a fixed amount of people-has not worked: only a % of the quota has been achieved by the different members. this system of quotes was firmly opposed by the central europe defence cooperation (cedc), arguing that the structures of their countries are not "ready" for supporting the social weight of the newcomers: it would be highly detrimental to the national security and sovereignty. they felt marginalized by angela merkel decision to keep germany's borders open to refugees at the peak of the crisis in , without any previous consultation; it seemed to them, the chancellor had turned them into transit corridors for undesirable migrants drawn by the promise of a cushy life there. they suggest as alternative to accept the free choice of country. following this rationale, the polish minister of foreign affairs in years - , witold waszczykowski, was backing the disagreement of his president, andrzej duda, to force the entrance of immigrants against the wishes of the polish people, asserts that "the security of poland is more important than the unjustified decisions of the european institutions on the issue of the refugees". viktor orban even dares to declare central europe a "migrant-free zone". the central european countries are pushing for the eu to get involved in the custody of the external borders and accuse the southern countries of letting irregular migrants pass unchecked through their territory to the rest of the eu, and ending up circulating in europe at will. for instance, sebastian kurz, at that time austrian kanzler and rotatory president of the council of the eu, told in a local newspaper "i am afraid that many are trying to avoid the high number of migrant records that they would have to do" (referred in abc, / , ) . his words suggested that national authorities sometimes turn a blind eye to not registering migrants and that, on the other hand, a community official who did not work directly for any state would not allow those distractions. the eu summit in brussels on june th , following a suggestion of angela merkel and horst seehofer, reached a transitory agreement based in two points: (a) bilateral agreements between different states, stopping secondary movements in their inner borders, i.e. sending the refugees back to the state in which their asylum application was first submitted, obviously with an economical compensation; and (b) more resources for setting up centres of transit (internment) or "landing regional platforms" with the task of reviewing asylum applications, "distinguishing between economic migrants and those needed of international protection". this move would speed up the deportations, disincentives dangerous adventures and reduce drownings at sea. this seems to partially accept sebastian kurz's proposal of a "copernican revolution" in asylum policy migratory model, as a new possible alternative similar to the one applied in australia: to implement the number of naval patrols for intercepting boats with refugees and confine them in islands like nauru o papua-new guinea": control first; then generosity. following this model means two things: first, taking tough action along borders, at sea and "upstream" (inside africa) to slash the number of asylum-seekers smuggled to europe; thwarting smuggling, the argument goes, would reduce drownings at sea, and reassure voters who might otherwise be tempted by the far right. second, striking deals with poorer countries to establish camps, run with un agencies, to receive, detain and, eventually, return migrants. it is a laudable but ill-defined goal, because it is unclear where to establish those camps. it was mentioned "in safe countries outside the eu". but where? some members want deals with north african countries to reduce departures, but it still unknown which non-european countries would be willing or able to host such centres. in front of this north african rejection, the danish prime minister at that time, lars lokke rasmussen, revealed that some communitarian countries are austria, which occupied the eu presidency that semester, hoped for a quick agreement to equip frontex with a supranational force of up to , members and to establish a landing platform for irregular migrants in north africa. algeria: just the day after the summit, algerian foreign minister abdelkader messahel said in an interview with the french broadcaster rfi: "i believe that europeans have enough capacity, means and imagination to manage these situations." "it is excluded that algeria opens any retention zone. "morocco: the next day, the moroccan foreign minister, naser burita, emphatically stressed that this country has always "rejected and rejected" in its territory the detention centers for foreign migrants. tunisia: for logistical and political reasons, it could be the ideal candidate to host this type of centers: its coasts are the closest to the maritime zone where the majority of migrants sailing from the western strip of libya are rescued; and, its democratic transition seems to be quite consolidated, being the country in the region that receives the highest volume of eu aid funds per capita. however, the tunisian ambassador to the eu, tahar cherif. abounded in categorical rejection by his political class and public opinion. "for tunisia, the creation of reception centers is a red line," says valentin bonnefoy, a researcher at the tunisian ftdes, a ngo specialized in migration. more than seven years after the revolution, this maghreb country does not have an asylum law, something that many observers attribute to a veiled strategy to avoid becoming a host country. egypt also rejected the possibility, although in a not-so-sharp way: "the eu migrant reception facilities in egypt would violate the laws and the constitution of our country," said parliament president ali abdel seeking to establish camps for failed asylum-seekers in a continental country, but out of ue, more specifically in the balkans. there is even a third possibility to consider: within the own eu border. jean-claude juncker, in his speech on the state of the eu, proposed to establish a more efficient control of the eu's external border, converting frontex, created in and reinforced in as a european guard of coasts and borders, into an authentic border police, but not in charge of rescuing. although still subject to the control of the national authorities, it is provided with broad competences in areas such as the control of irregular migratory flows from outside the eu, the return of irregular migrants to their countries of origin, the detection of illegal steps between countries of the club and the fight against the channels of transit in third countries. on november th , the eu decided to grow it from , s to a standing corps of , , with a % jump in funding next year, to m. e, for the first time, the eu will be able to dispatch gun-toting men and women clad in eu uniforms to patrol its fringes, without asking member-states to cough up guards. in this way, the surveillance capacity in european territory will be reinforced. this necessary hard-headed policy of tough border controls, swift return of illegal immigrants and encouraging would-be migrants to stay home obliges governments to work with others in the control of its migratory flows. europe cannot maintain the schengen system of internal free migration if it does not control its external borders. and, we have to admit it, it does not. the eu has so far failed in all its attempts to establish a common policy to address the problem; it has become impossible to have a level-headed conversation about managing migration in europe. the malta agreement (september rd, ) is a tentative deal, signed by a group of five eu interior ministers (germany and france, as well as finland, italy and malta), on a temporary scheme for a rapid relocation in other countries of asylum seekers, who are rescued from the mediterranean sea. it could open the way to a comprehensive overhaul of the dublin regulation by which the migrant's country of arrival is responsible for verifying the right to asylum of each person. it states that "the relocation member state will assume responsibility for the relocated person" and contemplates a quick procedure to say in advance the number of potential refugees each state is willing to host, setting a period of only four weeks to relocate rescued refugees in the mediterranean in other member states. this would allow the frontline first-arrival countries (the mediterranean), to be discharged from the responsibility of participating in their reception, quite heavy in periods of strong migratory pressure. in return, berlin and paris hope to achieve a reduction in the socalled "secondary movements" or movements of irregular migrants from the country of entry to other eu states. aal in welt am sonntag. in addition, aal said that his country already has millions of refugees from nearby countries, such as syria, yemen, iraq or sudan, so its reception capacity is at the limit. the eu ministers discussed on - - , in luxembourg this proposal to relocate asylum seekers rescued at sea, but they got a lack of solidarity of the whole european bloc, and the sole support of portugal, luxembourg and ireland. the agreement also speaks of a return protocol "immediately after landing", redoubling diplomatic pressure on migrant countries of origin, using "appropriate incentives to ensure full cooperation, including consular cooperation, from countries of origin", although at least it includes everyone passing a "medical and safety exam". it also underlines the need to "commit to improving the capabilities of the coastguards of mediterranean third countries". it is hoped that the deal will put an end to the game of pass-the-migrant spectacle of some countries squabbling over which should accept responsibility for small numbers of asylum-seekers, breaching in what until now has been a guiding principle: that irregular migrants must be dealt with by their country of first arrival. since participation in the system will be voluntary, much will now depend on how many countries will take part, how many asylum-seekers each will accept and whether penalties are to be imposed on those countries that refuse to co-operate (this last seems unlikely, given that such an idea would have to be approved by all the eu's members, including the countries liable to be affected (economist ). summarizing, there is a widespread perception that a series of instruments to control its external borders are not working well -the dublin asylum agreements, refugee quotas, frontex, return and development policies…-and that a lack of trust has grown not only between the member states, but also between the states and the european institutions, especially after the refugee reception crisis in . in few words, there is a deficient management of migration and a weak european solidarity on this issue (de la cámara ; de wenden ). the call thus is now for a joint cooperation towards a true common policy on asylum and immigration with a complete and efficient control of the eu's external border, reinforcing the role of frontex. everybody accepts this priority as the only possibility left for preventing a reinstatement of inner borders controls which would lead to the end of one of the most valued achievements of the eu, the schengen space. a positive step in this direction has just being announced, after the starting of their new mandate, by margaritis schinas, vice president of the european commission in charge of completing a new architecture that guarantees solidarity to the countries of the external border: the eu is going to make sure that there is a sufficient dimension of responsibility in terms of border control and returns. and as tangible measures in that direction, they promise an improvement of the management of external borders with , permanent staff; moving towards a federalization model of border management, this coming spring there will be the first community corps with their own boats and carry weapons, with the deploying the first european coastguards. the responsibility concerning the immigrants does not finish at the border. once accepted as our guests, we cannot forget about them. and, among our humanitarian obligations, we have to help properly integrating newcomers into our own society, avoiding their eventual fondness towards a multiculturalism, which only produces ghettos of their own culture, or wrongly thinking that the mere acceptance as migrants give them the right to have a claim to social welfare. and, on the contrary, who arrive without being invited cannot impose the host other people's rules. once they find a home in a new country, they have to accept the laws, rules, traditions and culture of the adopted society that welcomes them, learn the local language, mix with the natives, and be aware of the specific needs and priorities of their new home. in few words, they come to european territory with equal rights and obligations, but no more. whoever is not able to assimilate to their new society, should better return to their origin (ramirez (ramirez , . according to the dublin regulation, asylum-seekers are the responsibility of the first country to record their presence and, if they move later to another european country, this second receptor may return them to the first state, most of them arrive to the southern coasts heading north, trying to slip there unnoticed, as illegal paperless "invisible migrants", to avoid being picked up and returned to their first country of arrival. officials in the country of arrival can also use bureaucracy to slow the process of registration. and so, after six months, the new host state becomes responsible. this gives a strong incentive for foot-dragging. the recent malta tentative deal ( ) tries to partially solve this problem, allowing the frontline states to be discharged from the responsibility of participating in the relocation of the newcomers. once accepted as our guests, what to do with them? let us focus on the policy towards them in sweden and germany, preferential asylum of most migrants. strange enough, they are far from coincident at all. in sweden, immigrants received ample food and shelter, a generous welfare benefits, . times higher than the ones received by host taxpayers, as well as many facilities for family reunification, without any special focus on their social integration. even more, most of them are not allowed to work. this almost open bar policy, paying migrants to do nothing, has produced (a) an increment of the social expenses on the foreign population, with the consequent reduction of the benefits for the natives -the newcomers have priority to the swedish people; (b) a call effect on other tentative immigrants; and (c) increase of criminality and insecurity, which triggers the anti-immigrant feelings of host taxpayers who feel swamped. in my opinion, migrants should be encouraged to work, getting them language classes and education and offering job training, and introducing them into the labor market, meeting the main demands of the host country: f. ex, in nordic countries, anticipating a shortfall of geriatric nurses. in germany, the arrival of nearly one and a half million asylum seekers since polarized the country, with a consequent rise of a climate of political anxiety. it seems they have finally realized that the solution of the problem is to integrate into the labor market those who are already in the country, and relax the requirements to allow the entry of more workers. with this purpose, in december , the german government approved the fachkräfteeinwanderungsgesetz ("skilled workers immigration law"), an ambitious legislative package to attract qualified labor from non-eu countries and alleviate the pressing lack of workers in some sectors and regions of the country. this will extend the rules covering foreign graduates to vocationally trained workers, cautiously opening the door for rejected applicants for asylum, but who are already integrated into the labor market, and recruit more workers from outside the eu with medium and high education to find qualified work under certain conditions. germany economy enjoys enviable health, registering an unemployment rate of . %, the lowest since the reunification of the country. figures from the institute for employment research (iab), under the ministry of labor, estimate that there are about . million jobs vacancies, while posts actually registered in employment offices in november amounted to , ( , more than the same month of the previous year). however, one of the biggest concerns of the german businessmen, the so-called mittelstand, the motor of the exporting power and the backbone of the german economy, is the lack of skilled workers. unlike in other european countries, small and medium-sized german companies are distributed throughout the country, not necessarily concentrated in industrial centers. this often hinders the recruitment of workers who prefer to live in urban areas. there is a shortage mostly of workers with a level of professional training, such as plumbers, or drivers, and diploma courses, for example, of children's educators. elderly care and tourism, are also crying out for workers. this legislative text allows non-eu citizens to go to germany to seek work for six months provided they have the necessary training, know the language and have the means to survive during that time. in the case of persons with temporary permits, such as rejected asylum seekers, they must show that they have been working in germany for at least months and that they do not have a criminal record. the head of the employers' association, ingo kramer, recently indicated that , of the asylum seekers who arrived in are working or receiving some vocational training. in addition to the labour shortages, there are also demographic forecasts, which warn of a marked aging of the population. these projections will also affect eastern europe, where a good part of foreign workers in germany come from and whose arrival is expected to decrease in the coming years. according to thomas liebig, expert on migration issues at the oecd, "these countries are becoming places of immigration. we have to look for workers outside the eu". although the labor integration of immigrants advances, experts warn that it will take time. "it's a slow process; sometimes they are people who do not speak a word of german, and many of them come from afghanistan or somalia, where they have not had schooling" explains liebig ( ) . tangible achievements, indeed! milanovic and branco ( ) proposes an intermediate position between open to all or closed borders, under the name of "circular migration": to admit workers who cover specific positions, having salaries and work conditions similar to those of the locals, but with not vote rights, nor social benefits for children, retirement or free education; and at the end of their contracts, they will have to return to their countries. in few words, they will be partial citizens for a limited time, like it is already happening elsewhere: in gulf, singapore, iraq, usa, canada. perhaps one country may need extra workers and be in position of offering them stable working conditions; but this may not occur in other eu members. this is also suggested by alejandro portes, princess of asturias of social sciences award : offering a temporary, flexible and comprehensive program of visas to allow access to young people who want to come to work or study for a while, allowing a fruitful flow between countries. come in that way would also be much more economical, and would do a lot of damage to the traffickers, because those who come in that way would not have to pay them ( october ). psychological experiences of refugees and the response of the community in the lake chad region summa theologica (fathers of the english dominican province translation, prima secundae, question letter to the editor, the economist de la cámara m ( ) the eu migration challenge inmigración y cuestión religiosa, abc, ago de ramón-laca j ( ) operación sophia: paradojas de la acción exterior europea. análisis en minutos | nº a new european pact on immigration and asylum in response to the "migration challenge the southern frontline: eu counter-terrorism cooperation with tunisia and morocco the problem with eu foreign policy. too much historical baggage, the economist a migrant move in malta. the eu reaches a tentative deal to share out migrants rescued at sea. the economist taking european defence seriously: the naval operations of the european union as a model for a security and defence union, cuadernos europeos de deusto los buques de la operación sophia en el dique seco: elementos de un revés para la política común de seguridad y defensa regulation (eu) no / of the european parliament and of the council of maritime dimension in the fight against illegal migration on the western mediterranean route sbarchi? un nuovo schiavismo leguina joaquín ( ) migraciones sin respuestas alemania busca extranjeros para , millones de empleos, el país, dic how to stop migration towards big cities? research gate la inevitable migración hacia europa, el pais confessioni di un trafficante di uomini. reverse niño elena ( ) terrorismo e inmigración: cambiando el foco lazos y nudos con marruecos, el mundo europe's partnership with morocco. proyect syndicate apostolic constitution exsul familia nazarethana, castel gandolfo portes a ( ) princess of asturias of social sciences award buenismo ante el problema de los refugiados, migraciones en el siglo xxi: riesgos y oportunidades el terrorismo como desafío a la seguridad global the refugees issue in the frame of the european security: a realistic approach bondad y buenismo, abc, ago sarah r ( ) le soir approche et déjà le jour baisse turkish directorate general of migration management (turkish: göçİdaresi genel müdürlügü) ( ) migration management global compact for safe, orderly and regular migration. marraquesh global trends: forced displacement in he is member of the advisory board of the society for terrorism research and of the professors world peace academy. he has also chaired the complutense research group on sociopsychobiology of aggression and the departments of psychobiology at the seville and complutense universities, as well as being director of the rector office at the autonomous university of madrid. dr. martin ramirez was a humboldt and fullbright fellow but, let us close here our considerations, stressing that a revision of national and eu legislation is required, focused towards a cooperation with the countries of origin and transit; and that, instead of dreaming naively in a chimeric -non-existing-european eldorado, we have to promote the great possibilities that african continent has, knowing that, as the journalist lucia mbimio says, "we must not stop dreaming, but change the compass of dreams! returning from europe to africa is not a failure." ( , ). key: cord- -z bjkl g authors: brossman, charles title: planning for known and unknown risks date: - - journal: building a travel risk management program doi: . /b - - - - . - sha: doc_id: cord_uid: z bjkl g this chapter covers standard definitions of duty of care, example case law where employer duty of care was applicable, a variety of sample risks and concerns that employers and travelers should be aware of, in context with a travel risk management program. legal duty of care-definition "duty of care" stands for the principle that directors and officers of a corporation in making all decisions in their capacities as corporate fiduciaries, must act in the same manner as would a reasonably prudent person in their position. courts will generally adjudge lawsuits against director and officer actions to meet the duty of care, under the business judgment rule. the business judgment rule stands for the principle that courts will not second guess the business judgment of corporate managers and will find the duty of care has been met so long as the fiduciary executed a reasonably informed, good faith, rational judgment without the presence of a conflict of interest. the burden of proof lies with the plaintiff to prove that this standard has not been met. if the plaintiff meets the burden, the defendant fiduciary can still meet the duty of care by showing entire fairness, meaning that both a fair process was used to reach the decision and that the decision produced a substantively fair outcome for the corporation's shareholders. ijet international defines "duty of care" specific to trm as follows: duty of care: this is the legal responsibility of an organization to do everything "reasonably practical" to protect the health and safety of employees. though interpretation of this language will likely vary with the degree of risk, this obligation exposes an organization to liability if a traveler suffers harm. some of the specific elements encompassed by duty of care include: • a safe working environment-this extends to hotels, airlines, rental cars, etc. • providing information and instruction on potential hazards and supervision in safe work (in this case, travel) • monitoring the health and safety of employees and keeping good records • employment of qualified persons to provide health and safety advice • relative to "duty of care" is the "standard of care" that companies are compared to in defending what is "reasonable best efforts" or "reasonably practical," based upon what resources and programs are put into place by an organization's peers to keep travelers safe. prior to , business travelers thought nothing of being able to walk into an airport and meet their loved ones at their arrival gate. no security barriers, no cause for concern because air travel was something that at the time, our collective psyche felt generally safe, with the exception of a hijacking upon occasion. fast forward to a post- / world, and consider what the world's airports look like now and how the processes surrounding airport security have changed the way that we travel, whether for business or pleasure. why would any of us believe that the need for added security, particularly around those traveling for business, begins and ends at the airport? for companies who have been paying attention since / , the ones who, outside of the public eye, have had to deal with critical incidents that had the potential for loss of lives, corporate liability, and damage to their company's reputation, having a structured trm program not only reduced the potential for risk, but heightened the awareness of risk to their travelers. their definition of "travelers" extended beyond employees (transient travelers to expatriates) to contractors, subcontractors, and dependents. keeping travelers aware of imminent dangers takes effort and planning, and isn't something that employers can any longer react to after the fact. in some countries, lack of planning or resources to support business travelers has the potential to be grounds for claims of negligence in a company's duty of care responsibilities, and can lead to a criminal offense, such as with the united kingdom's (uk) corporate manslaughter and corporate homicide act of . what the "business judgment rule" in the above duty of care definition means in layman's terms is that a company must be able to prove that it put forth reasonable best efforts to keep its travelers safe. how this applies in different circumstances, jurisdictions and countries will vary. most countries' duty of care requirements fall under their occupational safety and health laws. for a comprehensive list of occupational health and safety legislation by country, an updated global database is maintained by the international labour organization (www.ilo.org ). simply put, companies cannot afford to no longer have a proactive trm program and just react after an incident takes place. the end result could reflect negligence on behalf of the company. for extensive detail on the uk's definition of duty of care in relation to the corporate manslaughter and corporate homicide act of , visit http://www.legislation.gov.uk/ukpga/ / . because each of the u.s. states is a separate sovereign free to develop its own tort law under the tenth amendment, there are several tests to consider for finding a duty of care under u.s. tort law, in the absence of a federal law. tests include: • foreseeability-in some states, the only test is whether the harm to the plaintiff that resulted from the defendant's actions was foreseeable. • multifactor test-california has developed a complex balancing test consisting of multiple factors that must be carefully weighed against one another to determine whether a duty of care exists in a negligence action. california civil code section imposes a general duty of ordinary care, which by default requires all persons to take "reasonable measures" to prevent harm to others. in the case of rowland v. christian (after and based on this case, the majority of states adopted this or similar standards), the court held that judicial exceptions to this general duty of care should only be created if clearly justified based on the following public-policy factors: • the foreseeability of harm to the injured party; • the degree of certainty that he or she suffered injury; • the closeness of the connection between the defendant's conduct and the injury suffered; • the moral blame attached to the defendant's conduct; • the policy of preventing future harm; • the extent of the burden to the defendant and the consequences to the community of imposing a duty of care with resulting liability for breach; and the availability, cost, and prevalence of insurance for the risk involved; • the social utility of the defendant's conduct from which the injury arose. pioneering companies (often in the energy services sector or government contractors) who were some of the first to adopt and implement forward-thinking programs, recognized early on that a critical incident or "crisis," isn't usually defined as an event impacting large numbers of people. they found that the largest percentages of incidents that required support, involved individual travelers or small groups. so while policies, plans, and readiness exercises are good to have in place for those highly visible incidents impacting large numbers of people, if handled improperly, the smaller incidents can cost companies considerably in damages and litigation costs, should their travelers or their travelers' surviving families prove that the companies in question weren't properly prepared to handle such incidents as they arise. case study-u.s. workers compensation and arbitration khan v. parsons global services, ltd united states court of appeals, district of columbia circuit-decided april , (https://www.cadc.uscourts.gov/internet/opinions.nsf/ dd d dd bce f d/$file/ - - .pdf) • during the course of employment in the philippines, on a day off, mr. khan was kidnapped and subsequently tortured. • employment contract included a broadly worded arbitration clause, and a separate clause specifying "workers compensation insurance" as "full and exclusive compensation for any compensable bodily injury" should damages be sought. • allegations that employer's disregard for mr. khan's safety in favor of minimizing future corporate kidnappings considering the way parsons handled the situation provoked mr. khan's kidnappers to torture him, cutting of a piece of his ear, sending a video tape of the incident to the employer, causing the khans severe mental distress. • mrs. khan alleged efforts by the employer to prevent her from privately paying the ransom, despite threats of torture, may have exposed mrs. khan to guilt of knowing that she could have prevented mr. khan's suffering if the employer had not withheld the ransom details from her. • mr. and mrs. khan filed a lawsuit for parsons' alleged mishandling of ransom demands by the kidnappers, and also alleging negligence and intentional infliction of emotional distress in d.c. superior court in . the employer removed the case to the federal district court, arguing on the merits of the new york convention for the recognition and enforcement of foreign arbitral awards, and then filed a single motion to dismiss or, as an alternative, to obtain summary judgment to compel arbitration. the employer initially received a summary judgment to compel arbitration. • upon appeal, this judgment was reversed. the court found that the recovery of the khans' tort claims were not limited by mr. khan's contract to workers' compensation insurance. • an additional appeal contended that the initial summary judgment granted by the court denied the khan's discovery requests, and dismissed mrs. khan's claim for intentional infliction of emotional distress • through the appeals process, the court found that the employer had in effect waived their right to arbitration. this case study calls into question legal jurisdiction, u.s. workers' compensation liability limitations for employers, and the value of being prepared for such an incident as kidnapping. this chapter outlines at a high level general categories that all companies must take into consideration when developing a trm program. very often the question is asked, "do i really need to do any of this, because our company hasn't been sued to date?" if you have employees or contractors traveling on your behalf (especially internationally), whereby your company is paying for their time and/or expenses, then the answer is absolutely yes. the level of investment and complexity may vary between companies, but in general, all companies must have a plan for how to address the issues provided herein and others. duty of care is never finite in its definition because companies must consider how laws from one country to the next will apply to travelers, contractors, potential subcontractors, and expatriates and their dependents, as well as any potential for conflict of law. also, as shown in the khan v. parsons global services, ltd. case study listed earlier in this chapter, employer remedies such as worker's compensation insurance in the u.s. aren't absolute; and therefore, warrants additional efforts and protections. consider the following incident types or risk exposures, which in some instances can impact large numbers of travelers, but more commonly impact only one person. according to the u.s. department of commerce international trade administration, only percent of international business travelers receive pretravel health care. pretravel health care can include, but is not limited to things like new or updates to vaccinations or inoculations, general health exams, medical treatment or procedures for a condition that may be risky to travel with, or prescription medicine planning for travel lasting for extended periods (longer than days). the chief operating officer at ijet, john rose, comments that, "a percentage of calls into our crisis response center are for minor, individual medical issues." however, callers may not always know that the situation is minor until they reach someone for support, which is why having an easy-to-identify, easy-to-access, single contact number or hotline for medical and security support is so important to all companies. a contracted crisis support service will know based upon predetermined protocols, which providers will support the traveler in the part of the world where they are traveling for medical issues, and ensure that the traveler gets the immediate advice that they need from a vetted medical professional. sometimes with a brief conversation with a nurse, the parties can determine a minor treatment that the traveler can facilitate, and in other circumstances a referral to a more senior medical official or emergency medical resource may be necessary based upon the initial consultation by the first-level medical support personnel contracted by the traveler's company. as discussed later in the book, who provides the crisis response case management and who provides the medical or security services specific to the traveler in question are not necessarily mutually exclusive. there could be different providers in different parts of the world, used for different reasons that are outlined in company policies and protocols. the consequences of mistakes as a result of a lack of preparation or resources can be costly, from financial loss and traveler productivity loss to the company, to a serious health issue for the traveler, or simply a ruined trip. while clarity via training and policies on who supports traveler medical issues should be very clear to everyone within an organization, the following common medical mistakes should be avoided where possible, as recommended by dr. sarah kohl, md of travelreadymd (http://www.travelreadymd.com): statistically, most medical problems you are likely to experience while traveling overseas cannot be prevented with a vaccine. for example, there are no vaccines for jet lag, diarrhea, blood clots, malaria, or viral infections such as dengue. before you travel overseas, make sure you are educated about these potential problems. most can be prevented with simple measures. information from different sources on the internet can be conflicting and can lead you to believe you need more interventions than actually necessary. as travelers prepare to depart, employers should provide them with access to resources that can advise on medical concerns relative to your destinations. of course, travelers should also discuss any personal medical condition concerns with their own or qualified medical professionals in addition to receiving employer provided risk intelligence regarding their trip. unfortunately, travelers regularly suffer needless medical complications because they fail to take simple steps to avoid predictable issues. simple precautions can save you a lot of discomfort and make your trip safer and more enjoyable. here are some examples: medical compression stockings, if properly fitted, can protect you from a life-threatening blood clot. knowing the right insect spray to choose, from the multitude of choices available, can protect you from insect-borne disease. avoiding seemingly harmless activities in certain locations (ones that a hotel concierge might even recommend) can protect you from parasites, respiratory illness or malaria. travelers often fail to recognize how a common illness such as diarrhea or a respiratory infection can cause a flare-up of an underlying condition. travelers who are good at managing food allergies, asthma, and diabetes at home may experience difficulty finding the resources they need overseas. in addition, these individuals may find themselves looking to a non-english-speaking doctor for help. measles, tuberculosis, and other infections are gaining a foothold in some european countries. low immunization rates within these communities are thought to be the root cause. don't risk becoming ill or bringing an infection home. check with your health care provider before you travel to discuss preventive measures. if you have a chronic health problem that is well under control, you will want to be prepared to self-treat under certain conditions. you may also want to be prepared to access a network of doctors who speak your native language, if needed. lastly, travelers should never assume that a pre-existing condition is covered by corporate-or consumer-based travel insurance or medical membership programs. when in doubt, always ask your human resources department or trm program administrator. companies commonly expect that corporate insurance policies or business travel accident (bta) policies provide enough coverage for travelers, when sometimes they may not. this is why protocols and regular training exercises for internal risk program stakeholders take place, to understand what is covered and what is not, as well as how to handle each situation. whether insured or not, consider the value and cost savings of prevention based treatment as shown in the examples provided below. consider the possibility that anything that an employee or representative comes in contact with during the course of a business trip (during or after hours) that can potentially make them ill or kill them is a liability to the employer. biological hazards or biohazards are pathogens that pose a threat to the health of a living organism, which can include medical waste, microorganisms, viruses, or toxins. toxicity is the degree to which a substance can damage an organism (not exclusively biological, as it could be chemical). brett vollus, a former qantas airline employee of years, filed suit against the airline claiming that his spraying of government-mandated insecticides on planes to prevent the spread of insect-related diseases like malaria, caused him to develop parkinson disease after years of administering the chemicals in the flight cabins. it was also discovered from a brain scan after a tripping incident that vollus had a malignant brain tumor. considering this was a government mandate, it will be interesting to see if the question becomes: what did the government know about the risks of these chemicals? if a precedent is set in this suit, will liability extend to other airlines using or who have used such chemicals for extended periods, against repeat business travelers who regularly flew or fly in markets where such spraying was or is common practice over a long period of time? epidemics are outbreaks of disease that far exceed expected population exposures during a defined period of time. epidemics are usually restricted to a specific area, as opposed to pandemics that cover multiple countries or continents. mature trm programs monitor these more visible outbreaks and recommend vaccinations for travelers going to impacted areas; they also provide access to emergency medical resources when necessary, but also have a large focus on education, training, and prevention. however, employers should always be mindful of other environmental factors in the traveler's workplace both at home or abroad, such as urban or rural environmental factors. examples may include prolonged exposure to pollution, lack of sanitation (particularly when it comes to their expat communities). employers should work towards limiting those exposures or changing the environment through continuous process improvement reviews. according to major medical and security evacuations suppliers, corporate-sponsored evacuations involving one or more travelers happen almost every day when you include both medical and security-related evacuations. it is a mistake to think that just because a case study or example is slightly dated, the instances they represent occur infrequently. it's quite the opposite. however, most incidents are not publicly documented to the degree that they can be reported upon. the five primary things that companies must be concerned with when facing a pandemic situation are: . the potential impact on personnel. . the pandemic, crisis response plan. . the potential impact on business operations. . the potential impact on business supply chain. . the potential impact to share value or price. what many companies don't consider is the potential for shareholder lawsuits against executives for business losses resulting from a lack of planning for situations such as pandemics. from shared sick time policies to work-at-home policies during is your organization pandemic ready? harvard's school of public health recently released survey data showing how deeply concerned u.s. businesses are about the possibility of widespread employee absenteeism that might follow an outbreak of the swine flu (h n ). researchers from the school questioned more than businesses across the country. two-thirds of companies said they couldn't operate normally if more than half of their workers were out for weeks. and four of five organizations predicted severe operating problems if half of their workers missed a month of work. a crisis, being able to quickly communicate a position or a plan, and to answer questions in the event of such an emergency, can not only save money and productivity, but garner employee confidence and calm nerves. chapter elaborates on the relationship between travel risk management (trm) and other aspects of risk management across the enterprise (erm-enterprise risk management). according to the new zealand herald, the country's largest company, fonterra, could lose $ million because of the ebola epidemic. fonterra ceo, theo spierings, noted that when african countries lock down their borders to control the disease, demand dropped for fonterra's products. he commented, "so…movements in west africa become more and more difficult, so that limits movement of food as well, movement of people-people going to the market, doing their groceries-so you see demand really dropping pretty fast." "if the market in west africa slowed down or dropped off that would affect , tonnes of powder," mr. spierings said. "that's about percent, percent of our exports. so you talk…$ million or something like that." these survey results should encourage all organizations to prepare for the worst by developing a crisis management plan. in addition to ample warning, senior management has ample reason to prepare, and no excuse not to. an organization's executives won't be blamed for the outbreak, but they do risk censure if they fail to prepare, respond, and communicate with internal and external stakeholders. this white paper tells how. to help organizations and their leaders prepare for a possible h n pandemic, certain key issues must be addressed to keep operations running as smoothly as possible: • human resource (hr) issues that drive pandemic planning. • planning for steps necessary to keep an organization operating during the pandemic period. • implementing steps needed to create an enterprise-wide crisis management plan. • internal and external issues that crisis communications must address. why bother planning for the h n pandemic? to put it simply, companies and organizations that plan for any type of crisis demonstrate the behavior of responsible citizens. formulating a detailed crisis management plan specifically for h n achieves four things: . protects employees' health and safety. . lessens the chance of a major interruption of your daily business. . protects your company's or your brand's reputation. . allows daily business activity to continue with minimal disruption if you are affected. companies must establish open lines of communication with all audiences while dealing with the effects of the pandemic or other significant events. should one occur, these stakeholders will want to know what you are doing to manage the situation and minimize their risks. if you communicate with these stakeholders openly and promptly, you send four valuable messages: • you are taking charge of the situation. • you take it seriously. • you have the best interests of your staff and customers at heart. • you run a responsible company with nothing to hide. pandemics have a disastrous effect on a company's optimal functioning because they prevent large numbers of critical employees from showing up for work. the resulting interruption to normal operations can have a disastrous cascading effect, affecting nearly every corner of the organization at considerable cost. employees unable to work or prevented from working become anxious and insecure. when they start asking management questions that aren't answered sufficiently or quickly, it exposes the fact that management hasn't developed contingency plans or that management failed to consider what employees need to know. part of the cost of failing to prepare can be measured by the resultant loss of trust in management's capability, judgment, and credibility. we know from experience there are certain predictable questions that employees will ask and hr departments must be prepared to answer. for example: hr departments should, as a matter of urgency, review attendance and sickday policies to ensure they have made allowances for managing the largerthan-normal issues h n creates. some of the policies that will need to be considered for implementing or addressing include: . how/when to start monitoring/screening employees at the workplace to determine if they are sick or pose a risk. how/when sick employees should be sent home to protect colleagues at work or be stopped/prevented from coming to work where they could infect colleagues. . how/when the company should be temporarily closed due to the number of sick employees. . how/when to implement steps to minimize face-to-face contact at work. . how/when to allow certain employees, including senior management, to work remotely from home or another branch/office. . how/when employees should be allowed to stay at home to look after sick family members. . how/when the company's travel policies should be changed/suspended. . how/when to stop employees from coming into contact with suppliers and customers. . how/when to implement and enforce a "wash your hands" and "cover your mouth and nose when coughing and sneezing" policy; this must include making face masks and the use of hand sanitizers mandatory across the company. how/when to change the company payroll policy so that all employees receive electronic payments into their accounts; consider establishing an emergency "employee help" fund. . any and all extensions/additions to your existing payroll and work hours' policies. at the core of your h n crisis plan, your hr department must be fully prepared to explain and communicate any new policies or changes to employees on an ongoing basis in all offices. this includes offices and employees that may not be affected by the pandemic at all. international and regional offices must also be briefed as they, too, could be directly impacted if there is an h n outbreak. employees should also be asked for input and ideas. this may help to highlight potential management or operating aspects that have not been considered. it will also make employees feel part of the pandemic planning process and thus, more accepting of and cooperative with the final plan. if appropriate to your workplace and organizational culture, additional steps can be taken to protect employees by putting up educational posters, using training materials, and even arranging for annual flu shots (under doctor's supervision) to be provided in the workplace for convenience. employees should also be encouraged to learn and do more on their own and away from work. all of these actions send a message to employees that you are looking out for them, their jobs, and the company's well-being. in return, employees are much more likely to "go the extra mile" in order to lessen the business impact of widespread absences. communicating during a crisis is important, but what businesses do is always more important than what they say. making good decisions and providing straightforward, honest and factual information to all employees with frequent updates is one of the most critical actions management can take. ideally, all companies and organizations would have enterprise-wide crisis plans in place before a crisis breaks. but realistically, we know from multiple surveys that at least half don't. too many companies assume an "it can't happen to me" mentality or, in tough business or competitive conditions, they decide not to invest in "insurance" activities. unfortunately, some find out the hard way that you cannot choose your crisis; it chooses you-and almost always at the most inconvenient time. if yours is an organization that hasn't taken the steps necessary to implement crisis preparedness, here are some interim steps that you can take quickly to address h n . remember, the most effective and least costly way to manage a crisis is to prevent it from happening in the first place. you cannot stop h n , but you can take steps to keep it from damaging your operations, your reputation, and your bottom line. here's a quick checklist of things an organization can do, even at this late date: . appoint a pandemic coordinator or team. this individual or team will lead the organization through various steps to become pandemic-ready. have them first conduct a vulnerability and risk assessment. that means identifying areas in which you are at heightened risk of infection or in which your responses or ability to compensate will probably be weak. armed with this knowledge, you should be able to prepare for worst-case scenarios and begin planning accordingly. . get your crisis management team up to speed. a crisis management team consists of senior employees who will deal full time with a crisis while the rest of the organization runs as normally as possible. the most effective crisis teams typically consist of no more than five members who serve as its decision-making leadership. crises are not situations for committees or consensus building. they demand swift and certain decisions and actions be made under "battlefield conditions." we strongly recommend that you have a "five-star general" heading up your team. . a crisis management team must possess sufficient inherent or delegated power to command unrestricted access to a full cross-section of corporate disciplines, including hr, sales, customer service, information technology (it), security, operations, facilities management, communications, department/business unit headsfrom every corner of your organization. the crisis managers must know who from these disciplines are to be brought on to support the crisis management team on an as-needed "on-demand" basis. note that these disciplines are for advice and support, not crisis decision making. give them full authority to carry them out. . the team should also include someone who will be company spokesperson throughout the crisis. ideally, the spokesperson should be a senior company executive. he or she should have received formal media training, and should have the stamina, self-discipline, and inner strength to be able to convey trust and believability when speaking during a time when bad news may need to be delivered to various audiences. . think about including external experts on your team. these could include public health consultants, doctors, hr consultants, and business continuity experts. no organization can hope to be crisis-ready unless it is prepared with messaging ready to be disseminated to audiences on short notice and under pressure. crisis messaging typically consists of fully or partially (fill-in-the-blanks type) prepared statements addressing a range of potential situations anticipated in advance. prepared organizations keep them in a template format. then, as a crisis develops and the actual facts of the situation become known, the relevant template can be rapidly updated with all pertinent information. in a crisis, you simply do not have time to agonize for long over "what are we supposed to say?" remember, it is only during the first minutes of a crisis that you have your one chance to take control of the situation via proactive communication. in that time, messages must be disseminated internally to staff and externally to the relevant audiences, such as customers, stockholders, suppliers, and partners, and possibly the media. businesses that conduct vulnerability and risk assessments will have a better idea of the templates and draft messaging they will need for a flu outbreak. these situations range from temporarily closing a site to announcing an interruption of service. the tone of all messaging must demonstrate that management is taking the situation seriously. employees are your first priority and must receive crisis-related messaging before anyone else. the media and relevant external stakeholders can then receive the same or similar messaging soon after. department heads in your company can be used to communicate directly with employees. employees should also be provided with messaging that they can share with others outside the organization. in today's "always-on" instantaneous online world, whatever employees are told invariably becomes public knowledge within minutes. from time to time, someone will ask a question that cannot be answered using prepared messaging. the crisis team must be prepared to reply "i don't know," and then either explain why, honestly and plainly, or commit to providing the answer at a given time in the future. nothing destroys trust and creates anger more than speculating or guessing at answers that may be proven wrong at a later stage. while you must respond quickly to all questions, you may not be able to answer them all. the crisis team must understand the difference. stakeholders want reassurance you are doing everything possible to manage the situation and communicating without a hidden agenda. if you intend to keep your business open and running during a significant event, say so. for credibility, communicate the steps that you are taking to ensure it is kept open. if you are asked questions and are uncertain about what will take place, acknowledge this honestly. make every effort to find the answer quickly and, when you have it, follow up as soon as possible. plan to work with third parties. adopting a go-it-alone attitude in dealing with a pandemic is needlessly dangerous. organizations are wise to be working with key third-party consultants to make crisis preparedness as robust as possible. key third parties could include: don't overlook your supply chains. companies providing each other with operations-critical products, goods, or services become inextricably linked. a problem in another company may cascade to yours, affecting your ability to meet contractual obligations. steps they take to stay in business may be beneficial or disruptive to you. knowing ahead of time will help you make appropriate arrangements or establish alternatives. cooperating with customers, partners, suppliers, and local governments helps you become pandemic-resilient. expert legal opinion must be obtained on how to address contractual obligations should a full scale pandemic break out. if you're prevented from delivering products or services and thus break legally binding contracts, customers/ partners could hold you liable for failing to plan adequately. such legal action could expand or precipitate a second crisis, when the media reports the legal action and you are forced to deal with a reputational crisis. during a pandemic, organizations must communicate effectively with all internal and external audiences. being ready to communicate proactively and at a moment's notice requires advance preparations. in all cases, employees are the most important communications targets during a crisis. friends and family will contact them along with many of their external business relationships (including the media) to ask "what's really going on?" and we know from experience that poorly briefed employees tend to speculate in the absence of solid information. this could easily precipitate a secondary crisis, forcing you to deal with rumor-mongering by employees and potentially false reporting by the media. either could cause serious damage. thus, you must designate in advance your primary or "official" internal communication channels, and let everyone in your organization know what they are. while face-to-face verbal communication is the best medium for internal audiences during a crisis, it may not be possible if h n strikes. depending on your specific situation, one of the following channels should be considered in order to communicate companywide: remember: what is written and given to employees can be passed on to the media and other parties. communication with all external stakeholders must be timely and accurate, with messages consistent with what is being communicated internally. messaging differences should be determined by relevance to the receiver. but be safe: when in doubt, overcommunicate. in a crisis, everyone wants more information, not less. if you had to communicate with % of your customers within minutes, could you? do you have up-to-date accurate contact information housed in databases that can support mass messaging such as blast e-mail or recorded voice messages with outbound autodialing? blast-fax? cell phone information for texting? nobody has time to build these contact databases once a crisis strikes. assemble them now. the best time to start communicating is when there is no crisis. a proactive information campaign could spearhead the opening of new channels of communication with your various external audiences prior to a crisis. the following external communication channels can be used proactively or reactively depending on the situation: while social media tools such as twitter, facebook, youtube, and blogs can play a role in crisis communication, at this time we believe they are not the tools best suited to be your primary or "official" communication channel to the outside world. especially for business organizations, social media are not yet universally accessible. but more importantly, they are not within your complete control. you must be extremely careful about what you say via social media, as it is very difficult to change anything after it has been sent out. it's the very nature of most crises that the situations and facts change, and change often. social media messages containing old information can too easily recirculate, causing misunderstandings and conflicts precisely at a time when they can do the most damage. a major h n breakout could devastate supply-and-value chains, and possibly close down entire industry sectors. this will prevent companies from providing or delivering much needed services. customers, partners, suppliers, and employees will feel a significant impact. there will also be financial repercussions. in short, a business could be forced to close down if it is not ready for all eventualities. to be truly resilient in a crisis, the organization must have an up-to-date business continuity plan detailing how it will restore its operating functions, either totally or partially, within a certain period of time. to achieve this, key decision makers must: • have an in-depth look at their company to identify essential functions needed to keep doors open. nonessential ones can be temporarily discontinued without impacting day-to-day operations. people with key skills that are important to the business during the pandemic must be identified and protected whenever possible. those with nonessential skills may be told not to report for work during the pandemic. • consider contingency plans to switch operations to other sites, if possible. • identify alternative suppliers that you can switch to at a moment's notice. your primary suppliers of utilities, goods, products and services may suddenly shut down because of poor planning. you should ask current suppliers to disclose what contingency plans they have in place to ensure the provision of uninterrupted service to you. put backup plans in place to switch to other/competing suppliers and contractors if you're the least bit unsure of their preparedness. • determine if their it systems are sufficiently robust so critical technology-dependent business processes would still function. even though more than one billion people travel via commercial aircraft every year, illness as a direct result of air transportation isn't common; however, there are risk exposures associated with air travel that both employers and travelers should be cognizant of in order to mitigate the risks when possible. most modern aircraft are equipped with hepa (high efficiency particulate air) filters, which, according to the european air filter efficiency classification, can be any filter element that has between % and . % removal efficiency. according to pall corporation, for aircraft cabin recirculation systems, the definition has been tightened by the aerospace industry to a standard of . % minimum removal efficiency. most modern aircraft provide a total change of aircraft cabin air to times per hour, passing through these hepa filters, which trap dust particles, bacteria, fungi, and viruses. many airlines have an airflow mix of approximately % outside air, and % recirculated, filtered air whereby the environmental control systems circulate the air in a compartmentalized fashion by pushing air into the cabin from the ceiling area, and taking it in at the floor level from side to side, versus air movement from the front to back of the aircraft. however, most viral respiratory, infectious diseases, such as influenza and the common cold, are transmitted via droplets that are most commonly transmitted between passengers by sneezing or coughing. these droplets can typically only travel only a few feet this way. however, it is their survival rate once they land on seats, seatbelts, tray tables, and other parts of the passenger cabin that can provide additional exposure, which is why sanitation of your personal seating area when traveling, particularly your hands with an alcohol-based sanitizer before eating, is important. surgical masks have been shown to reduce the spread of influenza in combination with hand sanitization, particularly when worn and practiced by the infected individual. viral outbreaks in recent years of concern to business travelers have included middle east respiratory syndrome (mers), severe acute respiratory syndrome (sars), and ebola, h n (swine flu), among others. the international air transport association (iata) has developed an "emergency response plan template" for air carriers during a public health emergency, which can be found at the following link: http://www.iata.org/whatwedo/safety/health/ documents/airlines-erp-checklist.pdf disinsection is the use of chemical insecticides on international flights for insect and disease control. international law allows disinsection and the world health organization (who) and the international civil aviation organization suggest methods for aircraft disinsection, which include spraying the aircraft cabin with an aerosolized insecticide while passengers are on board, or by treating aircraft interior surfaces with a residual insecticide when passengers are not on board. two countries, panama and american samoa, have adopted a third method for spraying aerosolized insecticide without passengers on board. not specific to just air travel, blood clots or dvt (deep vein thrombosis) can be a serious and potentially deadly health risk for any traveler with restricted mobility in an aircraft, car, bus, or train. anyone traveling for more than hours without sufficient movement can be at risk. many blood clots are not necessarily visible and can go away on their own, but when a part of one breaks off, there is the possibility of it traveling to your lungs, creating a pulmonary embolism, which could be deadly. in addition to traveler training on prevention of dvt, companies should take this threat into consideration with regards to international class of service policies or reimbursement consideration for upgrades. according to the u.s. centers for disease control (cdc), the level of dvt risk depends on whether you have any other risks of blood clots in addition to immobility, as well as the length or duration of travel. the cdc also states that most people who develop blood clots have one or more other risks for them, such as: • older age (risk increases after age years) civil unrest generally takes place when a group of people in a specific location is angry, resulting in protests and violence. around the world, there are countless incidents of civil unrest that erupt, which can not only cause inconvenience and safety concerns for business travelers, but can also cause mental and emotional stress for which the employer is ultimately responsible to try to limit the effects of whenever possible, and to treat as early as possible after the incident is over. within the first months of , the world saw civil unrest and protests in turkey, brazil, ukraine, thailand, venezuela, malaysia, cambodia, india, egypt, hong kong, russia, china, and the united states (excluding military acts of war or civil war). in january of , governments and private organizations from around the world began evacuating people from egypt due to civil unrest. approximately , americans lived and worked throughout egypt at the time, and approximately requested evacuation assistance from the u.s. government. such an exercise requires massive planning and resource availability, even for much smaller groups of people. consider the number of other companies competing for the same resources to evacuate their people, as well as the general public trying to leave. companies without a plan in place, along with proper strategic crisis response resources, would have been last in line to evacuate their impacted travelers and at greater risk for someone getting hurt or killed. at one time, civil unrest may have been considered primarily politically motivated, but today, there are many factors that lead to the spark that starts the fires of violence. things such as overpopulation, lack of food and resources, poverty versus wealth (income inequality), crime, lack of jobs and religious persecution, while sometimes related to political causes, are all reasons for the increased violence we see today. with the advent of mobile technology being increasingly available to the middle and lower classes of the world, it doesn't take much or long time-wise, to incite anger or hatred in others who can assemble quickly, sometimes before one has a chance to react. throughout the text of this book, readers should see a common theme about the importance of quality risk intelligence. the previous statement about violence breaking out before one can react, is a perfect example of how real, risk intelligence (not simply recycled news) can often predict these events as they are starting to come together and warn people in advance, so that companies and individuals can take steps to mitigate their exposure. in such examples, would employers and travelers want "cheap information" from a provider that primarily scrapes news wires on the internet, or qualified, vetted security analysts with thousands of sources? if a life depended on it, i'm confident that people would choose vetted intelligence. another way to understand the value of news versus intelligence is that "intelligence" is in effect "analysis + news + context + advice." experienced security analysts specializing in specific geographic areas and subject matter produce quality intelligence. climate change can also drive civil unrest with sea-level risings, damage to property, water shortages, and increased costs associated with lost productivity or infrastructure collapse. people simply go where the goods and the work are provided. when that is lost for various reasons over a large area, there can be mass migrations that sometimes see the intervention of military units to prevent border crossings and an unanticipated drain on other population's resources. property damage and serious violence in vietnam in may , as a result of anti-chinese protests, was experienced not only by chinese businesses, but by other assets owned by companies from additional countries. some manufacturing experienced an interruption to production, causing between percent and percent decreases in company share prices. these figures and insight are intended to support business cases for companies to invest in not just products and programs to avoid business disruptions caused by civil unrest and other factors, but the time required to simply have plans in place to mitigate the risk. imagine being in a foreign country on business and getting pulled over on the road in your rental car by a local police officer. unaware of any laws that you may have broken, after a quick discussion with the officer, you realize that they are extorting you for a bribe and you simply don't have the cash or the training to respond to the situation properly. alternatively, a traveler arrives in foreign country via a commercial flight, carrying marketing collateral and merchandise to give away at a conference that they are attending. the local customs authorities misinterpret part of your merchandise, because the conference is being held in a deeply religious country with harsh laws regarding morality. not only does the traveler fear for their safety, the company doesn't want to cause an international incident, which can be difficult to clean up. does your company provide resources and training to travelers regarding how to handle themselves in such situations? women from western countries may still find it hard to believe how many places in the world where their personal safety, and possibly their lives, can depend upon the length of their skirt and sleeves, or the time of day that they are out and about, particularly without a male escort. in , a woman from new york was found dead in turkey; a turkish man confessed to killing her after allegedly trying to kiss her. according to news reports, she was a first-time international traveler, an avid social media user, and was in constant contact with friends and family. it is reported that she wasn't off the beaten path or doing anything risky, simply taking photographs. sometimes just having some awareness training about your destination can save female travelers the potential for conflict or incident, such as holding one's purse in her lap or at her feet with a thick strap around her leg to secure it, or ensuring that luggage tags do not openly display addresses and have a cover that must be opened to reveal the information. according to joni morgan, director of analytic personnel at ijet international, "in some cultures, for instance, it's not appropriate for a woman to initiate a handshake." "in afghanistan, it's considered an insult to show the bottom of your shoe, so when crossing your legs, you want to be aware of that." female road warriors are learning important skills that are notably helpful in all destinations, but in some more than others, additional care should be taken. indications of when to take additional care is an important part of pretrip travel intelligence provided by an employer's trm program, supported by a vetted travel risk intelligence provider. some considerations for female business travelers while traveling alone or even with peers on business include the following: . always plan your route before going anywhere. never leave your hotel or office without understanding where you are going and appropriate routes. travelers do not want to look lost in the street looking at maps or their mobile devices for directions. . use vetted taxis or ground transportation providers. make an attempt to prebook all transportation with providers that your company has preapproved, and have appropriate security policies and procedures in place, such as identifiable car numbers, driver identification, tracking, and electronic order confirmation. removing the potential for unfamiliar, unvetted ground transportation providers can drastically reduce the potential for assault or abduction. can purchase a device to block the outside view of the inside of their hotel room by assailants who have devices that enable broad visibility inside hotel rooms from the outside via peepholes. in the absence of such a device, place tape or a sticker over the inside peephole opening. . choose your hotels carefully. make it clear to your employer that you take safety seriously and that you expect safety considerations to have been taken into account when designating preferred hotels for employees to stay at. employers should be able to articulate what kinds of safety standards go into their preferred hotel selections, which form the basis for how different incidents can be mitigated or handled should an incident occur. . never stay at hotels or motels where the room door is exposed to the open air (outside). . try to not accept hotel rooms on the ground floor. being on a higher floor makes it more difficult for an assailant to get away or not be seen on surveillance cameras. . never tell anyone your room number verbally. if a hotel employee asks for it, provide them with it in writing and personally hand it to them. do not write it on a check and leave it unattended. you don't want someone in the area to overhear you providing this information verbally or to view it on your check. . alcohol consumption-never leave your drink unattended or out of your sight. a momentary distraction is an opportunity for someone to place drugs into your drink. also, never drink until intoxicated while on business and be mindful of locations where drinking alcohol may even be illegal. . emergency phone numbers-know the equivalent of or the local emergency services phone number and your local consulate or embassy phone numbers and preprogram them into your mobile phone, in addition to your company's provided crisis response hotline. whichever number you are instructed to call first according to your company's policies (if your company provides a crisis hotline), having those numbers handy can save your life when moments count. . never tell anyone that you are traveling alone. avoid solitary situations. try to remain in social situations where plenty of people are around. if you feel uncomfortable, leave. . leave a tv or radio on when you leave your hotel room to provide the perception that someone is in the room. . never hesitate to ask security or someone to escort you to your room, and avoid exiting an elevator on your hotel room's floor when sharing the elevator with a man. if necessary, go back to the lobby level until more people get on the elevator or you can ride it alone. use valet parking. self-parking can often put individuals at risk of assault in unsupervised car parks or garages. . upon arrival at your hotel, take a hotel business card or postcard and keep it with you at all times. if ever you are away and need to return, and you either don't remember the address, or your driver doesn't know where it is, or you don't have a signal on your mobile device, you can use the card to provide address details (usually in the local language). . do not use door-hanging room service order forms (typically for breakfast), as they often note how many guests you are ordering for. . make sure you have adequate insurance. just because you are on a business trip, doesn't mean that your employer has obtained enough insurance or services to support you in the event that a crisis occurs. hopefully, employer-provided insurance and support services are adequate and have been effectively communicated, but don't travel for business without a thorough understanding of what kind of coverage and support you have. in particular, any medical coverage should guarantee advance payment to local service providers and not require travelers to pay for services and file for reimbursement upon their return home. most people don't have access to the many thousands of dollars that might be necessary to procure sufficient treatment and support. . travel with smart travel accessories. travel with a small, high-powered flashlight and one or more rubber door stops for the inside of your hotel room (be aware of the downside of using in case of a fire). . leave copies of your passport with someone at home who can easily get a copy to you if you need it. having a copy can expedite the replacement of a lost or stolen passport if needed. an honor killing is a homicide of a family member, typically by another family member, based upon the premise that the victim has brought dishonor or shame to the family, in such a way that violates religious and/or cultural beliefs. again, as with religious or cultural restrictions on modest clothing, honor killings are not exclusive to women, but within the cultures and countries where honor killings are more generally accepted, men are more commonly the sources or perpetrators of the revenge or honor killings, very often charged by the family to watch over and police female family member behavior, restricting or prohibiting things such as adultery, refusal to accept an arranged marriage, drinking alcohol, or homosexuality. honor killings are not exclusive to any one country or religious faith, because they are found in a broad scope of cultures, religions, and countries. although more common in places such as the middle east and asia, there have been documented cases of honor killings in the united states and europe. if honor killings were based largely on the premise of family honor, why would nonfamily members or business travelers need to be concerned? honor killings have been known to happen to nonfamily members in strict, culturally conservative countries. perceived inappropriate behavior, typically with a female member of a conservative family, could result in the killing of the female family member and the nonfamily suspect. such killings can even take place in broad daylight. in lahore, pakistan in , one such incident occurred involving multiple participants while the police looked on. the victim killed for marrying a man that she loved without family consent. often these crimes are hard to document or record because they are disguised as suicides or, in some latin american countries, as "crimes of passion." the united nations fund for population activities (unfpa) estimates that as many as women fall victim to honor killings each year. article of qatar's constitution states that it is a "duty of all" who resides in or enters the country to "abide by public order and morality, observe national traditions and established customs." this means that wearing clothing considered indecent or engaging in public behavior that is considered obscene is prohibited to all, including visitors. in qatar, the punishment could be a fine and up to months in prison. with kissing or any kind of physical intimacy in public, as well as homosexuality, being outlawed under sharia law, all travelers to or via the middle east for business or tourism purposes (e.g., to attend the world cup), should take heed. the qatar islamic cultural centre has launched the "reflect your respect" social media campaign to promote and preserve qatar's culture and values. posters and leaflets advise visitors, "if you are in qatar, you are one of us. help preserve qatar's culture and values, please dress modestly in public places." while research finds no definition in qatar's article for modest clothing, campaigns such as this suggest that people cover up from their shoulders to their knees and avoid wearing leggings. they are not considered pants or modest dress. an example of the campaign leaflet can be found in "qatar launches campaign for 'modest' dress code for tourists" published by the independent (uk newspaper). modest dress applies to both men and women. of course, strict laws, preferences or rules regarding dress expectations for women are not exclusive to any one country. http://www.pewresearch.org/fact-tank/ / / / what-is-appropriate-attire-for-women-in-muslim-countries/. while each employer may have specific approaches to handling an incident such as sexual assault, there must be a defined process for reporting such an event that involves crisis response resources that can intervene and provide advice on how to handle the situation with local authorities, perhaps first by contacting diplomatic contacts before contacting the police. facing local authorities alone in a foreign country for such a sensitive issue as sexual assault can be daunting and intimidating nbc news, "family stones pakistani woman to death in 'honor killing' outside court," may , , http://www.nbcnews.com/news/world/family-stones-pakistani-woman-death-honor-killing-outsidecourt-n . united nations, resources for speakers on global issues, "violence against women and girls: ending violence against women and girls," http://www.un.org/en/globalissues/briefingpapers/endviol/. lizzie dearden, "qatar launches campaign for 'modest' dress code for tourists," independent, may , , http://www.independent.co.uk/news/world/middle-east/qatar-launches-campaign-for-modest-dresscode-for-tourists- .html. without a company or diplomatic representative being there to assist. crisis response suppliers should be equipped with necessary contacts, recommended protocols, and resources to help the victim and employer to address the situation and get help as soon as possible. this is another good example of why employers should have a single global crisis response hotline for any crisis that a traveler may encounter while on business travel. sexual harassment can happen anywhere. what happens if you require a traveler to use a supplier per the company's travel policy, and a representative of that supplier sexually harasses the traveler? in addition to standard protocols within the workplace, considerations must be given to business travel, which from many perspectives today is an extension of the workplace. a hate crime is a criminal act of violence targeting people or property that is motivated by hatred or prejudice toward victims, typically as part of a group, based upon creed, race, gender, or sexual orientation. a critical component of any trm program is disclosure of potential risks to the traveler prior to taking a trip to a destination. in consideration of laws and cultural beliefs in select countries or regions that sanction the persecution, imprisonment or killing of members of the lgbt (lesbian, gay, bisexual, and transgender) community, specific races, religions, or sex (mainly women), travelers must be prepared a female business traveler, over the course of several months on a project, travels during the week, returning home on weekends. over time, a car rental clerk at the location she rented from weekly, began making comments to her about her appearance each time she checked-in or returned a car. eventually, the rental clerk began calling her mobile phone to share how he liked what she was wearing and began sending her text messages while she was in town, using the mobile number she provided at check-in. not responding and scared, the traveler canceled all future reservations and books rental cars with another provider. shortly thereafter, the clerk began calling and texting her, asking why she canceled and when she would be coming back. a concerned colleague of the traveler brought the situation to the company's travel manager, who intervened with their human resources and legal departments to proactively address the situation with the authorities and the supplier, and to provide appropriate support for the traveler as best they could. the end result, after much investigation, was the issuance of restraining orders against the clerk and termination of his employment. it turned out that the supplier hadn't done sufficient background checks on its employees and the clerk in question had a history of similar behavior. with information and training on acceptable behavior when traveling to these destinations and understand how to get help should they find themselves in a difficult position or a potential victim of a hate crime. saying the wrong thing, at the wrong time, in the wrong place, or wearing something inappropriate, or acting a certain way that isn't culturally acceptable in some parts of the world, can put travelers in real danger. how does your company prepare your travelers for facing these challenges as they travel? while some laws that promote discrimination that can lead to hate crimes are more notable in the press, such as the antigay propaganda law put into place in russia prior to the sochi olympics, some are less obvious to the average business traveler, such as up to years in prison in nigeria for simply being gay, or india's supreme court ban on gay sex, or the execution of homosexuals in saudi arabia. in april , an -year-old man wearing islamic dress was attacked and killed while walking home from his mosque in birmingham, uk, by a -year-old ukrainian student who told police that he murdered the victim because he hated "nonwhites." according to "one in six gay or bisexual people has suffered hate crimes, poll reveals," a article in the the guardian (uk), some , gay and bisexual people in the uk have been victims of hate crimes in the previous years, prompting police to take the problem more seriously. such examples continue to support the notion that a crisis doesn't need to be an incident that impacts large numbers of people at once. quite often they involve one person at a time, and they don't need to take place in a high-risk destination, thus discounting the argument by some companies that trm isn't necessary for those who don't travel to high-risk destinations. a crisis can happen anywhere for many different reasons, affecting as few as one person at a time. although privacy laws generally prohibit companies from asking employees about sexual orientation, making sure that all employees (of any sexual orientation) understand the dangers that face lgbt travelers, can help to mitigate risks for themselves (if lgbt, traveling with an lgbt person, or if perceived as lgbt) or their fellow travelers, considering that there are many countries still in the world where homosexuality is a crime. • in mauritania, sudan, northern nigeria, and southern somalia, individuals found guilty of "homosexuality" face the death penalty. the last five years have witnessed attempts to further criminalize homosexuality in uganda, south sudan, burundi, liberia, and nigeria. • south africa has also seen at least seven people murdered between june and november in what appears to be targeted violence related to their sexual orientation or gender identity. five of them lesbian women and the other two were non gender-conforming gay men. • in cameroon, jean-claude roger mbede was sentenced to three years in prison for 'homosexuality' on the basis of a text message he sent to a male acquaintance. • in cameroon, people arrested on suspicion of being gay can be subjected to forced anal exams in an attempt to obtain 'proof' of same-sex sexual conduct. • in most countries, laws criminalizing same-sex conduct are a legacy of colonialism, but this has not stopped some national leaders from framing homosexuality as alien to african culture. • a cave painting in zimbabwe depicting male-male sex is over years old. • historically, woman-woman marriages have been documented in more than ethnic groups in africa, including in nigeria, kenya, and south sudan. • in some african countries, conservative leaders openly and falsely accuse lgbti (lesbian, gay, bisexual, transgender, and intersex) individuals of spreading human immunodeficiency virus (hiv)/acquired immune deficiency syndrome (aids) and of "converting" children to homosexuality and thus increasing levels of hatred and hostility towards lgbti people within the broader population. lgbti individuals are more likely to experience discrimination when accessing health services. this makes them less likely to seek medical care when needed, making it harder to undertake hiv prevention work for, and to deliver treatment where it is available. in many government programs they are not identified as an "at risk" same-sex marriage laws restricting freedom of expression and association kidnapping and ransom activities targeting military enemies and employees of multinational companies who are from countries considered to be enemies to terrorist causes, are the primary fundraising strategies of organized terrorist groups. even for companies that do not routinely visit high-risk locations, having some sort of policy in place for proof of life, which is the means for verifying that a captive is in fact who the captors say they are and that the captive is still alive, such as by providing information that only the alleged victim would know, can save valuable time in a sensitive situation and perhaps someone's life. additionally, a kidnap and ransom insurance policy is something for all companies to consider, with an understanding that kidnappings happen at anytime around the world, and largely go unreported. according to the guardian news and media (uk), approximately % of fortune companies have kidnap and ransom (k&r) insurance. k&r insurance originates from , when it was first offered by insurance provider lloyd's of london, after the kidnapping and murder of american aviator charles lindbergh's infant son. in , the uk's home secretary, theresa may, supported and passed the uk's "counter-terrorism and security act of ," which prohibits insurers from paying claims used to finance payments to terrorist groups. the uk is where many of the world's k&r insurers operate. many insurers insist that it shouldn't matter because they claim to not pay or finance ransoms, but instead pay claims for services and expenses related to negotiating the release of the captives in question, medical and counseling treatment, along with things such as employee salaries while in captivity. it's difficult to obtain information from clients who hold such policies, because most policies have strict cancelation provisions to prevent a company from disclosing the fact that it has such a policy. details specific to restrictions on insurance related payments associated with terrorist related ransoms in the uk's counter-terrorism act of can be found at http://www.legislation.gov.uk/ukpga/ / /section/ /enacted. companies with any travel to high-risk destinations have a responsibility to provide some kind of survival training for those travelers, in addition to access to resources and provision of current intelligence before, during, and sometimes after their travel is complete. to complicate matters, based upon a g summit, an agreement was made to not pay ransoms to kidnappers for fear that the money was directly funding terrorist organizations; therefore, some countries, such as the uk, are enacting laws to prohibit the transfer of funds for hostages in certain circumstances or locations. senior foreign and commonwealth office (fco) officials in the uk estimate over $ million has been paid in ransoms to terrorists during the years leading up to the report. it isn't safe to assume that your government will help bankroll your hostages' release if you find yourself in such a situation, and you may face criminal prosecution if you offer a ransom to specific groups. people who commit kidnappings do so for a variety of reasons, including political or religious views, but most often they are purely financially motivated. perception is everything, so identifying traveling employees of large or multinational companies, makes them an easy target, thus the reason for using code names for arriving ground transportation signs. of course, how one dresses and where one goes, also have an impact on how victims are targeted (i.e., wearing expensive jewelry, standing out from the crowd in expensive clothing or making it clear that you work for a large multinational company [clothing with logos or meeting drivers with company names on greeting placards]). later in this book, kidnappings are explored in greater detail. some statistics will be presented that both companies and travelers should find serious enough to change their perception about the possibility of kidnapping happening to them. kidnapping incidents should be accounted for in all corporate crisis response plans. while some medical emergencies may require the need for evacuation, it is more common to receive calls for assistance involving acute or preexisting conditions that can be diagnosed and treated locally. lost or stolen medication, allergic reactions to food or the environment, and unexpected illnesses, are common occurrences when calling a corporate crisis response hotline. however, in some instances, individuals must be quickly assessed to determine if adequate medical care can be obtained locally, and if not, a decision must be made to evacuate that person to the closest logical facility capable of treating the individual. many domestic health insurance plans do not provide coverage for individuals traveling abroad, and often when they do, they require out of pocket expenditures for services; in other words upfront payment by the patient, leaving the patient to file for reimbursement upon the patient's return. more often than not, in these circumstances, this equates to thousands of dollars that most people do not have immediate access to, especially on short notice. the cdc recommends that if domestic u.s. coverage applies, and supplemental coverage is being considered, the following characteristics should be considered when examining coverage for planned trips: • exclusions for treating exacerbations of preexisting medical conditions. the company's policy for "out of network" services. • coverage for complications of pregnancy (or for a neonate, especially if the newborn requires intensive care). • exclusions for high-risk activities such as skydiving, scuba diving, and mountain climbing. • exclusions regarding psychiatric emergencies or injuries related to terrorist attacks or acts of war. • whether preauthorization is needed for treatment, hospital admission, or other services. • whether a second opinion is required before obtaining emergency treatment. • whether there is a -hour physician-backed support center. additionally, one should have coverage for repatriation of mortal remains, should someone covered unfortunately die while away from their home country. because so many domestic healthcare plans do not provide for international coverage and evacuations services, companies must provide comprehensive coverage for their employees globally and employees should be fully aware of what is included in said coverage. employees may decide that what the company offers is not enough by their personal standards and consider purchasing additional coverage to supplement what the company provides. when purchasing different types of travel-related insurance, it's important to understand the differences between the different products offered in the marketplace, especially the differences between consumer and business travel products. options can include: . travel insurance, which provides trip cancellation coverage for the cost of the trip, delays or interruptions, and lost luggage coverage. it can and often does provide some amount of emergency medical and evacuation coverage, but often requires payment of medical expenses by the insured in the country where services are rendered (versus direct payment by the insurer), and the filing of paperwork for reimbursement upon the insured's return home. buyers should be mindful of whether or not the policy provides guaranteed payment directly to the suppliers in question. . generally, some consumer based travel health insurance pays for specified or covered emergency medical expenses while abroad; however, such insurance (and others) may require that the individual pay any medical expenses in the country where services are rendered and file for reimbursement upon the individual's return home. insured parties should always check whether guaranteed payment to providers is included in coverage, as with some consumer-based travel insurance. medical evacuation coverage is for medical transport to either the closest available treatment facility or the insured's home country for medical attention, depending upon the policy and the situation or medical condition. considering the cost of medical evacuations, depending upon the distance and the services required for the transport, expenses can vary greatly, but can be very costly. it is recommended that policies have greater than us$ , in coverage (some provide up to us$ , or more), and include transportation support for an accompanying loved one or family member. policies with less than us$ , in coverage should be reconsidered for possibly not providing enough coverage. buyers should note that these products cover primarily just the evacuation and not medical services or treatments. . medical membership programs can cater to individual travelers on a per-trip or annual basis or on a companywide basis. these programs can vary widely by provider and membership type, but can potentially provide access to network services resources with separate liability for payment, or network access with some coverage for payment of specified services rendered based upon premiums and policy guidelines. the lii at cornell university law school provides a third-party overview of workers' compensation. variable forms of this type of coverage are provided at both the state and federal levels in the united states, with similar forms of workers' compensation laws also in place in select countries around the world. these laws are typically intended to provide some form of medical benefits and wage replacement for employees who are injured on the job. this coverage is often provided to employees in exchange for releasing their right to sue their employer for negligence, sometimes with fixed limits on payment of damages. employers need to understand whether the workers' compensation coverage that is applicable and in place for their and their employees' protection, covers international travel. in some cases, additional policies or riders will be required to provide coverage for travel outside of the traveler's home country or state. additional considerations to this kind of coverage should be as to "when" and "where" the coverage is in effect outside of a company office or facility (e.g., business travel). in some cases this may limit employer liability, but whether it does varies by jurisdiction and circumstance. considering how workers' compensation benefits have been reduced in recent years, especially in the united states, much consideration needs to be given to assessing what coverage is needed for traveling employees above and beyond workers' compensation, and coordinated with crisis response protocols and risk management support providers for efficient case management, claims, and documentation. all of these considerations provide a strong business case for why employers should have unique and specific programs in place for medical services and evacuations for employees and contractors traveling abroad in addition to their standard domestic health care plans and workers' compensation plans. no traveler should embark on a business trip without the complete confidence that medical coverage and resources not requiring their personal, out-of-pocket expenditure is being provided by their employer. a study that included disclosures from institutional investors, representing us$ trillion in assets, provided by sustainable-economy nonprofit gross domestic product (gdp), stated that in addition to increased physical risks that are being caused by climate change, climate change is already impacting their bottom line. one major uk retailer has stated that percent of its global fresh produce is already at risk from global warming. according to the french foreign minister, commenting at a un conference in japan, two-thirds of disasters stem from climate change. comments were made days after the -year anniversary of the fukushima nuclear disaster that killed approximately , people in from an earthquake and tsunami. margareta wahlstrom, the head of the un disaster risk reduction agency, stated that preventative measures provided a very good return as compared to reconstruction. un secretary general ban ki-moon asked world nations to spend us$ billion dollars a year on prevention. an important aspect of both a company's trm and business continuity plan is to determine what are the unique dangers or risks associated with where your offices or facilities are located, as well as where you travel to on a regular basis, making emergency evacuation and safety plans in the event that a unique incident occurs, such as the following case study related to the japanese earthquake and tsunami. it is important to know what local governments have made available in close proximity to your travelers' or expats' locations in terms of resources, or something that your company itself may provide, such as "vertical evacuation points" to escape rising tsunami flood waters. these vertical evacuation points may be in a building that is tall enough to support large numbers of the local population at a high water level, with ample support systems and supplies. not understanding and communicating these plans to your people when appropriate could exact a cost in lives, money, and corporate reputation. * american red cross, "japan earthquake and tsunami: one year update, march ," http:// www.redcross.org/images/media_customproductcatalog/m _japanearthquaketsunami_ oneyear.pdf. on march , , a . magnitude earthquake created a -foot tsunami. more than , people died or were presumed dead, with more than , people evacuated and more than . million people impacted across the country.* for the first time in more than years, iceland's eyjafjallajökull volcano erupted on march , , with massive lava flows and ash clouds that closed most of europe's commercial air space for several days, but then the ashcloud spread to other parts of the world, stranding millions of air travel passengers. based upon the composite map from the london volcanic ash advisory centre for the period april to , , one can clearly see the massive geographic scale of this incident, and why almost all commercial and private air transportation was prohibited and severe shortages of lodging and emergency shelters occurred. whether or not you believe in climate change and the reasons behind it, the statistics demonstrating the depletion of the world's ice sheets and glaciers, warmer ocean waters, and consistent year-over-year sea-level increases, will touch most multinational companies profoundly in the st century. the new york times states that sea levels worldwide are expected to rise to feet by the year , but rates are not occurring evenly worldwide. the times' referenced study states that the atlantic seaboard could rise by up to feet, with boston, new york, and norfolk, virginia, named as the three most vulnerable areas. if current warming trends and rising sea levels continue, cities such as london, bangkok, new york, shanghai and mumbai could eventually end up under water according to greenpeace, displacing millions of people and causing massive economic damage. consider a weather event the size of 's hurricane sandy, which tips the scales of expected water levels in a low-lying urban city, and results in the displacement of thousands or millions of people, with your travelers or expatriates stuck in the middle of it. when evacuation is not an immediate option, questions regarding the availability of safe accommodation, power, food, and water become priorities as demand far outweighs supply under such circumstances. these occurrences are much more common now than in our recent past. whether working in their local office or manufacturing facility, or traveling for business, many companies have employees with disabilities. although building or facility laws and rules may require designated escape routes, ramps, and elevators/lifts in the event of an emergency such as a fire, what about plans for when a disabled traveler is in transit or at a hotel? special considerations need to be made for disabled travelers in the event of a medical or security-related evacuation, such as: the need to relocate travelers can be caused by any number of factors, but before the decision to evacuate is made (usually at considerably more expense than traditional commercial air travel), someone with access to quality intelligence has to make the call as to whether to "shelter in place," assuming safe shelter is available, or to evacuate to the closest safe location. nonmedical causes for evacuation could be biohazards (e.g., the fukushima nuclear facility damage in japan), or civil unrest, or incoming natural disasters. to evacuate or not to evacuate requires thoughtful planning and resources, in order to insure that companies aren't competing with the rest of the world in a reactive situation where many others were caught off guard as well. ijet case study-ijet and the south sudan evacuations in december , ijet international provided continuous monitoring, intelligence, and analysis of the situation involving heavy ethnic fighting in south sudan to existing clients with operations in the country. support included providing real-time situational updates, establishing direct lines of communications with client personnel, and arranging for safe havens and security evacuations. on december , , the situation worsened to include the closure of the juba international airport. during the first days of fighting, prior to the airport closure, more than people were killed and more than wounded in the violence. during this time, several client personnel traveled across the country's borders to safe havens, but soon after the airport closure, with mounting concerns about large numbers of refugees, those borders quickly closed. ijet successfully evacuated its clients within the first hours of the airport's reopening, bringing in a -seat light-passenger aircraft from nairobi, kenya, performing some of the first successful group evacuations from this incident without injury. the ijet case study excerpt is an example of why a company's trm program cannot consist of technology alone, and discounted news being marketed as intelligence. in situations like these, quality intelligence is what saves people's lives. in this instance, quality intelligence was critical to the coordination of ijet's incident management team's on-the-ground services and support, which lead to not only evacuating its clients, but knowing when was the right time to move its clients to the airport and into the air. some medical evacuation services do not provide security-based evacuations, while some can offer both. companies should consider that one provider for both medical and security services and support, intelligence and insurance, might not always be the best solution. some companies select one provider for their terms and coverage for medical services, support, and evacuations, but another provider for security-related intelligence, services, and evacuations. there are even those companies with multiple providers for each medical and security service in different parts of the world, working with completely separate insurance providers to pay for the services rendered. each company must consider the coverage and resources currently available to them via their existing insurance relationship, and then solicit proposals for coverage based upon a clear outline of what the company needs are based upon claims history. ultimately, companies need a program that can coordinate with all contracted services and insurers, providing a seamless experience for travelers and administrators, and consolidated documentation. the term "open booking" refers to a booking made by a traveler that was made outside of their managed corporate travel program, avoiding usage of any contracted travel management company (tmc). technical advances have found ways to incorporate reservations data from multiple websites or suppliers for a traveler's trips into one place for reporting and calendar population. however, to properly capture this data, there are two primary methods available. the first is to allow the applications the ability to scan our inbox for travel-related e-mails and import the data accordingly. the second method is having travelers or independent suppliers e-mail reservation confirmations to an application or "parser," which can parse the data into a standardized database. with some major travel suppliers (such as airlines, for example) there are "direct connections" from their websites to some of these applications. however, in the absence of a direct connection, if you cannot get beyond the security concerns of a third-party application scanning your inbox, one cannot guarantee the automatic capture of percent of open booking data because of human error. for that reason and many others relative to policy and program management, and because of the high probability of human error, for effective trm, open booking should not be promoted as a primary booking method within a managed travel program. however, there is a place for open booking technology within a managed travel program: to help capture data from travel data normally considered "leakage," which is often not collected for reporting. such data can originate from conference-or meeting-based bookings made via housing authorities or meeting planners, or perhaps for travel that is booked and paid for by a client. companies who allow open booking for all travel struggle to effectively locate travelers in a crisis, disclose any potential risks or alerts, or provide services to some travelers in the event of a crisis. outside of suppliers with direct connections to open booking applications or parsers, even when your travelers are trained to e-mail those open booking itineraries to the required application for data capture, employers have no control over when they do this. within a managed program (via most tmcs), all new bookings, modifications and cancelations are usually updated in the database in real time or close to it, providing employers with ample opportunities to mitigate risk in a number of ways when time is of the essence. some well-known companies, offering travel-related solutions, claim that open bookings equate to more traveler choice and that their solutions can bridge the gap for any potentially missing data. when using an open booking application's itinerary data for security purposes, changes and cancelations can be a major issue. some applications require user intervention to manually delete trips that have been canceled, or to resubmit trips for changes unless an update can be e-mailed or picked up by an e-mail scan. consider a situation where a trip is booked and ticketed via an airline website, the itinerary is e-mailed to the traveler, who either allows their inbox to be scanned or they forward the e-mail to the open booking application. days later, the traveler needs to cancel that booking and rebook with another airline to travel with someone else from the company. the arrangements are made with the new airline, but the traveler forgets to delete the original trip in the open booking application. now there are two trips in the system for the traveler. imagine the confusion this could cause with employers if similar circumstances impacted multiple employees at the same time? a good managed travel program can still provide a variety of options, including easy methods of making reservations, yet still capture critical reservations data needed to effectively manage risk for business travelers. trying to manage risk with a completely unmanaged booking process for the sake of open booking, even if it did offer more traveler choice, is not worth the risk, considering that in a crisis you have a higher likelihood of inaccurate data unlike if the traveler had booked via your managed program (via a contracted tmc working in conjunction with your trm provider). does that mean that managed program data is perfect? no, but if implemented properly, reservations data can be more tightly controlled. on january , , when us airways flight went down in the hudson river in new york city, a regional office for an employer received a phone call from an employee's relative who was hysterical, insisting that his family member was on that plane. the office in question contacted their tmc, but was unable to obtain any information on the traveler, so they then turned to the travel manager. by this time, the inquiring family member had intentions of coming into the office because he wanted "some answers," for which there were none at the time. human resources suggested that the relative contact the crisis response hotline, while dispatching security to the office in question to protect the facility and its personnel. human resources also advised the person to stay home for any communications, and for their safety, considering the person was so upset. it turns out that the traveler in question was on a legitimate business trip, but that the traveler had purchased the trip online (outside of the employer's managed program), with the traveler's personal credit card, and without using an open booking application for itinerary data capture. because of this situation, it was difficult or nearly impossible to get helpful intelligence to the traveler or the traveler's family or to provide adequate resources and support, and had there been a death or severe bodily injury involved, the traveler wouldn't have been eligible for their corporate credit card's accidental death and dismemberment (ad&d) coverage. consider the personal losses of a business traveler whose hotel room was just broken into. what if as a result of such a theft, the traveler's identity was stolen? will your company support the needs of the traveler to ensure that the traveler's assets and identity are preserved? the traveler wouldn't have been where the traveler was if it weren't for the business trip! identity theft has reached epidemic proportions globally, with plenty of statistics published by consumer advocacy groups and government agencies, such as the u.s. federal trade commission. the u.s. federal trade commission's consumer sentinel network data book listed identity theft as the top reported complaint by consumers for the th year in a row, with approximately , complaints. the act of traveling for business presents many opportunities for a traveler to be exposed to scam artists looking to steal the traveler's identity. while taking precautions may be inconvenient and time consuming, there are many things that business travelers can do to reduce their chances of having their personal information stolen, such as: • keep a copy of all account numbers and relative account information in a safe place that is separate from where debit and credit cards are kept. • put mail and newspaper delivery on hold. this can prevent mail theft or an indication that the person is away, which can lead to the person's home being robbed. • don't travel with a checkbook; use only credit cards and cash. • don't use debit cards as pins (personal identification numbers) can be stored in some card reader devices and if the information is stolen, criminals could steal all of the cash available in the account(s) linked to the debit card. • notify credit card issuers prior to travel, especially if traveling internationally, so that they can authorize legitimate charges and notify the card holder promptly if activity on the account doesn't match their records. • use vpns (virtual private networks) when using the internet. if the traveler's company doesn't provide one, the traveler should purchase their own annual subscription. what if your employee had prescription medicine that may have black market value and it got taken as well? now, a theft has turned into a potential medical issue. ask yourself the following: • some medicines cannot be refilled before their due date, and other medicines are not easily refilled before their due dates. do you have the resources and support available globally ( × × ) to get those medicines replaced? • do you have the means to get the traveler replacement medicine before the traveler experiences any serious medical issues? • what kind of medical support do you have available, particularly outside of the traveler's home country, should the traveler need immediate medical attention? having someone steal property from your hotel room or safe is bad enough, but when theft has happened, the event itself ends quickly. but if your computer is hacked, the problem could linger in many ways. hotels are ideal places for business travelers to fall victim to hackers who not only may want access to some of your intellectual property, but to your identity as well. referenced in subsequent chapters, there are tips about using hotel and public access wi-fi, if you must use them. however, by whatever means you access the internet while on business travel (e.g., personal hotspot, or wi-fi with vpn, or other tools), try to not conduct any financial transactions or to log into financial-related websites while traveling. losing personal passwords to e-mail accounts or other personal use websites can not only be financially damaging to the individual, but can occasionally be humiliating when private information is made public. the most important thing to remember when faced with a mugging or pickpocketing incident is to not resist in the event of any confrontation and do not pursue assailants. things can be replaced, but not your life or well-being. your first priority should be to get away to a safe place, typically a business or well-lit public place with lots of people, where you can contact the authorities. according to the united states cdc (centers for disease control and prevention), the percentage of adults aged - , during the years to : • percent of persons using - prescription drugs in the past days: . % • percent of persons using five or more prescription drugs in the past days: . % source: http://www.cdc.gov/nchs/data/hus/hus .pdf# according to a report by cbs news atlanta, approximately in americans use prescription drugs. consider that with such a large percentage of the working population taking prescription medications regularly, people taking medications need a basic understanding and awareness to always do their research prior to international travel about bringing the drugs with them into another country. in general, most countries allow up to a -day supply of legitimately prescribed medications, in their original bottle. more than days of prescription medication on a traveler can be considered a violation of many country's laws, particularly when it comes to controlled substances, such as narcotic pain medication or psychotropic drugs. in some cases, it simply isn't enough to carry the original prescription bottles with medication in them; travelers may be required to carry additional documentation along with having filed advance approval forms to be in compliance with the jurisdiction in question. in particular, narcotics or psychotropic drugs must have extensive paperwork prepared by your doctor and submitted to the government of the country that you are visiting well in advance of travel, in order to process your paperwork for approval. employers must consider providing this kind of information to travelers with their pretrip briefings or risk reports, where applicable. the possibility of medicine being confiscated and/or criminal charges filed against someone for lack of approval to transport controlled substances into some countries is very real, and could cost someone their life if stranded on international travel without their medicine. tclara, a travel data analytics firm, has developed a scoring system to track how much wear and tear each traveler accumulates from his or her travels. the goal is to predict which road warriors are at the highest risk of burnout, so that management can intervene in a timely manner. the system uses a company's managed travel data to score a dozen factors found in each traveler's itineraries. trip friction points are assigned to factors such as the length of the flight, the cabin, the number of connections and time zones crossed, the time and day of week of each flight, etc. this allows for traveler-specific and companyspecific benchmarking, which in turn helps senior executives to influence travel policy, procurement strategy, and traveler behavior to optimize a managed travel program. push travelers through too many pain points, and the traveler may soon find reasons to not take the next trip. for example, think about flying coach from chicago to singapore, or taking a short haul connection for a lower fare. tighten the travel policy too much, and you could have recruiting and retention problems, which could have serious cost or business implications. companies shouldn't focus solely on minimizing the transaction cost of their trips; instead, they should focus on minimizing the total cost of traveling. that's the sum of the trip's transaction cost plus the cost of traveler friction (the black curve in the figure below) or the "total cost paradigm." to put trip friction into perspective, tclara provides two trip examples (refer to the figure below) showing a low level of trip friction in "trip a" versus a higher level in "trip b." according to tclara (refer to the figure below), their data shows a correlation between trip friction and higher numbers of road warrior or frequent traveler turnover. trip friction is clearly correlated with higher road warrior turnover. while strong travel policies under managed corporate travel programs are critical to successful trm (versus unmanaged, open booking allowances), there is a delicate balance between cost savings, safety, traveler satisfaction, and, very importantly, business continuity. trip friction and traveler friction are good examples of the link between trm and operational risk management (see chapter ), which shows how losses of productivity or employees managed under the guise of trm can impact company production and/or success. personal well-being of travelers might be the most surprising of topics for consideration, but it certainly is relevant in context with trm programs today. believe it or not, employers must be as cognizant of their employees' or contractor's mental wellbeing as of their physical safety. stressed out, tired, or even unhappy employees can represent lower productivity and a higher threat of risk. from something as simple as knowingly requiring someone to work in a stressful environment without trying to make it better, or just working them to excess, can cause an employee to suffer various forms of posttraumatic stress or depression. however, it can also be as extreme as requiring employees to work in a stressful situation without being properly trained or counseled, as was the case with some flight attendants who may have been forced to immediately fly again out of new york after witnessing the / attacks, when the commercial flights began operating again, without consideration of stress or trauma, proper treatment, and counseling. to the extent that employers monitor and evaluate the physical safety of employees or contractors in the workplace, they must now take notice of the level of employee/contractor stress and contribute to overall happiness. it turns out that employees with high states of well-being have lower health care costs. it's unfortunate that employers must usually see a financial benefit associated with such things before implementing them, but in addition to health care costs, if people are happier and healthier, it stands to reason that they are also more productive. the cwt solutions group conducted a study to shed light on the hidden costs of business travel caused by travel-related stress. their aim was to understand and measure how and to what extent traveler stress accumulates during regular business trips. they defined a methodology and a set of key performance indicators (kpis) to estimate the impact that this travel-induced stress has on an organization (see "the carlson wagonlit travel solutions group study"). the scope of the study includes data from million business trips booked and recorded by carlson wagonlit travel (cwt) over a -year period. they followed a divide-and-conquer approach: each trip was conceptually broken down into potentially stressful activities covering pretrip, during trip (transportation-and destination-related elements), and posttrip. associated stress was measured based on the duration and the perceived stress intensity for each activity. in essence, each of the steps of the trip was viewed as having two components: stress-free time and lost time. to quantify the effects of stress, we introduced the following kpis [key performance indicators]: the travel stress index (tsi) across all trips booked through cwt is %. our results show that the actual lost time is . hours per trip, on average. the largest contributions to this lost time arise from flying economy class on medium and long-haul flights ( . hours) and getting to the airport/train station ( . hours). the financial equivalent of this . hours is us$ . the lost time greatly depends on the type of trip taken: an increase in the transportation time typically generates an increase in the lost time. the average actual lost time values by trip type are: finally, the study indicates that the impact of stress can be reduced, but not entirely eliminated. they analyzed the tsi on a client-by-client basis and found out that companies can expect to control, on average, percent of the actual lost time. in a previous publication [ref . ] , cwt solutions group presented the perceived stress reported for activities related to a typical business trip. the current study incorporates of these factors (table . ), including nine of the be provided directly to suppliers for services as needed, or will prepayment be required by the family or loved ones, only to request reimbursement later? if it can be avoided, such understanding can reduce stress associated with paperwork, authorizations, and payment. according to the cornell university law school, in general terms, intellectual property is any product of the human intellect that the law protects from unauthorized use by others. the ownership of intellectual property inherently creates a limited monopoly in the protected property. intellectual property is traditionally comprised of four categories: patent, copyright, trademark, and trade secrets. in summary, if you are in business, you likely have some intellectual property to protect. it could be an idea, or simply a process that you use, which gives you a competitive edge. most people think of a stolen laptop or mobile phone when they think of vehicles for stolen intellectual property, but a far more common vehicle is a flash drive, which most business travelers carry with them today on business trips and aren't monitored or regulated in the same manner as phones, computers, or tablets. companies should either limit the use of flash drives to those drives that have some level of fips (u.s. federal information processing standard) to encrypt the data and/or destroy the data should the drive be tampered with physically in an attempt to access its contents. information on current fips standards (fips - ) and announcements regarding the upcoming fips - standard, can be found by visiting http://csrc.nist.gov/ groups/stm/cmvp/standards.html# . many companies have policies specific to certain countries whereby, when travelers intend to visit the countries in question, the travelers either cannot take laptops or standard mobile devices with them, or the travelers must take "clean machines" or hardware designed for travel specifically to countries with high numbers of intellectual property theft. some of this hardware may have special configuration or software to add layers of protection, in addition to not storing important files locally (i.e., cloud computing), or transportation of valuable files is done via one-time-use usb flash drives. because there are times when identifying intellectual property thieves can be nearly impossible, one might not have the opportunity to take advantage of any legislation or treaties. however, it is good to know that programs are developing and in place to try and protect intellectual property owners, such as the trips (trade related aspects of intellectual property rights) agreement from the wto (world trade organization). trips was designed to set some standards for how intellectual property rights are protected around the world under common international rules. these trade rules are seen as a way to provide more predictability and order, and a system for dispute resolution, providing a minimum level of protection for all wto member governments. for more details on the trips agreement, see https://www.wto.org/english/ thewto_e/whatis_e/tif_e/agrm _e.htm. as of may , countries place various forms of restrictions for the entry, stay, and/or residence of people who are hiv-positive. in , the united states removed its entry restrictions for people living with hiv, which received considerable media coverage and is believed to have had an influence on many another country's legislation on the matter, as the number of countries with such restrictions has declined from in to in . restrictions vary from country to country, but are broken down into the following categories: reminder: although this text provides various reference materials found on the internet, there is no substitute for or comparison to the quality of medical and security intelligence created, monitored, and provided by qualified risk intelligence providers, which are at the core of employer-managed trm programs. one specific reason for the importance of risk intelligence providers is because guidelines, laws and requirements regularly change. what is surprising to realize is that some of the countries from which an hivpositive traveler could be deported if the traveler's hiv status were known, are countries that are common destinations for many business travelers today. imagine a security check that uncovers prescription hiv treatment medication in a country where there are entry restrictions? this is a difficult position for employers because of the privacy concerns of employees or travelers and their medical records, which are not typically the kinds of records or information that a person shares with employers. however, just as with prescription medications that people can travel with, employers need to provide appropriate training and information to travelers going to places where hiv concerns may be an issue. while adding this kind of information on top of standard risk and policy disclosures may be an extensive and painfully large amount of information to read and understand prior to travel, employers have a duty to provide it, and travelers have a duty to understand it and act accordingly if one or more of any disclosed travel restrictions apply to them. in some of the more strict countries with legislation that allows deportation of hiv-positive travelers, deportation often doesn't apply to travelers connecting or in transit only. however, employers and travelers have to decide whether or not they want to take such a chance. some countries require medical exams for those who intend to stay longer than days, and if hiv is discovered, doctors are required to report it to the government, and the law will be administered relative to the country in question. exploding the myths: pandemic influenza center for infectious disease research and policy (cidrap) -point framework for pandemic influenza business preparedness pandemic planning and your supply chain four-fifths of businesses foresee severe problems maintaining operations if significant h n flu outbreak pandemic influenza planning: a guide for individuals and families at the time of this publishing, the following countries maintain strict regulations for travelers with restricted medications (see full list in the incb "yellow list measuring traveler wear and tear too much travel can burn many a road warrior out. the costs of this burnout are well known: lost productivity, increased safety risks, poor health, increased stress at work and home, unwillingness to travel, and, ultimately, increased attrition. top -those with scores above / . the remaining factors are either challenging to quantify (e.g., "eating healthily at destination") or require certain data that was not available at this time. several stress factors, such as flight delays, mishandled baggage, and traveling to a high-risk destination, require the usage of external data stress triggers for business travel is a leading publisher of flight information to travelers and businesses around the world sita (www.sita.aero) com) is an intelligence-driven provider of operational risk management solutions, working with more than multinational corporations and government organizations . having adequate medical supplies available during and after evacuation transportation. . an accessible method of handicap transport. . addressing any additional criteria needed to determine whether the disabled traveler should be transported or be sheltered in place. a. deciding who makes the call about whether it is safer to "stand by for assistance." . determining whether the transport destination is handicap accessible. . determining whether the transport destination has adequate food, shelter, and supplies for any special needs. . determining whether employers prepared to incur any additional costs relative to evacuating disabled travelers. a. determining whether adequate resources are available. b. identifying the risks or costs for lack of planning.the adoption of this convention is regarded as a milestone in the history of international drug control. the single convention codified all existing multilateral treaties on drug control and extended the existing control systems to include the cultivation of plants that were grown as the raw material of narcotic drugs. the principal objectives of the convention are to limit the possession, use, trade in, distribution, import, export, manufacture, and production of drugs exclusively to medical and scientific purposes and to address drug trafficking through international cooperation to deter and discourage drug traffickers. the convention also established the international narcotics control board, merging the permanent central board and the drug supervisory board. article , penal provisions of single convention on narcotic drugs, , as amended by the protocol amending the single convention on narcotic drugs, , provides: . a. subject to its constitutional limitations, each party shall adopt such measures as will ensure that cultivation, production, manufacture, extraction, preparation, possession, offering, offering for sale, distribution, purchase, sale, delivery on any terms whatsoever, brokerage, dispatch, dispatch in transit, transport, importation and exportation of drugs contrary to the provisions of this convention, and any other action which in the opinion of such party may be contrary to the provisions of this convention, shall be punishable offences when committed intentionally, and that serious offences shall be liable to adequate punishment particularly by imprisonment or other penalties of deprivation of liberty. b. notwithstanding the preceding subparagraph, when abusers of drugs have committed such offences, the parties may provide, either as an alternative to conviction or punishment or in addition to conviction or punishment, that such abusers shall undergo measures of treatment, education, after-care, rehabilitation and social reintegration in conformity with paragraph of article . unfortunately, people sometimes die while away from home on business. making arrangements to transport their remains across international borders can be complicated and expensive, as legislation and protocols vary greatly from country to country, as do suppliers who will provide such services. don't assume that your tmc will or can handle this for you. usually these situations are handled by medical emergency or insurance providers. the following items should be covered in repatriation of mortal remains insurance:• if passing takes place outside of a medical facility, adequate transportation (ambulance, airplane, or helicopter) equipped with proper storage and handling capabilities for the body during transport to the closest appropriate medical facility prior to international transport.• treatment costs incurred (including embalming).• legally approved container for shipment of the remains.• transportation costs for the deceased and an accompanying adult to the country of residence.• cremation if legally required (conditional).other coverage may be included for things such as hotel accommodations preor posttreatment prior to the passing of the insured, but coverage will vary widely between providers. under such stressful circumstances, it is very important for the insured's family to understand the claims process and coverage, such as will payment key: cord- -xcblqg z authors: harmon, shawn h.e.; faour, david e.; macdonald, noni e.; graham, janice e.; steffen, christoph; henaff, louise; shendale, stephanie title: immunization governance: mandatory immunization in global nitag network countries() date: - - journal: vaccine doi: . /j.vaccine. . . sha: doc_id: cord_uid: xcblqg z international trends currently favour greater use of mandatory immunization. there has been little academic consideration or comparison of the existence and scope of mandatory immunization internationally. in this paper, we examine mandatory immunization in global nitag (national immunization technical advisory group) network (gnn) countries, including countries from every who region and world bank income level classification. we found that although mandatory immunization programs, or mandatory elements within broader immunization programs, are relatively common, jurisdictions vary significantly with respect to the immunizations required, population groups affected, grounds for exemptions, and penalties for non-compliance. we also observed some loose associations with geography and income level. based on these data, we categorized policies into a spectrum ranging from narrow to broad scope. in the assessment report of the global vaccine action plan (gvap), the world health organization's (who) strategic advisory group of experts on immunization (sage) noted a need to understand the variety of ways in which legislation and regulation have been used to advance or undermine the cause of immunization [ ] . given the public health threat posed by low or slumping immunization rates, some countries have implemented, or have considered implementing, mandatory immunization. although there is no globally standardized definition of 'mandatory immunization', it is generally exemplified by requiring certain vaccinations at the individual level to control a vaccinepreventable disease at the population level [ ] . for present purposes, we define it as the governmental imposition of vaccination of an identified group with refusal, if permitted at all, being possible only through a formal 'opt-out' procedure (for example, obtain-ing a medically-indicated exemption due to allergy), independent of whether a legal or economical consequence exists for improper refusal [ , , ] . in this article, we present findings from the national immunization technical advisory group (nitag) environmental scan, a pilot project funded by a small contract from the who's department of immunization, vaccines and biologicals in . it received ethics approval from the research ethics board of the iwk health centre in halifax, nova scotia, canada (ethics approval no. ). the project surveyed global nitag network (gnn) countries on a range of issues relating to their nitags and national immunization programs (nips). we report the binary presence or absence of mandates within nips, and their scope as shaped by the mandated vaccines, applicable population groups, and permitted exemptions. these countries represent a broad range of low, lower-middle, upper-middle, and high-income countries as defined by the world bank, as well as all six who regions. although this kind of landscape analysis has been conducted on a regional level [ , ] , and across high-income settings [ ] , there does not appear to be any recent academic consideration of the content and scope of mandatory immunization on a crossregional international scale. the primary means of data collection in the nitag environmental scan was a secure online survey developed iteratively by the research team, with questions and structure refined through team interactions. the survey, available in both english and french, was piloted for comprehensibility and answerability with the help of five reviewers from three different who regions, all of whom were familiar with nitags. all gnn country members ( as of june ) were invited to participate in the survey by a national representative drawn from the gnn secretariat list; they entered the survey via a password-protected portal. the survey was open from june-september , with three reminders issued by the gnn secretariat. the online survey contained questions in three primary components, as follows: . tick-box questions tabulated quantitatively using simple descriptive statistics; . free-text comments analyzed qualitatively for specific jurisdictional insights and themes; and . requests for legal and/or policy instruments (provided via url or email). in addition to questions around nitag governance and operation, the survey inquired after the existence and content of any mandatory elements of national immunization programs. respondents in countries with mandatory elements were then asked: . what vaccinations were required by law; . what population groups were subject to mandates; and . what grounds, if any, were available for requesting exemptions. wherever possible, answers were corroborated through independent desktop research seeking official (governmental) and peer-reviewed sources. we reviewed government webpages (e.g., ministries of justice, health, public health agencies, and online legislation registries), a range of legal repositories (e.g., vaccine european new integrated collaborative effort [venice], international labor organization's national legislation database [natlex]), un, who global and regional policy webpages, and academic literature accessed through google scholar, westlaw and worldlii. we then supplied results of this research to national experts in the country to verify results and/or seek clarity around certain aspects of the instruments provided. the project received responses from of gnn countries. this represents a response rate of %, a strong majority of the gnn countries worldwide at the time the survey was issued in . of those responding countries, (all respondent countries save nigeria) provided information about mandatory immunization in their country. our sample comprises a broad range of countries in terms of size (geography and population) and government structures (federal and unitary), representation from all six who regions (africa: ; americas: ; eastern mediterranean: ; europe: ; south-east asia: ; western pacific: ), and all world bank income level classifications (low: ; lower-middle: ; upper-middle: ; high: ). as membership in the gnn is voluntary, it is likely that our emphasis on this self-selecting group means that our respondents (and our findings) are indicative of countries for whom immunization is a strong priority. in other words, countries with nitags that have proactively joined the gnn and responded to the survey might have a different profile than those who have not enrolled in the gnn, or who did not respond to the survey invitation. nonetheless, given the scope of our sample, we expect that our findings would likely be repeated across the gnn, and it is not entirely clear what new information could be found by a broader investigation within the gnn absent different and further inquiries. the above highlights several limitations that must be explicitly addressed. first, we acknowledge that, by the end of , there were nitags worldwide meeting gvap process criteria. the sample of gnn-associated nitags ( ) is therefore approximately one-third of all nitags, and our respondents represent % of functional nitags (and % of all countries worldwide). thus, although our data provide an important and interesting snapshot representing all regions, any trends observed in a sample of this size cannot be generalized globally. related to this, the sample does not include any small-country cluster that might share immunization resources and structures (such as the caribbean). inclusion of such clusters could introduce new forms, processes, and observations. a second caveat relates to the limitation on the number of questions we could reasonably pose in the survey and still expect sufficient response rates. this meant that we did not ask respondents about the reasons for the presence or absence of mandatory immunization, as this inquiry would be more amenable to a survey focused entirely on mandates. third, immunization in some countries is governed at the subnational level which means that a single country may exhibit heterogeneity in both their nips and mandates. for example, in canada and the usa, immunization programs are designed and developed, and mandates imposed (or not), at the provincial and state levels respectively. mandatory immunization currently exists in only two canadian provinces (ontario and new brunswick; previously, manitoba also had mandatory immunization). although all us states impose some mandatory immunization, the particular vaccines required and the procedures for enforcement vary widely from state to state [ ] . as such, it is not always entirely appropriate to talk about 'national' programs and mandates, or to draw overly general conclusions (in relation to, for example, significance of geography) from the data. the final limitation is with respect to the fact that vaccination policy is an ever-changing function of government agendas, public health objectives, economic constraints, and practical realities. accordingly, while our data represents (to the best of our knowledge) an accurate picture of mandatory immunization in these countries as of summer , it is likely -particularly in light of the ongoing covid- pandemic -that in at least some jurisdictions, vaccination practice and policy has changed. just over half ( of ) of the responding countries indicated some mandatory element(s) in their nip (table ; note that we were not able to independently verify the existence of mandatory immunization in côte d'ivoire). given the almost pervasive emphasis on autonomy and consent to treatment in the medical setting, this represents a relatively high rate of compulsory treatment. however, these raw data tell only a partial story, for the reality is more complex and nuanced than the numbers convey. in the following sections, we examine more closely the nature and extent of the mandates, taking into account the following factors: before exploring these factors, however, we made several observations from the raw data. for example, country affluence or income level does seem to influence the presence of mandatory immunization (fig. ) . drawing on categories applied by the world bank, high and upper-middle income countries appear more likely to have a mandatory nip element than lower-middle and lowincome countries. for example, seven of the high-income countries ( %), and four of the six upper-middle-income countries ( %) reported having mandatory elements in their nips. conversely, just one of the six low-income countries, uganda, reported a mandatory element. more detailed empirical case studies would be necessary to uncover the policy reasons for the presence or absence of mandates within nips. nonetheless, it may be reasonable to infer that lower-income countries have fewer human and financial resources to undertake, administer, and enforce manda- ywe were unable to verify the legal basis for mandatory immunization in jordan. àat the time of our survey, germany did not have mandatory immunization. however, in march , the measles protection act came into force, mandating measles immunity for certain individuals, including children and health care workers. tory immunization, or that programs are less mature and potentially still evolving. conversely, given the burden of disease in low-income countries and the difficulties that residents thereof sometimes face in accessing healthcare, demand for, and public acceptance of, vaccines may be quite robust, negating the need for mandates. in addition to the economic component, some association was observed between geographic region and the existence of mandates. for two regions -europe and south-east asia -no clear association was observed; mandates existed in exactly half of the respondent countries. the one eastern mediterranean region respondent (jordan) reported mandatory immunization, but no regional conclusion can be drawn from a single response; the similarly small sample of two western pacific countries (china and australia) reporting no mandatory immunization is not helpful. however, mandatory programs appeared to be somewhat less common in the african region, with only two of the six responding countries ( %) reporting a mandatory element. conversely, all five respondent countries from the americas ( %) reported mandatory immunization. this strong response suggests a trend in that region toward mandatory immunization that is not fully explained by income level. although all the respondent countries in the americas were high-or upper-middle income, income status alone is probably not a sufficient explanation because just two of six highincome countries outside the americas reported mandatory immunization. furthermore, countries in the americas appear to have much broader or inclusive mandates. excluding canada and the usa (due to variation across subnational jurisdictions ), respondent countries in the americas required immunization against an average of . diseases, with the next broadest mandates found in south-east asia ( . diseases). respondents from all other regions fell below the total average of . diseases covered (fig. ). all told, there may be something about the approach to immunization, the developmental history of the public health and immunization field, or the politico-legal culture in the americas that makes mandatory immunization more palatable or feasible as a policy option. incentivization of healthcare workers, urbanization/remoteness, public health infrastructure, cold chain issues, and public trust of government or health authorities could also play a role, with potentially profound differences between the americas and other regions. a full explanation for this apparent link would require a more focused empirical case study. for countries reporting the presence of a mandatory element in their nip, we asked which vaccines were required. the responses reveal a great variety of vaccine schedules and a broad spectrum of vaccines that are mandated, with no country mandating all scheduled vaccines (tables and ). for example, belgium mandates just a single childhood vaccination (polio), whereas argentina mandates childhood vaccinations. the average number of mandated vaccines across respondents was . . every mandating country required the polio vaccine, reflecting the historical global burden and long-standing international efforts to eradicate polio [ , ] . measles, bcg, and tdap/dtwp/dtap/td (grouped together in our survey due to their nearly ubiquitous concurrent administration) were the second most commonly mandated vaccines, with every mandating jurisdiction (including vaccine-requiring canadian provinces and all us states) except belgium reporting their inclusion. also of note are the hpv and rotavirus vaccines, which, despite being relatively new, have approximately % of countries reporting their inclusion. in addition to the vaccines listed in table , mandates in some countries included hepatitis a, influenza, japanese encephalitis, typhoid, tick-borne encephalitis, and varicella. of these, the most common mandatory vaccines were hepatitis a and japanese encephalitis, with four and two respondent countries respectively mandating their use. survey participants in countries with mandatory immunization were asked about specific populations subject to mandates (i.e., age [children under and years of age and school-aged children -that yexcludes canada and the usa due to subnational variation in those countries. àthere were no western pacific countries reporting mandatory immunization in our survey. although the mandatory elements in canada and the usa do vary by subnational jurisdiction. the sub-national jurisdictions (provinces and states respectively), which have authority over the implementation of the immunization programs within these districts, have resulted in (at times significant) variation across those countries. however, it should be noted that these subnational jurisdictions appear also to have relatively broad mandates -ontario and new brunswick require immunization against and infectious diseases, respectively, for school entry, with similarthough varying -numbers for us states. . they were also given the opportunity to identify any other population groups subject to mandatory vaccination. finally, they were asked the year in which mandatory immunization was introduced for that specific population. amongst countries with mandatory elements to their nip, children under one year of age and under five years of age were by far the most frequently subject to mandatory vaccination, with of the respondent countries ( %) reporting specific provisions for these groups. mandatory immunization upon school enrolment, and for school-aged children were also highly prevalent. for example, eight of the responding countries ( %) reported requiring immunization for school enrolment and for school-aged children. this likely reflects policy recognition of the importance to individual health of immunization relatively early in life, together with the public health objective of facilitating herd immunity [ ] , particularly in relatively enclosed school environments. with respect to other targeted populations, seven of the respondent countries ( %) reported mandating vaccinations for healthcare workers. respondents from six countries (argentina, belgium, chile, indonesia, maldives, and uganda) indicated that they also require immunization for other specific populations. the most common 'other' category was pregnant women and/or women of childbearing age, although two countries (indonesia and maldives) reported mandating vaccinations (or proof of immunization) for travellers, particularly hajj and umrah pilgrims, and for other, unspecified, 'at-risk populations'. for further specifics on target populations, see table . in rights-conscious societies, many public services will contain some degree of flexibility to account for differences in individual circumstances. as such, an important aspect of any mandatory nip will be the availability and scope of exemptions from the mandate. respondents were therefore asked about the circumstances under which an exemption to any mandatory vaccines will be granted. exemptions can be categorized broadly into medical and non-medical exemptions. medical exemptions are granted to individuals who cannot safely receive a vaccine, usually due to suspected or demonstrated allergic reaction to a vaccine component, or in the presence of immunosuppression. non-medical exemptions include those granted for any other reason; most commonly for religious, philosophical, or other personal objections to immunization [ ] . every respondent country reported allowing exemptions in the event of medical contra-indication (table ) . however, such exemptions are not granted equally across countries. as there is no universally-agreed upon definition of a valid medical exemption for immunization, what constitutes valid grounds in one jurisdiction may not necessarily satisfy another jurisdiction's requirements (even within the same country) [ ] . further, for any given jurisdiction, the presence or absence of non-medical exemptions may also impact how frequently medical exemptions are requested and granted. for example, in california, usa, the proportion of medical exemptions granted more than doubled (from . % to . %) the year after personal belief exemptions were prohibited and the grounds for medical exemptions were broadened [ ] . as shown in table , non-medical exemptions appear far less common in our sample -perhaps unsurprisingly, given that mandatory vaccination is directly undermined by easy access to non-medical exemptions [ ] . in our survey, only canada, indonesia, and the usa reported allowing exemptions for religious, table mandatory childhood immunizations. country kazakh. note canada and the usa are excluded from the table due to significant subnational variability in those countries. key the number ' represents children under one year old. the number ' represents children one year and older, but less than five years old. the letter 's' represents children, of any age, who are attending school. the 'totals' in the bottom row refer to the total number of countries which have mandated for at least one age group the vaccine identified in the column. the 'totals' in the far-right column refer to the total number of vaccines for which each country has erected a mandate. each column counts as one regardless of whether there is one, two, or three checkmarks. the 'other' column signals additional vaccines that are mandated (and reported as 'other vaccines' in the survey). a single checkmark could refer to one or more other vaccines; the actual number is reflected in the figure in the 'totals' row in the far-right column. for details on these additional vaccines, see table . includes dtwp, dtap, td. includes ipv or opv. although most states allow exemptions based on religious or personal belief, five states permit exemptions only for medical contraindication [ ] . to discourage the use of non-medical exemptions, some jurisdictions impose additional requirements before such an exemption may be granted. for example, in ontario, canada, parents must file a sworn statement of conscience or religious belief with a medical officer of health, and must additionally attend an education session on the benefits and risks of immunization prior to obtaining a non-medical exemption [ ] . it is unclear how effective these measures are at reducing the use of non-medical exemptions. the policy objectives advanced by mandating immunization may be seriously undermined if there are no consequences for failure to comply, and no actual enforcement of the mandate. for reasons of survey length, we did not ask direct questions about enforcement dispositions and practices. however, we did pose questions about penalties for non-compliance (table ) . penalties vary considerably between countries. most jurisdictions reported relatively benign, non-compelling, or non-existent sanctions. the approaches taken by these countries largely correspond with the level and level legislative approaches to immunization proposed by the sabin institute [ ] ; that is, mandatory provisions are prescribed either administratively (e.g., as a requirement for school entry) or by law, but such provisions are not supported by serious sanctions, nor by consistent or strong enforcement of those sanctions [ ] . conversely, some respondent countries reported much more severe sanctions. four countries -argentina, belgium, the maldives, and uganda -impose fines for failure to immunize. in uganda, vaccine refusers may additionally face incarceration for up to months [ ]. these countries would likely correspond to sabin institute's level approaches -that is, mandatory provisions are prescribed by law, and sanctions are imposed for failure to comply. again, however, sanctions are distinct from enforcement. regardless of the nature or severity of sanctions for failure to vaccinate, actual enforcement of the mandate is necessary to make the mandate real. our preliminary, albeit incomplete, evidence shows that enforcement varies considerably between jurisdictions, and is not always in compliance with statutory instruction. one respondent, for example, stated that although in their jurisdiction, schools are required to ensure that students are immunized, the penalties for not getting vaccinated are ''not very strict". in other countries, enforcement provisions might be ignored except in the case of an imminent epidemic. our limited data on this issue suggests that significant discretion is exercised in the determination of whether to enforce mandates. this is an important aspect of mandatory immunization that is worthy of further empirical research. this study reveals a spectrum of approaches to mandatory immunization. at one end of the spectrum is a very narrow or largely permissive approach. under this approach, a very small number of vaccines are mandated, or the groups subject to mandatory vaccination is limited, or both. the calculus for setting these very narrow or modest targets in relation to vaccines administered or groups compelled is not clear from the responses given or the instruments examined. this approach could be informed by: national desires to exercise sovereignty in favour of more direct adoption of international policies when otherwise seeking to meet international obligations; national political ambitions to control specific diseases, and to not expend political or economic capital on broader mandates; local disease and cultural conditions that favour a generally permissive or autonomy-privileging approach (i.e., lower social acceptance of vaccination, which would entail expenditure of political capital, or high social acceptance of vaccination, which may negate the need to mandate); or acute or persistent supply-side management issues such as shortages of healthcare workers and stock-outs of vaccines (either nationally or locally). any one or more of these could be in operation in any given jurisdiction, but determining their presence would require detailed investigation. in our data, belgium exemplifies this narrow or largely permissive approach; it mandates just one childhood vaccine -polioand only for newborns. within canada, the province of manitoba previously exemplified this approach; until its restructuring of provincial public health regulations, manitoba required children to demonstrate immunity to measles only (via immunization or natural infection) prior to entry into grade- . [ ] . such a narrow approach may have certain advantages. first, mandating only a few vaccines, instead of many, for a small group of people, instead of a larger group of people, will result in lesser financial (ie, vaccine procurement) and administrative (ie, vaccine delivery and monitoring) burdens on the state. in practice, of course, the financial savings may be modest, especially for countries that publish a relatively inclusive recommended immunization schedule of publicly funded vaccines (as do both belgium and manitoba). in such circumstances, the financial savings may be insignificant, and unlikely to be the driver behind such policies. a more pertinent advantage of this narrow approach may be the avoidance of perceptions of government coercion. mandatory immunization is, by its nature, coercive [ ] ; compelling individuals to receive vaccinations may have unintended negative (political) consequences. many populations, perhaps especially in fragile states, have legitimate concerns relating to trust in their governments and fear of government officials [ ] . attempts by some countries to implement broader mandatory immunization policies have incited some public backlash and increased attention to negative vaccine messages in the media [ ] . mandatory immunization pro- table sanctions for failure to immunize. type of sanction no sanctions reported or found by authors * we were unable to corroborate the sanction for jordan. belgium does also require immunizations for certain other (adult) population groups, but even they tend to be fairly restrictive in nature (for example, requiring tetanus immunization for agricultural workers and animal researchers, as opposed to broader mandates found in other countries such as requiring influenza vaccination for all adults over age or for all pregnant women). currently, all vaccinations in manitoba are voluntary. a true assessment of the financial cost and saving associated with mandates would, of course, go beyond procurement and delivery, and would also have to take into account the costs of subsequent morbidity, hospitalization, and mortality from vaccine preventable diseases. [ ] . ultimately, a narrow or permissive approach to mandates may provide governments with a greater ability to take a balanced and flexible approach to immunization. it may offer an avenue for imposing a strong but otherwise gentle 'nudge' in relation to diseases considered essential to control given local conditions with only minimal encroachment on individual freedoms (thereby maintaining public support). such nudge strategies may include public education campaigns and positive, science-based messaging, and they can be more easily revised for the prevailing situation than can legislated mandates. at the other end of the spectrum is a broad and more inclusive approach to mandates, which requires a relatively large number of vaccinations for a relatively large segment of the population (including specified target groups). as with the narrow approach, this approach was not widely represented in our data. it is perhaps best exemplified by argentina and indonesia, which require and childhood vaccinations respectively. argentina additionally requires vaccines for healthcare workers, women who are pregnant and/or postpartum, and the elderly. indonesia requires vaccines for healthcare workers, women who are pregnant and/or of child-bearing age, some military personnel, and certain travellers. the advantages and disadvantages to a broad or inclusive approach are roughly the inverse of the narrow or permissive approach. essentially, it prioritizes prevention through compelled uptake and coverage, while risking public resistance for government infringements -real or perceived -to bodily or religious integrity. this approach may also be more expensive to administer and deliver, not only because of increased procurement costs, but also because of potentially increased monitoring and enforcement costs. as one might expect, most respondent countries fall between the two ends of the spectrum, though they lean toward the broader or more inclusive approach. it is not clear from the data the extent to which countries falling between these extremes do so as a matter of conscious policy choice. other shaping factors may be vaccine supply issues, national capacity in relation to program delivery, or constitutional conditions. for example, these rather simple characterizations are insufficient to convey the complexity of the approaches taken by countries like canada and usa, where healthcare is a constitutionally devolved and fragmented policy field. in such countries, decisions about mandatory immunization are made largely at subnational levels. this within-country diversity of approach toward mandates can be profound, and generates challenges. for example, it can create uncertainty and stress when residents move from one jurisdiction to another with different immunization schedules and mandatory elements [ ] . to counteract this uncertainty, a robust national vaccine monitoring system seems advisable. however, to date, no such system exists nationally in either canada or the usa, although most states do possess local monitoring databases [ , ] . in addition to the narrow (or largely permissive) and broad (or largely inclusive) continuum, there is a continuum for enforcement which may map loosely but imperfectly on the above continuum. in this regard, approaches on one end can be described as loose (and again permissive), and on the other end as tight (or coercive). the former, exemplified by belgium and certain canadian provinces/territories, applies no substantial consequences for failure to vaccinate. in jurisdictions where few or no vaccines are mandated, and few or no target groups are identified for specific treatment, the loose approach would be expected. in jurisdictions falling closer to the broad/inclusive approach to mandates, tighter or more coercive controls may be expected. in our sample, only uganda legislated the possibility of imprisonment, whereas argentina, belgium, the maldives, and uganda all imposed fines. seven countries (table ) stipulated the possibility of denial of school entry for children. although the latter might be characterized as a positive coercive approach (i.e., forming a gateway to public services, with possible work-arounds), the former are negative coercive measures. a further factor in identifying the character of any given jurisdiction is to assess the actual application or enforcement of sanctions, which was beyond the scope of the project. this project generated data on the status and nature of mandatory vaccination in gnn countries, providing the following insights: obvious diversity occurs in the number of childhood vaccines mandated, ranging from one (belgium) to (argentina), with the average being . per country. every mandating jurisdiction within our survey required vaccination against polio. measles, bcg, and tdap/dtwp/dtap/td immunizations were the second most commonly mandated. children were by far the most common population group subject to mandatory immunization; healthcare workers were second, mandated in over half of our respondent jurisdictions (nine of jurisdictions = %). exemptions from mandates for medical purposes were universal. non-medical exemptions were far rarer (three of jurisdictions = %). sanctions for failure to immunize vary broadly, ranging from no penalty, to loss of access to social services (most particularly admission to school), monetary fines, and incarceration. further, there appears to be some variance between countries as to how strictly immunization mandates are enforced. our findings show the existence of a variety of general approaches to mandatory immunization. this heterogeneity in approaches to nips and the treatment of mandates within them speaks volumes. although differences in disease burdens and healthcare incentives are almost certainly key factors, the differences that exist between countries with respect to legal and healthcare cultures should not be ignored, and these social differences might be more significant shapers of policy choices than actual disease risks and burdens. furthermore, although our data suggest that mandatory immunization plays a significant role in these countries, it is not clear whether the trends noticed here (e.g., wide variety, with the majority of systems occupying the broad or inclusive end of the approaches spectrum) would be reflected worldwide. more detailed and coordinated regional case studies of the situation are warranted to offer a global picture. such investigations could illuminate the extent to which mandatory immunization actually increases immunization rates, an association very difficult to establish [ ] . without robust evidence to support mandates, or differences in policies within mandatory immunization schemes, policymakers are forced to act solely on social, political, or financial grounds, which undermines the notion of evidence-informed policymaking. having said that, a very recent study [ ] did find slightly higher but statistically significant immunization rates for measles and pertussis vaccines in countries with mandatory immunization (i.e., . % and . % higher, respectively). however, the authors acknowledge the inherent difficulty in accounting for the numerous factors that influence coverage rates. therefore, these results must be interpreted cautiously. furthermore, the data and analysis were restricted to european countries (only seven of which mandated vaccination). research from an international perspective in this area is scarce, likely due to the vast heterogeneity in approaches to mandatory immunization worldwide, which poses challenges for generalizability, and by the absence of funding to undertake a suitably robust multi-jurisdictional project. we have highlighted some of the key factors that are relevant to shaping and operating a mandatory nip. these factors are likely to: expand or contract the nip by including or excluding vaccines, target groups, and exemptions; influence the operation and efficiency of the nip by allowing or excluding exemptions, and by managing them in certain ways; and bear on the actual immunization rates achieved by the nip by implementing sanctions (or not), and by enforcing the nip's mandates (or not). countries with mandatory nips -or those considering imposing mandatory elements within their nip -should consciously, cautiously, and collaboratively consider which approach best reflects the political, legal, and healthcare values of their country, as well as their collective public health objectives and risks. ''all authors attest they meet the icmje criteria for authorship." the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. armenia: armenian national advisory committee on immunization (naci) belgium: veerle mertens, belgian superior health council. canada: national advisory committee on immunization (naci) togo: groupe technique consultative pour la vaccination-togo (gtcv-togo). uganda: celia nalwadda, uganda national academy of sciences. uruguay: comisión asesora de vacunaciones. sri lanka: deepa gamage, epidemiology unit, ministry of health strategic advisory group of experts on immunization state vaccination policies: requirements and exemptions for entering school scientific declaration on polio eradication polio working group of the phac committee to advise on tropical medicine and travel. statement on poliovirus and the international traveller medical versus nonmedical immunization exemptions for child care and school attendance medical exemptions to school immunization requirements in the united states -association of state policies with medical exemption rates letters: change in medical exemptions from immunization in california after elimination of personal belief exemptions mandatory infant & childhood immunization: rationales, issues and knowledge gaps national conference of state legislators. states with religious and philosophical exemptions from school immunization requirements immunization of school pupils act. canada legislative landscape review: legislative approaches to immunization across the european region strengthening legal frameworks for vaccination: the experiences of armenia, georgia, and moldova. vaccine public health act, diseases and dead bodies regulation controversies in vaccine mandates. curr probl pediatr adolesc health care world health organization. global vaccine safety blueprint . (draft ) a harmonized immunization schedule for canada: a call to action. paediatr child health (oxford) immunisation registers in canada: progress made, current situation, and challenges for the future progress in childhood vaccination data in immunization information systems -united states mandatory vaccination in europe e the authors wish to thank the who department of immunization, vaccines, and biologicals for the funding of this research, as well as for providing translations into english for the texts of a number of very technical legal documents. they also wish to thank the gnn member countries who participated in the survey, and the specific respondents who answered our queries. key: cord- -ev pvr s authors: werth, annette; gravino, pietro; prevedello, giulio title: impact analysis of covid- responses on energy grid dynamics in europe date: - - journal: appl energy doi: . /j.apenergy. . sha: doc_id: cord_uid: ev pvr s when covid- pandemic spread in europe, governments imposed unprecedented confinement measures with mostly unknown repercussions on contemporary societies. in some cases, a considerable drop in energy consumption was observed, anticipating a scenario of sizable low-cost energy generation, from renewable sources, expected only for years later. in this paper, the impact of governmental restrictions on electrical load, generation and transmission was investigated in european countries. using the indices provided by the oxford covid- government response tracker, precise restriction types were found to correlate with the load drop. then the european grid was analysed to assess how the load drop was balanced by the change in generation and transmission patterns. the same restriction period from was compared to previous years, accounting for yearly variability with ad-hoc statistical technique. as a result, generation was found to be heavily impacted in most countries with significant load drop. overall, generation from nuclear, and fossil coal and gas sources was reduced, in favour of renewables and, in some countries, fossil gas. moreover, intermittent renewables generation increased in most countries without indicating an exceptional amount of curtailments. finally, the european grid helped balance those changes with an increase in both energy exports and imports, with some net exporting countries becoming net importers, notably germany, and vice versa. together, these findings show the far reaching implications of the covid- crisis, and contribute to the understanding and planning of higher renewables share scenarios, which will become more prevalent in the battle against climate change. the covid- emergency established an unprecedented challenge for modern societies. governments had to face a novel disease with exponential spread and considerable death rate. while intensive care cases were overwhelming healthcare systems, scientific experts tried to determine new behavioural models with little scientific knowledge, due to the substantial novelty of the situation. despite the economic and political interconnections between european countries, the countermeasures against the epidemic were diverse in severity and temporal implementation. the efficacy of these interventions and their economic impact on industries [ ] , stock markets [ ] , environment [ , ] and energy markets are still unclear. as governments try relaunching economies and softening restrictions, it is crucial to understand the short and long term consequences of the adopted measures, not only to be better prepared for future crises, but also to unveil potential opportunities [ ] , in particular for sustainability research on electricity [ , ] . with the analysis of electricity data, available at almost real time, it was possible to provide a fine-grained view on the economic and environmental impact of covid- . indeed, as fezzi and colleagues [ ] demonstrated for the case of italy, high frequency electricity data could be used to estimate the effect of covid- on the national gdp. previous studies reported that national lockdowns had a strong influence on the electricity consumption in many countries heavily affected by the epidemic [ , , ] . norouzi and colleagues [ ] used an artificial neural network model to evaluate the elasticity of oil and electricity demand in china, based on parameters including number of infections and gross domestic product without actual electricity data in input. ruiz and colleagues [ ] found that electricity consumption in china increased due to large quarantine and health service demand. other studies ascribed the decrease in energy consumption to governmental interventions in the usa and canada [ , , , ] , in brazil [ ] and in europe [ , , , ] . the present work aims at understanding the impact that restrictions, associated to covid- , had on the electrical energy consumption in europe, and the downstream consequences to generation and international exchange of electricity. leveraging the work from [ ] , the types of intervention whose severity correlated with consumption loss were identified, and their time of implementation was determined. following this data driven approach, such period of active restrictions in was analysed comparing it the same time interval from past years, using the percent deviation statistic, and accounting for yearly variability with ad hoc statistical procedures. with this methodology, energy load, generation and international transmission were studied for european countries, for which data were available, to understand how europe's electric grid was affected by the epidemic. the data were obtained from the transparency platform of the european network of transmission system operators for electricity (entsoe [ ] ). the available data consist of time-series with a , or minute resolution depending on the country. following time series for european countries from / / to / / were used: • generation data for each type of source • generation capacities for each type of source (annually) • cross-country power flows for neighbouring countries (imports and exports) because of inconsistencies or omissions in the data, the following were removed: • netherlands generation data, since they disagreed with load data, particularly for the years before ; • italy and switzerland generation data, because largely incomplete. all other non-substantial missing data points were imputed by linear interpolation. in the evolving scenario of covid- emergency, quantifying in a comparable way governments responses is a very complex task. several attempts have been done to systematize institutional intervention data [ , ] . the oxford covid- government response tracker [ ] (oxcgrt in the following) provides a systematic cross-national, cross-temporal measure to understand how governmental responses have evolved during the epidemic. this reference was identified as most suitable to compare the intensity of interventions in the covid- emergency with different nations' electricity load. the oxcgrt includes indices sorted into main categories: "containment and closure", "economic response", "health systems". each indicator quantifies, on a daily basis, the intensity of a governmental restriction executed from a country included in their data-set. for the present analysis, all the indices of the "containment and closure" were used, that most obviously have a more direct relation with the energy load. "economic response" indices were instead excluded for the lack of a direct relation with the electric load and also for the timescale of their action. economic responses, in fact, do have consequences on a longer time scale while the present study takes into account only the first months of . "health systems" indices were also excluded because of their negligible impact on the energy load, with the exception of the "public info campaigns", which, in principle, could affect people behaviours and thus energy consumption on a large scale. the list of the indices taken in consideration can be found in table . for each of these indices, the time of action was determined for each country. the time of action was defined as the days when the relative index is greater than zero. summing an index over its time of action provided the cumulative extent of severity for the governmental actions associated with it, in that country, for the first months of . this quantity was named cumulative index. in order to study the relation between intervention intensity and load variations, also the cumulative energy load was calculated in the time of action of each index in each country. the mean of the cumulative load of the five previous years was then used as a forecast reference for cumulative load, and the cumulative forecast excess (cfe) was calculated as where cl y is the cumulative load in the time of action of a given index for the year y. e.g. cl is the cumulative load observed in in the same days corresponding to the time of action in of the given index. from this procedure, two values were obtained for each combination of one oxcgrt index and one country: • the cumulative index, representing the cumulative severity of the intervention; • the cumulative forecast excess of the load, representing the total decrease in the load in the observed period compared to the same period in previous years. to understand and measure the impact of governmental restrictions on the electrical power system, at a country level, it is necessary to assess the data recorded during covid- emergency against a counterfactual scenario where the epidemic did not occur. therefore, defined the real number x y as the total energy transmitted, generated or consumed, over a fixed time period of year y (for y ∈ { , ..., }), the fluctuation of x y was estimated by the percent deviation from years before , namely restrictions as the deviation of x from the average of previous years, which estimates year without epidemic. to quantify how largely s deviated from past years, taking yearly variability into account, the number of years that were more extreme than were compared against the others averaged, using the value r = #{y < : p y ≥ s }, and #a being the number of elements in a set a. this approach follows the same rationale as a test for statistical significance by permutations [ ] assessing the null hypothesis that x y , for y = , . . . , , are independent observations from the same distribution. when r = , the test leads to the rejection of the null hypothesis, with a level of significance equal to /#{y: y ≤ } (i.e. . or about . for or yearly data points, respectively). when r > , instead, the null hypothesis cannot be rejected. note that this measure does not take into account special weather conditions. after the spread of covid- in europe, lockdowns were imposed in several countries to oppose the epidemic. simultaneously, large drops in electric load were reported ( fig. ) , which is mostly due to a reduction in industrial and commercial activities with a possible increase in residential sector [ ] . for instance, for the month of april, all countries combined had a mean load drop of gw, or % if compared to the previous years. yet, load levels did not revert to normality after the confinements ended, as observed in fig. , and other limitations persisted throughout the pandemic and after strictest restrictions were lifted. first, the oxcgrt indicators whose impact resulted in reduced load were identified. for every index, using the cumulative index and the cumulative forecast excess from each country, the spearman's correlation coefficient and the relative p-value were calculated. the indices with significant correlations j o u r n a l p r e -p r o o f (p-value < %) were selected. results are reported in table . only indices showed positive and significant correlations: "school closing", "workplace closing", "restriction on internal movements", and "stay at home". these four indices were then combined into a novel macro index named "energy stringency index ". this new index was then used to calculate its time of action, i.e. the time range where the index is greater than zero. the days in when the energy stringency index is not null, determine a period of active restrictions with a strong relation on a country's energy load. thus, this temporal arc will be hereafter referred to as the "restrictions period". this procedure enabled a systematic determination of the interval of time to study how european countries modulated electrical energy generation, and transmission in order to balance for the reduced consumption. each nation had its own time range, based on when the energy stringency index was greater than zero in that nation. they had different starting dates but the ending date is the same for every country, the st of july , because the index happened to be greater than zero at least until that date. finally, the energy stringency index was compared against the load drops, resulting in a strong and significant positive correlation ( . with p-value of . ), as outlined in fig. reported results suggest that the quantification of severity for governmental restrictions could be exploited to improve the forecast of the load, which became loads [ , ] , that cancelled out upon aggregation. therefore, a more in depth study (with finer data) is required to pin down the actual causes and impact. overall, out of countries present null r-value (in brackets next to each country's name), indicating as the most extreme year, with many loads reducing by % from past years average. j o u r n a l p r e -p r o o f journal pre-proof as energy load dropped in the restrictions period, significant changes were expected at the level of electricity generation. observing the weekly rolling mean of generation from january to june , sorted by energy source, many countries presented a generation decrease, particularly in concomitance with march and april when most severe lockdown measures were imposed (fig. ) . for some cases, such as italy, the drop steepness suggested causes other than the changing of weather or seasons, when transitioning from winter to spring time energy production typically reduces with the increasing of atmospheric temperatures. for instance, during the month of april, the total mean generation, from all countries combined, decreased by gw (- %) compared to the previous years averaged. during that same month, fossil fuel generation dropped by gw (- %), nuclear by gw (- %) while combined renewable generation increased by gw (+ %). also, more in general, the load comparisons presented in the previous section suggested that seasonality could not be responsible for all the variation observed. in order to account for the seasonality, the data from the restrictions period for the generation (total and split by different source groups) were analysed using the percent deviation statistic. this procedure enabled the study of how generation was regulated among different energy sources, and which of these were reduced or curtailed. the difference between imported and exported energy, namely the net energy balance, was finally investigated to achieve a complete overview of the energy composition for each country. total generation. as hypothesised, most of the countries with significant load decrease also showed a significant generation decrease (fig. a , r-value = ), with two exceptions: austria and belgium. austria, however, presented a remarkable change of trend with respect to the previous three years. inference for belgium, instead, was hindered by the high variability in its generation pattern, thus no conclusion could be drawn. nuclear and fossil generation. the non-renewable energy sources, such as nuclear and fossil (which includes gas, oil and coal) that typically cover the baseline load, were observed decreasing in generation for most countries, although yearly productions were quite variable (fig. b,c) . still, nuclear output reduced significantly in france and the uk, two eu countries with large nuclear generation. each point is a cumulative sum over a country's restriction period. baseline value (at %) corresponds to the average from years before (excluded), by which all points relative to a given country are centered. next to a country's name, within parentheses, the r-value depicts how many years are more extreme, compared to others, than . to reduce their output than nuclear. this agrees with the evidence that energy generation from fossil fuels was affected by largest percent deviation drops (fig. c ). in particular, coal and oil decreased over the past years (fig. ) , replaced by cleaner alternatives (see supplementary material) . still, germany, poland and czechia, countries whose production share of coal is still relatively high, shifted to more fossil gas generation over the years (fig. e) , a trend continuing also through . renewable generation. renewable energy has no fuel cost and should therefore be prioritised for both environmental and economic reasons. the variability and intermittency in generation from wind and solar, however, challenges the matching of supply and demand, and may result in curtailments. in particular, generation from renewables -specifically intermittent renewables-was queried about its full utilization even during the load drop. to analyse renewable sources, these were grouped into intermittent renewables (solar, wind onshore and wind offshore), and non-intermittent renewables (hydro, biomass, geothermal, waste), on the basis that the output from intermittent renewables cannot be shifted in time, but only curtailed. indeed, as low load and favourable weather conditions co-occurred in april , an unprecedented number of negative wholesale market prices was witnessed across europe (especially in germany) [ , ] , thus raising the question whether intermittent renewable energy was extraordinarily curtailed due to covid- restrictions. as new wind and solar generation capacity was progressively added over the years (fig. a) , generation from intermittent renewables steadily increased as well, and this trend seemed to continue in , for all european countries but portugal, spain, germany and austria (fig. f) . a more in depth study of weather conditions and markets would be needed to determine reasons for this. for another viewpoint, generation was divided by the installed capacity, which measures the proportion of utilization from the installed assets. for the analyzed countries, no significant percentage deviation in generation/capacity was observed for the lockdown phase of , except for portugal and spain (fig. b ). this could suggest that the other countries did not recur to exceptional curtailments in , and intermittent renewable output was consumed or exported similarly as previous years. as for portugal (and to a lesser about non-intermittent renewables (mostly hydro), their output considerably increased in the united kingdom and slightly decreased in czechia from previous years, but did not present outstanding deviations overall. in fact, being hydro a mature and flexible technology, its utilisation did not change significantly over the years (fig. g ). the unusual situation of , showed that the european grid helps balancing between countries with often greatly different generation mixes or -in this case-government interventions leading to load drops. in general, both exports and imports were higher compared to previous years. to inspect the international exchange of electrical energy, countries were first separated into net importers and net exporters, respectively depending on the positive or negative sign of the net energy balance summed over the restrictions periods from years to . in figure (fig. ) , net balance naturally presented a larger percentage variations than load or generation, because of smaller amount of energy that is imported and exported, relative to the load (with portugal being the most extreme example -see supplementary material). during the restriction period of , italy, traditionally a big net-importing country, diminished the net balance by %, indicating that imports were much reduced as the load dropped. for belgium and austria, instead, the declining trend, over the past years trade, slowed and inverted, respectively, and exports overcame imports by . in this year, a significant increase in net balance occurred for poland and czechia, which are fossil based, and for germany. strikingly, the latter country incremented so much as to become a net importer during the restrictions period related to the covid- . the understanding of covid- emergency is an important case study to prepare for scenarios of large load reduction, and high renewable output. the present paper investigates the impact of restrictions, related to the epidemic, on the electricity flows in european countries. using the oxcgrt indices, four limitation types, that significantly correlated with the load reduction observed during the crisis, were identified: "stay at home", "school closing", "restriction on internal movements", and "workplace closing", ordered by increasing correlation. these findings highlighted how the daily severity of these interventions could be accounted for in energy consumption forecast models, to obtain more accurate predictions in the eventuality of successive waves or in future emergencies. in the period of active restrictions, most of europe was characterized by a remarkable load drop, except for scandinavia and switzerland, whose consumption did not decrease significantly (possibly due to less restrictive limitations, peculiarities concerning the load compartments, or a country's industrial activity). concurrently, energy generation by coal, oil and nuclear was reduced considerably, in favour of intermittent renewable sources and, in some countries, fossil gas. in most countries, no extraordinary curtailment was found concerning intermittent renewables, confirming the general trend of increasing exploitation of these sustainable sources, even in critical times. the energy transmissions between countries was also explored, showing a general increase of both imports and exports. coal-based countries, such as poland, czechia and germany, highly increased their net incoming energy, with germany even becoming a net importer in . italy, instead, halved its net imports, which is significant for such a big net-importing country. future studies are required to precisely model the impact of restrictions on generation, net balance and load, ideally split the latter by sector (residential, industrial, commercial). such models will allow for a better long-term forecast, which could be strategic for policy-makers. also short-term forecast will be improved by these models, supporting the activity of the electric grid stake-holders. the results outlined above provide an overview on how energy dynamics in the european electric system played out, adapting to rapidly changing conditions as a consequence of the covid- restrictions imposed by governments. understanding the ramifications of covid- responses provides unique insights not only on how different societies manage critical situations but also on how higher shares of intermittent renewables will impact the grid infrastructure, the energy markets and related investments. as gillingham and colleagues pointed out [ ], pushing back renewable investments would outweigh emission reductions from march to june of and only an energy policy response could change that. the path undertaken through this crisis will be incorporated into j o u r n a l p r e -p r o o f new policies and determine long-term consequences towards a more sustainable future and the avoidance of coming crisis. the evaluation of the final impact of wuhan covid- on trade, tourism, transport, and electricity consumption of china the unprecedented stock market reaction to covid- , economics working paper temporary reduction in daily global co emissions during the covid- forced confinement the covid- lockdowns: a window into the earth system what opportunities could the covid- outbreak offer for sustainability transitions research on electricity and mobility? contextualizing the covid- pandemic for a carbon-constrained world: insights for sustainability transitions, energy justice, and research methodology real-time estimation of the short-run impact of covid- on economic activity using electricity market data, environmental and resource economics covid- impact on electricity a cross-domain approach to analyzing the short-run impact of covid- on the u.s. electricity sector, ssrn electronic enevoldsen, when pandemics impact economies and climate change: exploring the impacts of covid- on oil and electricity demand in china analysis of the electricity demand trends amidst the covid- coronavirus pandemic canadian electricity markets during the covid- pandemic:an initial assessment effects of the covid- pandemic on the brazilian electricity consumption patterns the impact of different covid- containment measures on electricity consumption in europe variation in government responses to covid- -blavatnik school of government the csg covid- control strategies list (cccsl testing statistical hypotheses emergency measures to protect energy consumers during the covid- pandemic: a global review and critical analysis commercial down vs. residential up: covid- 's electricity impact eu day-ahead markets see th week of negative hourly prices the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord- -hprwqi n authors: löscher, thomas; prüfer-krämer, luise title: emerging and re-emerging infectious diseases date: - - journal: modern infectious disease epidemiology doi: . / - - - - _ sha: doc_id: cord_uid: hprwqi n emerging infectious diseases (eids) are characterized by a new or an increased occurrence within the last few decades. they include the following categories emerging diagnosis of infectious diseases: old diseases that are newly classified as infectious diseases because of the discovery of a responsible infectious agent. europe including great britain as well as in india, china, and japan. emerging vector-borne disease events concentrated in densely populated subtropical and tropical regions mostly in india, indonesia, china, sub-saharan africa, and central america (see figs. . , . , and . ). the identification of new infectious agents in old diseases with unknown etiology is still the basis in many epidemiological studies. such newly detected bacteria and viruses in the last few decades are listed in table . . since the detection of helicobacter pylori in , this infection has been identified as the causative agent in % of b-gastritis cases. the risk of duodenal ulcer is increased by - -fold in patients with helicobacter-associated gastritis. who declared h. pylori as a carcinogen of first order because of its potential to enhance the risk of stomach carcinoma and malt lymphoma in long-term infection. in highprevalence regions for h. pylori, the frequency of stomach carcinoma is significantly higher compared to low-endemic areas (correa et al. ). the identification of h. pylori facilitates curative treatment of most associated diseases in individuals. but the most important epidemiological effect on associated diseases is attributed to increased hygienic standards in industrialized countries with a substantial reduction of h. pylori prevalences in younger age cohorts. transmission of h. pylori occurs mainly in childhood. in western developed countries the overall prevalence is around %, higher in older age groups due to a cohort effect, and this increases with low socioeconomic status (rothenbacher et al. ). in countries with low hygienic standards the prevalences are still high in younger age groups and reach % in developing countries. in developed countries, migrant subpopulations from less-developed regions show significantly higher prevalences in comparison to the nonmigrant population (mégraud ). since the early th century, a characteristic expanding skin lesion, erythema migrans (em), and an arthritis associated with previous tick bites were known. borrelia for many decades. increased outdoor activities facilitated contacts between humans and ticks in the s and the s and increased transmission of borrelia to humans at the northeastern coast of north america, leading to the discovery of borrelia burgdorferi in by willy burgdorfer. three different stages of the disease that describe the stage of infection and the involvement of different organ systems are known: stage , early localized infection; stage , early but disseminated infection; and stage , late stage with persistent infection. lyme disease is endemic at the east coast and in minnesota in the united states, in eastern and central europe, and russia. seroprevalence rates that reflect about % of nonclinical infections vary between and % in the general population in germany (hassler et al. ; weiland et al. ) . in high-risk groups like forest workers in germany the prevalences reach - % (robert koch institute a). in ticks (ixodes) the prevalences are between and % depending on the geographical area and the testing method used [immunofluorescence test, ift and polymerase chain reaction (pcr)]. in most studies the main risk factors of infection are age (children: - years, adults - years), outdoor activities, skin contacts with bushes and grass, and the presence of ticks in domestic animals (robert koch institute b) . the probability of infection (seroconversion) after a tick bite in germany is - % and the probability of a clinical disease is . - . %. the probability that the bite of an infectious tick leads to infection in the host is - %. this depends on the time duration that the tick is feeding on the human body. since the detection of the etiologic infectious agent and the subsequent development of laboratory diagnostic tests in the s, the number of reported cases of lyme disease has increased from to , per year, indicating that it is an "emerging diagnosis." the reported numbers vary depending on the reproduction of the hosting rodents for ticks as well as the contacts between humans and nature (spach et al. ) . ticks may live for several years and their survival, reproduction rate, and activity are directly affected by changes in seasonal climate through induced changes in vegetation zones and biodiversity, hence causing local alterations of the tick's habitat and in the occurrence of animals that are carriers of different pathogens (like small rodents). several studies in europe have shown that in recent decades the tick ixodes ricinus, transmitting lyme borreliosis and tick-borne encephalitis (tbe), has spread into higher latitudes (e.g., sweden) and altitudes (e.g., czech republic, austria), and has become more abundant in many places. such variations have been shown to be associated with recent variations in climate. as a result, new risk areas of both diseases have recently been reported from the czech republic. climate change in europe seems likely to facilitate the spread of lyme borreliosis and tbe into higher latitudes and altitudes, and to contribute to extended and more intense transmission seasons. currently, the most effective adaptive strategies available are tbe vaccination of risk populations and preventive information to the general public (danielova et al. ; lindgren et al. ; materna et al. ). an effective vaccine was licensed for b. burgdorferi in . in europe, where different variants of borrelia are present (mostly b. afzelii and b. garinii), this vaccine is not protective. trivalent vaccines for europe are in clinical trials. in recent years, norovirus infections are increasingly recognized as the cause of large outbreaks of diarrheal diseases in the general population, school classes, nursing homes, hospitals, and cruise ships in western countries with peaks in colder seasons (winter epidemics) (centers of disease control ; verhoef et al. ; robert koch institute a) . this is a typical example for emerging diagnosis due to increasing availability of routine pcr testing for these viruses in stool samples. noroviruses (family caliciviridae) are a group of related, single-stranded rna viruses first described in an outbreak of gastroenteritis in a school at norwalk, ohio, in . five genogroups are known. immunity seems to be strain specific and lasts only for limited periods, so individuals are likely to get the infection repeatedly throughout their life. it is estimated that noroviruses are the cause of about % of all food-borne outbreaks of gastroenteritis. for several years there has been an ongoing epidemic in several european countries due to drift variants of a new genotype (gg ii. jamboree) previously unknown to this nonimmune population (robert koch institute a). as a result of an analysis of outbreaks in the united states between and , direct contamination of food by a food handler was the most common cause ( %), person-to-person transmission was less prevalent ( %), and even less frequently waterborne transmission could be proved ( %) (centers for disease control ). vomiting is a frequent symptom of norovirus enteritis and may result in infectious droplets or aerosols causing airborne or contact transmission. this may explain the difficulty to stop outbreaks in hospitals, nursing homes, and similar settings despite precautions to prevent fecal-oral transmission. also on cruise ships, person-to-person transmission is most likely in those closed settings, and drinking tap water is a risk factor as well (verhoef et al. ). searching for an agent which causes large outbreaks of enterically transmitted non-a hepatitis in asia and other parts of the world, the hepatitis e virus (hev) was first described in and cloned and sequenced in (reyes et al. ). meanwhile, hev has been shown to be a zoonotic virus circulating in pigs and other animals. it is implicated in about % of sporadic cases of acute hepatitis in developing countries and associated with a high case fatality rate in the third trimester of pregnancy ( - %). hev is a major cause of large epidemics in asia, and to a lesser extent in africa and latin america, typically promoted through postmonsoon flooding with contamination of drinking water by human and animal feces. recent data show hev also to circulate in european countries and to be associated with severe and fatal disease not only during pregnancy but also in the elderly and in patients with chronic liver conditions. in patients with solid organ transplants, hev may even cause chronic hepatitis and liver cirrhosis (kamar et al. ) . a recombinant hev vaccine candidate has demonstrated a high protection rate of approximately % during clinical trials in nepal (shrestha et al. ). for years, specific human papillomaviruses have been linked to certain human cancers and have been identified as causative agents of malignant proliferations. in the s the detection of papillomavirus dna from cervical carcinoma biopsies were published, showing that hpv types and are the most frequent (dürst et al. ; boshart et al. ) . the relation of hpv infections and cancer is further discussed in chapter . definition: only infections that are newly discovered in humans are listed in this chapter: hiv, new variant of creutzfeldt-jakob disease (vcjd), hemorrhagic uremic syndrome (hus) caused by enterohemorrhagic escherichia coli, viral hemorrhagic fevers like hanta, lassa, ebola, and marburg fever, nipah virus encephalitis, monkeypox, human ehrlichiosis, severe acute respiratory syndrome (coronavirus infection, sars), and avian influenza (h n ) (see fig. . and table . ). these infections mostly have their origin in zoonotic wildlife (e.g., avian influenza, monkeypox, hantavirus, nipah virus, and filoviruses) or livestock (e.g., vcjd). factors promoting the spread of these infections in humans are contacts with wildlife, mass food production of animal origin, and globalization (migration, transportation of goods and vectors) (see fig. . ). in addition, new strains or variants of well-known pathogens have emerged showing increased or altered virulence such as clostridium difficile ribotype or staphylococcus aureus strains expressing the panton-valentine leukocidin (see also chapter ). the epidemiology of hiv is treated in chapter and that of avian influenza and new influenza h n in chapter . in the year , years after the peak of the bse epidemic in the united kingdom, with an annual incidence rate in cows of . per million bovines aged over months, the first mortalities in humans with a new variant of creutzfeldt-jakob disease were observed in the united kingdom. until , smaller incidence rates of bse cases had been reported by other european countries in indigenous bovines and up to more than , per million in in ireland. from , bse started to increase in switzerland and portugal, from in spain and in recent years has spread to eastern european countries (organisation mondiale de la santé animale ). the infectious agent is a self-replicating protein, a "prion." the source of infection for cows is infectious animal flour. the transmission to humans occurs through oral intake of cow products, most likely undercooked meat and nerval tissues as well as transplants of cornea, dura mater, contaminated surgical instruments, or the treatment with hypophyseal hormones extracted from animal tissues. after a statuary ban on the feeding of protein derived from ruminants to any ruminant and the export ban of all cow products from england, the epidemic of bse in cows and the occurrence of human infections decreased in the united kingdom since . by june the total number of deaths in definite/probable cases of vcjd in the united kingdom was (the national creutzfeldt-jakob disease surveillance unit ). only a few numbers of vcjd were reported from other european countries and the united states (who ). nipah virus encephalitis was first observed in / in malaysia. the disease was transmitted by pigs to laborers in slaughterhouses and showed a lethality of %. the infectious agent was detected in (chua et al. ; lam and chua ) . since then, several outbreaks of nipah virus infections have been observed in asian countries: singapore in , india , and bangladesh since (who a harit et al. ) . the virus has been isolated repeatedly from various species of fruit bats, which seem to be the natural reservoir (yob et al. ). west nile is a mosquito-borne flavivirus that was first isolated from a woman with a febrile illness in uganda in . from the s, west nile fever endemicity and epidemics started being reported from africa and the middle east. severe neurological symptoms were thought to be rare. more recent epidemics in northern africa, eastern europe, and russia suggested a higher prevalence of meningoencephalitis with case fatality rates of - %. in , west nile virus was identified as the cause of an epidemic of encephalitis at the east coast of the united states (nash et al. ) . a seroepidemiological household-based survey showed that the first outbreak consisted of about , infections of which about , developed fever and less than % experienced neurological disease ). since then, epidemics occur during summer months in north america each year, with an estimated , febrile illnesses and over , encephalitis or meningitis cases in the united states in (centers for disease control ). age above years is the main risk factor for developing severe disease. the virus is transmitted mainly by culex mosquitoes, but also by sandflies, ceratopogonids, and ticks, with birds as reservoir hosts and incidental hosts such as cats, dogs, and horses. efforts are made to reduce the transmitting mosquito population and to prevent mosquito bites through personal protection as well as to prevent transmission through blood donations by screening (centers of disease control ). the first case of sars occurred in guangdong (china) in november of , leading to an outbreak with cases in china and hong kong ( cases worldwide) until july . the case fatality rate was . %. a new coronavirus (sars-cov) was identified as the causative agent (drosten et al. ) , being transmitted first by infected semidomesticated animals such as the palm civet and subsequently from human to human. some cases were exported to other countries, causing smaller outbreaks there, canada being the most affected country outside asia with cases, before control of transmission was effective. eight thousand and ninety-six cases were reported worldwide, until july , then further transmission stopped (besides one more case of laboratory transmission in ), indicating an efficient international cooperation in disease control (who b) . recently, sars-cov has been found in horseshoe bats, which seem to be the natural reservoir of the virus. about , - , cases of hemorrhagic fever with renal syndrome (hfrs) caused by hantaviruses are reported annually worldwide, with more than half in china, many from russia and korea, and numerous cases from japan, finland, sweden, bulgaria, greece, hungary, france, and the balkan with different death rates depending on the responsible virus, ranging from . % in puumala to - % in hantaan infections (schmaljohn and hjelle ) . hantaviruses are transmitted from rodent to rodent through body fluids and excreta. only occasionally do humans get infected. different types of hantaviruses are circulating in europe and the eastern hemisphere, predominantly puumala virus, dobrava virus, and tula virus, adapted to different mouse species. depending on the virus type the case fatality rate is between and %. as an example, the annual rate of reported cases in germany was about cases per year from onward. this started to change in with reported cases and rose dramatically to cases in . that year, hantavirus infections were among the five most reported viral infections in germany. reasons for the rise in human infections were an increase in the hosting rodent population due to a very mild winter / and an early start of warm temperatures in spring which led to favorable nutritional situations for the mice influencing their population dynamics. in addition, favorable climatic conditions enhanced the outdoor behaviors of humans facilitating transmission in rural areas (robert koch institute b; hofmann et al. ) . since , a previously unknown group of hantaviruses (sin nombre, new york, black creek canal, bayou-in the united states and canada; andes, in south america) emerged in the americas as a cause of hantavirus pulmonary syndrome (hps), an acute respiratory disease with high case fatality rates (approx. %), causing a new, significant public health concern. a total of cases had been reported until march in states, most of them in the western part of the united states (centers for disease control ). lassa virus was detected for the first time in during an outbreak affecting nurses in a missionary hospital in lassa, nigeria. however, the disease had previously been described in the s. lassa virus is enzootic in a common peridomestic rodent in west africa, the multimammate rat mastomys natalensis, which is chronically infected and sheds the virus in urine and saliva. human infection through direct or indirect contact with rats or their excretions is rather common in some west african countries and estimates from seroepidemiological and clinical studies suggest that there are several hundred thousand cases annually. however, only a minority of infections seems to progress to severe hemorrhagic disease with a case fatality rate of - % in hospitalized cases. the virus can be transmitted by close person-to-person contact and nosocomial spread has been observed under poor hygienic conditions. marburg and ebola viruses, which were first detected during outbreaks in and , respectively, have so far been observed only during several limited outbreaks and a few isolated cases in certain countries of sub-saharan africa. however, very high case fatality rates ( - %), the occurrence of outbreaks that were difficult to control in resource-poor settings, and the obscure origin of these viruses have attracted considerable public interest worldwide. recently, evidence was found for both marburg and ebola viruses to occur in certain species of bats that probably constitute the natural reservoir of these filoviruses (towner et al. ). although the disease burden of these viral hemorrhagic fevers is low, they gained considerable international attention due to -their high case fatality rates, -the risk of person-to-person transmission, -several imported cases to industrialized countries, and -fears of abuse of these agents for bioterrorism. as a consequence, considerable resources have been invested, even in nonendemic countries, in the setting up of task forces and high containment facilities for both laboratory diagnostic services and treatment of patients using barrier nursing. this highly virulent strain of c. difficile expresses both cytotoxins a and b and, in addition, the binary toxin cdt, an adp-ribosyltransferase. due to a deletion in the regulatory tcdc gene, the synthesis rates of toxin a and b are increased by -and -fold, respectively. this strain was detected in for the first time in pittsburgh, usa. since then it has spread to canada, and in it reached europe causing multiple outbreaks in hospitals and nursing homes (warny et al. ) . c. difficile -associated colitis has shown high case fatality rates ( - %) and an increased relapse rate. containment of outbreaks in hospitals and other institutions necessitates isolation of patients or cohorts and strict hygienic measures. during recent decades, a large variety of well known infectious diseases has shown regional or global re-emergence with considerable public health relevance (table . ). globally, tuberculosis is probably the most important re-emerging infectious disease. in developing countries, tb infection still is extremely common and, in the wake of the hiv pandemic, the percentage of those developing overt disease has increased dramatically. worldwide, tb is the most common opportunistic infection in patients with aids. the significance of tb and hiv/tb coinfection is reviewed in chapters and . the re-emergence of some infectious diseases is closely related to the lack or the breakdown of basic infrastructures as seen in periurban slums and in refugee camps in developing countries, or as a consequence of war, breakdown of the civil society, or natural or man-made disasters. cholera is a formidable example for both re-emergence and epidemic spread under those conditions. another important group of re-emerging infectious diseases is caused by various vector-borne infections, such as malaria, dengue fever, and yellow fever. these major vector-borne diseases are treated in more detail in chapter . in addition, there are a variety of re-emerging infections transmitted by arthropod vectors such as various arboviral diseases and some protozoal diseases other than malaria (i.e., leishmaniasis, human african trypanosomiasis). the reasons for the emergence of several vector-borne diseases are rather variable and may range from climatic factors (e.g., global warming, rainfall), lack or breakdown of control, to changes in agriculture and farming and in human behavior (e.g., outdoor activities). these factors are usually quite specific for each of these diseases and largely depend on the specific ecology of the agent, its vectors, and reservoirs. cholera, an acute diarrheal infection transmitted by fecally contaminated water and food, had been endemic for centuries in the ganges and brahmaputra deltas in the th century before it started to spread to the rest of the world. since , six pandemics caused by the classical biotype of vibrio cholerae were recorded that killed millions of people across europe, africa, and the americas. it has been a major driving force for the improvement of sanitation and safe water supply. the seventh pandemic was caused by the el tor biotype, first isolated from pilgrims at the el tor quarantine station in sinai in . it started in in south asia, reached africa in , and is still ongoing. after more than hundred years, cholera spread to the americas in , and beginning in peru, a large epidemic hit numerous latin american countries with . million cases and more than , fatalities reported within years. out of the serogroups of v. cholerae, only o and o can cause epidemics. the serogroup o , first identified in bangladesh in , possesses the same virulence factors as o and creates a similar clinical picture. currently, the presence of o has been detected only in southeast and east asia, but it is still unclear whether v. cholerae o will extend to other regions. since , the re-emergence of cholera has been noted in parallel with the everincreasing size of vulnerable populations living in unsanitary conditions. cholera remains a global threat to public health and one of the key indicators of social development. while the disease is no longer an issue in countries where minimum hygiene standards are met, it remains a threat in almost every developing country. the number of cholera cases reported to the who during rose dramatically, reaching the level of the late s. a total of , cases were notified from countries, including , deaths, an overall increase of % compared with the number of cases reported in . this increased number of cases is the result of several major outbreaks that occurred in countries where cases had not been reported for several years such as sudan and angola. it is estimated that only a small proportion of cases -less than % -are reported. the true burden of disease is therefore grossly underestimated. the absence or the shortage of safe water and sufficient sanitation combined with a generally poor environmental status are the main causes of spread of the disease. typical at-risk areas include periurban slums where basic infrastructure is not available, as well as camps for internally displaced people or refugees where minimum requirements of clean water and sanitation are not met. however, it is important to stress that the belief that cholera epidemics are caused by dead bodies after disasters, whether natural or manmade, is false. on the other hand, the consequences of a disaster-such as disruption of water and sanitation systems or massive displacement of population to inadequate and overcrowded camps-will increase the risk of transmission. chikungunya virus, an arbovirus belonging to the alphavirus group, is transmitted by various mosquitoes. the virus was first isolated in tanzania in and since then has caused smaller epidemics in sub-saharan africa and parts of asia with low public health impact. in , the largest epidemic ever recorded started in east africa, spread to réunion and some other islands of the indian ocean, and then spread further to asia, with more than . million cases in india alone so far. characteristics of the disease are high fever and a debilitating polyarthritis, mainly of the small joints that can persist for months in some patients. now, for the first time, severe and fatal cases have been observed that may be due to certain mutations of the epidemic strain (parola et al. ) . the asian tiger mosquito aedes albopictus has proved to be an extremely effective vector in recent epidemics causing high transmission rates in big cities and leading to epidemics with high public health impact. this southeast asian mosquito species has been shipped by transport of used tires and plants harboring water contaminated with larvae to other continents and, since , ae. albopictus has successfully spread in italy and other parts of southern europe. in august , an outbreak of chikungunya fever occurred in northern italy with more than confirmed cases. the index case was a visitor from india who fell ill while visiting relatives in one of the villages and further transmission was facilitated by an abundant mosquito population during that time, as a consequence of seasonal synchronicity (rezza et al. ). ross river virus (rrv) is another arbovirus of the alphavirus group that causes an acute disease with or without fever and/or rash. most patients experience arthritis or arthralgia primarily affecting the wrist, knee, ankle, and small joints of the extremities (epidemic polyarthritis). about one-quarter of patients have rheumatic symptoms that persist for up to a year. the disease can cause incapacity and inability to work for months. it is the most common arboviral disease in australia with an average of almost , notified cases per year. rrv is transmitted by various mosquito species and circulates in a primary mosquito-mammal cycle involving kangaroos, wallabies, bats, and rodents. a human-mosquito cycle may be present in explosive outbreaks which occur irregularly during the summer months in australia and parts of oceania. heavy rainfalls as well as increasing travel and outdoor activities are considered as important factors contributing to the emergence of rrv epidemics. this flavivirus is transmitted by certain culex mosquitoes and is a leading cause of viral encephalitis in asia with , - , clinical cases reported annually. it occurs from the islands of the western pacific in the east to the pakistani border in the west, and from korea in the north to papua new guinea in the south. only in - infections will lead to encephalitis, which is, however, often severe with fatality rates of - % and with a high incidence of neurological sequelae. despite the availability of effective vaccines, je causes large epidemics and has spread to new areas during recent decades (e.g., india, sri lanka, pakistan, torres strait islands, and isolated cases in northern australia). je is particularly common in areas where flooded rice fields attract water fowl and other birds as the natural reservoir and provide abundant breeding sites for mosquitoes such as culex tritaeniorhynchus, which transmit the virus to humans. pigs act as important amplifying hosts, and therefore je distribution is very significantly linked to irrigated rice production combined with pig rearing. because of the critical role of pigs, je presence in muslim countries is low. crimean-congo virus is a bunyavirus causing an acute febrile disease often with extensive hepatitis resulting in jaundice in some cases. about one-quarter of patients present hemorrhages that can be severe. fatality rates of . - % have been reported in hospitalized patients. cchf is transmitted by hyalomma ticks to a wide range of domestic and wild animals including birds. human infection is acquired by tick bites or crushing infected ticks, and also by contact with blood or tissue from infected animals that usually do not become ill but do develop viremia. in addition, nosocomial transmission is possible and is usually related to extensive blood exposure or needle sticks. human cases have been reported from more than countries in africa, asia, southeastern europe, and the middle east. in recent years, an increase in the number of cases during tick seasons has been observed in several countries such as russia, south africa, kosovo, and greece. in turkey, where before no human cchf cases had been observed, a total of , confirmed cases, including deaths, were reported between and june . the emergence of cchf has been associated with factors such as climatic features (temperature, humidity, etc.), changes of vector population, geographical conditions, flora, wildlife, and the animal husbandry sector. rvf is a mosquito-borne bunyavirus infection occurring in many parts of sub-saharan africa. it infects primarily sheep, cattle, and goats, and is maintained in nature by transovarial transmission in floodwater aedes mosquitoes. it has been shown that infected eggs remain dormant in the dambos (i.e., depressions) of east africa and hatch after heavy rains and initiate mosquito-livestock-mosquito transmission giving rise to large epizootics. remote sensing via satellite can predict the likelihood of rvf transmission by detecting both the ecological changes associated with heavy rainfall and the depressions from which the floodwater mosquitoes emerge. transmission to humans is also possible from direct and aerosol exposure to blood and amniotic fluids of livestock. most human infections manifest themselves as uncomplicated febrile illness, but severe hemorrhagic disease, encephalitis, or retinal vasculitis is possible. in , rvf has been transported, probably by infected camels to egypt, where it caused major epidemics with several hundred thousand infections of humans. it has been suggested that introduction of rvf may be a risk to other potentially receptive areas such as parts of asia and the americas. floods occurring during the el niño phenomenon of in east africa subsequently gave rise to large epidemics and further spread to the arabian peninsula. most recent epidemics occurred in and following heavy rainfalls in kenya, somalia, and sudan, causing several hundred deaths. besides mosquito control, epidemics are best prevented by vaccination of livestock. leishmaniasis, a protozoal transmitted by sandflies, has shown a sharp increase in the number of recorded cases and spread to new endemic regions over the last decade. presently, countries are affected with an estimated million cases worldwide. there are about . million new cases of cutaneous and mucocutaneous leishmaniasis, a nonfatal but debilitating disease with % of cases occurring in afghanistan, brazil, bolivia, iran, peru, saudi arabia, and syria. the incidence of visceral leishmaniasis (vl), a disease with a high fatality rate when untreated, is estimated at around , per year. the situation is further aggravated by emerging drug resistance (table . ) and the deadly synergy of vl/hiv coinfection. epidemics usually affect the poorest part of the population and have occurred recently in bangladesh, brazil, india, nepal, and sudan. for many years, the public health impact of the leishmaniases has been grossly underestimated. they seriously hamper socioeconomic progress and epidemics have significantly delayed the implementation of numerous development programs. the spread of leishmaniasis is associated with factors favoring the vector such as deforestation, building of dams, new irrigation schemes, and climate changes, but also with urbanization, migration of nonimmune people to endemic areas, poverty, malnutrition, and the breakdown of public health. antimicrobial resistance of epidemiological relevance has emerged as a major problem in the treatment of many infectious diseases (table . ). resistance is no longer a problem that predominantly affects the chemotherapy of bacterial infections. it became increasingly important in parasitic and fungal diseases, and despite the short history of antiviral chemotherapy, it already plays a prominent role in the treatment of hiv infection and other viral diseases. resistance is also a problem in some of the emerging infections and will further complicate their treatment and control. resistance of bacterial pathogens has become a common feature in nosocomial infections, especially in the icu and in surgical wards. currently, the number one problem in most hospitals is s. aureus resistant to methicillin (mrsa, see chapter ). however, common problems of resistance also extend to other major bacterial pathogens such as enterococci, various gram-negative enteric bacilli, and pseudomonas species. resistance has developed not only to standard antibiotics (e.g., penicillins, cephalosporins, aminoglycosides, macrolides, or quinolones) but also to second-line antibiotics including carbapenems, glycopeptides, and newer quinolones. however, there is considerable geographic variation. in , the european antimicrobial resistance surveillance system (earss), a network of national surveillance systems, reported vancomycin-resistant rates among enterococci ranging from none in iceland, norway, romania, bulgaria, denmark, and hungary to % of enterococcus faecium strains in greece (earss ) . a surveillance study conducted in the united states hospitals from to showed that % of nosocomial bloodstream infections were caused by enterococci and that % of e. faecalis isolates and % of e. faecium isolates were vancomycin resistant (wisplinghof et al. ) . rates and spectrum of antibacterial resistance of e. coli and other gram-negative enteric bacilli may differ considerably from one hospital to the other. in some important pathogens of hospital-related infections such as klebsiella, enterobacter, and pseudomonas species, resistance to almost all available antimicrobials has been observed. this may complicate the choice of an effective initial chemotherapy considerably. therefore, each hospital has to monitor the epidemiological situation of resistance regularly, at least for the most important bacteria causing nosocomial infections, such as staphylococci, enterococci, gram-negative enteric bacilli, and pseudomonas. even in community-acquired infections, there has been a considerable increase in resistance problems. at present, approximately % of pneumococcal isolates in the united states are resistant to penicillin, and % exhibit intermediate resistance. the rate of resistance is lower in countries that, by tradition, are conservative in their antibiotic use (e.g., netherlands, germany) and higher in countries where use is more liberal (e.g., france). in hong kong and korea, resistance rates approach %. in addition, about one-quarter of all pneumococcal isolates in the united states are resistant to macrolides. this rate is even higher in strains highly resistant to penicillin, and increasingly there is multiresistance against other antibiotics such as cephalosporins. the prevalence of meningococci with reduced susceptibility to penicillin has been increasing, and high-level resistance has been reported in some countries (e.g., spain, united kingdom). although high-dose penicillin is effective in infections with strains of intermediate resistance, most national and international guidelines recommend broad-spectrum cephalosporins such as ceftriaxone as first-line drugs. however, in most developing countries, penicillin and chloramphenicol are the only affordable drugs. in recent years, certain strains of community-acquired s. aureus with resistance to methicillin (cmrsa) have been observed which produce a toxin (panton-valentine leukocidin) that is cytolytic to pmns, macrophages, and monocytes, and which are an emerging cause of community-acquired cases and outbreaks of necrotic lesions involving the skin or the mucosa, and in some patients also of necrotic hemorrhagic pneumonia with a high case fatality (vandenesch et al. ) . development of resistance is mainly determined by two factors: -the genetic potential of a certain pathogen, i.e., mobile elements such as plasmids, transposons, or bacteriophages, genes coding for resistance, and mutation rate. -the selection pressure caused by the therapeutic or the para-therapeutic application of antimicrobial drugs. in the hospital these factors are supported by -microbial strains that are highly adapted to this environment (e.g., rapid colonization of patients, resistance to disinfectants), -an increasing percentage of patients who are highly susceptible to infections due to old age, multimorbidity, immunosuppression, extended surgery, and invasive procedures, and -the frequent use of broad-spectrum antibiotics or combinations of antimicrobial drugs. another source of resistant bacteria has been identified in mass animal production and the use of antimicrobials as growth promoters (e.g., the glycopeptide avoparcin, the streptogramin virginiamycin) or as mass treatment in the therapy or the prevention of infections. the inadequate use of antimicrobial drugs is also an important factor responsible for the development of resistance in community-acquired infections. this is especially true in developing countries where only a limited spectrum of antibiotics is available, where shortage of drugs often leads to treatment that is underdosed or too short, and where uncontrolled sale and use of antibiotics is commonplace. as a consequence, resistance of gonococci is extremely frequent in southeast asia, and resistance of salmonella typhi, shigella, and campylobacter to standard antibiotics is common. some of the still effective second-line antibiotics have to be given parenterally or are not available because they are too costly. a typical example of the consequences of insufficient chemotherapy due to lack of compliance and/or unavailability of drugs is the alarming increase in multiresistance and extreme resistance in tb (see chapter ). resistance is also a problem in parasitic diseases such as malaria (see chapter ), leishmaniasis, or african trypanosomiasis. plasmodium falciparum developed resistance against all major antimalarial drugs as soon as they were used on a broad scale. resistance had contributed significantly to the increase in malaria-associated morbidity and mortality observed in many endemic areas (wongsichranalai et al. ) . a recent report on failures of the new artemisinin combination treatment for p. falciparum malaria at the thai-cambodian border supports fears of the development of resistance to this most promising class of drug at present (dondrop et al. ). resistance against antiviral drugs has developed almost from the beginning of antiviral chemotherapy (table . ). in the treatment of hiv infection, the risk of development of resistance has been drastically reduced by the combination of several drugs with different mechanisms of action (see chapter ). however, drug resistance remains the achilles' heel of the highly active antiretroviral therapy (haart) and may be at a considerable risk of expanding haart to the developing world. today, we have to realize that as we develop antimicrobial drugs, microbes will develop strategies of counterattack. antimicrobial resistance occurs at an alarming rate among all classes of pathogens. even in rich countries it causes real clinical problems in managing infections that were easily treatable just a few years ago. in life-threatening infections such as sepsis, nosocomial infections, or falciparum malaria, there is a substantial risk that the initial chemotherapy might not be effective. in addition, the delay caused by inadequate treatment might favor transmission to other people and support the spread of resistant pathogens (e.g., multiresistant tb). last but not the least, surveillance and control and the necessity to use expensive second-line drugs or combinations of antimicrobials are enormous cost factors. for developing countries this is a major limitation in the treatment and control of infections caused by resistant agents. so, in many ways, emerging resistance contributes to the emergence of infectious diseases. despite the availability of effective strategies for treatment and prevention, infectious diseases have remained a major cause of morbidity and mortality worldwide. however, the problems associated with infections are due to considerable changes. in industrialized countries the mortality caused by infectious diseases has decreased tremendously during more than years. however, during recent years, both mortality and morbidity associated with infections are increasing again. ironically, this is closely associated with the advances in medicine which have contributed to profound changes in the spectrum of both patients and their infections. advanced age, underlying conditions, and an altered immune response are common features in the seriously infected hospital patient today. immunosuppressive therapy is frequently used to treat neoplastic and inflammatory diseases or to prevent the rejection of transplants. some infections, most notably hiv/aids, cause immunosuppression by itself. in the compromised patient, infections are generally more severe or may be caused by opportunistic pathogens that will not harm the immunocompetent host. antimicrobial treatment is often less effective in these patients and tends to be further complicated by antimicrobial resistance which may manifest itself or develop at a higher frequency in the immunocompromised patient. an increasing percentage of infections are hospital acquired or otherwise health care associated. it is estimated that nosocomial infections affect . million patients and contribute to approximately , deaths in us hospitals annually (klevens et al. ). considering the rising number of elderly and immunocompromised patients, a further increase in severe infections can be predicted. in developing countries, the significance of infectious diseases has remained high for ages and despite the advances in medicine. until now, infections are by far the leading cause of both disability-adjusted life years and life years lost. the reasons are obvious and mostly related to poverty and lack of development causing poor and unhealthy living conditions, inadequate health systems, and lack of resources for prevention and treatment. this is, of course, just an integral part of the general socioeconomic problems of developing countries. however, poor health conditions per se are an important obstacle to development, and infections such as hiv/aids in sub-saharan africa can be a major cause of lack of development, increasing poverty, and political instability. generally, the situation of many developing countries has not improved during the last two decades, and the gap between the first and the third world has increased. however, most of the mortality and morbidity associated with infectious diseases is avoidable. as laid down in the millennium goals, a major task of the world community will be to counteract the imbalance between the industrialized and the developing countries and to find strategies to ensure participation in the progress of modern medicine for all. developing countries also carry the main burden of diseases caused by newly emerging and re-emerging infections (table . and . ) . however, the consequences of economical and political crises on emerging infectious diseases are obvious in industrialized countries also-such as the return of diphtheria or the increase in tb and multiresistant tb after the breakdown of the former soviet union. today, all countries worldwide are affected by emerging infections as well as by emerging antimicrobial resistance. in the age of globalization, travel and transport of people, animals, and goods of all kinds have increased tremendously. as a consequence, infectious agents may travel over long distances and at high speed. this is clearly evident with influenza pandemics or outbreaks such as the sars epidemic or with imported cases of viral hemorrhagic fever transmissible from person to person. the spread of antimicrobial resistance or the re-emergence of tb seems to be less spectacular, but the consequences may be at least as important in the long run. management and control of emerging and re-emerging infectious diseases can be very different from disease to disease and has to allow for all relevant factors of the populations at risk and of the specific disease including the ecology of the agent, its vectors, and reservoirs. however, some basic principles apply to all situations: -surveillance -information and communication -preemptive planning and preparedness -provision and implementation of • adequate treatment • adequate control and prevention -international cooperation active and passive surveillance systems with rapid reporting and analysis of data are essential for the early detection of outbreaks, changes in epidemiology, and other events of public health concern (see chapters and ). however, many resourcepoor countries do not have functional surveillance systems. in addition, reporting of infectious diseases may be neglected or delayed because of fears of stigma, international sanctions including trade and travel restrictions, or interference with tourism. classical examples are plague and cholera, but also recent examples such as the bse/vcjd crisis in the united kingdom or sars originating from china showed undue delays between first occurrence of cases and information to the public. although, in outbreaks of new and unknown diseases it may be difficult, or even impossible, to predict or assess the magnitude of the problem and the potential consequences, timely and adequate information and communication is not only obligatory, according to international regulations, but also the best strategy to avoid rumors, misbeliefs, panic, or disregard. in recent years, many countries have installed national plans of action for important epidemiological scenarios and outbreaks such as pandemic influenza, bioterrorism, import of viral hemorrhagic fevers transmissible from person to person, sars, and comparable diseases or outbreaks. all member states of the world health assembly that have so far not been able to install functional surveillance and/or pre-emptive planning are obliged to do so within a maximum of years after their ratification of the new international health regulations (who ) . preparedness not only means surveillance and planning but also has to include the provision of facilities to adequately treat and, if necessary, to isolate patients with infectious diseases of public health importance and relevant epidemic potential and/or at risk of transmission to other persons including health-care workers. task forces and high containment facilities for both laboratory diagnostic services and treatment of patients using barrier nursing have been set up in several countries. however, all health facilities of a certain level such as general hospitals should be prepared by their organization and structure to treat patients with infections of public health relevance such as multiresistant tb under appropriate isolation and barrier nursing conditions. this also applies to hospitals in resource-poor countries. adequate training of health-care workers and strict management have been effective to control outbreaks of highly contagious infections within rural african hospitals lacking sophisticated technical equipments (cdc ) . strategies for control and prevention may be quite different for various emerging infections. effective vaccinations are available only for some infections and are usually lacking for newly emerging infections (table . ). for the majority of emerging infections, control and prevention have to rely on information, education and exposure prophylaxis, interruption of transmission by vector control and control of reservoir hosts (e.g., rodents), and case finding with early diagnosis and treatment. for diseases and outbreaks caused by infections of public health relevance that are transmissible from person to person, containment procedures including isolation and treatment of patients under condition of barrier nursing as well as tracking and surveillance of contacts are warranted by national and international health regulations. here, international cooperation is essential to successfully contain outbreaks and epidemics such as the sars epidemic in . despite dramatic progress in their treatment and prevention, infectious diseases are still of enormous global significance with tremendous economic and political implications. emerging and re-emerging infectious diseases as well as emerging antimicrobial resistance are major challenges to all countries worldwide. for the management of current and future problems, it will be most important to counteract the imbalance between the industrialized world, new economies, and developing countries, and to adequately and timely react to new threats on a global scale. a new type of papillomavirus dna, its presence in genital cancer and in cell lines derived from genital cancer world health organization: infection control for viral haemorrhagic fevers in the african health care setting nipah virus: a recently emergent deadly paramyxovirus helicobacter and gastric carcinoma. serum antibody prevalence in populations with contrasting cancer risks effects of climate change on the incidence of tick-borne encephalitis in the czech republic in the past two decades artemisinin resistance in plasmodium falciparum malaria identification of a novel coronavirus in patients with severe acute respiratory syndrome a papillomavirus dann from a cervical carcinoma and its prevalence in cancer biopsy samples from different geographic regions susceptibility results for e. faecium isolates lyme-borreliose in einem europäischen endemiegebiet: antikörperprävalenz und klinisches spektrum hantavirus outbreak global trends in emerging infectious diseases hepatitis e virus and chronic hepatitis in organtransplant recipients estimating health care-associated infections and deaths in u.s. hospitals nipah virus encephalitis outbreak in malaysia lyme borreliosis in europe: influences of climate and climate change, epidemiology, ecology and adaptation measures. who regional office for europe altitudinal distribution limit of the tick ixodes ricinus shifted considerably towards higher altitudes in central europe: results of three years monitoring in the krkonose mts epidemiology of helicobacter pylori infection : results of a household-based seroepidemiological survey outbreak of west nile virus infection novel chikungunya virus variant in travelers returning from indian ocean islands isolation of a cdna from the virus responsible for enterically transmitted non-a, non-b hepatitis infection with chikungunya virus in italy: an outbreak in a temperate region waldarbeiter-studie berlin-brandenburg zu zeckenübertragenen und andere zoonosen risikofaktoren für lyme-borreliose: ergebnisse einer studie in einem brandenburger landkreis übertrifft die infektionszahlen der vorjahre zahl der hantavirus-erkrankungen erreichte in deutschland einen neuen höchststand prevalence and determinants of helicobacter pylori infection in preschool children: a population-based study from germany hantaviruses: a global disease problem safety and efficacy of a recombinant hepatitis e vaccine tick-borne diseases in the united states the national creutzfeld-jakob disease surveillance unit (ncjdsu) marburg virus infection detected in a common african bat community-acquired methicillin-resistant staphylococcus aureus carrying panton-valentine leukocidin genes: worldwide emergence multiple exposures during a norovirus outbreak on a river-cruise sailing through europe toxin production by an emerging strain of clostridium difficile associated with outbreaks of severe disease in north america and europe prevalence of borrelia burgdorferi antibodies in hamburg blood donors nipah virus outbreaks in bangladesh revision of the international health regulations nosocomial bloodstream infections in us hospitals: analysis of cases from a prospective nationwide surveillance study large outbreak of norovirus: the baker who should have known better epidemiology of drugresistant malaria nipah virus infection in bats (order chiroptera) in peninsular malaysia key: cord- -y g ceq authors: affolder, rebecca; zaffran, michel; lob-levyt, julian title: global immunization challenge: progress and opportunities date: - - journal: maternal and child health doi: . /b _ sha: doc_id: cord_uid: y g ceq after reading this chapter and answering the discussion questions that follow, you should be able to: outline important milestones in the emergence of vaccines as a means of disease control and prevention. discuss factors that underpin the disparity in access to vaccines between rich and poor countries. identify and appraise innovative options for financing vaccine development, and for ensuring wider access to new and underused vaccines in developing countries. evaluate strategies for ensuring sustainability in vaccine development, management, and access. outline priorities for future research, policy, and practice with regard to vaccine development, procurement, and access. vaccines, having been developed over the last years to become one of the most cost-effective and successful public health interventions, are one of the most exciting technologies in the world today. yet every year, around . million children die from diseases that can be prevented by currently available or new vaccines. vaccines have the potential to erase some of the most glaring global health inequities which currently shape the lives of millions. often the most vulnerable -women, children, and adolescents in even the poorest countries, could be protected against life-threatening and debilitating disease within a generation. this chapter presents a historical perspective on the emergence of vaccines as a means of disease control and prevention over the past two centuries. beginning with discov- inequity in access to vaccines between rich and poor countries and the underpinning factors are discussed, including lack of safety and quality assurance systems in poor countries, focus of research and development on rich nations' priorities, and the diversion of scarce resources to other emerging global health priorities. various innovative options for financing wider access to new and underused vaccines in poor countries are explored, including the role of the international finance facility for immunization (iffim), the advanced market commitment (amcs), the heavily indebted poor countries (hipci) and multilateral debt relief (mdri) initiatives, and the debt buy-down program of the world bank. issues of sustainability in vaccine development, procurement, and management are discussed as are priorities for future research, policy, and practice. the first immunization -and the origin of a smallpox vaccine -is believed to have been in (table . ) when british physician edward jenner administered fluid from a cowpox lesion obtained from a milkmaid named sarah nelmes andre ( ) ; plotkin ( ) to a -year-old boy named james phipps. jenner later found that the boy was ''secure'' to smallpox virus (andre ) . louis pasteur later coined the term vaccine in reference to the latin word for cow: vacca. records of a similar medical approach can be found in chinese literature dating back to the eleventh century and linked with the fight against the smallpox virus (plotkin ) . according to the national library of medicine (u.s. national library of medicine ), the practice of variolation, where small scabs of tissue containing smallpox were inhaled causing the individual to contract the disease in a mild form, reduced the mortality rate among those exposed to the disease to - % as opposed to % when individuals contracted the disease naturally. by , the practice of variolation as a response to smallpox had expanded to india, africa, and throughout the ottoman empire. variolation was first practiced in europe by and, by , in the american colonies (u.s. national library of medicine ). the immunization field grew in the th and th centuries, with major breakthroughs in the mid-to late th century through discovery of vaccines that protect against such diseases as influenza, polio, and yellow fever (table . ) . prior to the development of such vaccines, the loss of life from disease is illustrated in some staggering figures. for example, the influenza (or ''spanish flu'') outbreak of - resulted in more deaths than enemy fire in world war i (plotkin ) . the period of - can be considered a second phase in the history of immunization. the world health organization (who) launched the expanded program on immunization (epi) in , expanding the smallpox eradication effort which was focused on one single vaccine into an infant program of six vaccines (against diphtheria, pertussis, tetanus, poliomyelitis, measles, and tuberculosis). at the time, less than % of the world's children were immunized against these six diseases. meanwhile, an increased degree of population mobility, for example, through commercial air travel, helped bring about the recognition that infectious disease prevention required a coordinated, global effort. the epi launch marked an important turning point: immunization became an international public good. in response to a world health assembly challenge (world health assembly ), immunization coverage rose over the next decade, with the united nations children's fund (uni-cef) declaring % of the world's children under the age of immunized against tuberculosis, polio, and measles by (hardon and blume ) . a number of global initiatives contributed to the progression of immunization coverage rates in the s. unicef, with the support of other international organizations, launched the ' 'child survival revolution'' in (unicef . this initiative comprised four interventions for reducing mortality: growth monitoring, oral rehydration, breastfeeding, and immunization (gobi). at the same time, who led major vertical programs to combat vaccine-preventable disease, diarrhea, and acute respiratory infections (hardon and blume ) . the universal childhood immunization (uci) goal was launched in to catalyze efforts toward universal immunization coverage. uci aimed at accelerating epi, capitalizing on the success in mobilizing support. as a result of these dedicated efforts, child mortality declined in many countries (hardon and blume ) . yet, despite the overall success of accelerating immunization coverage in the period described above, significant disparities are apparent ( fig. . ). the expansion in coverage was largely in developed countries with large populations. one hundred and seven countries did not reach the immunization coverage of %, and the declaration of success did not reflect the uneven coverage within many countries -where some of the most vulnerable children in hard-to-reach areas were missed. a great success for some masked the growing divide in access between north and south. the characteristics of the north/south divide, which remains the current global situation, developed during the s. a gap in the routine immunization schedules for children in developed and developing countries emerged as new vaccines, including those for hepatitis b, haemophilus influenzae b (hib), varicella, pneumococcal, meningococcal, and combination formulations became a routine part of the immunization schedule for children and adolescents in high-income countries (hardon and blume ) . research and development priorities favored those products targeting developed countries. vaccine quality and safety, taken for granted in many countries with robust regulatory agencies, fell behind in many countries lacking an effective quality assurance program for medical products. quality and safety issues also point to the weakness of health delivery systems in many poor countries which limited the effective rollout of routine immunization. the gap in financial commitment to maternal and child healthwhich underpins and drives the north/south divide in access to immunization -widened over the s as scarce resources were diverted to other emerging global health priorities. many developing countries struggled to improve or even maintain their immunization rates. the end of the decade saw an overall decline in global immunization and vaccine production, and particularly among the poorest populations in the poorest parts of the world. the new millennium set the stage for a major shift in the global response to the growing inequities between north and south. under the leadership of the then un secretary general kofi annan, the un millennium summit, the largest-ever gathering of world leaders, was convened at the united nations headquarters in new york, usa, in september (united nations development program . at the close of the summit, world leaders unanimously adopted the ''united nations millennium declaration'' taking on a clear obligation to act through commitment to the millennium development goals (mdgs) (united nations ) . these goal comprised a set of time-bound and measurable goals and targets for combating poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women. corresponding financial commitments from the developed world in the form of aid, trade, debt relief, and investment were made at the international conference on financing for development in monterrey, mexico (ifad ). as part of a renewed commitment to poverty reduction and human development, the international community moved to address the growing inequalities in immunization and the unacceptable toll of infectious disease in developing countries. marking the start of a ''third phase'' in the history of immunization, the global alliance for vaccines and immunization (now the gavi alliance) was launched in january to accelerate access to new and underused vaccines in the poorest countries. gavi, an innovative public/private partnership, brought together the major stakeholders in immunization in order to achieve global immunization targets. these stakeholders included national governments, unicef, who, the world bank, the bill and melinda gates foundation, the vaccine industry, public health institutions, and nongovernmental organizations (gavi alliance a). soon after gavi's launch its mandate came to include action on the child mortality target of the millennium development goals -namely, a / reduction of the under- mortality rate by (gavi alliance b). in the years since gavi's launch, overall dtp coverage increased from % in to % in in gavi-eligible countries, i.e., those with a gross national income (gni) of less - than $ , per capita. the figures are more pronounced in the who african region where dtp coverage increased from % ( ) to % ( ) and has overtaken southeast asia ( % in ), which is now the region with most unimmunized children (who b) . much of this increase in dtp coverage has been attributed, through independent evaluation, to the immunization services support provided by gavi to strengthen immunization delivery systems and infrastructure (lu et al. ) . in terms of new and underused vaccine introduction, the cumulative achievement of the poorest countries to improve coverage is impressive (gavi alliance b). over years, . million additional children were immunized against hepb ( ) ( ) ( ) ( ) ( ) ( ) . four and a half million additional children were immunized against yellow fever in , equaling a cumulative . million additional children immunized over years against yellow fever. an additional . million additional children were immunized with hib vaccine in , equaling a cumulative . million additional children immunized with hib vaccine over years. critical to these improvements has been the ability of the gavi alliance to raise new and additional resources -providing funds to introduce new and underused vaccines, improve injection safety, improve immunization delivery services, and strengthen health systems. gavi-supported countries are continuing to produce impressive results (gavi alliance a). despite the exciting results, we must not lose sight that the key challenges remain gaining better data on disease burden to stimulate demand and ensuring the affordability and long-term sustainability of new vaccine introduction. until prices become more affordable, slow uptake of new vaccines in the poorest countries remains inevitable. how this challenge can be better addressed through innovative approaches is covered in the discussion on funding challenges below. the gavi alliance is but one element of a growing complexity of agencies working on maternal and child health issues; while it maintains a niche focus, this requires close collaboration with partners in the broader global health community. the launch of the global immunization vision and strategy (givs) in (who/unicef ) provided a critical overarching framework that exhibits the need for coordinated mix of instruments and approaches. these approaches may be in the form of highly successful vertical campaign strategies for the global eradication of polio and control of measles, delivery of basic vaccines in conflict environments, or in the longer-term efforts to create sustainable markets for new and underused vaccines in the poorest countries. givs was approved by the member states of who and the executive board of unicef in . it sets out a plan to address the global immunization challenges over the decade - and strives to act with equity and gender equality, in addition to personal ownership, partnership, and responsibility. placing immunization firmly within the health system strengthening agenda, givs ''aims to sustain existing levels of vaccine coverage, extend immunization services to those who are currently unreached and to age groups beyond infancy, introduce new vaccines and technologies, and link immunization with the delivery of other health interventions and the overall development of the health sector'' (who/ unicef ). the vision and goals of givs are a world in that highly values immunization and that has equal access to immunizations for all. this world would also support sustainable interventions in diverse social situations, changing demographics and economies, as well as being a world that will put vaccines to the best global health and security use. addressing the key challenges: funding, sustainability, equity following the launch of givs in , a who/ unicef study examined the cost, financing, and impact of immunization programs in the poorest countries (who/unicef ). implementation of givs would protect more than million children in the world's poorest countries against the major childhood diseases by . the estimated total price tag for immunization activities for - in these countries is us $ billion, one-third of which would be spent on vaccines and two-thirds of which would be spent on immunization delivery systems. the study concluded that spending on immunization will need to rise from us $ . billion per year ( ) to us $ . billion by and us $ billion by (who/unicef ) . national budgets will ultimately fund vaccines and health services. the challenge will be to grow and sustain financing from domestic resources. how will the poorest countries reach this point? donor funding in the interim and the growth of poor economies will determine the ability of countries to finance their health sectors. to illustrate the additional sums required, it is worth noting that the report of the commission for africa ( ) recommended that donors spend around % of the commission's proposed us $ billion package for africa to strengthen health systems and ensure a satisfactory response to hiv and aids by . this call for additional spending is supported by analysis which shows that many countries will be able to work within a substantially increased spending envelope for health (foster ). yet donor aid remains volatile. in health, the shortcomings of traditional aid -from poor allocation to an absence of a results-focused, coordinated effort among donors -have clearly, if not tragically, been illustrated over the last decades (radelet and levine ) . innovative financing mechanisms provide a way to overcome some of the current limitations of aid while mitigating the political risks that many donors associate with significantly scaling up finance to developing countries, for example, through transfers such as budget support. global funds and partnerships such as gavi have shown that innovative solutions to development challenges, including raising additional finance for development, can be generated by bringing together public and private stakeholders, including the civil society. gavi provides the leverage so that both donor and developing country governments can employ new and innovative funding strategies -such as performance-based grants and co-financing (long-term subsidy agreements) for new vaccines -which characterize gavi as an instrument for innovative financing. while it is too early to make any conclusive statement on the long-term market-shaping impact of gavi, an independent study states that ''emerging suppliers view the gavi market as attractive and credibility-building, with the added economic advantage of alignment with domestic or middle-income markets. this is thanks to the significant size and growth of gavi, as well as the price levels it has provided'' (boston consulting group ) . as a catalyst for further innovation in finance, gavi has had a critical role in developing two further mechanisms for financing vaccine introduction and development: the international finance facility for immunization (iffim) and advance market commitments (amcs). the iffim, launched in , is a pilot of the larger international finance facility (iff) that was originally proposed by the government of the united kingdom in to double global aid for development and to accelerate the availability of funds through the gavi alliance in of the poorest countries around the world. the mechanism takes long term ( years), legally binding commitments from donors (iffim ) and borrows against them for years in the capital markets, producing upfront finance and thus stabilizing a portion of aid flow to developing countries. because of the innovative ''frontloading'' funding program, an anticipated iffim investment of us $ billion is expected to prevent million child deaths between and and more than million future adult deaths from hepatitis b-related liver disease. advance market commitments (amcs) provide legally binding promises, usually offered by governments or other financial entities, to guarantee a viable market if a vaccine is successfully developed. this ensures revenues will be generated from the newly developed vaccine that will match those of other comparable medicines. amcs speed the development of new vaccines by enabling biotech and pharmaceutical companies to successfully invest in vaccine development (iavi ) . beyond the clear benefit of providing long-term, predictable finance to countries, allowing them to make longer-term budgeting and planning decisions, the predictable funding for immunization through iffim has the potential to leverage significant market benefits by allowing bulk purchasing of vaccines. the predictability and legally binding nature of the financial commitment provides strengthened negotiating power and the ability to negotiate longer-term arrangements with suppliers, generating lower prices and therefore more vaccines for the same envelope of funds. a second market-shaping innovative mechanism -an ''advance market commitment'' (amc) pilot for a pneumococcal vaccine -was launched in february . an amc is a financial commitment to subsidize the future purchase, up to a pre-agreed price, of a currently unavailable vaccine -if an appropriate vaccine is developed and providing the demand exists when the vaccine is finally produced. by guaranteeing that the funds will be available to purchase vaccines once they are developed and produced, the amc mimics a secure vaccine market and takes away the risk that countries will not be able to afford a high-priority vaccine, addressing current market failure: vaccines that would prevent millions of deaths facing long delays before they are developed, tested, and produced for use in the poorest developing countries. by establishing a valuable market, amcs provide incentives for private investment in the development of vaccines against neglected diseases. such a ''pull mechanism'' is not an alternative, but is highly complementary to other public and philanthropic interventions in the health sector and, more generally, in development aid. amcs will be most effective when combined with push interventions because of the network effects of the increased number of scientific researchers working on the target diseases as well as the enhanced probability that scientific research swiftly translates into the production of effective and safe vaccines. push interventions include public and philanthropic funding of research through academia, public-private partnerships, and other bodies. the private resources mobilized by successful amcs would act in synergy with initiatives to expand immunization (e.g., gavi and iffim) and strengthen health systems. the success to date of raising funds through innovative financing instruments will continue to catalyze more thinking on both innovative means for raising and delivering development aid and how to better align these new instruments with more traditional aid streams. debt relief is an emerging area in innovative financing for health which could usefully be applied to accelerate sustainable vaccine introduction. the two major broad initiatives for debt relief are the heavily indebted poor countries initiative (hipc) and multilateral debt relief initiative (mdri) programs. the hipc initiative was launched by the international monetary fund (imf) and the world bank in and aims to reduce debt for heavily indebted poor countries that face unsustainable debt burdens, that are pursuing reform programs, and that have developed a poverty reduction strategy paper. the hipc estimates providing debt assistance in the amount of us $ billion dollars in debt relief, funded by bilateral creditors and multilateral lenders, to a total of countries ( taking the hipc a step further, the multilateral debt relief initiative (mdri) was launched by the group of eight industrialized countries (g ) in and will provide % cancellation of debt owed by hipcs to the international development association (ida), to the african development fund (afdf), and to the imf (international monetary fund, b) . this program enacts up-front, irrevocable debt cancellation for eligible countries (table . ). the main objective of the mdri is to enable hipcs to mobilize funding for poverty reduction programs in order to reach the millennium development goals. the intent is that additional resources made available through debt relief should be allocated to poverty alleviation programs. but as there is no formal obligation to allocate resources relieved by the mdri to any specific sector, competition between departments for the use of these extra resources is likely. potential impact of the mdri on health system strengthening and on financing immunization programs could be significant. as annual amounts of debt service relief will be significant in many hipcs, especially around - , a small percentage of these resources could have a reasonable impact on the health sector and in particular on immunization financing. the gavi alliance partners are currently exploring options for using debt relief -in the form of an international development association (ida) buy-down -to specifically support countries' vaccine programs. in addition, a number of bilateral debt relief programs may also offer an opportunity for targeted debt relief. ida buy-downs are currently being explored as new innovative financing mechanisms for vaccines. ida is member of the world bank group. it provides long-term loans (also called concessional loans or credits) and grants to the poorest of the developing countries, particularly those that are severely constrained by conflict, epidemics, and debt. a buy-down refers to a third party paying off all or part of a specific ida credit on behalf of the government upon successful achievement of pre-determined performance indicators. the world bank began an ida buy-down pilot in , when it provided the governments of nigeria and pakistan with roughly $ million in ida credits for the purchase of vaccine to help achieve the global polio eradication objective. the bill and melinda gates foundation, rotary international, and the united nations foundation agreed to pay off the ida credits upon successful achievement of the performance indicators, in this case receipt and distribution of vaccine and specified polio immunization coverage levels. innovative financing, while not a magic bullet, will nonetheless offer a range of new possibilities for countries to help reach the significant increases in finance required to meet the mdgs. ultimately, the real test will be whether the donor community is successful in working together to ensure traditional aid is aligned to a mixed instrument approach. this has been done before. bangladesh, one of the poorest countries in the world, has achieved the most radical improvements in reproductive health the world has ever seen. this has impacted significantly on women's and child mortality and morbidity, their social status and economic growth -despite poverty, poor governance, political upheaval, and an apparent lack of any potential for economic growth in the early years. the key was that for years from the mid- s, through a mixture of aid instruments, donors and multilateral agencies provided substantial, predictable but coordinated financial and technical support for salaries, a radical expansion in the workforce (notably paramedics), associated infrastructure, and ''expensive'' reproductive commodities which the government delivered through state and civil society structures. it has become clear that new technologies such as vaccines or antiretrovirals (arvs) for hiv have the potential to deliver a generational leap in achieving the mdgs. the health gains made in europe over years could be achieved in africa over a - year period (who/unicef ). of the more than million annual child deaths, an estimated % could be avoided through immunization with existing and newly developed vaccines such as pneumococcal and rotavirus vaccines. procurement of essential health commodities is an area where this can be carried forward without risk to macroeconomic stability. yet without basic health systemsessential for the sustainable availability of medical products -the poor will never access these benefits. despite evidence of the cost-effectiveness of vaccines in particular and the economic and social benefits of health in general, the track record of national and donor budget allocations to date is not good. gavi-eligible countries have very modest health budgets, with government health spending across africa, for instance, averaging $ -$ per capita and with many countries below $ . responding to the needs of poor countries by investing in the critical foundation for the delivery of basic health services requires a long-term view. while vertical approaches have been effective at raising the profile and funding levels for vaccines, countries must now be supported to move systematically to introducing the full range of vaccines in immunization programs as part of integrated maternal and child health services. with expensive new vaccines coming to market (for example, three doses each of pentavalent (dtp-hepb-hib), rotavirus, and pneumococcal conjugate vaccines could amount to more than us $ per child) it is clearly no longer appropriate to focus on financial sustainability of a single product in isolation from broader system sustainability. moving toward a truly sustainable planning framework will not be a simple endeavor, yet it represents an exciting opportunity for the gavi alliance partners. one challenge will be to gather the information on demand and future prices required by countries to inform longer-term planning and decision making. unicef's commitment and global procurement ability over the years has brought great benefits in terms of quality, security, and better prices for such long established vaccines as bcg, dpt, measles, and polio. but it has become clear that this procurement model is most effective in mature markets with overcapacity and competition, and notably capacity in countries located in emerging markets (e.g., india, brazil, indonesia, and cuba). new or combination vaccines such as dtp-hepb-hib challenge the established means of procurement, where cost limits the ability of donors to deliver affordable products to the poorest parts of the world. it is only through competition that the prices of new vaccines will become affordable to the poorest countries. clearly the key to success will be the ability to mobilize additional donor funds, but to use those funds in such a way that the vaccine market is shaped to promote competition and to bring prices within reach of the poorest countries. beginning in , gavi support shifted toward national co-financing (as opposed to gavi providing vaccines free). this is based on the intent by the gavi alliance partners to ensure that gavi financial support is seen by all stakeholders as time limited and to ensure that countries move to a fuller ownership of their immunization program, including the introduction of new vaccines. co-financing therefore aims at supporting and stimulating evidence-based priority-setting within the immunization program and within the health sector more generally. financial commitments, however small, also generally require a higher level of government engagement. through this approach, which will be evaluated in , gavi alliance partners are working to help countries to be on a trajectory of eventual independence from gavi support, acknowledging, however, that, for most of the gavi-eligible countries this is likely to require a very long time over the next decade, the ability of developing countries to achieve sustainable introduction of new technologies will be largely dependent on how donor funds are provided, particularly whether there is a shift toward long-term, predictable aid and if innovative financing instruments are appropriately aligned and taken to scale. the other key determinant will be sustained political support for health and for vaccines by developing country governments. guyana is an example of a country that has been highly successful in achieving high immunization coverage and is the first gavi-supported country to fully finance the purchase of pentavalent vaccine from its national budget (united nations ). guyana's continuing success is in part due to a very strong political commitment at the highest levels to finance the national immunization program, including efforts to protect it from economic shocks and shifts in donor priorities. more broadly, there has been a remarkable growth in the health budget from us $ . per capita in to us $ in (excluding overseas development assistance). this accounts for % of national expenditure, while the government's goal is to reach % (ministry of health, guyana ; editorial, pharmacoeconomics and outcomes news, ) . from an equity point of view, gavi's condition of support to the ministry of health, china, was that vaccines be made available at no cost (removing the previous charge). this policy was subsequently adopted across china for all vaccines. while the spread of hiv and aids has led to recent discourse on health as a global security issue, most arguments -and certainly those related to maternal and child health -have at their root the principle of equity and the belief that health is a basic human right. equity in health has been defined (for measurement and operationalization) as ''the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage -that is wealth, power or prestige'' (braveman and gruskin ) . the world development report, making services work for poor people, noted that ''the concern for equity is either a social choice or based on the notion that health is a human right'' (world bank ) . as an ethical or social justice issue, equity in health is therefore a critical element for consideration and measurement, particularly when looking at the trade-offs and choices made around financial sustainability issues discussed in the previous section. many of the disparities in health result from social determinants such as poverty, access to services, education, gender, and ethnicity. harnessing the potential of new medical technologies, such as vaccines, to reach underserved groups will take concerted effort and in some cases, explicitly defined political choices. new vaccines against human papilloma virus (hpv) provide the opportunity for such a political choice: to ensure that all women, rather than just those in wealthy countries, are provided with a vaccine that will prevent most cervical cancer cases. hpv vaccines, as the first vaccines to focus primarily on women's health, provide the global health community an unprecedented opportunity to tackle a key neglected women's health issue -one which especially impacts on the poorest women. cervical cancer is not difficult to prevent; yet, it affects an estimated , women each year and leads to more than , deaths (ferlay et al. ) . it is largely a disease of poor women who have limited access to health services; about % of women dying from cervical cancer live in developing countries (fig. . ) (ferlay et al. ) . the lack of effective cervical cancer prevention interventions -part of a regular medical checkup for women in wealthy countries -is a major factor in the high rates of cervical cancer among poor women. if current trends in women's health continue, there are projected to be over , , new cases of hpv annually by the year (boyle ) . many challenges must be addressed before hpv vaccine can reach the millions of girls and young women who would benefit from it, especially those living in the developing world where the need is greatest. with the right combination of scientific, educational, and financing efforts, hpv vaccine could become available globally within a few years. accelerating access to hpv vaccine could make cervical cancer -the second most common cancer among women worldwide -a rarity in just a few decades. another social determinant of health is where one lives. within large developing countries, such as india, nigeria, or china, there are significant inequities in the population's health. disparities in access to, and utilization of, services within these countries are often a result of factors such as geography, social barriers, conflict, and weak governance. of the million children that missed out of immunization in more than % live in countries (fig. . ). india and nigeria stand out as countries with the largest number of unimmunized children in the world. reaching mdg will thus require a significant increase in investment in immunization -both domestic and external -in countries with large numbers of unimmunized children who account for more than half of all vaccine-preventable deaths among children less than years of age. with some states or regions in some of these countries being equal or larger in population to many countries, a fresh state-or region-based approach will likely be required, with a focus on the poorest. for example, child and maternal mortality rates in the poorest eastern provinces of china equal or exceed those found in much of africa (world bank ) . despite economic growth, equity is worsening. national political commitment in such countries will be key. a program approach, tailored to country-specific challenges, will be required. additional long-term finance (domestic and global) will be critical to support that political commitment. new technology, including new and better vaccines, will be vital. which vaccines for the future? research and development for vaccines and other essential health commodities point to another disparity between north and south and constitute a market failure. priorities in the global allocation of resources for vaccine research and development do not match the global burden of death and disease. few resources are allocated to tackling diseases that disproportionately affect people in developing countries; new vaccines are therefore expensive and out of the reach of the poor. this discrepancy between need and reality is illustrated in table . , illustrating that normal market mechanisms do not work for the poor. among the vaccines currently under development, the three most needed today in terms of their potential public health impact are for aids, tb, and malaria. jointly, these diseases account for over million deaths per year or around % et al. ( ) of all infectious disease deaths. the total investment in vaccines against these diseases is far lower than their importance as dictated by disease burden and it will probably take at least - years before a vaccine against any of these diseases is available. in the past two decades, advances in biotechnology have resulted in the licensure of new vaccines such as hib, acellular pertussis, hepb, and attenuated varicella. most of the basic scientific breakthroughs have been generated in research institutions in the public sector whereas the cost for clinical development is borne by the pharmaceutical industry. this requires heavy investments that need to be recouped from profits. the markets needed to recoup these investments are in industrialized countries that can afford to buy. the evolving disease burden in developing countries will bring new diseases into prominence while sometimes allowing old ones to resurface. this will influence priorities for vaccine research (table . ). the severe acute respiratory syndrome (sars) epidemic, the outbreak of avian influenza, and the emergence of bioterrorism threats such as anthrax have led to new research avenues for vaccines against these infections. the threat of a reassorted influenza pandemic virus strain has highlighted the need for more resources and attention to the development and distribution of effective flu vaccines. alternative administration routes for vaccines would greatly contribute to improving immunization program safety and potentially reduce the quantity of contaminated waste which needs to be safely disposed. this could help avoid needle transmission of blood-borne pathogens and ease vaccine delivery strategies where non-professionals can administer vaccines. new administration routes such as oral, nasal, and transcutaneous are currently being explored. one option currently being explored through collaboration by who, path, and the serum institute of india is focusing on the development of a measles aerosol vaccine that could make a big difference in eliminating this disease by facilitating administration, during mass campaigns (burger et al. ) . the measles aerosol vaccine is useful in situations where the availability of trained medical personnel, who can safely administer injections, is limited. immunogenically in studies, the aerosol vaccine was proven effective > % of the time among infants < months of age and - % among infants > months and school-aged children (henao ) . this vaccine continues to be tested in clinical trials in order to find the most appropriate and effective aerosol delivery method. another interesting option is the concept of using plant-derived or edible vaccines that involve encoding protective antigens from pathogens into transgenic plants (mor et al. ). the plants are processed so that they can deliver a uniform dose of vaccines. human clinical trials have been conducted with bananas and raw potatoes, which showed encouraging antibody responses (sala et al. ) . plant-derived vaccines are formed when a gene is integrated with a plant nucleus or chloroplast genome. this transforms higher plants (e.g., tobacco, potato, tomato, and banana) into bioreactors for the production of subunit vaccines for oral or parental administration (sala et al. ). the potential advantage of this technology could include thermostability, low investment needs, multivalency, and oral administration. new technologies that strengthen vaccine delivery are under development. priority is given to such technologies that will (a) expand access, (b) improve safety, and (c) cut the cost of immunization programs. they include the following five technologies: (i) ''sharps'' processing: the increased use of autodisable (ad) syringes (syringes which lock themselves after a single injection) has greatly improved the safety of immunization programs by avoiding the reuse of contaminated syringes and reducing risks of transmission of blood-borne pathogens such as hepatitis b, hepatitis c, and hiv (lloyd ) . this success is, however, highlighting another problem which the health sector is facing, that of the handling of contaminated medical waste. in the case of immunization, this is mainly related to the disposal of used syringes and needles (these syringes represent between and % of all injections given in the health sector but nevertheless the push to introduce ad syringes is increasing the pressure on immunization programs to tackle this challenge). sharps are rarely disposed of at the point of use. since sharps are transported to the point of destruction, the risk of infection from accidental exposure to sharps must be minimized. four different technologies are being explored for this purpose: corrosive disinfectants, thermoprocessing, needle destruction, and plastic melting (lloyd ) . however, none of these options is currently sufficiently developed to be put into use in the field. (ii) monodose pre-filled devices: vaccine wastage constitutes a considerable cost to immunization programs. monodose presentations eliminate wastage and the risk of contamination. when the monodose is pre-filled into an injection device, it increases quality and safety at the point of use. uniject is one such device that has been tested with hepb and tetanus toxoid (tt) (lloyd ) . village health workers can administer it. currently, major obstacles reside in the cost of the device and the need for additional cold storage space when multidose presentation is exchanged for monodose, but ultimately, the objective would be to provide an increasing number of immunizations with monodose preparations that would not require increased cold chain capacity. (iii) needle-free injections: needle-free injectors deliver vaccine at high velocity into the skin without penetration of a needle, thereby reducing the risk of transmission of blood-borne pathogens (who c) . technologies are being developed for both mono-and multidose presentations. multidose injectors available have not been found safe and new models are under development. there are several monodose models available; however, they are not feasible for large-scale programs because of regulatory obstacles and high cost (who ) . (iv) thermostable vaccine: vaccine distribution and storage without a cold chain would considerably simplify the delivery system, reduce cost, and allow for integrated supply mechanisms. removal of vaccines from the cold chain should be the highest priority for technology research. sugar glass drying is one such technology that has shown great promise (lloyd ) . it can be used to produce multivalent vaccines that are completely heat stable, except under extreme climatic conditions. the high cost of regulation/licensing and the uncertainty about market prospects in industrialized countries have so far impeded the development and use of this technology. vaccines are delicate products that are easily destroyed if handled incorrectly. vaccine management spans a spectrum of aspects involving the use and disposal of vaccines, from the manufacturers to the end-users, for which plans must be in place and regularly updated to ensure an effective and efficient service delivery including (i) inventory and forecasting; (ii) stock control; (iii) in-country distribution; (iv) storing and handling; (v) equipment replacement; (vi) procedures for the use of vaccine; (vii) monitoring of vaccine storage; (viii) transport management; and (ix) operational management. all of these areas would benefit significantly from research efforts to find alternative and innovative approaches. for instance, the heavy reliance on the cold chain remains a major economic and logistical burden on programs. the possibility of taking greater advantage of the real thermostability of vaccines and the increasing use of the vaccine vial monitor by taking vaccines ''out of the cold chain'' is a field which has only begun but could potentially revolutionize immunization delivery (table . ) . vaccine vial monitors are heat-sensitive circular labels, no wider than a centimeter, that change color as vaccines are exposed to heat. they are time-temperature indicators used to (i) ensure that the vaccines have not been damaged by excessive exposure to heat, (ii) identify weaknesses in the cold chain, and (iii) take vaccines beyond the cold chain to reach out to children who have no access to fixed health facilities. health workers can use the vaccine vial monitor color to tell if the vaccine has been overexposed to heat and whether or not it is safe for immunization. this indicator cuts down on the uncertainty of vaccine safety due to potential temperature changes during transport along the cold chain. therefore, the vaccine vial monitor reduces waste. immunization remains one of the most cost-effective of all public health interventions. maternal and child health-related mdgs will be difficult to meet without significantly scaling up the coverage of existing vaccines and successfully introducing new pipeline products -ensuring that research and development priorities are aligned with the diseases for which preventative technologies are needed most. financing this effort, however, poses a considerable challenge. a serious commitment to closing the north/south divide and meeting mdgs will require a joint approach that involves increased investment by developing country governments and better, more stable aid flows from donors. increased investment, particularly in the social sector, will be critical to finance costs such as system building that require large amounts of sustained finance. in-kind investments in commodities can be scaled up rapidly without major concerns around absorptive capacity or macroeconomic stability. long-term, predictable aid flows are also needed to reduce volatility and provide increased certainty over future budget flows to enable better planning in countries. as a global community, we must start approaching our work from a perspective that evaluates who is taking on the burden of risk -it clearly should not be the poorest countries. risk analysis is a common tool in the private sector -companies only take decisions based on the probable level of risk it implies for them. yet the donor community consistently places the poorest countries in a position where it is very difficult for them to make choices of how or whether to radically scale up access to basic services. the donor community, including the gavi alliance and the international financial institutions, needs to develop strategies to reduce financial and political risks. this means adjusting processes and requirements to support the long-term integrated plans of developing countries. the financial risks of development strategies must be more equitably shared between donors and national governments. development will be led by developing countries when they are enabled to plan ahead; what factors account for the disparity in immunization coverage between developed and less developed countries? . what is the gavi alliance? how does its mission compare with those of global immunization vision strategy what major barriers confront the gavi alliance and givs in their efforts 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committee on new delivery systems international fund for agricultural development (ifad) ( ) international conference on financing for development -statement by lennart ba˚ge, president of ifad advance market commitments: helping to accelerate aids vaccine development debt relief under heavily indebted poor countries (hipc) initiative the multilateral debt relief initiative (mdri) benin: third review under the three-year arrangement under the poverty reduction growth facility, request for waiver of nonobservance of a performance criterion, and request for extension of the arrangement technologies for vaccine delivery in the st century effect of the global alliance for vaccines and immunization on diphtheria, tetanus, and pertussis vaccine coverage: an independent assessment guyana financial immunization sustainability plan . brickdam, georgetown: ministry of health/ministry of finance perspective: edible vaccines -a concept coming of age why certain vaccines have been delayed or not developed at all can we build a better mousetrap? three new institutions designed to improve aid effectiveness vaccine antigen production in transgenic plants: strategies, gene constructs, and perspectives. vaccines united nations children's fund (unicef) ( ) the state of the world's children : the s: campaign for child survival human development report: millennium development goals: a compact among nations to end human poverty developing countries join gavi alliance and who to ''co-finance'' vaccines for poor children the world development report -making services work for poor people china's progress toward the health mdgs proceedings of the first global vaccine research forum traditional medicine. the fifty-sixth world health assembly (wha . ) geneva: world health organization china immunises millions of children against hepatitis b in historic collaboration between government and gavi alliance united nations children's fund (unicef) ( ) global immunization strategy who ivb human papillomavirus & hpv vaccines: technical information for policy-makers and health professionals world health organization (who) ( b) who report on gavi progress world health organization (who) ( c) immunization safety for ensuring sustainability in procurement, access, and uptake of vaccines in less developed countries. what are the major barriers? . what should be the priorities for future vaccine research and development globally? provide justification for your position. key: cord- -edb yozz authors: narula, rajneesh title: policy opportunities and challenges from the covid- pandemic for economies with large informal sectors date: - - journal: j int bus policy doi: . /s - - - sha: doc_id: cord_uid: edb yozz in the developing world, the informal economy can account for as much as % of the population. i focus on the urban component of informality, where both informal employment and informal enterprises are especially vulnerable to the pandemic-induced economic shock. i explain the complex nature of informality, some of the reasons for its persistence and its interdependency with the formal economy, especially in the manufacturing sector, through global value chains (gvcs). large firms (whether mnes or domestic firms) sub-contract considerable activity to informal enterprises, but this is precarious in character. i suggest the crisis provides the circumstances for greater active engagement with informal actors, by placing informal enterprises on a par with formal firms within industrial policy. i propose integration and registration, as opposed to formalisation, and the provision of state support without taxation. the role of the state is also crucial in matchmaking, creating incentives for gvcs to engage with informal actors systematically, and to reduce the transaction costs for informal actors in such engagement. these actions are likely to provide benefits in the longer run, even if they prove costly in the short run. the most visible effect of the covid- crisis in the developed world has been to the unemployed, the self-employed, casual and gig-workers, and small-scale entrepreneurs and businesses, which can be imperfectly described as those people and enterprises being in the informal sector. informality is a universal feature of every economy, a term used to describe workers, activities and enterprises that are not (or weakly) monitored, regulated or registered by the government, and, by extension, have limited or no access to public support. the developed world tends to have low levels of informality, rarely more than a quarter of the population. these actors are fortunate that developed country governments have been able to extend emergency relief, in addition to a pre-existing safety net, however imperfect this safety net might be. in the developing world, informality is a much more pervasive phenomenon, with more than billion people, representing % of workers and % of enterprises (ilo, ) . the covid- crisis is a stark reminder of the absence of any sort of social safety net. in this paper, i focus on the urban component of developing country informality (lewis, ; godfrey, ; gollin, ; narula, narula, , for three reasons. first, the rural economy tends to be overwhelmingly in subsistence agriculture, and less at risk economically from the crisis. second, the urban poor account for at least half of the population in developing countries, and reside in high-density localities with precarious sanitary and health conditions. third, the urban poor are disproportionally dependent on direct and indirect employment in the 'modern' economy (in the sense proposed by lewis, ) , mainly in manufacturing and service sectors. in the urban arena, international trade and investment often plays a significant role in commercial activity. the urban economy will be the most severely affected by the pandemic, because, even when the country in question has low levels of infection, both demand and supply of goods and services from abroad have been severely disrupted. even where there has been low domestic mortality, this does not negate the possible economic shock. the more globally integrated the economy through supply chains, the more severe the economic implications of the pandemic (sforza & steininger, ) . developing country governments do not always have the resources to implement the basic who guidelines to counter the spread of covid- , although several have effectively tackled previous epidemics and pandemics. the scale and rapid spread of this pandemic may well overwhelm their public health infrastructure and its ability to trace, isolate or test infections. physical distancing and large-scale lockdowns for extended periods are challenging where poverty levels are high and the urban populations are already close to (or below) the poverty line. in this paper, i emphasise two aspects of informality: informal employment and informal enterprises. i also explain the complex nature of informality, some of the reasons for its persistence, and its interdependency with the formal economy, especially in the manufacturing sector, through global value chains (gvcs). larger firms within supply chains (whether mnes or domestic firms) often sub-contract considerable activity to informal enterprises, but this is precarious in character. i suggest the crisis may nonetheless generate the impetus for greater active engagement with informal actors. i propose that this should be done by placing informal enterprises on a par with formal firms within industrial policy. that is, i recommend integration and registration, as opposed to formalisation, and the provision of state support without taxation. the role of the state is also crucial in matchmaking, creating incentives for gvcs to engage with informal actors systematically, and to reduce the transaction costs for informal actors in such engagement. these actions are likely to provide benefits in the longer run, even if they prove costly in the shorter run. table gives a good sense of the significance of the informal economy by region, and a selection of countries. the self-employed and micro-enterprises account for almost per cent of employment in the middle east and north africa, and for more than per cent in both south asia and sub-saharan africa (ilo, ). india alone officially records million micro-enterprises, employing million people (government of india, ). the unregistered enterprises, casual workers and subsistence traders likely account for a further - million. likewise, africa has an estimated million are in the informal sector (jayaram, leke, ooko-ombaka, & sun ) . two types of informality are prevalent in an urban economy. the first is informal employment. this refers to workers employed by formal, registered firms on a casual, day-wage basis, as well as subsistence actors such as self-employed workers. this includes individuals and entrepreneurs that might undertake piecework in their own premises, street vendors and most domestic workers. they lack protection for non-payment of wages and retrenchment without notice, and often work under limited occupational safety conditions with no sick pay and health insurance. the second group, and the focus of this paper, involves informal enterprises. they engage in coordinated commercial activity, such as bazaar traders, restaurants, and small ad hoc factories. they may or may not have a discernible organisational structure, with operations (and employment) that grows or shrinks, depending upon the demand for the enterprises' outputs or services. they are built around an actor/entrepreneur who engages in a series of spot market transactions with customers, suppliers and workers, depending upon demand (geertz, ) . informal enterprises are unable to seek (formal) credit, and have limited access to social programmes and public goods. informal enterprises rarely invest in productivity-enhancing equipment, upgrade workers' skills, or achieve economies of scale, and tend to function on razor-thin margins. they have no recourse to legal protection should their customers renege on payment, and can offer no form of security to their employees, pay no taxes, and ignore minimum wage regulations. for instance, in bangladesh, workers in the informal sector earn three times less than in formal firms (ilo, ) . the supply of low-skilled, low-cost labour in lessdeveloped economies is almost infinite, with considerable movement of surplus rural informal labour to urban locations, where employment in the urban informal sector provides opportunities less dependent on the vagaries of small-scale agriculture. when the economy is characterised by high unemployment, working below minimum wage is better than not working at all. following the arguments of lewis ( ) , a near-inexhaustible supply of labour -in the absence of labour rights -keeps wage costs low, with workers as price-takers. low-cost labour is thus a key comparative advantage for most developing countries. this cost advantage through informality underlies much of the basis for participation in manufacturing value chains, especially in asia. south asia exports sports equipment, apparel and carpets, while agricultural products (from beef and wine to grain, tomatoes and coffee) play a significant role more evenly across much of the developing world, especially in africa and latin america. a majority of developing country exports are from these sectors, coordinated overwhelmingly by multinational enterprises (mnes) through global value chains (gvcs). in less-developed economies and in agricultural gvcs, domestic actors tend to have a transactional relationship, selling 'raw' inputs to mnes. in higher-income 'emerging' countries with manufacturing gvcs, there is a greater domestic engagement. gvcs are vertically de-integrated, relying on a variety of suppliers coordinated by the mne affiliate. formal suppliers (whether mnes or domestic firms) tend to rely on informal employees, and sub-contract considerable activity to a network of informal enterprises. neither public nor private regulators monitor this wide network of indirect suppliers and pieceworkers. the use of the informal sector is an important 'valve' for the formal firms (narula, ) . during periods of peak demand, informal enterprises take on tasks for which the formal firm has insufficient capacity, in addition to the formal firm drafting in extra casual workers as needed. unfortunately, when demand is low, the reverse is the case -formal firms can act quickly to reduce costs by laying off informal employees and terminate purchasing from informal enterprises (or simply decline to pay, since they have no legal recourse). it is uncontroversial that high levels of informality can limit human development. however, reducing informality significantly is no straightforward matter, requiring extended but gradual and sustained engagement with informal institutions that are deeply embedded in political, cultural and structural structures. indeed, there is little clarity as to informality's causes, its persistence, or its remedy. what we do know is that a proliferation of informal activity in an economy reflects systemic failures, leading to weak institutions, endemic corruption, and large bureaucratic obstacles (and high entry barriers) to formal activity. others point to political and regulatory capture by powerful interest groups, for whom a persistent supply of cheap (and unorganised) labour is an opportunity for rents (estrin & mickiewicz, ) . political actors may have stakes in perpetuating the status quo. this is especially so in countries with weak political institutions, where inconsistency of policy and weak legal recourse is combined with political biases in favour of elites (autio & fu ) . however, informality casts a long shadow. even where institutions become more business friendly, actors may prefer to remain in the informal sector (williams, shahid, & martínez, ) . a considerable literature has persuasively argued that informal actors are rational. they often choose to remain informal because there are viable economic reasons to do so. even where economic and political institutions are stable and functional, the entrepreneur may possess an ownership advantage from being able to leverage complex networks across both sides of the economy, and therefore may perceive no economic benefit from formalisation. in other words, becoming formal may actually limit their capacity to generate rent. when the barriers to formalisation are high, this reinforces the tendency to remain informal. as implied by a variety of authors, in an environment of weak political and economic institutions, informality may well be a solution to poverty (de soto, ; godfrey, ; estrin & mickiewicz, ; autio & fu, ) . from society's perspective, however, when entrepreneurs prefer to remain in the informal sector, this limits the funds available for public expenditures, leading to a vicious circle of increased taxation and fees on the formal firms, thereby reducing the competitiveness of formal firms, and encouraging further informality. the charitable view is that the formal/informal interdependency reflects a pragmatic action by governments, or rather, a pragmatic inaction. countries at the time of writing, a number of developing countries have chosen to initiate enforced physical distancing to limit the spread of the pandemic, although few governments are unable to offer significant support to incumbent formal actors, let alone informal actors. already-high unemployment levels are likely to increase significantly. stiglitz and fitoussi ( ) do not exaggerate when they say that 'anything unmeasured is invisible to policymakers'. governments rarely have reliable data on the size and structure of their informal economy, and, to a large degree, they have mostly been ineffective in tackling informality even prior to the crisis. it is therefore unlikely that policymakers can reliably address the economic disruption to the informal sector. according to jayaram et al. ( ) , in the case of africa, million informal service sector jobs are vulnerable, as well as million in the manufacturing and construction sectors. i consider this an under-estimation. the streamlining and shedding of direct employment by the non-agricultural sector is already happening in response to covid- . private businesses, both foreign and domestic, will respond to the crisis by reducing their staff. with so much of their populations in the informal sector, it is both logistically impossible and financially unmanageable to implement sophisticated 'rescue packages' for the vast numbers of small business owners/entrepreneurs and casual/subsistence workers, as have the developed countries (joyce & xu, ) . lockdowns and physical distancing are impractical in densely populated slums and barrios. residents literally live from hand to mouth. if they do not work, they do not eat, and this certainly means that they do not have money for rent, or such 'luxuries' as a hospital bed or medicines. images from india during march/ april showed literally millions of informal workers trying to return to their ancestral villages, underscoring this point. even modest rescue packages will lead to a rise in both public and private debt. eclac ( ) estimates public debt levels across latin america, already at % of gdp, will rise (despite debt forgiveness from lenders and donors and reduced interest rates). prior to the crisis, imf ( a) noted that of the less-developed economies were at ''high risk'' of falling into debt distress or were already distressed, up from zero as recently as . the imf also noted that many state-owned enterprises and private firms had taken advantage of cheap capital to significantly increase their debt over the last decade. shortfalls in revenues by both states and firms will require further borrowing, and greater dependence on aid. countries dependent upon remittances as a key source of capital inflows are likely to experience a shock, as host countries ponder sending migrant workers back to their home countries (largely informally employed with limited labour rights, both in their host and home countries). the countries of the gulf cooperation council host almost million such workers. in bangladesh, pakistan and the philippines, remittances rival fdi as a source of capital. in el salvador and honduras, remittances contributed around % of gdp in . countries dependent on natural resource-intensive sectors have already suffered from declining prices over the last decade. eclac ( ) estimates for latin america that the value of exports could fall by nearly %, with an . % drop in prices and a % decline in volume. nigeria's budget was planned against an oil price of $ ; it hovered around $ in may . collapse in demand from industrialised economies are not the only cause of revenue contraction: breakdowns in logistics and transport chains mean that agricultural exports will see a significant contraction (despite good harvests projected), as storage capacities for perishable goods are often poor in developing countries. even if the pandemic subsides, we cannot expect things to return to their pre-pandemic state even in the medium run. although there is much talk about what policy actions less-developed countries can undertake to mitigate the economic costs of the pandemic (escap, ; eclac, ), in reality, outside a handful of middle-income 'emerging' countries endowed with the appropriate infrastructure, few have the means to afford prudent and meaningful policy action. some countries are taking steps to strengthen health systems and expand social safety nets, as well as to offer tax relief measures and credit guarantees, but meaningful action requires that there are efficient government agencies that can implement these measures. developing-country firms engaged in manufacturing gvcs are already experiencing an employment contraction, as they reduce employment of informal workers in line with depressed demand. the effect on informal enterprises is more ambiguous. on the one hand, few informal enterprises have the resources to remain in operation during a slowdown. on the other hand, since they tend to 'own' few physical assets, and employ people only on an intermittent basis, some are likely to reconstitute themselves once demand returns. after the crisis, it is not obvious that manufacturing gvcs will return to the same reliance of formal-informal networks. over the last decade, mnes have been trying to reduce their dependence on informal enterprises, as ngos, consumer groups and other stakeholders have continued to pressure them to take full chain responsibility, by reducing their dependence on suppliers with lower labour, health and safety standards (narula, ) . major formal suppliers have been encouraged to involve fewer informal actors. covid- will permit a further realignment. first, there may be a move to use suppliers in locations that are more expensive (but closer to key markets) through the substitution of capital for labour (javorcik, ) . second, in the medium term, we will see a greater exclusion of the informal economy from productive activity by gvcs. both will be to the detriment of countries seeking to leverage their low labour costs by engaging with manufacturing supply chains. a thin silver lining: using the crisis to upgrade the informal economy i see some benefits in this otherwise dismal crisis, because it highlights the precariousness of the informal sector and underscores the need to address informality. industrial, investment and development policy that does not do so is necessarily incomplete. why might governments address this more efficiently now? after all, the limits that informality places on growth have been well known for a few decades, nor have the system failures that have perpetuated informality suddenly disappeared, nor the government inefficiencies that discourage formality. certainly, there are countries where political and social interest groups will act to maintain the status quo, and yet others where government inefficiencies verge on government failure. there are, nevertheless, developing countries whose policymakers recognise that a collapse of the informal sector removes the backbone of developing countries' economies. i believe that the pandemic is an exogenous shock of sufficient magnitude that it will motivate policymakers to realise that the long-term effects of not tackling informality now will be truly disastrous. put more strongly, i believe that, if policymakers fail to act in the interests of such a significant majority of their populations, it will greatly exacerbate poverty levels due to the pandemic-related economic crisis. thus, i remain optimistic that there is a thin 'silver lining' to the crisis. the crisis has exposed significant market failures (e.g. allocative and productive inefficiencies, 'strategic' restrictions on exports) that represent new opportunities for entrepreneurs, and provide the circumstances for a modest infant industry industrialisation, by placing informal enterprises on a par with formal domestic firms. note that i place emphasis on informal enterprises in this paper, largely because the nature of informal employment is much more complex and not yet well understood. addressing informal employment more generally thus falls outside the scope of a single modest paper. i do not make the case for new incentives to formalise informal enterprises; i am proposing acknowledging the informal economy and integrating it with the formal one. formalisation has largely failed in the past, and there is no reason to expect that the current circumstances are that different. informal entrepreneurs are also astute and riskaverse. past government failures, policy reversals and inefficiencies live long in the public perception, and deter actors from formalising. in other words, even where there are good intentions, governments are distrusted due to prior inactions, entrenched regulatory capture or prior poor governance. indeed, it is well established that economic actors crave stability of institutions and policy (narula & dunning, , narula & pineli, and countries with high informality tend to have weak institutions and unstable political and regulatory track records. some states recognise their inability to address these structural and organisational challenges behind informality, and choose instead to accept the status quo. this is the passive and suboptimal option, and i propose that governments actively engage with informal actors as they do with formal enterprises. the informal sector is a crucial source of start-ups (webb, ireland, & ketchen, ) . for the entrepreneur, trying out a business model is best done before incurring the costs of formalisation. this is especially so where the bureaucracy and cost of getting the necessary permissions is high. i recommend including the informal sector in what are considered as 'horizontal actions' in industrial policy; programmes implemented on a universal basis across sectors. changing perceptions about government ineptitude is as important as reducing the bureaucratic hurdles to formalise, but the latter requires systemic social changes. integrating informal actors into existing schemes for formal firms is an incremental step, and relatively costless. it is easier to adapt state organs to recognise informal firms as an important aspect of their economies. just as there are one-stop windows for foreign investors, there should be similar options for informal actors, along the classic lines of 'attraction, embedding and aftercare' (unctad, ; narula & dunning, ) . to be clear, i propose integration and registration, as opposed to formalisation. i am also proposing the provision of state support without taxation. states should actively champion informal enterprises, even though, unlike formal firms, there is likely little revenue benefit (but increased costs) to the state in the short and medium run. most governments offer mnes incentives to engage with formal enterprises within their supply chains; these should be extended to informal enterprises, which also tend to be micro-firms. such enterprises (formal or informal) should be assisted -for instance, by providing training or by subsidising the certification of these firms -in the provision of higher workplace safety standards and better protection for workers. in other words, help the informal sector firms integrate in gvcs by providing the necessary transparency and accountability. this requires the active cooperation of lead firms and key suppliers. given that mnes are less constrained by existing network relationships, it is likely that foreign greenfield investors will prove more willing to do so than long-established foreign subsidiaries and domestic firms with well-developed local linkages. this role of the state as impartial 'matchmaker' (evans, ) is a critical one. older, more established investors are normally reluctant to try new local suppliers and may have long-term relationships with foreign suppliers (wade, ) . we have seen cross-border value chains being disrupted as foreign inputs experience logistical and transportation delays, or because of export restrictions on these inputs. this is an opportunity for investment promotion agencies (ipas) to refine their 'aftercare' services, visiting larger mne subsidiaries to identify (and resolve) bottlenecks in supply chains in the wake of covid- . it is often the case that foreign affiliates do not have sufficient knowledge of local capabilities, or have doubts about the quality and reliability of local alternatives. ipas and governments can help reduce this search cost, and mitigate quality and price challenges for the local supplier through technical and financial assistance. at the very least, governments can act as guarantor for the local alternative, not only to prospective customers but also to financial institutions. deriving from this, there is an immediate shortterm opportunity from the covid- pandemic. there is a window of opportunity for developing countries to encourage local actors to step in to fill the supply gap due to these market failures in international trade (even if it means subsidising the local supplier to meet the import prices). a simple example is the global shortage of personal protective equipment for hospitals (bown, ) . hospitals, care homes and so forth are unable to purchase these goods as the global shortage has raised prices. micro-firms and local entrepreneurs can produce hospital gowns and facemasks locally (with the government taking responsibility for sterilising and deep-cleaning the final product). countries where there is a strong apparel and textile capacity have a key opportunity to retool their informal enterprises to meet new demand. jayaram et al. ( ) reports that an apparel factory in kenya shifted rapidly to mask production, and is already manufacturing , masks per day. informal actors are already selling these masks on the streets of lagos, calcutta and rio, but these entrepreneurs can be assisted to improve their products, hygiene and marketing, and to increase their productivity. more generally, it is important to incentivise local firms/informal entrepreneurs to enter new markets. during the pandemic, and likely for some while after the pandemic, there will be greater demand for personalised assistance -in the form of tutors to educate children, delivery services, workers to take care of the elderly, and so on. governments can offer, for instance, transportation to bring the unemployed graduates to rural and suburban areas where school-age children need assistance in their studies. in other instances, they might offer micro-firms assistance to advertise via social media, and to engage in e-commerce, by guaranteeing payment. this may simply require a method to provide quality assurance -that the tutor, helper or carpenter is indeed certified and qualified to provide services, and that their rates and quality of work is at the expected level. these actions -reducing transaction costs for informal actors, and matchmaking -do not have to be expensive. the ubiquity of the smartphone in the developing world is an untapped benefit of the ict revolution. there is no reason why 'paperwork' is still essential, nor the need to engage with unnecessary bureaucracy. matchmaking, marketing, registration, permits, and so forth, can be done digitally, and the capabilities exist among local digital developers and entrepreneurs to provide these. countries like tanzania and malawi have been fairly successful in doing so, despite limited resources (unctad, a (unctad, , b . the covid- pandemic simply underscores this lost opportunity. as physical distancing and remote working may become a norm, here is a fresh (and urgent) opportunity to develop it expertise. pockets of fintech start-up firms in countries as diverse as kenya, nigeria and south africa illustrate that the skills and the expertise are easily available locally, but governments have been unaccountably reluctant to draw upon them (imf, b). some closing remarks fdi and trade have a complex relationship with economic development. i have conjectured elsewhere (narula, ) that one of the reasons that there is so little evidence that mnes have a significant positive influence on economic development is that spillovers and linkages are limited largely to the formal economy, as well as having a primarily urban footprint. the persistence of a large informal sector that is mired in low productivity, with limited absorptive capacity and poor access to public goods, and with few opportunities for social and economic growth, is a matter of great consternation to policymakers and development experts. the covid- crisis has simply exacerbated the vulnerability of informal actors. i have not addressed the challenges of informal employment, nor indeed the challenges of informality in resource-dependent sectors, in countries such as south africa. peru, bolivia and ghana, where the informal/formal nexus is just as vexing and deeprooted. informality, more broadly speaking, has historical, cultural and social causes, and can only be addressed through longer-term actions. i am proposing that covid- presents an opportunity for key horizontal actions to integrate informal enterprises into the commercial fabric of society. a number of governments have simplified the process of registration for formal firms, but these bureaucracies are often cumbersome, timeconsuming and expensive. this is the time not only to simplify but also to permit those entrepreneurs shy of formalisation, because of a fear of past bureaucratic excesses and inequities, a chance to avail of state support without expanded transaction costs. i extend this proposal for active integration to assisting informal enterprises to upgrade their capabilities to join gvcs and local supply chains, with governments facilitating this through digital market places, assistance with certifications, acting as guarantors, and providing (free) training in basic business skills to raise their productivity. integration does not have to imply formalisation, but if these efforts to make their businesses more sustainable are successful, informal actors will likely choose to formalise if the benefits of doing so become obvious. to address the precariousness of informal actors is to address the key bottleneck to growth. at the onset of the covid- economic crisis, this is a crucial juncture to protect the most fragile of economic actors, regardless of their status. comments and feedback to an earlier version from saul estrin, angela garcia-calvo, mark attah, james walker, khadija van der straaten and ari van assche have helped immensely. all errors and misjudgements are strictly my own. a key insight of the nobel laureate arthur lewis ( ) was that developing countries tend to have a dual structure: a 'traditional' sector, which is largely informal, and resource-and labour-intensive; and a 'modern' sector, which is more formal, and knowledge-and capital-intensive. each part of this duality is associated with sectors and spatial locations, as there are different endowments of resources, reflecting a divide common in the post-industrial revolution era between the land economy (associated with rural areas and commodities) and the capital economy (associated with cities and human, technological and financial capital). narula ( narula ( , refines this argument to emphasise the further duality within the urban and rural economies, and explains why fdi may prove less beneficial in economies with a large informal sector. the absence of data means that solid economic studies from which to develop concrete recommendations are rare. economic and political institutions and entry into formal and informal entrepreneurship global supply chains will not be the same in the post-covid- world mystery of capital measuring the impact of covid- with a view to reactivation escap. . the impact and policy responses for covid- in asia and the pacific shadow economy and entrepreneurial entry embedded autonomy: states and industrial. transformation peddlers and princes: social development and economic change in two indonesian towns toward a theory of the informal economy the lewis model: a -year retrospective bangladesh: seeking better employment conditions for better socioeconomic outcomes women and men in the informal economy: a statistical picture small matters: global evidence on the contribution to employment by the self-employed, micro-enterprises and smes covid- and the world of work: updated estimates and analysis, ilo monitor nd ed global financial stability report: lower for longer fintech in sub-saharan african countries: a game changer? the african department global supply chains will not be the same in the post-covid- world finding africa's path: shaping bold solutions to save lives and livelihoods in the covid- crisis sector shutdowns during the coronavirus crisis: which workers are most exposed? institute for fiscal studies briefing note bn economic development with unlimited supplies of labour the viability of sustained growth by india's mnes: india's dual economy and constraints from location assets an extended dual economy model: implications for emerging economies and their multinational firms enforcing higher labour standards within developing country value chains: consequences for mnes and informal actors in a dual economy multinational enterprises, development and globalization: some clarifications and a research agenda improving the developmental impact of multinational enterprises: policy and research challenges globalization in the time of covid- cesifo working paper no measuring what counts: the global movement for well-being aftercare: a core function in investment promotion malawi rapid etrade readiness assessment tanzania rapid etrade readiness assessment governing the market: economic theory and the role of government in east asian industrialization toward a greater understanding of entrepreneurship and strategy in the informal economy determinants of the level of informality of informal micro-enterprises: some evidence from the city of lahore about the author rajneesh narula is the john h. dunning chair of international business regulation at the henley business school, university of reading. his research and consulting have focused on the role of multinational firms in economic development, innovation and industrial policy, informality, r&d alliances and outsourcing.accepted by ari van assche, deputy editor, may . this paper is part of a series of contributions dealing with the implications of the covid- pandemic on international business policy, and it was single-blind reviewed.publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -zhk fyfc authors: gerard, françois; imbert, clément; orkin, kate title: social protection response to the covid- crisis: options for developing countries date: - - journal: nan doi: . /oxrep/graa sha: doc_id: cord_uid: zhk fyfc the public health response to covid- in many countries has involved strict restrictions on movement and economic activity which threaten the livelihoods of economically vulnerable households. in response, governments are adopting emergency economic measures to provide households with some safety net. we provide an overview of the policies that could form a comprehensive social protection strategy in low-income and middle-income countries, with examples of specific policies that have been adopted. our core argument is that these countries can cast an emergency safety net with extensive coverage if they use a broader patchwork of solutions than higher-income countries. these strategies could include expanding their social insurance system, building on existing social assistance programmes, and involving local governments and non-state institutions to identify and assist vulnerable groups who are otherwise harder to reach. covid- has now reached low-income and middle-income countries. the public health response in many countries has involved strict restrictions on movement and economic activity (e.g. closing workplaces, banning gatherings, restricting travel) and others are considering imposing similar policies. domestic measures, as well as similar measures adopted globally, are likely to have an immediate negative impact on household incomes, and might threaten the livelihoods of households who are already vulnerable economically. in response, governments are adopting emergency economic measures to provide households with some safety net. we provide an overview of the policies that could form a comprehensive social protection strategy in developing countries, with examples of specific policies adopted around the developing world in recent days. our core argument is that middle-income and lower-income countries can cast an emergency safety net with extensive coverage if they use a broader patchwork of solutions than higher-income countries. these strategies could include: . expanding their social insurance system, which typically covers a much smaller share of the labour force than in higher-income countries; . building on existing social assistance programmes, which reach a large share of households in many developing countries; . involving local governments and non-state institutions to identify and assist vulnerable groups who may not be reached by ( ) and ( ). the debate on social protection responses occurs as countries face both a public health and a public finance crisis. first, governments have to design a public health response to mitigate or suppress the virus which balances provision of covid- health care against other health needs and which can be implemented in contexts where strict social distancing is not practical. the strictness and duration of the restrictions imposed on mobility and economic activity will, to a large extent, determine the immediate impact on household incomes, and thus the scale of the social protection response needed to mitigate it. in turn, the support provided to help households could increase compliance with public health policies. second, governments have to finance both health and economic measures, while experiencing shortfalls in tax revenues. many developing countries were already heavily indebted before the crisis, and investors have sold emerging market assets, making borrowing on the open market difficult. without novel solutions to allow governments to borrow internationally and secure additional aid quickly, the scale of their social protection response will be limited, and developing countries may not afford a public health response imposing strict restrictions on their economies. low-income and middle-income countries share features that present specific challenges and opportunities for their social protection response, compared to higherincome countries. . the economic consequences of the crisis for households in developing countries will be severe. a larger share of workers are in occupations and industries less compatible with social distancing (e.g. construction, labour-intensive manufacturing, small retail). households have more limited access to credit and hold limited savings or buffer stock. their usual means of smoothing income shocks, casual work and migration, are not possible when economic activity and mobility are restricted. support from social networks is also more limited when everyone experiences a simultaneous shock, which in the case of a global crisis is true even of the most extended networks (e.g. international remittances). complying with public health guidelines will incur out-of-pocket costs (e.g. access to water in urban slums) that are high as a portion of available income. in this context, households may take short-term decisions out of necessity that leave them in long-term poverty, such as selling assets to finance food consumption. moreover, firms often face more severe liquidity constraints in developing countries, limiting their ability to keep paying their workers during the crisis. the need for government intervention is thus particularly severe in developing countries today. . yet, government programmes insuring against job or earnings loss have more limited scope in developing countries. first, a larger share of workers are in employment categories that are difficult to insure against such risks. many employees work for informal (i.e. unregistered) businesses, which may not contribute to existing social insurance programmes, while others work for formal businesses on informal contracts. the self-employed-whose 'regular' income is more difficult to assess even in richer countries-account for a larger share of employment, and many of them also carry out their activities informally. second, government programmes insuring workers against such risks are more limited in developing countries even for formal (i.e. registered) employees. for instance, the share of developing countries in which these workers are eligible for some form of unemployment insurance is much lower than in higherincome countries (see figure ). existing social insurance programmes will thus be less effective in supporting workers in developing countries. . at the same time, many developing countries can build on large existing social assistance programmes. as figure (a) shows, these cover a sizeable share of the population, including contexts where informal work and self-employment are the norm. these programmes take various forms, such as conditional or unconditional cash transfers, work guarantees, or the direct delivery of food and other necessities (see figure (b)). they target poor households and are not necessarily designed to mitigate job loss or income shocks. they can be made more generous in this time of crisis. they can also provide a base for emergency assistance, e.g. they often rely on detailed registries and effective infrastructure for transferring resources. existing social assistance programmes thus provide invaluable mechanisms to provide emergency relief to many households. . some vulnerable populations are not easily covered by social insurance and are usually outside the populations targeted by social assistance programmes (e.g. informal workers with volatile incomes, migrant workers), making them particularly hard to reach in an emergency. however, local governments in many developing countries are in a good position to assess unmet needs and to deliver direct assistance. the same is true of a range of non-state actors (e.g. ngos, savings and loan associations, mutual insurance organizations), which are active in contexts where state capacity is limited (e.g. remote rural areas or urban slums). involving local actors, especially non-state ones, is an opportunity but also a challenge, as their efforts need to be coordinated, and they need to be monitored by both citizens and national governments. credible partners thus exist for central governments to help 'harder-to-reach' segments of the population, as long as their actions are in line with the national effort and are accountable to the public they serve. despite pervasive informality, formal employees constitute a major employment category in many developing countries, particularly in middle-income countries. moreover, these workers are possibly even less well prepared than their counterparts in richer countries to cope with the economic impact of the crisis. therefore, expanding the social insurance system to provide more support to formal employees could be an important pillar of the social protection strategy of developing countries, even if it will not be sufficient to reach all workers (e.g. informal workers). governments around the world have adopted new job retention schemes in the last few weeks. such schemes already existed in some countries (e.g. germany, italy), including developing countries (e.g. brazil), to help firms cope with temporary shocks (e.g. drop in demand, insolvency issues, natural disasters). they provide subsidies for temporary reductions in the number of hours worked, replacing a share of the earnings forgone by the worker due to the hours not worked, over a maximum period of time (a few weeks or months). their advantage in the current crisis is to avoid the destruction of existing jobs (giupponi and landais, ) , which should be viable again once the public health response is relaxed. subsidizing these jobs could allow firms to continue to operate, even if at some reduced level, without imposing large pay cuts. subsidizing the survival of jobs that must be temporarily suspended could also spare workers and firms the costs of finding a new job and replacing the worker, speeding up the economic recovery. the argument in favour of job retention schemes is strong for developing countries. without such schemes, many workers will be laid off with no unemployment insurance. moreover, setting up a new job retention scheme might be logistically easier than setting up an unemployment insurance programme, as governments could use firms as intermediaries to channel the income support to their workers. job retention schemes are also most valuable in labour markets where search frictions are high. recent research shows (i) that finding the right workers is a major challenge to firm growth in developing countries (hardy and mccasland, ) ; (ii) that workers struggle to find formal employment because of difficulties signalling their skills credibly to firms (abebe et al., , carranza et al., ; and (iii) that displaced formal employees take much longer to find a new formal job than in higher-income countries (gerard and gonzaga, ) . the destruction of existing jobs might thus have severe longer-term impacts on the size and productivity of developing countries' formal sectors, which are a key policy focus (levy, ) . some implementation details might be particularly important in developing countries: • targeting. in thailand, a recent job retention scheme covers a fixed share of workers' monthly earnings; in morocco, a new programme provides a fixed monthly amount to workers whose job must be temporarily suspended; the amount received under the brazilian and south african schemes is not fixed, but the share of forgone earnings that it replaces is lower for higher-wage workers. targeting the income support to low-wage workers can help more workers for a given budget and leave more financial resources to help other worker categories. however, it will require higher-wage workers to make relatively larger adjustments and increase the risk that their jobs will not survive the crisis. additionally, targeting support to low-wage workers may not necessarily target jobs for which search frictions are most important, which may slow down the economic recovery. • payment. in contrast to some pre-existing job retention schemes (e.g. in france), the above-mentioned schemes do not rely on firms advancing the payment of the earnings subsidy. firms in developing countries may not have enough liquidity to make such advances or may not trust the government to reimburse them quickly, disincentivizing participation (see levinsohn et al. ( ) on an earlier wage subsidy in south africa). • other firm contributions. job retention schemes sometimes require firms to contribute towards their workers' compensation beyond the hours actually worked (e.g. for larger firms in the brazil scheme). this could incentivize firms struggling to stay afloat to lay off their workers rather than to participate in the scheme. more generally, firms face other costs than their payroll and helping them cover these costs might be necessary for existing jobs to survive. several countries have implemented a range of policies in this regard, such as low-interest loans, rent moratoriums, or tax relief. even with a job retention scheme, many workers will likely be laid off and developing countries with unemployment insurance programmes will be in a better place to support these workers. however, it might be important to adjust their programmes, such as by relaxing job search requirements and extending eligibility rules. for instance, in south africa, workers are usually eligible for day of unemployment insurance for every days of employment. in brazil, many workers must accumulate up to months of employment to become eligible for any benefits. such rules could leave laid-off workers who have limited job tenure (e.g. less than a year) with little income support throughout this crisis and no other employment options in the short run. a policy that is more common than unemployment insurance in developing countries is mandatory severance payments that firms must pay to workers at layoff. the insurance value of such lump-sum payments is limited when workers cannot find new jobs quickly. moreover, firms facing severe reductions in cash-flow might struggle to pay what they owe to their workers and governments may need to provide firms with low-interest loans to fund severance pay obligations (gerard and naritomi, ) . governments could also consider topping up the severance amount and spreading its payment over time to avoid workers spending it too quickly after layoff. another common component of the social insurance system in developing countries is mandatory contributions by firms or workers to forced (illiquid) savings accounts for long-term objectives, e.g. to fund a complementary severance payment at layoff or a complementary pension at retirement. workers could be allowed to withdraw some amount from these accounts in the current crisis. for instance, the indian government recently allowed formal workers to withdraw up to months' worth of salary (but no more than per cent of the amount in the account) from their employee provident fund. the benefits for workers from such early withdrawals might greatly exceed their costs, particularly for younger workers who will be able to replenish their forced savings accounts in coming years. finally, some countries have considered extending the logic of these social insurance programmes to formal (i.e. registered) self-employed workers. however, it is more challenging to determine (a) their 'usual' earnings level prior to the crisis and (b) the reduction in earnings caused by the crisis. these challenges will only be exacerbated in developing countries, as governments likely have less information about these workers' past or current earnings than in higher-income countries, even for self-employed workers who are formally registered. in this context, developing country governments may be left with fewer options. • one option is to make unconditional monthly transfers of a fixed amount. for instance, the auxilio emergencial in brazil will provide self-employed workers with a monthly payment of per cent of the minimum wage for the next months. it might be possible to design a more fine-grained payment scheme, e.g. based on some presumptive income varying across sectors of activity. however, the costs of designing a more complicated scheme might outweigh its benefits if it leads to long delays in disbursements (as in the uk ). • a complementary option is to provide emergency low-interest credit lines for self-employed workers, allowing them to borrow a maximum amount to pay themselves in the coming months. such policies have been recently implemented in some countries to help small and medium firms pay their workers' wages throughout the crisis, and could be extended to self-employed workers. repayment of loans could be made contingent on self-employed workers' future income or gross revenue crossing above a certain threshold, to mitigate concerns of taking on more debt at this time. social insurance programmes will fail to reach a large share of households in developing countries, in particular those mostly active in the informal sector of the economy. however, many of these households could be reached through social assistance programmes. for example, south africa's child support grant reaches many poor households who are in informal jobs and will not be covered by its job retention scheme. maintaining these programmes throughout the crisis will already provide some minimal support to many affected households, although some of their rules might need to be adapted. these programmes could also be made temporarily more generous to compensate current beneficiaries for income losses. finally, these programmes could be temporarily extended to new households, e.g. to households whose information was collected to target these programmes, and who were deemed ineligible. in practice, these programmes take many forms and their key features determine how they can be used in response to the crisis. the first feature is the type of assistance that these programmes provide. some programmes dispense cash; some provide in-kind assistance (e.g. food, fuel); others subsidize access to essential goods and services (e.g. health services, housing). in cases where supply chains are impacted or prices rise, in-kind provision will be most powerful, and public procurement will support producers as well. for instance, the indian government doubled the monthly foodgrain (wheat and rice) household allowance and added pulses to the ration provided by the public distribution system. when households can buy goods and services at reasonable prices, cash transfers are quicker to implement and more fungible than in-kind transfers. many countries have temporarily topped up the amount received by the current beneficiaries of social assistance programmes. for instance, the indonesian government increased both the benefit amounts of its cash transfer programme (pkh) and the frequency of its payments (from quarterly to monthly). kenya has increased the amount of its pension and orphan and vulnerable children's grant. provision or delay payments, especially for utilities that are publicly owned (e.g. electricity bills or rents). indonesia has recently granted months of free electricity to m customers with low power connections. the second feature is the conditionality of the social assistance. conditional cash transfers (cct) programmes are a popular form of income support in developing countries (e.g. mexico's prospera or brazil's bolsa familia). they make assistance conditional on a particular behaviour encouraged by the state, e.g. enrolling children at school or immunizing them. public works programmes are also often used for antipoverty relief in the developing world (e.g. india's mg-nregs or ethiopia's psnp). these conditions cannot be fulfilled at the time when countries have closed schools and public works sites because of safety, or when hospitals are overwhelmed. to provide social protection in the current crisis, cct and public works programmes need to become temporarily unconditional. removing conditionalities may be legally or politically difficult. for instance, india's relief package increases the wage for mg-nregs workers, but it makes no provision to make public work sites compatible with social distancing. other public works programmes, such as ethiopia's psnp (berhane et al., ) , already provide cash or food for those identified by communities as unable to work and could perhaps extend this feature to all programme recipients. the third feature of social assistance programmes is the population that they target. some programmes help specific socio-demographic groups (e.g. non-contributory social pensions for the elderly or grants for orphans and children). some provide relief to specific occupational groups (e.g. farmer drought relief funds). others are targeted according to economic indicators, such as transfer to households deemed poor based on their assets (e.g. indonesia's conditional cash transfer pkh). developing countries can leverage all their programmes simultaneously to provide assistance to a wide range of vulnerable groups. each of these programmes suffers from inclusion errors, with resources being diverted to non-eligible households or stolen by corrupt bureaucrats, and from exclusion errors, with eligible households deterred from applying (hanna and olken, ) . in these times of emergency, governments will have to rely on social assistance programmes, even if their targeting is not perfect. direct beneficiary payments, and transparency in how much is given to whom, may help keep 'fund leakages' under control (muralidharan et al., ; banerjee et al., ) . using existing programmes to extend assistance to new beneficiaries is possible, but requires both information on potential beneficiaries and payment infrastructure to reach them. some countries have built digital infrastructures linking governments and poor citizens for various programmes that can now be used for emergency payments (see rutkowski et al., ) . for example, chile has a national id-linked basic account for most poor people, which will be used to pay more than m low-income individuals a once-off grant. india also has sent money to jan dhan accounts linked to the adhaar id system, which were created to promote financial inclusion among the poor. other countries have detailed censuses to identify the poorest citizens for social assistance. these censuses can now be used to extend assistance to people who were initially deemed too well-off for assistance. for example, the peruvian programme bono yo me quedo en casa offers an additional transfer equivalent to per cent of the minimum wage to . m poor households identified in a dataset created to target the peruvian juntos cct. beneficiaries can check their availability online, and payments are routed via a national bank. in countries in which no pre-existing databases are available, or where governments would not automatically enrol large parts of the population in emergency assistance programmes, they may prefer to ask people in need of assistance to opt in. for instance, pakistan has announced a relief package with large transfers to the poor, but the emergency programme requires people to self-identify as vulnerable and to text the existing social programme ehsass with their national identification number. enrolling new beneficiaries and paying them is a challenge in many settings. in noncrisis times, enrolling people and checking eligibility may be more effective to target the poorest than automatic enrolment (alatas et al., ) . but enrolment systems set up in times of emergency may not necessarily target the most vulnerable efficiently. for instance, the state of bihar in india has announced a transfer to all migrant workers stranded in other states and plans to perform identity checks through a phone app. households recorded in the cadastro unico-i.e. the brazilian census of the poor-will be eligible for the same auxilio emergencial as formal self-employed workers (see above), but the government also created a new website to extend coverage of this emergency assistance programme to informal workers at large. the use of these technologies may prevent individuals without a computer or smartphone from enrolling, unless complementary systems are set up. even if they successfully enrol, transferring money to these new beneficiaries can be difficult. relying on digital payment infrastructures is quicker and safer in an epidemic, but it might exclude particularly vulnerable households: globally, only per cent of adults have any digital bank or mobile money account; only per cent have received wages or government transfer payments directly to an account (findex, ) . in this context, it will be necessary to set up physical collection points or direct delivery systems for these households while still respecting social distancing measures. in peru, bank branches were overcrowded when recipients of the bono yo me quedo en casa programme came to cash their benefits. a strategy based on expanding social insurance and building on existing social assistance programmes will likely leave important needs unmet. for instance, informal workers with volatile incomes (especially in urban areas) or with weak ties to their place of residence (e.g. migrant workers) are often beyond the reach of social insurance and usually outside the populations targeted by social assistance. a comprehensive social protection response could involve local governments and a range of non-state actors to collect better information on these unmet needs and to deliver targeted assistance. state and municipal governments may play a complementary role to national governments, who often have the main mandate for social insurance and assistance. many developing countries have decentralized extensively over the last decades, and have devolved a range of government functions to lower echelons of government, including responsibilities related to social assistance. for example, the responsibility for implementing india's employment guarantee mg-nregs is devolved from the central government to the state, the district, the block, down to the gram panchayat, a local government of about households. it is common for developing countries to elect or select a large cadre of leaders at very local levels. in kenya, each village of ~ - households has a volunteer village leader who reports to the lowest level of paid civil servant, the assistant chief, adjudicates disputes, and spreads information from the state (orkin and walker, ; walker, ) . these structures can play multiple roles during this crisis. first, local structures can channel information up to decision-making structures, which is important when travel is limited. information could be movements of people, price and availability of food, whether new social protection measures have been successfully implemented, and whether specific groups remain unexpectedly not covered. in food-insecure countries such as malawi and ethiopia, infrastructure has been built to collect local data on food security and channel food or cash to famine-affected areas and public works programmes to food-insecure areas (berhane et al., , beegle et al., . similarly, for public health success against ebola, it was vital that local structures relayed data back to coordinating structures for better decisions. second, local structures could be involved in the identification of individuals in dire need of additional support. they were often involved in the targeting of social assistance programmes pre-crisis, both in the gathering of information on vulnerable populations for higher levels of government and in the prioritization of assistance to the most needed. for example, censuses of the poor used to target cct programmes are typically updated by local administrations in latin american countries. rwanda is using local structures to target in-kind food security packages, which will complement its existing social protection scheme. vulnerable households are identified at the most local (isibo) level, with information on numbers of households relayed up to higher government structures. to avoid exclusion errors, the capital city government set up a toll-free line for households who reported they missed out in the targeting. these institutions have particular strengths that may complement a national government response. they may have funding or staff already in place at local level. local authorities often receive block grant funding to address locally identified needs, with local structures in place to monitor how it is allocated. funding could be temporarily repurposed or these structures could be used to channel any additional funds granted. for example, the indian government allowed state governments to use disaster funds to provide shelter and food to migrant workers. local governments also have networks of employees (e.g. for education, health, welfare) in contact with more remote communities and able to support them in accessing services. for example, south africa's network of early childhood community care givers primarily conducts health promotion and prevention activities; pre-crisis, government tapped this network to assist families in enrolling for child support grants (hatipoglu et al., ) . local governments often have better information on local needs and preferences, so may be more responsive. as a result, their decisions may have more legitimacy. for example, in indonesia, leaders allocating cash transfer benefits via community targeting did reasonably well in terms of targeting the poor. communities were also more satisfied with community targeting than an externally administered proxy means test (alatas et al., ) . they may also be more easily held accountable to communities and may feel pressure to be more responsive, provided the resources and functions devolved to them are clearly communicated to the public (gadenne, ; martinez, ) . for example, the state government of bihar (india) has felt pressure to extend its attention to migrants in this crisis, a segment of the population which it does not usually serve or respond to, and which was excluded from the central government relief package. on the other hand, local structures may be more open to capture. for example, after a serious drought in in ethiopia, community-based food transfers were targeted to households with less access to support from relatives or friends, but were also twice as likely to be targeted to households with close associates in official positions (caeyers and dercon, ) . a range of non-state institutions are also particularly active in giving voice to specific groups or serving populations beyond the reach of the state. depending on the context, these institutions may be in a unique position to gather information on the needs of specific groups, and/or be credible partners for delivering assistance in an emergency. there are a broad range of examples of such institutions. illegal urban settlements sometimes have recognized local leaders who facilitate access to state services and social benefits and are accountable to local populations (e.g. in urban india). recognized local ngos also often provide a range of services and sometimes coordinate their efforts within a geographic area under an umbrella organization (e.g. in urban brazil ); they may have years of experience being accountable to both their donors and their beneficiaries. international ngos (e.g. brac, oxfam) have a strong presence across a range of contexts. there are also private associations with specific purposes, which can, in some instances, have wide coverage. for example, per cent of africans participated in community-organized savings groups (findex, ) . membership may be even higher in rural areas: per cent of a rural kenyan sample were members of a rotating savings group (rosca) (orkin and walker, ) . in ethiopia, over per cent of villagers in two separate samples are members of burial associations (dercon et al., ; bernard et al., ) . another type of private association are professional organizations, which may be active in sectors that employ many informal or poor workers. for example, india's relief package encourages building and other construction worker welfare funds to provide emergency assistance. these institutions could play a range of roles. some will likely repurpose themselves to provide emergency assistance in the current crisis spontaneously, an effort that could be leveraged and complemented by governments. governments could leverage their infrastructure to gather information on the needs of their many beneficiaries. many have a network of workers in remote areas, who are already part of public health responses, e.g. an ngo trained community volunteers, religious leaders, and traditional healers in senegal to monitor for common diseases in their villages. they could be used to recruit people into government programmes in environments where communication about new programmes is difficult. for instance, kenya used roscas to enrol participants into its new health insurance scheme (oraro and wyss, ) . india used national rural livelihood missions and their network of self-help groups (shg) to advertise and enrol people into many development programmes, such as rural sanitation (swachh bharat mission). it may be unusual to involve non-state actors directly in provision of state assistance, but unprecedented times may call for exploring new opportunities. although there may be justifiable concerns about a lack of accountability, institutions with a long history and broad base of membership may be particularly resistant to the capture of transfers (dercon et al., ) . they already need to be locally legitimate to sustain their work, as they have no formal legal authority and are regulated largely by social sanction (olken and singhal, ) . the most important concern is that community institutions remain inclusive in times of crisis and share broadly the emergency resources given to them (gugerty and kremer, ) . for example, rural communities need to provide support to returning migrants rather than banning them from coming home for fear of the contagion. another concern is that non-state institutions enrolled in social protection efforts need also be onboard with governments' public health strategy (e.g. some religious organizations have been promoting alternative ways of dealing with the pandemic ). our analysis highlights that governments in developing countries will have to find creative solutions to build a comprehensive social protection response to the economic impacts of the covid- epidemic. job retention programmes already existed in some countries (e.g. brazil) and could be used more widely to protect employment in the formal sector. some governments, as in chile or india, have leveraged id-linked bank accounts opened for financial inclusion purposes to provide direct support to the poor. even populations that live at the margins of social protection systems, like migrant workers in the informal sector who are not registered where they work, can be reached through associations that work with them (like the aajeevika bureau for internal migrants in india). yet, any government response will be imperfectly targeted, with important inclusion and exclusion errors. government responses based on social insurance programmes may reach many formal employees and registered self-employed (although coarsely), but will miss the informal sector, which is an important part of developing countries' workforce. social assistance programmes allow governments to broaden the base of their response, but their targeting is always specific to a particular dimension of poverty, and their delivery is often plagued with 'leakages'. involving local governments or non-state actors to help provide assistance presents clear opportunities, but also runs the risk of resources being diverted by local elites or used for clientelism. together, these policies may reach some households through several channels at once while leaving others with no direct support. however, in an emergency, the benefits from improving targeting and reducing leakages may not exceed the costs if an improved process leads to long delays in implementation. fortunately, even imperfectly targeted transfers will reach some 'left-behind' households through family, informal, or formal sharing structures. existing social protection transfers are often widely shared in families and extended networks even outside times of crisis. for instance, south african pensions received by grandparents benefit grandchildren (duflo, ) and young adults in the household (ardington et al., ) . households ineligible for progresa cash transfers still get loans and gifts from eligible households in the same village and have higher food consumption (angelucci and di giorgi, ). government could acknowledge explicitly that their emergency response will not reach all households and encourage beneficiaries to share their resources with others whom they identify as being in need, possibly subsidizing means of money transfers (e.g. reducing fees for bank or mobile money transfers ). charitable giving could be encouraged in response to the crisis and channelled to vulnerable populations (e.g. zakat funds in muslim communities in bangladesh before ramadam ). in fact, national funds run by governments and businesses have already raised record amounts in some countries. the challenge of mitigating the economic effects of the pandemic is enormous. any solution will be flawed in many ways because speed is of the essence. but governments, donors, and civil societies have made major gains in the last years in building infrastructure to reach the poorest. if internal and external financing can be found, developing countries can use this to create the economic space for an effective public health response. china has helped firms but does not seem to have protected employment (south china morning post transfer fees for kenya's popular mobile money system were recently waived, although for a public health reason (finextra defusing bangladesh's covid- time bomb thousands of ordinary south africans have 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and cash transfers: experimental evidence from kenya key: cord- - n pz authors: shet, anita; ray, debashree; malavige, neelika; santosham, mathuram; bar-zeev, naor title: differential covid- -attributable mortality and bcg vaccine use in countries date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: n pz while mortality attributable to covid- has devastated global health systems and economies, striking regional differences have been observed. the bacille calmette guerin (bcg) vaccine has previously been shown to have non-specific protective effects on infections, as well as long-term efficacy against tuberculosis. using publicly available data we built a simple log-linear regression model to assess the association of bcg use and covid- -attributable mortality per million population after adjusting for confounders including country economic status (gdp per capita), and proportion of elderly among the population. the timing of country entry into the pandemic epidemiological trajectory was aligned by plotting time since the th reported case. countries with economies classified as lower-middle-income, upper-middle-income and high-income countries (lmic, umic, hic) had median crude covid- log-mortality of . (interquartile range (iqr) . , . ), . (iqr . , . ) and . (iqr . , . ), respectively. covid- -attributable mortality among bcg-using countries was . times lower [ % ci . - . ] than in non bcg-using countries. notwithstanding limitations due to testing constraints in lmics, case ascertainment bias and a plausible rise of cases as countries progress along the epidemiological trajectory, these analyses provide intriguing observations that urgently warrant mobilization of resources for prospective randomized interventional studies and institution of systematic disease surveillance, particularly in lmics. novel sars-cov continues to wreak global havoc. mortality is of greatest concern directly influencing national response and policy. early reports from hubei province in china reported a case fatality rate (cfr) of % , which with widening surveillance, rapidly decreased to below % , . as new epidemics began in other countries, early testing strategies focused only on severe cases or contacts of known cases and those with known international travel, leading to positively biased cfr estimates. a high cfr of . % reported in italy was attributed to a greater proportion of the elderly in the population and a stringent testing strategy restricted to severe disease cases . with concurrent outbreaks occurring globally, marked discrepancies in cfr became increasingly apparent. in east asian countries (vietnam, thailand, and philippines), early rises in case incidence have not been followed by similarly sharp cfr increases. cfr estimation is sensitive to testing strategies, initiation of distancing measures, access to healthcare and population age structure. we surmised that since susceptibility to covid- infection extends to the entire population, crude national covid- -specific mortality within the country-specific population would be an informative outcome indicator to study differences in mortality patterns amongst countries, in addition to a priori defined potential exposure variables including bcg vaccine use in national immunization schedules. among vaccination strategies worldwide, bacille calmette guérin (bcg) vaccine has the widest use and is accompanied by a strong safety profile. it is given in infancy for prevention of severe forms of tuberculosis. epidemiological and randomized trial evidence suggest a protective effect of bcg on infant mortality via nonspecific heterologous protection against other infections possibly through innate immune epigenetic mechanisms , . bcg lowers experimental viremia in adult human volunteers through upregulation of interleukins such as il- β . in a randomized placebo-controlled trial in indonesia, bcg given monthly consecutively for months significantly reduced incidence of acute upper respiratory infections among individuals aged > years . in a trial among native americans, bcg vaccination given during childhood showed efficacy in preventing tuberculosis up to years after vaccination, indicating the durability of its protection . demonstration that exposure to bcg vaccination can ameliorate severe covid- disease and lower mortality could rationalize a therapeutic or preventive strategy that can have immediately deployable global impact. therefore, using existing publicly available data we examined at the ecological level whether country-level covid- mortality was associated with bcg use in national immunization schedules. . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint national covid- -attributable death counts as reported on march from the johns hopkins coronavirus resource center , for the top countries reporting highest case events were used to calculate crude covid- -attributable mortality per million population. population and economic data from (gross domestic product (gdp), and high, middle or low-income status) were derived from the world bank population data and open data repository . in order to mitigate the bias centered around the differential epidemic time curves experienced by the different countries, we calculated days from the th covid- -positive case to align the countries on a more comparable time curve. we included data on bcg vaccine inclusion in national immunization schedules from the bcg world atlas . to evaluate the effect of bcg vaccine on mortality attributable to covid- , we built a simple log-linear regression model using crude covid- -attributable mortality data per million population for each country as outcome, bcg vaccine inclusion in the national immunization schedule as exposure, and adjusted for the effects of the following variables on mortality: country-specific gdp per capita, the percentage of population years and above, and the relative position of each country on the epidemic timeline (days since th case reported as of march ). the shapiro-wilk normality test confirmed that the log-transformed covid- -specific mortality was normally distributed. as china, a bcg-using country with a large population and a relatively concentrated death count in a single province can conceivably demonstrate an artifically lowered mortality and skew these results towards bcg use, we did a sensitivity analysis by running our model with the same covariate adjustments but without china. all data were analysed using the r environment for statistical computing (r core team ) . the median crude covid- mortality per million population among countries with economies classified as low-middle-income, upper-midle-income and high-income countries (lmic, umic, hic) were . (interquartile range (iqr) . , . ), . (iqr . , . ) and . (iqr . , . ), respectively (fig. ) . characteristics of bcg using and non-bcg using countries with respect to the variables considered are shown in supplementary table s . in the log-linear regression adjusted for per capita gdp, age, and time since th case, covid- -attributable mortality among bcg-using countries was . times lower [ % confidence . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint the direct association between covid- -attributable mortality and country-level economic status observed in this analysis is starkly counterintuitive. prior global disease burden assessments have suggested that deaths from acute respiratory illness are typically higher in low-income settings due to multiple socio-demographic and economic risk factors , . among observed covid- -attributable risk factors for disease severity and death, age over years has been identified as a significant factor , , while it is inferred that lmics which typically have a younger population structure would potentially experience fewer overall deaths. another potential confounder was the time lag in deaths following detection of cases. we selected countries with at least reported cases and adjusted for time since this sentinel event. after adjusting for country economic status, proportion of older population and aligning the epidemic trajectories of the highest hit countries, the intriguing observation of a significant association between bcg use and lower covid- -attributable mortality remained discernable. recent non-peer reviewed work reported a similar negative association between bcg use and covid- mortality . unlike our report, their findings did not account for potential confounding effects of income status, age structure of the population or timing of the epidemic, and included only bcg non-using countries, making reliable inference challenging. currently, bcg vaccine is being considered for clinical trials in different settings to test its ability to . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint mitigate infection effects or protect healthcare workers and the elderly population against the sars-cov- disease . several other determinants related to host, viral and environmental factors may be ascribed to these mortality differences. prevalence of comorbidities such as diabetes, cardiovascular disease, chronic respiratory disease and cancer are rising in lmics, and in some settings have overtaken hic. in non-insulin dependant diabetes mellitus prevalence among adults was reported to be % in asian countries and % in europe . the world health organization estimates higher cardiovascular disease risk in asian regions than in european and north american regions . since we had no access to comprehensive nationally representative comorbidity data, the contribution of disease comorbidity as a population level risk factor for covid- -attributable mortality remains unclear. genetic risk factors associated with susceptibility to sars-cov- (in ccl , mannose binding lectin, cxcl /ip- or ace receptor) are currently under evaluation, and as more evidence accumulates, the role played by these factors may become evident , . variations in sars-cov receptor binding domain of the spike protein or nucleocapsid protein could alter disease severity , , although this is more likely to occur in an endemic setting rather than during a pandemic. temperature and relative humidity may be inversely associated with viral transmissibility. but the association has been modest and inconsistent , . early disease models that used assumptions based on cfrs from china and italy predicted higher mortality in lmics, which led to countries adopting severe lockdown measures . ongoing containment measures are critical for infection transmission mitigation. these measures should be balanced against predicted increases in non-covid- mortality arising directly from economic shutdowns and distancing measures. severe trade restrictions and lowered productivity can increase poverty and food insecurity globally . major and prolonged disruptions in crucial health service delivery such as immunization programs or access to emergency obstetric and newborn care can result in a direct increase in preventable deaths, as occurred during and after ebolavirus epidemics . balancing transmission mitigation against sustaining basic health and nutrition access is a difficult but urgent task. the limitations in our analyses are important to consider. deaths lag behind symptomatic infection by - weeks, and when compared with concurrent incidence cases may underestimate the cfr, although this is less likely to influence cumulative crude mortality . health system preparedness of each country and the institution of control measures such as social distancing and lockdowns can also determine the cases and mortality numbers. our data are not meant to falsely reassure countries that their use of bcg may lead to lower mortality. indeed, our analysis is ecological, does not take into account present bcg coverage, nor timing of bcg . cc-by-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint vaccine introduction into national schedules, and is not based on a randomized comparison. by far the most important source of unmeasured confounding in our analysis relates to differential testing and reporting. limited laboratory surveillance availability and access to facility-based care is common in countries using bcg. substantial case underascertainment or under-reporting of deaths can magnify any association between mortality and bcg use. in exponential functions, small iterations in time result in substantial changes in outcome. our findings need to be interpreted with caution; given vulnerable health systems and high levels of comorbidities in lmics, if an exponential rise of cases followed by deaths were to occur in ensuing weeks, this would alter the epidemiological predictions in this report. despite all these caveats, the inverse relationship between country economic status and covid- -attributable mortality, and the strong ecological association with bcg vaccination are intriguing. the findings warrant deeper epidemiological scrutiny and prospective evaluation in individually randomized trials. importantly the findings in this report illustrate the pivotal role that continuous systematic laboratory surveillance will have in improving our understanding of the pandemic, particularly in lmics. such data lead to informed policy making that are beneficial to health and economic outcomes. clinical features of patients infected with novel coronavirus in wuhan epidemiologic and clinical characteristics of novel coronavirus infections involving patients outside wuhan, china 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 case-fatality rate and characteristics of patients dying in relation to covid- in italy nonspecific effects of vaccines and the reduction of mortality in children non-specific effects of bcg vaccine on viral infections. clinical microbiology and infection bacille calmette-guerin induces nod -dependent nonspecific protection from reinfection via epigenetic reprogramming of bcg vaccination protects against experimental viral infection in humans through the induction of cytokines associated with trained immunity the efficacy of bacillus calmette-guerin vaccinations for the prevention of acute upper respiratory tract infection in the elderly long-term efficacy of bcg vaccine in american indians and alaska natives: a -year follow-up study coronavirus covid- global cases by the center for systems science and engineering an interactive web-based dashboard to track covid- in real time. the lancet infectious diseases. . . world bank population and open data repository a database of global bcg vaccination policies and practices, mcgill university and public health agency of canada r: a language and environment for statistical computing. r foundation for statistical computing risk factors for mortality from acute lower respiratory infections (alri) in children under five years of age in low and middleincome countries: a systematic review and meta-analysis of observational studies chronic respiratory diseases global mortality trends, treatment guidelines, life style modifications, and air pollution: preliminary analysis covid- ) -united states correlation between universal bcg vaccination policy and reduced morbidity and mortality for covid- : an epidemiological study international diabetes federation world health organization cardiovascular disease risk charts: revised models to estimate risk in global regions. the lancet global health functional polymorphisms of the ccl and mbl genes cumulatively increase susceptibility to severe acute respiratory syndrome coronavirus infection comparative genetic analysis of the novel coronavirus ( -ncov/sars-cov- ) receptor ace in different populations the proximal origin of sars-cov- . nature medicine genetic diversity and evolution of sars-cov- . infection, genetics and evolution : journal of molecular epidemiology and evolutionary genetics in infectious diseases high temperature and high humidity reduce the transmission of covid- preliminary evidence that higher temperatures are associated with lower incidence of covid- , for cases reported globally up to th the effect of control strategies to reduce social mixing on outcomes of the covid- epidemic in wuhan, china: a modelling study how much will global poverty increase because of covid- ? effects of the west africa ebola virus disease on health-care utilization -a systematic review real estimates of mortality following covid- infection. the lancet infectious diseases non bcg-using countries bcg-using countries key: cord- -vtids ns authors: laxminarayan, ramanan title: trans-boundary commons in infectious diseases date: - - journal: nan doi: . /oxrep/grv sha: doc_id: cord_uid: vtids ns emerging threats to global health, including drug-resistant pathogens, emerging pandemics, and outbreaks, represent global trans-boundary commons problems where the actions of individual countries have consequences for other countries. here, we review what economic analysis can offer in countering these problems through the design of interventions that modify the behaviour of institutions and nations in the direction of greatest global good. the past century has been marked by significant improvements in life expectancy, due to greater child survival and reductions in infectious disease. the greatest victories in global health have come through globally coordinated actions-the eradication of small pox in , the global polio eradication initiative (still ongoing), and the sharp reductions in malaria through the global malaria eradication program (gmep) in the s. just the first two of these initiatives resulted in roughly . m deaths averted each year (unicef, ; ehreth, ) , and the gmep was responsible for eliminating malaria in countries (kouznetsov, ) . largely as a consequence of these efforts and of improvements in wellbeing that have translated into better ability to prevent and treat infectious diseases, these conditions have diminished in importance as a source of ill health across much of the world. according to the global burden of disease estimates, the percentage of disability-adjusted life years (dalys) due to prominent infectious diseases (comprised of the following four cause groups: hiv/aids and tuberculosis; diarrhoea/lower respiratory infections/other infectious diseases; neglected tropical diseases and malaria; and other communicable diseases) decreased from . per cent in to . per cent in , while the percentage of deaths due to prominent infectious diseases decreased from to . per cent (ihme ) . nevertheless, infectious diseases continue to be a significant source of ill health globally and a number of the world's emerging global health threats involve infectious diseases that can easily cross boundaries. the emergence of a new infectious disease-ebola being the most recent example-poses a significant risk to other countries, no matter where it arises. the risk is not uniform: countries that are connected by geography or population movement with the country where the disease emerges, and those with weak health systems are particularly vulnerable. but there are counter-examples as well. new delhi metallo-β-lactamase (ndm) enzymes that cause drug resistance in bacteria, which were first reported in from one patient hospitalized in sweden, are now reported globally (nordmann et al., ) . multiple factors including human population growth, land-use changes, and infectious diseases originating from wildlife (also known as zoonoses) are accelerating the frequency with which infectious diseases emerge (jones et al., ) . even if the direct health toll from these emerging infections does not approach the levels that were observed during the global flu pandemic, when nearly m people died, these infections can nevertheless do serious damage to economies, health, and health systems by virtue of their speed of attack. ebola has killed roughly , people in the last year, mostly focused in the west african countries of guinea, liberia, and sierra leone, and resulted in a per cent loss of gdp in these countries (world bank, ) . a recent study projected that after - months of disruptions, the accumulation of a large connected cluster of children unvaccinated for measles across guinea, liberia, and sierra leone resulted in between , and , additional child deaths due to measles alone (takahashi et al., ) . the deaths of healthcare personnel may have ripple effects down the road and could even discourage people seeking to train to be tomorrow's healthcare workers. the overall damage to health systems due to the large numbers of health system professionals lost to ebola will only become apparent in coming years. drug resistance is now a global problem and threatens public health in nations regardless of economic status (laxminarayan et al., ) . antibiotic-resistant gonorrhoea emerged in vietnam in (holmes et al., ) , before spreading to the philippines and finally to the united states (rasnake et al., ) . ndm enzymes are now in nearly every country, as discussed earlier. in this paper, we discuss the global health threats that involve 'commons' problems. with such problems, the actions undertaken in one country have consequences for other countries, but these are 'externalities' that are not taken into consideration by decisionmakers. for instance, a country may not report a disease outbreak for fear that it would discourage tourism, but the failure to report the outbreak could put other countries at risk. other examples of country-level actions with global consequences include inadequate vaccination coverage; slow progress on disease elimination; failure to report and contain pandemic flu, antibiotic resistance, and counterfeit drugs; and climate-related health threats. we provide some examples and case studies of such negative externalities across borders. then, we discuss the need for international cooperation for tackling these global health threats. the remainder of the paper is organized as follows. section ii describes trans-boundary externalities in tackling infectious diseases. section iii deals with incentives for surveillance and reporting of disease outbreaks. section iv addresses incentives for disease elimination and eradication. section v addresses incentives and financing mechanisms for controlling drug-resistant pathogens. section vi concludes the paper. early examples of international medical cooperation in the modern age were based on the idea that because infectious diseases do not respect national boundaries, meaningful control necessarily transcends national programmes. the first international sanitary conference was convened in paris in to discuss the quarantine of ships to contain plague, yellow fever, and cholera; it predated the first geneva conventions on treatment of war casualties by years (stern and markel, ) . more recently, campaigns to eliminate smallpox and eradicate malaria have been built on the idea that infectious disease control depends not just on national priorities but also on the priorities of one's neighbours and trading partners. an understanding of transnational disease transmission was deeply rooted in the gmep, which was launched in . funding from the top contributors to the special account for malaria by member countries during - accounted for per cent of overall contributions over this period (table ) . of these contributors, only saudi arabia had any significant malaria. malariacontrol investments in the current era are also likely to be largely externally funded, but contributions are not likely to continue indefinitely. therefore, the gains made from control have to be sufficiently large not just in the focal country but also in neighbouring countries so that malaria control will continue to be a priority for national planners even after the donors have exited. malaria control benefits the country in which it occurs, of course, but in the longer term, its neighbours benefit as well because they face fewer cases of imported malaria. the spatial coordination problems introduced by trans-boundary malaria are also relevant for the problem of regional elimination within large countries, especially those with frequent in-country movement, such as india. in contrast, china has managed to eliminate malaria from most of the interior of the country, but imported malaria remains a problem on its southern border. the extent of the 'external' benefit (to a neighbour) depends on malaria prevalence in that neighbour and the frequency and direction of overland migration. if malaria is common, then the benefit of fewer imported cases is minimal. however, the benefits can be large if the neighbour has eliminated malaria but still has to deal with cases imported from the focal country. barrett describes four equilibria in interactions between two countries that share an infectious disease (barrett, ) . in the first equilibrium, neither country engages in control, irrespective of what the other country does. in the second, each country eliminates the disease, irrespective of what its neighbour decides to do. in the third, each country eliminates the disease only if the other can be relied upon to do so. in the fourth, one country does not eliminate the disease, irrespective of what the other does. when countries are not identical in either epidemiological conditions or economic prosperity, it may be in the interest of some countries to eliminate malaria but for others not to, even if all others have eliminated malaria. yet elimination may be the optimal outcome for the two countries as whole. this is the case in which richer adjacent countries have financed elimination in poorer countries, as we observe in the lubombo spatial development initiative (lsdi). lubombo spatial development initiative lsdi offers a recent example of trans-boundary control of infectious disease (sharp et al., ) . malaria control was seen as an essential element of economic development in the lubombo region of eastern swaziland, southern mozambique (maputo), and north-eastern kwazulu natal province in south africa. malaria prevalence in these three regions was closely intertwined because of the frequent migration of people (sharp and le sueur, ) . most malaria cases in swaziland and kwazulu natal were imported from mozambique: for instance, nearly per cent of the malaria cases in kwazulu were in the district adjoining mozambique. between november and february , indoor residual spraying with bendiocarb insecticide was carried out twice a year in mozambique. spraying started in zone ( figure ) and proceeded incrementally, eventually covering seven districts and a population of roughly , people. in swaziland, where there were no other changes in malaria control efforts over the same time period, new malaria cases declined by per cent (table ). malaria cases declined by per cent in mpumalanga province, probably because during this period, indoor residual spraying and artemisinin-combination treatment were introduced on the south africa side of the border. nevertheless, the sharp decline in malaria in swaziland and south africa was attributable at least in part to efforts in mozambique, which were largely paid for by south africa and, to a lesser extent, by the global fund to fight aids, tuberculosis and malaria. west african river blindness programme coordinated financing, specifically with reference to multi-lateral financing to more than one country, is essential to permit a coordinated approach to disease control. however, such coordination has rarely been accomplished outside of global disease eradication programmes. there are a few examples of regionally coordinated financing such as against river blindness. the onchocerciasis control programme (ocp), which was launched in , covered major portions of seven western african countries (burkina faso, benin, ghana, côte d'ivoire, mali, niger, and togo). because the initial set of countries did not cover the limits of the breeding sites of the main vector, the savannah blackfly, the programme was expanded in to also include guinea, guinea-bissau, senegal, and sierra leone. a rare example of a transnational disease control effort launched by the world bank (kim and benton, ) , ocp relied on regionally coordinated larvicide spraying along the niger river to control black fly populations, and, at its peak, the programme covered m people in countries. this coordinated funding was in recognition of the fact that controlling black fly populations in a single country would be infeasible and required the cooperation of all seven countries on the niger river. through the mectizan donation programme, which was initiated in , onchocerciasis was eliminated as a public health problem in west africa. over the period - , the programme prevented , cases of blindness, and brought about m hectares of arable land-enough to feed an additional m people a year-back into productive use. the earliest efforts in global cooperation in the context of sanitary conventions, which required countries to report cholera outbreaks, subsequently led to the establishment of the pan american health organization, a pre-cursor to the world health organization (who) in the twentieth century. despite the benefits of warnings and reports on infectious disease outbreaks, there are few incentives for countries to report disease outbreaks that occur within their borders. current international health regulations, which were first enacted in and most recently revised in , require countries to report disease outbreaks. however, as there are no penalties for non-reporting, reporting depends on the goodwill of nations (baker and fidler, ) . this may not be entirely true since 'the consequences of non-compliance may include a tarnished international image, increased morbidity/mortality of affected populations, unilateral travel and trade restrictions, economic and social disruption and public outrage' (who, ) . specifically, if countries do not report promptly, other countries may take actions to moderate their trade and travel relations with the target country for fear that a future outbreak may also not be reported. we have discussed this in detail below as ex ante sanctions that precede an actual future outbreak. from a practical standpoint, countries face conflicting incentives as to whether or not to report an outbreak. on the one hand, reporting brings the near certainty of trade sanctions that can impose large costs. for example, when peru reported an outbreak of cholera in , its south american neighbours imposed an immediate ban on peruvian food products. the $ m cost of these sanctions and the additional $ m lost from reduced tourist activity far exceeded the domestic health and productivity costs of the epidemic (panisset, ) . on the other hand, countries may report an outbreak in the belief that the information will be reported anyway through the media or informal channels. furthermore, reporting an outbreak may result in international assistance for containing the outbreak. for instance, in the same peruvian outbreak, foreign aid in the form of rehydration salts, saline solution, and antibiotics, while unable to prevent an epidemic, helped to significantly reduce the death rate (brooke, ; suárez and bradford, ) . the appearance of new infections is determined by a number of factors, but generally is mediated by large growing populations that have poor nutrition and lack access to medical care (woolhouse and gowtage-sequeria, ) . however, despite the regular appearance of novel infections (woolhouse et al., ) , few infections are able to spread effectively within a population. over the last century, although more than diseases are believed to have emerged, only five novel diseases have swept across the globe-three were novel strains of influenza, another was hiv/aids, and more recently we saw the spread of sars, which emerged in china in november and spread around the world infecting more than , people in countries and killing approximately before it was contained (zhong et al., ) . further delays in reporting sars by china could have resulted in catastrophic consequences worldwide if the pathogen had been more virulent (heymann and rodier, ) . there is evidence that countries respond to external incentives on whether or not they report infectious disease outbreaks. an outbreak of meningococcal meningitis during the hajj resulted in more vaccination requirements for travellers coming to saudi arabia (laxminarayan et al., ) . these requirements, which were introduced in , were associated with reduced reporting of meningitis outbreaks among countries in sub-saharan africa, especially among countries with relatively few cases reported between and . the announcement of a programme in to assist countries with immediate vaccines conditional on their reporting of outbreaks was associated with an increase in reporting among countries that had previously not reported meningitis outbreaks (laxminarayan et al., ) . incentives for surveillance and reporting lie at the heart of an effective strategy to respond to avian influenza . mathematical models have suggested that it may be possible to contain an emerging pandemic of avian influenza if detection and reporting of cases suggestive of increased human transmission occurs within approximately weeks of the initial case (ferguson et al., ; longini et al., ) . while the who is responsible for coordinating the global response to human cases of avian influenza, decisions on establishing surveillance networks and reporting of outbreaks are the province of national governments. incentives to report an outbreak once it has been detected are only one part of the story, since an outbreak must first be detected. incentives to invest in surveillance to detect an outbreak are likely to be endogenous, and depend on whether or not a country wishes to report an outbreak (malani and laxminarayan, ) . these incentives are driven in part by the 'private' value of early detection to the individual country, but also by the likely consequences of the availability of this information to the rest of the world, either through the act of formal reporting or by informal channels, such as news reports or rumours. the greater the anticipated sanctions, the less likely a country will be to invest in surveillance. conversely, the higher the perceived benefit of international assistance in preventing or ameliorating the cost of an outbreak, the greater the likely investment in surveillance. current international mechanisms to encourage better reporting of disease have, by and large, ignored the economic dilemma and strategic behaviour of countries with emergent outbreaks. investments in surveillance also depend on the likelihood that the detected outbreak will produce a significant epidemic. the more a country believes a disease will arise and spread, the more significant the incentive to invest in surveillance. however, this investment can be tempered by the likelihood of false positives-the detection of a disease when none exists (malani and laxminarayan, ) . thus, a trade-off exists between investing in increased surveillance and investing in more accurate surveillance. a government's decision to report an outbreak can be modelled as a signalling game in which a country has private but imperfect evidence of an outbreak (malani and laxminarayan, ). an important conclusion is that not all kinds of sanctions may discourage reporting. what does this mean? let us divide sanctions into two kinds. ex ante sanctions are imposed in the form of reduced trade and travel contact with countries that are perceived to be poor at reporting disease outbreaks promptly. it is for this reason that west africa is not a favoured tourist destination-even in the absence of ebola, one is never quite sure if the system is able to detect and report this and other diseases. in contrast, an ex post sanction is imposed following a disease outbreak. ex post sanctions discourage detection and reporting since they kick in only after an outbreak has been announced. however, ex ante sanctions do not deter reporting and if anything they encourage reporting so that countries can signal that they are on top of their disease surveillance programmes. furthermore, ex ante sanctions based on fears of an undetected outbreak can reduce reliance on ex post sanctions as ways of controlling outbreaks. second, improving the quality of surveillance networks to detect outbreaks may not promote the disclosure of an outbreak because the forgone trade from reporting truthfully is that much greater. in sum, obtaining accurate information about potential epidemics is as much about incentives for reporting as it is about the capability and accuracy of surveillance networks. solving trans-boundary disease problems requires coordinated financing solutions, as has been evident with global eradication programmes. eradication of a disease means that it is no longer prevalent in any country in the world and requires elimination in every country. elimination, however, requires only the absence of the disease from a single country. global small pox eradication was largely paid for by the united states, even though countries like india stood to gain from the reduction in the number of deaths but were unable to achieve elimination on their own. however, the united states continues to recoup its roughly $ m investment in small pox eradication every days through not having to vaccinate its citizens against the disease. the optimal coverage with a vaccination programme of a disease that can be eradicated is given by p c = /( −r ) where r is the reproductive number of the disease-the number of secondary infections generated by a single infected patient entering a completely susceptible population. note that this critical rate of vaccination coverage depends only on the reproductive number (an epidemiological variable) and not on the costs of vaccination averted or any other economic variables. eradication may not be optimal in the case of all diseases, however. for diseases like measles, where the pathogen can be easily engineered through artificial methods and re-introduced into the population, there is no option of stopping vaccination. indeed, the current cohort of immunized individuals represents a valuable stock that is not easily replaceable in the short term. the optimal level of vaccination coverage of a disease for which vaccination must continue even after the disease has been eliminated can be computed as below. total costs to society include the costs of the vaccination campaign (vaccination costs), which we assume to increase exponentially with coverage, and costs of infection (infection costs) that we use as an index of the severity of the disease. the assumption that costs are increasing exponentially with coverage is consistent with the idea that reaching the most difficult to access and geographically remote populations involves increasing marginal costs. the total infection costs are proportional to the total number of the infective individuals in the population. because there is little evidence for increasing or decreasing marginal costs of infection within a single population (the change in total costs that arises from having one additional infection in the population), we assume constant marginal cost and model the costs of infection as a linear function of the infected. the total cost of the vaccination plus infection is then, with per capita burden c i . the cost of coverage is c(p) = ae xp , where a is the cost of vaccinating the first child (the cost of setting up the programme), and x captures the increase in costs with the increasing coverage p. when there is no immigration, we can calculate the economic optimum by minimizing eq. to find the level of coverage that minimizes total costs, which is independent of transmission. if the economic optimum p i is above the critical elimination threshold, p c = − /  , the optimal strategy is to eliminate the infection locally: (details in appendix in klepac et al. ( ) ). local elimination can be optimal also in the case of very severe diseases. in fact, for large enough per capita burden c i , i.e. the economic optimum p i is always above p c , and optimal vaccination coverage p* is reduced to the critical elimination threshold determined by  (eq. ). the optimal level of vaccination coverage for a disease that cannot be eradicated is a function of only economic parameters. indeed, epidemiological parameters play no role at all. local elimination is optimal only for low  values that result in a critical elimination threshold p c that is smaller than p i . moreover, adding immigration of infection to a single population precludes elimination by local vaccination alone. drug resistance is a global commons problem and covers the full range of infectious disease-causing pathogens from viruses, bacteria, fungi, and parasites through to disease vectors including mosquitoes, blackflies, and sandflies. resistance can arise in any single country and move globally. in this section, we focus on bacterial resistance and parasite resistance in the context of malaria. the global burden of resistance is poorly quantified but is likely to be concentrated in three major categories: increasing costs of resistant infections, increasing costs of antibiotics, and inability to perform procedures that rely on effective antibiotics to prevent infection. a primary burden of resistance is that resistant infections are more expensive to treat, and patients infected with resistant strains of bacteria are more likely to require longer hospitalization and face higher treatment costs than patients infected with drug susceptible strains (holmberg et al., ; the genesis report, ). an estimated , people die each year in europe from antibiotic-resistant bacteria (ecdc/emea joint technical report, ). in the united states in , an estimated , invasive methicillin-resistant staphylococcus aureus, or mrsa, infections required hospitalization and were associated with , deaths (klevens et al., ) . these estimates are useful for indicating the order of magnitude, but are imprecise because resistant infections are more common in individuals on long courses of antibiotic treatment: it is difficult to ascertain whether resistance is the cause of death or a correlate of long antibiotic treatment, hospitalization, and underlying sickness. in low-and middle-income countries, where the ability to pay for second-line drugs is limited, worse health outcomes are common, particularly in newborn children. even with effective antibiotics, neonatal infections are the major cause of neonatal deaths, which in turn account for more than a third of the global burden of child mortality (zaidi et al., ) . over half of neonates with extended spectrum beta-lactamase (esbl) sepsis are likely to die (versus a quarter of neonates with non-esbl infections), and a half of neonates with mrsa die (versus per cent of neonates with methicillinsensitive staphylococcus aureus) (kayange et al., ) . at these rates of mortality, one can estimate roughly , neonatal deaths attributable to gram-negative organisms and s. aureus, and , neonatal deaths attributable to esbl resistance and mrsa in india alone. a further cost of resistance is that associated with the cost of introducing new, expensive, antimicrobials to replace old ineffective ones (office of technology assessment, ) . this represents forgone resources that society could deploy elsewhere (reed et al., ) . according to one estimate, between and , increases in drug resistance raised the cost of treating ear infections by about per cent in the united states ($ m) (howard and rask, ) . resistance can also render broader health system functions such as surgeries, transplantations, and chemotherapy ineffective (laxminarayan et al., ) . a recent study estimated that, without effective antibiotics, - per cent of patients undergoing total hip replacements would have a postoperative infection, with a case-fatality rate of roughly per cent (smith and coast, ) . this category of burden affects both low-and middle-income as well as highincome countries and is likely to be the predominant way in which resistance drives up health care costs. take the case of drugs to treat malaria. the use of antimalarials places selection pressure on parasites to evolve resistance to these drugs. moreover, resistance is bound to arise when these drugs are misused, and could have adverse consequences for all malaria-endemic countries. efforts to manage resistance across national borders would have to rely on international agreements and regulations (walker et al., ) or on tax or subsidy instruments (arrow et al., ) . in the absence of such agreements and regulation, countries are unable to commit themselves to an optimal use of antibiotics, which would be in all countries' interests. at the macroeconomic level, a too intensive use of antibiotics in the health sector results in excessive levels of resistance both for that country and to the rest of the world (cornes et al., ) . a supranational authority would have to consider both the externality benefits of antibiotic use, in terms of reducing infections, and the costs, in terms of resistance (rudholm, ) . whether antibiotic consumption should be taxed or subsidized to reach the first-best outcome then depends on the relative magnitude of the externalities. in practice, the consequences of antibiotic use in sectors such as to make livestock grow faster involve little by way of positive externalities but impose resistance costs on other sectors and should therefore be taxed. a new class of antimalarial drugs, called artemisinins, requires a different way of thinking about optimal subsidies to manage resistance. when chloroquine, a oncepowerful antimalarial drug, became obsolete, the public health world was left with the challenge of optimally deploying the last remaining effective drug class, artemisinins. the who has recommended that artemisinins be used in combination with a partner drug that is unrelated to artemisinin's mechanism of action and genetic bases of resistance, so that a single mutation cannot encode resistance to both components (who, ) . artemisinin combination treatments (acts), if used instead of monotherapies of either artemisinin or the partner drug on its own, should slow the emergence of antimalarial resistance. however, the who guidelines are routinely flouted because monotherapies are much less expensive than acts. in response to this problem, an institute of medicine report (arrow et al., ) recommended establishing an international fund to buy acts at producer cost and resell them at a small fraction of that cost. on economic efficiency grounds there is a second-best case for subsidizing acts, because the ideal policy-taxing monotherapies and other antimalarials according to the marginal external cost from the elevated risk of the evolution of resistance-is infeasible, given their widespread use in the informal sector. the efficiency argument is further strengthened by the positive externality, to the extent that effective treatment of one individual reduces the risk of infection transmission to other individuals. laxminarayan et al. ( ) show that it is possible to determine the optimal subsidy in a dynamic diseasemodelling framework. bioeconomic analysis has been helpful for determining whether the social benefit from the subsidy, in terms of delayed resistance and saved lives, exceeds the social cost of resistance because of increased use of acts (laxminarayan et al., ) . it was also instrumental in turning an idea into the affordable medicines facility for malaria (amfm), a global financing system launched in early . amfm was formally evaluated in . in the six pilots where the programme was implemented to a substantial degree, amfm met or exceeded benchmarks for availability, price, and market share of quality-assured acts. in private, for-profit pharmacies, the quality-assured act market share at baseline ranged from to per cent (tougher et al., ) . a drawback of this evaluation was that it did not attempt to measure the impact on malaria prevalence or artemisinin resistance, both of which would have been difficult to ascribe to the intervention in the timeframe of the evaluation. nevertheless, the global fund to fight aids, tuberculosis and malaria made a political decision to discontinue amfm based on political objections raised by some country delegations (arrow et al., ) . one way to improve the efficiency of amfm resources was possibly to target children, though it would avert significantly fewer deaths. however, the benefits of a child-targeted subsidy (i.e. deaths averted) are eroded as leakage increases (i.e. older individuals taking young child-targeted doses), with few of the benefits (i.e. reductions in overall prevalence) of a universal subsidy (klein et al., ) . although potentially more cost-effective, a child-targeted subsidy must contain measures to reduce the possibility of leakage. most global health problems are 'commons problems'. therefore, it is often essential to have cooperative financing mechanisms for global health interventions, whether to eradicate disease, encourage appropriate levels of disease surveillance and reporting, or to reduce the likelihood of drug resistance. innovative financing that takes into account cross-country spillovers can play a critical role in arriving at globally optimal outcomes. for instance, in the case of the amfm subsidy, a high-level financing mechanism that lowers the cost of quality acts to all countries, including those that were at highest risk of using monotherapies, both enabled access to effective treatment and also reduced the threat of resistance. no bilateral financing solution could have achieved the same impact because of potential leakage to other countries, as discussed earlier. a global mechanism that is able to provide resources that incentivize surveillance and reporting of disease outbreaks can successfully counter the disincentives faced by countries for prompt reporting. again, bilateral assistance that simply focuses on subsidizing surveillance but does not pay attention to the lack of incentives for reporting cannot solve the problem. the three exemplars of trans-boundary problems that we have discussed can be applied to other global health problems with a public goods nature. saving lives, buying time: economics of malaria drugs in an age of resistance, board on global health the affordable medicines facility-malaria: killing it slowly global public health surveillance under new international health regulations the smallpox eradication game peru's neighbors halt food imports', the new york times drugs and pests: intertemporal production externalities the bacterial challenge: time to react the global value of vaccination strategies for containing an emerging influenza pandemic in southeast asia the recent history of malaria control and eradication global surveillance, national surveillance, and sars health and economic impacts of antimicrobial resistance studies of venereal disease. i. probenecidprocaine penicillin g combination and tetracycline hydrochloride in the treatment of "penicillinresistant the impact of resistance on antibiotic demand in patients with ear infections gbd cause patterns global trends in emerging infectious diseases predictors of positive blood culture and deaths among neonates with suspected neonatal sepsis in a tertiary hospital cost-benefit analysis of the onchocerciasis control program (ocp)', world bank technical paper cost-effectiveness analysis of childtargeted subsidies for artemisinin combination therapies using a bioeconomic malaria model invasive methicillin-resistant staphylococcus aureus infections in the united states malaria control by application of indoor spraying of residual insecticides in tropical africa and its impact on community health will a global subsidy of new antimalarials delay the emergence of resistance and save lives? extending the cure: policy responses to the growing threat of antibiotic resistance should new antimalarial drugs be subsidized? antibiotic resistance-the need for global solutions containing pandemic influenza at the source incentives for surveillance and reporting of infectious disease outbreaks operational strategies to achieve and maintain malaria elimination global spread of carbapenemase-producing enterobacteriaceae impact of antibiotic-resistant bacteria: a report to the us congress international health statecraft: foreign policy and public health in peru's cholera epidemic history of us military contributions to the study of sexually transmitted diseases socioeconomic issues related to antibiotic use economic implications of antibiotic resistance in a global economy malaria in south africa--the past, the present and selected implications for the future seven years of regional malaria control collaboration the true cost of antimicrobial resistance the economic impact of the cholera epidemic in peru: an application of the cost of illness methodology', water and sanitation for health project reduced vaccination and the risk of measles and other childhood infections post-ebola the real war on drugs: bacteria are winning effect of the affordable medicines facility-malaria (amfm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: a before-and-after analysis of outlet survey data vaccines bring diseases under control', unicef, the progress of nations frequently asked questions about the international health regulations host range and emerging and reemerging pathogens temporal trends in the discovery of human viruses the economic impact of ebola on sub-saharan africa: updated estimates for hospital-acquired neonatal infections in developing countries epidemiology and cause of severe acute respiratory syndrome (sars) in guangdong, people's republic of china key: cord- -x e cz a authors: mishra, devanshu; haleem, abid; javaid, mohd title: analysing the behaviour of doubling rates in major countries affected by covid- virus date: - - journal: journal of oral biology and craniofacial research doi: . /j.jobcr. . . sha: doc_id: cord_uid: x e cz a abstract background and aims sars-cov is a novel coronavirus that is transmitted to humans through zoonosis and characterised by mild to moderate pneumonia-like symptoms. the outbreak began in wuhan, china, and has now spread on a global scale. doubling time is the amount of period taken for a particular entity (that tends to grow over time) to double its size/value. this study's prime target is to develop relationships between the variation in the doubling time of the number of cases of covid- virus and various socio-economic factors responsible for them. these frameworks focus on the relationships instead of relational data, so here in graph structures, we have generated different patterns of doubling rates and drawn the inferences. methods only significant countries affected by the covid- virus are studied, and accordingly, collected datasets of growth of cases in the form of spreadsheets. the doubling rate is determined by calculating the doubling time for each day and then plotting these datasets in graphical form. results the doubling time of various countries is vastly affected by the preventive measures taken and the lockdown implementation's success. higher testing rates helped identify the hosts of the virus; thus, countries with mass testing have lower doubling rates. countries, where the virus spread started earlier, had less time to prepare themselves, and they were in initial stages, the doubling time suffered. a sudden dip in doubling time is due to a large gathering of people or not effective lockdown; thus, people's attitude contributes to an essential role in affecting the doubling time. conclusion the relationships between the spread of the virus and various factors such as dissimilarities in ethnic values, demographics, governing bodies, human resources, economy, and tourism of major countries are carried out to understand the differences in the virus's behaviour. this fast-moving pandemic has shown various defects and weaknesses in our healthcare systems, political organisations & economic stability and gives numerous lessons on how to enhance the ways that the global societies address similar epidemics. there is also a component that may share the same denominator is the necessity for requisite healthcare systems and medical staff. still, the shortage of this component does not certainly mean that taking necessary steps would be ineffective. transmission of covid- to humans by zoonosis reveals that the global community is required to be observant concerning similar pandemics in the future. in december, an outbreak with pneumonia-like symptoms broke out in wuhan, china. the natural hosts of this virus are considered to be bats, yet other species are also regarded as sources. there has not been enough information accumulated by the epidemiologists to conclude how the virus spreads and affects the patients' bodies on a cellular level, but the figures indicate that the disease's reproduction number lies between and . covid- was the name announced of this new virus on th february , and the virus is caused by severe acute respiratory syndrome coronavirus (sars-cov- ). although similar relations were seen with sars-cov and mers-cov after genomic characterisation was done, the novel virus was more aggressive than other coronaviruses . since so far, confirmed cases are touching million, with more than . million deaths worldwide. preliminary data from the eu/eea show that around - % of confirmed covid- patients are hospitalised, and % are in severe conditions. for patients aged above or those having other medical conditions, there is an increase in the hospitalisation rates , . the incubation period for the disease is around days, with a high possibility of symptoms showing . days . the covid- outbreak is putting a massive strain on societies due to the considerable mortality and morbidity, the profound impact on healthcare and the societal and economic harm included with the physical distancing measures . different countries have variation in the geography, economy, culture, tourism, healthcare, education, leadership; thus, several such factors are responsible for altering doubling rates, which can explain why the outbreak in a few countries has been at an alarming rate . the developing countries have an immense amount of air traffic (easing foreign diseases to spread inside the country) but have overpopulated cities and underfunded healthcare systems. thus, in the long term, these countries may observe a slight increase in the doubling rates and show an exploding number of cases [ ] [ ] [ ] [ ] .the measures taken by the governing bodies are also an essential factor in coronavirus's behaviour in countries. we intend to add value to this discussion by analysing doubling rates of major countries and drawing inferences that can act as a resource for containing the outbreak of covid- virus. problem definition and research objectives of the paper here, the main focus of this paper is identifying the doubling rate of several covid- positive cases. this analysis aims to assess the relationship between the variations in the doubling rates in various countries with factors such as geography, culture, government, economy and tourism. our objective is to identify these relations, draw patterns and accumulate the ones which seem effective worldwide. scope of the paper the study focuses on drawing insights on publicly available datasets and statistics. the data considered for the study is the number of cases of covid- positive patients for each country, and spreadsheets are used to accumulate the data on a single platform. the study's depth is limited to analysing the current factors responsible for altering doubling rates through graphical representation and will not cover and sort of data forecasting. . the study's depth will be limited to some exploratory data analysis, data analysis for correlation and cause-and-effect relationships, bivariate analysis, and data visualisation, this study focuses on prediction. it will not cover any kind of data forecasting. the datasets used in the study are publicly available and taken for eight major countries. microsoft excel is used to gather the data on a single platform. the programming language used for converting the data in graphical form is r (used explicitly for statistical computing and graphics) data used www.worldometers.info/coronavirus is used as the data source for accumulating the datasets for each country in our study, epidemic doubling time refers to the sequence of intervals in which the cases of covid- doubles in value. it is an important factor in determining the rate at which the virus is multiplying in various countries. figure shows that after days, when the first infected patient was registered, the doubling rate was still at an alarming rate of hours. on st march, the state of são paulo issued a complete lockdown, and all sort of non-essential services were closed down for two weeks starting from rd march. this lockdown somewhat helped to improve the doubling rate from days to . days as the maximum cases were in the state of sao paulo only. however, as the cases spread, the doubling time suffered as the country's health system is underfunded. president jair bolsonaro is strictly against lockdown, which is seen on the graph as a numerous rise and dips. the increase in the doubling time is simply due to the citizens' precautions, but the country may suffer in the long term. the country's test positivity rate is %, which shows that the increase in doubling time may be false due to less testing done. initially, the government did not act quickly enough and even punished doctors who sounded the alarm, which caused initial lower rates of doubling time and also spread of the virus. figure shows the rapid improvement in the doubling time in china from day . this increase can be attributed to the government's vigorous measures to reallocate a vast chunk of its healthcare system to respond to the outbreak's centre and build new facilities specifically for the patients. the government also made testing free of charge even if the results were negative. it took quick actions to alert the public about infection symptoms and isolate confirmed cases and track their closer contacts to find the origins of infection clusters. on day , china updated its data with new , cases which can be seen as a sharp dip in the graph. being the epicentre, china has the most knowledge and experience in dealing with the virus, which also acts as an essential factor in the doubling time's steady rise. china has now successfully contained the epidemic, with the doubling time reaching more than days. germany recorded its first case earlier than italy, but its doubling time was far better than other european countries, as seen in figure . the initial low value of doubling time is due to german carnival, a hotspot for the virus's early spread. however, comprehensive mass testing& associated quality healthcare system is the main reason behind the success of improving the doubling rate. germany has successfully kept the doubling rate low through a well-thought-out strategy and adequately funded healthcare system with strong top leadership support. the country has tested far more people than other countries that have allowed authorities to slow the transmission of the disease by isolating known cases while they are infectious. therefore, health officials understood the situation early on and took the required measures. it can be seen as a steady increase in the graph from day . germany has a building block of strong public trust and smoothly functioning leaders. the improvement in doubling time of several cases also displays the significance of governing bodies and transparent data in controlling the virus's extent. thus, the country managed to increase its doubling time at a significant rate. earlier, the country was only testing citizens with travel history, which then broadened to only symptomatic cases. thus, not adopting extensive testing (which helps find mild and asymptomatic cases) led the virus to spread in the country's vast majority. on day , the government of india issued a nationwide lockdown. as we can see from figure , starting from day , there has been an improvement in the doubling time, i.e. from the th march. it is directly related to the lockdown issued by the government and adding the incubation period. the lockdown was placed when the number of positive covid- cases in india was around . lockdown slowed the pandemic rate by th april to a rate of doubling every six days, and by th april, to a rate of doubling every eight days. another factor responsible for mass spreading is massive economic migration in the country. the migrants in lockdown were forced to return to their homes (many on foot). although the lockdown was implemented early on, the governing bodies took slower actions in developing an effective strategy to contain the virus spread. the slow response can worsen the situation as mass testing and contact tracing is not being adopted on a mass scale. poor health infrastructure has also contributed to the lowering of the doubling rate. as seen in figure , the starting days of the coronavirus spread show no improvement in the doubling time mostly due to the government light response and the country held nationwide parliamentary elections on st february. the president called it a conspiracy by enemy countries to shut down the nation, showing no sign of declaring lowdown until the conditions got out of hand. after the cases hit more than , the country went under lockdown. it showed a slight improvement in the doubling rate from day to day . the country again suffered the second wave of corona cases due to people disobeying the nowruz holiday restrictions. thus, starting from day , there was a steady improvement in the doubling time with doubling time of . days.the initial doubling rates also displays the significance of governing bodies and transparent data in controlling the virus's extent. the initial days show an exponential growth of corona cases as the doubling time graph tends to alter from day to days, as shown in figure . a large number of people in northern italy showed pneumonia-like symptoms and thus becoming sites of infection. there is a high possibility that there were already people infected with the virus long before the first registered case appeared. the country had less time to prepare for the massive explosion that took place in various cities. in mid-february, the doubling time was on the lower side; still, no norms and rules limiting the population's movement were taken. on th march, the whole country went under lockdown, and strict measures were taken, and movement in and out of areas was prohibited. thus, the graph showed a steady upward trend starting on day . the majority of cases in the country came due to people travelling from spain, france and italy. the government initially adopted the mitigation approach, where it tried not to react and let the outbreak continue with only minor measures. finally, enough people are supposed to get infected and create herd immunity to permanently reduce the r (reproduction number) below . due to this reason, the cases multiplied quickly until days, as seen in figure . on th march, the government changed its approach and started promoting social distancing and self-isolation. furthermore, later in march, the country went into lockdown slowly, there was an upward trend in the doubling time of no. of cases. the country earlier adopted reactive testing, i.e. prioritising testing of people showing severe symptoms. thus, those are not actively seeking out the tests, and people with mild or no symptoms were left out. the initial days show the country's conditions worsening with doubling rate altering between and days, as seen in figure . this condition can be reflected due to the slow response towards the pandemic and people travelling to the country from china and no virus testing of those people done. social distancing precautions were taken in mid of march when the cases over flowed, and mass testing was carried out. no improvement in the doubling rate was also due to cultural issues with the people and the top leadership's poor role. this country has one of the best healthcare systems, but there has been a large number of residents have not following social distancing. the country has shown the highest number ofcovid- positive cases, but the governing bodies have shown improvement in doubling rate. after days, the doubling time started to increases due to mass testing being done, and social distancing being implemented. as of nd april, % of the population was under lockdown, which is reflected in day till day . the doubling time further increased as more testing was done, and preventive measures were taken. three different analyses are carried out for eight major countries, and results are drawn. the doubling time of various countries is vastly affected by the preventive measures taken, top leadership role with lockdown implementation and attitude of its citizens. countries such as brazil where the lockdown has still not been enacted, the cases have risen steadily. higher testing rates helped identify the hosts of the virus; thus, countries with mass testing have higher doubling time. the doubling time graph can also help countries where doubling time is low address the fact that increased medical staff and healthcare facilities are needed, including extra testing centres and ppe kits in countries with high cases. in terms of doubling rates, the worst affected countries are the developing countries due to their weak healthcare system covering an overpopulated expanse. if the conditions are not controlled, this may pose a severe threat to the country. the country with a weak economy suffered more due to underfunded health system and economic migration (causing the virus to spread to more regions). unemployment recession and unstable jobs also cause incapable individuals to disobey the lockdown to meet their daily needs to survive. the concerned government plays the most crucial role. thus, the need is for early and rapid actions for all the governments to control the virus's outreach. therefore, countries such as china that acted quickly to contain virus spread did not have an explosion of cases, whereas iran and brazil lack acting swiftly. countries such as brazil where the political assemblies did not take necessary actions and ignored the importance of lockdown and social norms suffered heavily. the strategy of contact tracing and aggressive testing is not easier to replicate in countries with large populations, thus usually countries with high population density will show lower doubling rates (china being the outlier). limitations of the study, tool, data the barrier to increasing the number of people getting tested is the limited number of testing facilities, medical staff, and healthcare facilities. the test positivity rate of countries such as brazil and the united kingdom is high, which shows that several other people suffer from the virus that is not getting tested. thus, inadequate information may be available for a large extent of areas. some governments' failure to provide transparent, up-to-date information about the spread of disease poses a barrier to precise results. there are specific patterns or sequence where the length of the path is unknown upfront, so it is hard to express with absolute certainty the outcome of the growth in the doubling time of the number of coronavirus positive cases. analysis of covid- pandemic requires multilayered parameters, here we have chosen an elementary model that could include the fundamental aspects of the dissimilarities in the doubling rate of cases of covid- only. another factor for possible bias is that the data used does not cover all the periods and countries from when the first case was recorded, thus making it tough to study homogenously about the outcomes. understanding the study done of covid- outbreak can help the authorities take new healthcare measures and other systems to more successfully take necessary action on other diseases lurking in the current time and prepare ourselves more efficiently any future outbreaks. the datasets can be used in conjunction with other systems such as analytics cloud or machine learning. these data sets' patterns give insights on what further measures can be taken by the governing bodies to combat the deadly virus. the possibility of horizontal scalability is there such that no matter what amount of data is there, one can add more resources to the infrastructure and carry out further analysis. the covid- outbreak reveals the significance of rapid actions and strategies in terms of containing the diseases to prevent any further pandemics. the lessons of this study can be learning for others and in dealing with multiple cases of outbreaks. the evolution of healthcare systems, scientific research and medical institutions with strong government support over the past years are important factors that could prove significant in containing any future diseases that may get spread on a global scale. this fast-moving pandemic has shown various defects and weaknesses in our healthcare systems, political organisations & economic stability and gives numerous lessons on how to enhance the ways that the global societies address similar epidemics. there is also a component that may share the same denominator is the necessity for requisite healthcare systems and medical staff. still, the shortage of this component does not certainly mean that taking necessary steps would be ineffective. transmission of covid- to humans by zoonosis reveals that the global community must be observant concerning similar pandemics in future. from what we have observed and from the inference that we have drawn, we can say that government response to the pandemic plays a vital role in affecting the virus's doubling time. mass testing can help identify hosts of the virus and prevent the virus from spreading to other regions. countries, where the virus spread early, had less time to be prepared and thus in initial stages, the doubling time suffered and vice versa. the people's attitude towards the government and the lockdown also alters the rate at which the doubling time increases. thus countries such as germany and south korea did far better than the united states of america and iran. the healthcare system and the economic conditions also affect the doubling time, where countries such as peru and brazil are immensely affected. the developing countries are the worst hit due to overpopulation and underfunded healthcare system and must take strictest measures to contain the virus spread. naming the coronavirus disease (covid- ) and the virus that causes it statement on the second meeting of the international health regulations remdesivir in adults with severe covid- : a randomised, double-blind, placebocontrolled, multicentre trial. the lancet a systematic review of covid- epidemiology based on current evidence ostwald growth rate in controlled covid- epidemic spreading as in arrested growth in a quantum complex matter effect of changing case definitions for covid- on the epidemic curve and transmission parameters in none key: cord- - d q authors: kobrin, stephen j. title: how globalization became a thing that goes bump in the night date: - - journal: j int bus policy doi: . /s - - -y sha: doc_id: cord_uid: d q for almost years, globalization has been seen as a positive development, albeit with costs and benefits, and as progress and modernization, a broadening of humanity’s scope from the local and parochial to the cosmopolitan and international. that changed dramatically with the great recession, the waves of migration of the last decade, and the global coronavirus (covid- ) pandemic of . for many, globalization now connotes economic dislocation, increasing inequality, unwanted immigration, and a vehicle for the transmission of disease. the pandemic reminds us that most economic activity takes place within national borders. it has emphasized the dangers rather than the benefits of efficient linkages between markets, laying bare the dangers of complex global supply chains where any node can become a “choke point”, and the risks of overspecialization or the concentration of technological knowledge and/or production capacity in a single country or region. a more positive view of globalization will require restoring the balance between independence and integration, mitigation of its costs within and between countries, and dealing with redundancy and supply risk. for almost years, globalization has been seen as a positive development -albeit with costs and benefits -if not an imperative, and as progress and modernization, a broadening of humanity's scope from the local and parochial to the cosmopolitan and international. while that sentiment was certainly not universal, for much of this period it was dominant. that changed dramatically with the great recession of , the waves of migration characteristic of the last decade, and, finally, the global coronavirus (covid- ) pandemic of . for many, globalization now connotes economic dislocation and increasing inequality, unwanted immigration, and, most recently, a vehicle for the transmission of disease. while marx and engels ( ( ) : ) bemoaned the destruction of ''old-established national industries'', they went on to say that, ''to the great chagrin of reactionists,'' bourgeois exploitation of the world market has given ''a cosmopolitan character to production and consumption in every country.' ' trotsky ( ) argued that the most advanced productive forces, the application of electricity and chemistry to the processes of production, were incompatible with national boundaries. at the other end of the political spectrum, the geneva school of neoliberals believed that commitments to national sovereignty and autonomy were dangerous; that the ''cardinal sin of the twentieth century was the belief in unfettered national independence.''; and that ''nations must remain embedded in an international institutional order that safeguarded capital and its right to move throughout the world'' (slobodian, : ) . keynes waxed eloquently about the global age that came to an end in . ''an inhabitant of london [of a certain class] could order by telephone, sipping his morning tea in bed, the various products of the whole earth…and reasonably expect their early delivery upon his doorstep…he could secure…cheap and comfortable means of transit to any country or climate without passport or other formality' ' ( : ) . there was a sense of inevitability associated with globalization, a sense of progress, and of a broadening of narrow, parochial, and local interests; a sense of inevitability driven by developments in transport and communication that linked markets and individuals and dramatically increased the ease and efficiency of international trade and investment. in a famous article at the turn of the twentieth century, mackinder ( ) argued that, with the end of the columbian epoch of exploration and thanks to improvements in transport, there now was a single, closed political system, worldwide in scope. a century later, with the digital revolution, container shipping, and jet aircraft, a great many citizens of the advanced countries were able to ''order the various products of the whole earth'' and expect -day delivery to their doorstep. the late nineteenth century global economy lost much of its steam with the outbreak of world war i, and ended precipitously with the depression following the american stock market crash in . in , the u.s. congress passed the smoot-hawley tariff which imposed levies on over , goods and was met by almost immediate retaliation by the other major trading nations. what is important here is that smoot-hawley was seen by most observers as a mistake. the tariff was opposed by over economists and was remedied after the election of roosevelt with the passage of the reciprocal tariff act of . when churchill and roosevelt issued the atlantic charter in , summarizing post-war aims, one of the eight points called for the lowering of trade barriers. in , immediately after the second world war, negotiations began for an international trade organization. while an agreement proved problematic, the gatt (general agreement on tariffs and trade) was established in and it provided a framework for trade negotiations until the world trade organization (wto) was established in . although there has been substantial opposition to both globalization in general and its institutions, in particular, the international monetary fund and the wto, that opposition tended to focus on welfare effects (the distribution of the gains from trade), sectoral impacts, or effects on developing countries. although it may be an over-generalization, it is fair to say that, until the very late twentieth century, globalization was seen as a net positive, that international trade, investment, and economic integration (e.g., the european union) allowed both the more efficient use of the world's resources and the development of large-scale technology. economic nationalism was seen as problematic, as a barrier to further international economic integration: as habermas ( ) argued, there was a need for politics to catch up with economics. late twentieth century globalization became synonymous with the idea of a hyper-efficient networked world economy. the combination of the digital revolution and dramatic improvements in transport allowed the value chain to be broken into small units or tasks with every task located wherever in the world it could be performed most efficiently. geography was seen as ambiguous in a ''post-modern'' economy (kobrin, ) . network theory emphasized the direct connections between nodes, as opposed to a hierarchical organization of local to national to global scales: plants or financial institutions interacted directly with multiple sites in other countries without the need to go through the organizational structure of the multinational corporation. the emphasis was on the linkages rather than the nodes, an assumption that the nodes or sites where specific tasks are performed were dependent for their value on the network as a whole. the risks of globalization become obvious the combination of the rise of populist nationalism with the great recession and the covid- pandemic has stood these arguments on their head, and emphasized the dangers rather than the benefits of the efficient linkages between markets (rodrik, a) . most obviously, the extensive and rapid international travel associated with globalization served as an ideal medium for the very rapid spread of the coronavirus: it became global in just a few months after first being isolated in china. the global pandemic reminds us that, at the end of the day, most economic activity does take place within national borders. it has again focused attention on the nodes, laying bare the dangers of complex global supply chains where any node can become a ''choke point'' that threatens to close down the entire network. it has also revealed the very real risks of letting efficiency drive the concentration of supply of critical goods and materials into a single market; the ''destruction of oldestablished national industries'' is no longer taken as an indicator of progress. my objective in this essay is to focus on the impacts of the coronavirus pandemic on how globalization is perceived. that said, it is clear that the great recession of was a turning point and that the economic dislocation and inequalities that it revealed, combined with the reaction against large-scale migration into the developed countries, resulted in a populist reaction against international integration -social and political as well as economic. that was exploited by economic nationalists such as donald trump in the u.s. and viktor orban in hungary and the ''leavers'' in britain who promoted brexit. while it has always been acknowledged that globalization entails both benefits and costs, it was generally assumed that the former far outweighed the latter, and that the welfare or distributional effects could be dealt with nationally. however, by the late twentieth century, the consensus that trade has only modest effects on income distribution became increasingly dated (autor, dorn, & hanson, ; krugman, ) . in what seemed at the time as a rapid reversal of opinion, globalization became a negative rather than a positive, a threat to social, cultural, and political as well as economic wellbeing (see kobrin, , for a more complete discussion of this point.) this was clear in a recent new york times article describing globalization (of recent decades) as ''an underregulated, complacent form of interconnection that has left communities vulnerable to a potent array of threats'' (goodman, : b ) . covid- dramatically exposed one of the most potent threats: the rapid transmission of the infection globally through the complex web of international air travel (and cruises). the world health organization (who) first announced the new virus in china on january , , by early february it had spread to seven asian countries, five in europe, and to the u.s. and canada. the who declared it a pandemic on march , and by may there were . million cases worldwide and , deaths (world health organization, ). the response was almost as immediate and very physical: one nation after another closed their borders and banned non-essential travel -the very antitheses of globalization. as of april , at least percent of the global population lived in countries with coronavirus-related travel restrictions, and about billion people were living in countries enforcing complete border closures to foreigners (salcedo & cherelus, ) . the u.s. state department has issued a level ''do not travel'' advisory and the u.s.-canadian and u.s.-mexican borders were closed. on april , president macron of france announced that the schengen member countries were considering extending the closing of their borders until september. for much of the twentieth century and the first decade of the twenty-first, globalization was an abstraction to much of the world's population. especially when economies were strong, economic dislocations attributable to globalization -while very real to those suffering the consequences -were limited in scope. that changed dramatically during the last decade. with the great recession, the negative economic impacts of globalization became much more widespread, directly affecting the middle classes of many industrial countries. that said, it took large-scale migration and the covid pandemic to firmly establish globalization as a widely seen threat. the waves of migrants fleeing conflict zones such as syria, and abject poverty and violence in africa and latin america, were very visible and immediate and leveraged by xenophobic groups to turn significant numbers of citizens of many countries against both immigrants specifically and globalization more generally. globalization was no longer abstract: it was waves of immigrants washing up on beaches in greece or president trump warning of ''armies of migrants'' marching to invade america's southern border. the covid pandemic was the next nail in the coffin. globalization and international travel became associated with an immediate and very visible threat -serious illness and death. globalization is no longer an abstraction to most of the world's population. it carries negative connotations as a vehicle for the transmission of a serious and potentially fatal disease, and the economic chaos associated with it, in virtually every country. of production digital communications provide for simultaneity in time without regard for space, and facilitate the creation of relational networks of flows for the coordination of complex processes without regard for place or geographic distance (amin, ) . that, in turn, has allowed for the extension of specialization -in every phase of the production process -with scant regard for national borders. this drive for efficiency combined with technological path dependence has resulted in the concentration of knowledge -in both research and development and production processes -in specific and often limited geographic areas. benefits of the application of the digital revolution to research and production include a dramatic increase in the rate of innovation and the flow of a very wide range of affordable products to consumers worldwide. a broad spectrum of inhabitants of most of the countries of the developed world had access to ''the various products of the whole earth'' in remarkably short order and at an affordable cost. that came with a price in terms of the loss of jobs, especially in developed countries' manufacturing sector, a price which became very obvious with the great recession and certainly played a role in the surge of populist nationalism in many countries. (advances in manufacturing technology are also relevant.) the covid- pandemic, however, revealed that, regardless of the simultaneity of time, the disregard of space -of geographyentailed very significant risks. both overspecialization or the concentration of technological knowledge and/or production capacity in a single country or region and the reliance on complex global supply chains proved problematic. ironically, some of the earliest indications of the dangers of overspecialization came from shortages of materials and drugs needed to treat the virus itself. chinese manufacturers produced half of the world's medical masks, and the production of reagents, a component of test kits, is dominated by just two companies (farrell & newman, ) . as plants were shut down in china and other countries, the flow of these very necessary supplies was significantly restricted and the ability to shift the location of production was limited. similarly, india has become the world's main supplier of generic drugs, and they, in turn, rely on china for percent of the active pharmaceutical ingredients (apis) for their medicines. in march , india restricted export of of these apis and the medicines made from them in order to insure an adequate supply for the domestic market in the face of the covid pandemic. europe was described in the press as ''panicking'' over the possible impacts on supplies of necessary medications, and the u.s. food and drug administration noted that indian imports accounted for almost a quarter of medicines in (dasgupta & burger, ) . in another of the covid ironies, at a time when a good portion of humanity is confined to their home, the lockdown in malaysia has resulted in concern about a ''devastating condom shortage'', as a single plant in that country produces percent of the world's condoms (france , ). as the pandemic spread, countries went into ''lockdown'' mode, production was disrupted, the trade-off between efficiency (lower prices and technological specialization) and security of supply became obvious as shortages, or threats of shortages, became evident. as with many issues related to international trade, the benefits in terms of a lower cost of goods, while widespread, are not always obvious while the costs -job losses or in this case, shortages of critical goods -bear more directly on specific industries and consumers. both the rise of economic nationalism (e.g., america first) and the covid pandemic revealed the serious risks of reliance on very complex networks of global supply chains in many industries. both have reemphasized the importance of places as opposed to flows, of the possibility that any given node in the network could serve as a ''choke point,'' disrupting or shutting down the entire supply chain (farrell & newman, ) . the u.s. auto industry, for example, relies heavily on parts sourced from china and their suppliers rely on chinese tool and die makers. for example, there is concern that the covid pandemic could result in a global food crisis in no small part due to supply chain disruption. as a recent atlantic council report (terp & jahn, ) noted, ''(l)arge amounts of seeds, fertilizer, and agro-chemicals are shipped between ports. as a result, ports can form a single point of failure in a complicated system, particularly where a country or region is heavily reliant on freight through a specific port.'' needless to say, any disruption of the food supply, in advanced or developing countries, will affect a broad swath of the population and certainly be seen as a risk of globalization. consumer electronics have complex supply chains that could certainly be affected by the virus. for example, virtually all of apple's iphones are assembled in china. the lockdown in malaysia impacted chip and circuit board suppliers, while the engineers who work on cellular modems are in germany and the plants that produce power management chips are located in italy, germany, and the uk, all suffering shut downs due to covid- (eadicicco, ) . a consumer who may use an iphone daily without thinking about the marvels of the complex global supply chain that brought it to them, will certainly become aware of the risks of globalization when a part needed for a repair or even a replacement phone is not available. as noted above, unlike lord keynes, the majority of the population most likely does not spend time marveling at the fact that global economic integration provides a vast cornucopia of goods at an affordable price. it is taken as the norm. however, the disruption of that flow of goods is inherently obvious to most observers and is certainly not taken as a normal state of affairs. a lack of leadership while america's leadership of the global economy since has been viewed ambivalently, it has also been seen by many as necessary. a stable, open international economy requires a hegemon, a dominant power who can provide some of the necessary public goods, absorb costs, and order the system. as kindleberger ( ) observed, the inability of u.k. and the unwillingness of the united states to continue or assume that leadership role was one of the primary causes of the collapse of the first global economy and the great depression. it is reasonable to argue that the u.s. is now neither willing nor able to assume leadership of the global economy, and that it will be difficult for either china or europe to take its place in the near future, resulting in what bremmer ( ) has called a ''g- world.'' the instability that is likely to result will certainly add to the negative views of globalization held by many. more generally, the repudiation of international economic integration and of the international system established after wwii to facilitate flows of trade and investment by the two countries most responsible for its birth -''america first'' and brexit -has unquestionably contributed to a more negative view of globalization. the leaders of both countries have demonized internationalism in general and opposed international economic, cultural, and social exchanges more specifically. while my purpose here is analysis rather than forecasting, it is reasonable to ask whether globalization will continue to be seen as ''the thing that goes bump in the night.'' over the last century and a half, globalization has been a cyclical phenomenon, and there is reason to believe that we have reached a plateau if not the peak of the second, late twentieth century wave. at the same time, we face an increasing flow of anti-globalization rhetoric and perceptions, fanned by populists taking full advantage of the covid- pandemic. the emergence of a more positive view of globalization will require at least three major interrelated changes to minimize its costs while still taking advantage of its benefits: first, restoring the balance between economic independence and integration; second, mitigation of the costs of globalization both within and between countries; and last, insuring some degree of redundancy and supply risk mitigation. ever since adam smith's argument for specialization in the manufacture of pins, the quest for economic efficiency has driven larger and largerscale integration of production, both in terms of plant size and geographic scope. by the late twentieth century, specialization -of both production and technology -was truly global in scope, and borders were no longer significant barriers to the flow of goods and ideas. hyper-globalization (rodrik, b ) entailed both great benefits and great risks. the unprecedented access to a wide range of more affordable goods and rapid technological development came with an unprecedented degree of economic (and political) interdependence and economic dislocation in advanced countries. it is reasonable to argue that what the u.s. trade representative has called a ''lemming-like desire for efficiency'' (lighthizer, ) and lower costs may have gone too far and that some balance between integration and national independence needs to be restored. restoring that balance, however, is a politically fraught, and an overreaction is likely. that overreaction will be compounded by populist demagogues exploiting the fear of the ''other'' who exacerbate concerns about socio-cultural integration. second, the costs in terms of dislocation and inequality will have to be dealt by each country on its own terms. within countries, more efforts will have to be made to offset the costs of globalization through retraining and social welfare programs, and to more fairly distribute the benefits. that will certainly require income transfers to both support welfare efforts and effect redistribution. to say that is politically fraught, given ideological differences among countries and the political influence of wealth in many, is an understatement. restoration of a positive attitude towards globalization will also require transfers between countries. the very negative reaction to the wave of migrants reaching europe is certainly a significant factor in the rise of anti-globalization sentiment. national and multi-national efforts to stem the flow through interdiction have very obvious limits. in the long run, the only solution, in both europe and the u.s., is to try to remedy the problem at its source: to increase standards of living in the countries that are the sources of migrants. that will also require income and wealth transfers of various forms from wealthy to poor countries. again, to say that an effort of that sort would be unpopular given current conditions is an understatement. last, some degree of redundancy and supply risk mitigation will have to be built into the system. regardless of efficiencies, the pandemic has shown that severe problems can result from depending on single sources of supply for critical products or technologies. similarly, complex global supply chains have proven vulnerable to problems at ''choke points'' that can bring the entire production process to a halt. resolving problems resulting from single-sourced products or technologies and complex supply chains will involve a large number of private firms, both global and national. coordination problems both within and across countries will be immense and conflicts between a firm's objectives and national interest will prove difficult to resolve. none of this bodes well for a dramatic change in attitudes about globalization in the short run. the covid- pandemic has raised some very real problems arising from global integration -social and political as well as economic -and reinforced national feeling and fears of ''the other'' that are all too easy to exploit. that said, the pandemic itself demonstrates that disintegration or de-globalization has its limits; it is one of a number of critical problems of a scale that require international cooperation. a successful search for a vaccine will require a global effort. while political borders may be closed, scientists have been ''creating a global collaboration unlike any in history. never before, researchers say, have so many experts in so many countries focused simultaneously on a single topic [development of a vaccine] and with such urgency'' (apuzzo & kirkpatrick, ) . climate change is another existential problem that cannot be dealt with on a country by country basis. no single country can prevent rising sea levels from ''invading'' its territory and mitigation demands global cooperation. unfortunately, that conclusion is not yet shared by all. it will be difficult to achieve that cooperation in the face of the economic nationalism characteristic of the world at this point. in particular, the ''mutual vilification'' between the united states and china, the two major powers, is limiting cooperation between them, and the current geopolitical environment creates a climate more conducive to national competition than international cooperation (sanger, kirkpatrick, zimmer, thomas, & wee, ) . we are in great danger of throwing the baby out with the bathwater. the china syndrome: local and labor market effects of income competition in the united states spatialities of globalization covid- changed how the world does science, together a g- world: the new economic club will produce conflict not cooperation euprope panicking over india's pharmaceutical export curbs apple's supply chain still strugeling to retrun to normal even a china recovers from the pandemic will the corona virus end globalization as we know it. foreign affairs: this week virus adds to backlash in a world intertwined the postnational coalition: political essays the economic consequences of the peace the world in depression the architecture of globalization: state sovereignty in a networked global economy bricks and mortar in a borderless world: globalization, the backlash and multinational enterprise trade and wages, reconsidered the era of offshoring of u.s. jobs is over the geographical pivot of history the communist manifesto populism and the econommics of globalization straight talk on trade: ideas for a sane world economy coronavirus travel restrictions, across the globe profits and pride at stake, the race for a vaccine intensifies the new global history: toward a narrative for pagaea two globalists: the end of empire and the birth of neoliberalism earth day call for action: mitigating the global food crisis associated with covid- world health organizaton. . situation reports this paper is part of a series of contributions dealing with the implications of the covid- pandemic on international business policy publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -kio itg authors: lafleur, jean-michel; vintila, daniela title: do eu member states care about their diasporas’ access to social protection? a comparison of consular and diaspora policies across eu date: - - journal: migration and social protection in europe and beyond (volume ) doi: . / - - - - _ sha: doc_id: cord_uid: kio itg despite the growing literature on sending states’ engagement with their populations abroad, little is known so far about their role in helping the diaspora deal with social risks. as argued in this chapter, this is mainly because past studies on sending states’ policies and institutions for the diaspora have failed to systematically focus on social protection, while also ignoring that regional integration dynamics often constrain domestic responses to the welfare needs of nationals residing abroad. this volume aims to fill this research gap by comparatively examining the type of diaspora infrastructure through which eu member states address the vulnerabilities faced by populations abroad in five core areas of social protection: health care, pensions, family, unemployment, and economic hardship. drawing on data from two original surveys with national experts, we operationalize the concepts of descriptive infrastructure for non-residents (i.e. the presence of diaspora-related institutions) and substantive infrastructure (i.e. policies that provide and facilitate access to welfare for nationals abroad) in order to propose a new typology of states’ engagement with their diaspora in the area of social protection. do sending states care about the well-being of their citizens residing abroad? in recent years, numerous studies have examined sending states' policies and institutions targeting non-resident nationals. to underline the fact that such policy arrangements and initiatives generally concern individuals sharing some form of heritage with a homeland of which they may or may not hold nationality, they tend to refer to this population as diaspora (adamson ) . in documenting the growth in sending states' activism and creativity in engaging with this population, scholars have identified several explanatory variables including increasing mobility, economic dependence on migration (especially remittances), democratization, the desire to gain political support from citizens abroad, or a shift to neo-liberal modes of government (ragazzi ) . in this introductory chapter, we argue that existing attempts to classify states' engagement with citizens abroad face four important limitations. first, past studies focused mainly on policy innovations developed by sending states to engage with citizens abroad in areas such as citizenship, education, business, culture or religion. this hinders the possibility of generalising existing classifications to other specific policy areas that are of key interest for the diaspora, such as the one of social protection. while recent work has acknowledged the existence of sending states' policies aiming to respond to the social risks faced by non-resident citizens (delano ) , the role of welfare institutions in their design and implementation has not received sufficient scholarly attention. second, existing studies do not engage sufficiently with the concept of consular assistance that, despite the limitations set by the vienna convention on consular relations, still varies greatly in its availability and content across states. third, whether it draws on small or large-n studies, past research mainly focused on sending states from the global south, therefore failing to notice developments in this area in the north and particularly among european union (eu) member states. finally, the focus on the nation state overlooks the fact that sending states' ability to respond to the needs of citizens abroad can be seriously constrained or triggered by regional integration dynamics (such as the eu), intergovernmental bodies (such as the international organization for migration) or complemented by policies adopted by sub-national public entities. this volume focuses on eu member states' engagement with their diaspora in the field of social protection. to do so, we use the concept of diaspora infrastructure to identify how engaged sending states are in addressing the social risks faced by populations residing abroad in five key areas of social protection: health, employment, old age, family, and economic hardship. for each eu member state, authors closely examine the core policies by which consular, social affairs-related ministries and ad-hoc diaspora institutions address risks in those areas. to highlight the variation in countries' engagement with their diaspora in the field of welfare, this volume insists particularly on policies that go beyond the eu framework of social security coordination as established by regulations no. / and / . overall, the objective of this introduction and the country chapters included in this volume is to reconsider the meaning of sending states' policies for nationals abroad and provide an alternative typology of their engagement by taking into account the array of policies and institutions through which they deal with social protection issues faced by their diaspora. full text available here: http://legal.un.org/ilc/texts/instruments/english/conventions/ _ _ . pdf. accessed march . looking at the success of the concept of diaspora in the study of the relation that migrants maintains with their homeland, some scholars have noted that this notion is regularly described as over-used and under-theorized (anthias ) . following a period of heavy proliferation of the term, scholars such as dufoix ( ) or brubaker ( ) have stressed the confusion around the concept. brubaker ( ) however, argued that it matters less to clearly identify what constitute a legitimate use of the concept than to acknowledge the existence of narrower and broader ways of using this notion. such variations rely on the meaning given to its three core constitutive characteristics: dispersion, orientation towards the homeland, and relations with the host society. the country chapters included in this volume demonstrate that states define their diaspora very differently and this definition naturally influences the type of policies they adopt. for instance, the chapter on france shows how the french government has developed specific social programmes for nationals residing abroad in situation of need and/or unable to join destination countries' social protection schemes. the extension of state-sponsored solidarity towards nonresidents is therefore justified as a privilege associated to citizenship. on the contrary, several central and eastern european countries such as hungary or slovakia (see country chapters in this volume) also developed policies for individuals considered as part of their diaspora based on ethnic or cultural criteria. however, in the case of dual nationals or individuals who gave up their nationality while acquiring the citizenship of another country, the incentive for the homeland to engage in welfare may be more limited, as these individuals can access their residence countries' social protection system. in this scenario, homeland authorities may consider cultural or return policies-more than social policies-as critical instruments to maintain or strengthen links with co-ethnics residing abroad. the perimeter of eu member states' diaspora engagement strategies is further blurred by three additional elements. first, because of the different historical, political, and socio-economic contexts in which emigration from eu countries has taken place, this phenomenon is not equally salient across all member states. variations in the demographic weight of the diaspora -often derived from the different timing of migration outflows-still exist, thus representing an important contextual element for examining states' engagement with this population. as shown in fig. . , the relative size of the diaspora over the total population of each eu member state varies greatly, from less than % in spain or france to % or more for latvia, romania, lithuania, ireland, cyprus, croatia or malta. of course, timing of emigration is a particularly relevant aspect here. countries with longer history of emigration (e.g. italy, ireland, spain, greece, finland) naturally have had more time to respond to these significant outflows by implementing policies for citizens abroad compared to newer emigration countries (especially member states from central and eastern europe). second, eu member states have to deal with different categories of nationals residing abroad who potentially have different social protection needs, depending on their countries of residence. on the one hand, there are those residing in other eu member states. this first group benefits from the eu citizenship status and associated rights, including the right to free movement and residence in the eu, as well as the eu legislation on equal treatment and social security coordination. as shown in fig. . , more than % of the diaspora population of belgium, finland, luxembourg, romania, and slovakia are intra-eu migrants. these countries may thus have fewer incentives to develop diaspora and consular policies in the area of welfare since the vast majority of their non-resident nationals are, in any case, covered by the eu legislation. yet, as noted by ragazzi ( ) , existing diaspora studies tend to neglect regional integration as a form of state engagement with citizens abroad. this entails that our current understanding of who is a "protective" state for its diaspora and who is not does not take the reality of eu integration into consideration. figure . also points towards a second cluster of eu member states (including malta, estonia, latvia, germany, croatia, greece, italy, denmark, and sweden) for which more than a half of their diaspora resides in non-eu destinations. these states' engagement with non-resident nationals in the area of welfare is often limited to basic consular services (themselves regulated by the vienna convention), a right to be helped by consular authorities of other eu countries (deriving from the directive on consular protection for eu citizens living or travelling outside the eu ) and social security agreements signed with third countries. less frequently, eu citizens residing in non-eu countries can benefit from ad-hoc social protection policies designed for the diaspora and/or maintain some access to homeland welfare benefits (see the discussion on substantive infrastructure below). third, beyond the distinction between eu and non-eu destination countries, diaspora populations tend to concentrate in a handful of countries of residence. table . displays the top five destination countries of each eu member state's diaspora. interestingly, more than a half of the irish, finnish or slovak diaspora is concentrated in a single country. less surprisingly, some large western democracies such as the united states of america (usa) or canada have become important destinations for the diaspora population of several eu countries, whereas germany and the united kingdom (uk) rank as top host countries for more than % of the non-resident population of other eu member states. concentration of the diaspora, we argue, is an important element that could shape states' policies towards their nationals abroad. more specifically, concentration and mobilization of the diaspora in one host country in particular may push homeland authorities to adopt tailoredmade policies that apply only to citizens residing in that country (as opposed to developing policies for all non-resident nationals, regardless of their destination countries). chapters included in this volume therefore take the precaution of specifying the geographical scope of policies when they are restricted to certain destination countries. in the previous section we have called for a broadening of the definition of states' engagement with nationals abroad, to take into account different types of sending states' social protection interventions. in prior attempts to measure states' commitment with populations abroad, scholars have coined new concepts that move partially or fully away from an exclusive focus on diaspora policies. unterreiner and weinar ( : ) , for instance, distinguish immigration policies from emigration policies, which they define as "all policies that regulate (either facilitate or limit) outward migration, mobility across countries and possible return". although this categorization is conceptually attractive, it however neglects that certain policies (such as bilateral social security agreements) are often both emigration policies through which sending states facilitate physical relocation (e.g. by allowing pension contributions in home countries to be recognized in host countries) and immigration policies through which receiving states aim to facilitate integration by limiting individuals' exposure to social risks. clear-cut distinctions are thus not obvious. in line with the literature that focuses on intentionality, unterreiner and weinar ( ) further distinguish diaspora policies as "policies that engage emigrants and members of diaspora communities (both organised groups and individuals) with the countries of origin, building a sense of belonging and strengthening ties". their definition of diaspora policies is therefore close to what pedroza et al. ( : ) understand as emigrant policies, that is "policies that states develop specifically to establish a new relationship towards, or keep links with, their emigrants". for pedroza and colleagues, emigrant policies therefore exclude the hard-to-distinguish host states' immigration policies, home states' policies enabling departure and, most importantly, most consular tasks as defined by the vienna convention on consular relations. surprisingly, with the exception of the work of delano ( delano ( , , the role of consulates in assisting emigrants to deal with risks abroad has not received significant scholarly attention. so far, the literature has assumed that, while important cross-country variations in the presence of consulates exist, services are broadly similar and limited to: strengthening commercial, economic, cultural, and scientific relations between home and host countries; issuing passports and travel documents; serving as a notary and civil registry; and assisting detained nationals abroad (aceves ) . these missions derive from article (e) of the vienna convention that vaguely defines consular functions as "helping and assisting nationals, both individuals and bodies corporate, of the sending state". for okano-heijmans ( ), the concept of 'consular affairs' is commonly used to refer to assistance to non-resident citizens in distress, but states tend to leave these concepts open to interpretation which, de facto, leaves significant discretionary power to consulates in dealing with citizens abroad. the lack of conceptual clarity in the definition of consular services and the fact that the delivery of certain services is sometimes left at the discretion of authorities renders the comparison between eu member states difficult. accordingly, when examining consular policies (along with other diaspora policies), this volume focuses primarily on policies based on norms adopted by legislative and/or executive-level homeland authorities; and discretionary measures and administrative practices are only mentioned for illustrative purposes. in the case of eu countries, significant attention has also been paid to consular functions exercised by any eu member state for eu citizens living in third countries in which their state of nationality is not represented. council directive / stipulates that consular assistance is limited to cases of: death, serious accidents or serious illness, arrest or detention, being a victim of crime, relief and repatriation in case of emergency, and the need for emergency travel documents (see faro and moraru ( ) for an in-depth discussion of consular practices of eu countries). however, the emphasis on this specific policy -presented as a response to the needs of eu citizens residing in third countries-is limitative in two ways. first, it overlooks the fact that consulates may play a critical role in their nationals' access to social protection even within the eu. as discussed by palop-garcía (this volume) or nica and moraru (this volume), the presence of romanian and spanish social affairs attachés in different consulates throughout the eu is a testimony of the relevance of such consular actors whose presence and activities aim to reduce practical inequalities in access to welfare. second, consular services of many member states are moving away from a model based on physical presence in destination countries to a more diverse offer that also includes e-services and mobile consular services (i.e. temporary detachment of consular personnel) in cities where no consulate is present. overall, this brief discussion on consular services in the eu highlights the necessity for our country chapters to provide a deeper analysis of the physical availability (and variations in content) of consular services for eu citizens in situation of international mobility, whether they live inside or outside the eu. facing difficulties in accessing benefits in the host country and loosing entitlements gained previously in their home country are frequent issues met by international migrants. state cooperation in the area of welfare can address these problems, although this cooperation is often hindered by varying conditions of access to benefits across states and their different funding schemes. even within the eu, specific benefits can be contribution-based in one member state and simply not exist or be tax-financed with severe means testing in another (see lafleur and vintila a in this series). when it comes to accessing public healthcare or contributory pensions, for instance, mobile eu citizens benefit from the most advanced regime of state cooperation to deal with the social risks of individuals in situation of international mobility (holzmann et al. ; avato et al. ). this privileged position when compared to other international migrants is further reinforced by the legal framework on non-discrimination, equal treatment, and the right to reside applicable across the eu. in other words, in the process of encouraging labour mobility to achieve the single market (maas ) , eu member states have contributed to the deterritorialization of their social protection systems. as a result, residence outside the territory of a specific welfare state stopped being an obstacle to maintain some form of access to social benefits from that state. portability and exportability of welfare entitlements are thus key features of this deterritorialization process. portability is one's ability the preserve, maintain and transfer acquired social security rights in areas such as pensions or healthcare, independently of one's nationality or residence country (holzmann et al. ) . welfare authorities of migrants' sending and receiving states typically tend to agree on portability of pension entitlements to ensure that individuals with a history of international mobility who have paid contributions in different countries are not deprived from accessing pensions. for eu citizens overseas who do not benefit from the eu legal framework on pensions, a number of international treaties and conventions from institutions such as the international labour organisation or the united nations are designed to set minimum standards and encourage-with little binding force-good global practices. nonetheless, because of the lack of coordination in the external dimension of eu social security, portability rights of eu citizens living outside the eu still depend on member states' ability to enter social security agreements with third countries. in this volume, country chapters explicitly discuss such agreements and show that almost all member states have signed bilateral or multilateral social security agreements with the third countries that represent the main destinations for their diaspora. exportability refers to individuals' ability to receive a particular benefit to which they are entitled while residing outside of the territory of the welfare state that pays for it. here again, pensions are, by far, the most commonly accepted form of exportable benefit (holzmann et al. ; vintila and lafleur ) . country chapters in this volume also show that bilateral agreements between eu member states and third countries tend to include pension exportability. however, only contributory pensions tend to be exportable, as non-contributory pensions are frequently reserved for residents. similarly, some member states may reduce the amount of pensions when beneficiaries reside in specific third countries (pennings ) . regulation / on social security coordination provides further illustrations of the fact that mobile eu citizens residing in other member states have access to a more favourable exportability regime when compared to eu nationals residing in third countries. for instance, the regulation allows eu citizens moving to another member state for the purposes of finding a job to export unemployment benefits for three months (up to a maximum of six months). it also explicitly envisages the exportability of family benefits when the country where the parent works and the country where the child resides are not the same. for eu citizens moving outside the eu, on the contrary, the assumption is that their access to family benefits will be determined by the host country' regulations and, when applicable, bilateral/multilateral agreements. additionally, the european health insurance card (ehic) also allows eu nationals to access state-provided medical healthcare during temporary stays in other eu member states, iceland, liechtenstein, norway and switzerland, under the same conditions and at the same costs as individuals insured in those countries. beyond these examples, only few benefits are exportable; and in general, non-contributory benefits are typically designed to respond to the needs of residents (vintila and lafleur ) . yet, in the next section, we highlight the fact that several member states have adopted specific responses to the social protection needs of their diaspora. in this section, we use the concept of diaspora infrastructure to compare eu sending states' diaspora institutions and policies that address the social protection needs of their non-resident nationals. as discussed, existing conceptualizations of sending states' policies do not capture adequately the specificities of eu member states, while also overlooking origin countries' policies in the area of welfare. past studies usually distinguished between two types of diaspora institutions (agunias and newland ; gamlen ). first, there are government-led bodies such as ministries, sub-ministries or agencies functioning as administrations which respond to the specific needs of populations abroad or maintain a connection (of economic, cultural or political nature) with non-residents. second, other bodies function as consultative or representative institutions of the diaspora and often include members from the diaspora via election or appointment. their function is generally to defend diaspora's interests in the home country's policy-making process. sending states' institutions that enable citizens abroad to access host or home countries' welfare benefits have therefore often been overlooked in the literature. the concept of infrastructure has experienced a growing use in migration studies with the literature on "arrival infrastructure" studying the interaction between the local environment and immigrant integration (meeus et al. ). anthropologists such as kleinman ( ) also refer to infrastructure to describe both the physical environment and the web of social interactions that allow precarious migrants to get by. with the concept of diaspora infrastructure, we aim to highlight the fact that sending states' engagement with nationals abroad in the area of welfare consists of both institutions (consulates, ministries or sub-ministries in charge of emigration issues) and policies (rights and support services) aiming to protect the diaspora against vulnerability or social risks. confronted with the diversity of home country institutions and policies relevant for citizens abroad, we have chosen to articulate the notion of diaspora infrastructure based on two different (but sometimes interconnected) conceptual dimensions. inspired by the literature on political representation of minorities (see pitkin ; phillips ; powell ; bird et al. , among others ), we distinguish between descriptive and substantive state infrastructure for nationals abroad. considering the well-documented trend among sending states to engage only symbolically with their diaspora by creating institutions that perform limited tasks or by adopting policies with limited impact on diaspora's welfare (gamlen ) , the distinction between descriptive and substantive infrastructure is particularly appealing to qualitatively assess sending states' engagement. in our view, descriptive infrastructure captures the extent to which sending states create an institutional setting that specifically targets the diaspora in its scope and aims. this concept captures the "presence" of homeland institutions that explicitly acknowledge the diaspora as main reason for their existence, while formally being granted the mission to act in its interests (including welfare-related interests). as discussed below, descriptive infrastructure may include a sending country's consular network, but also ministries, sub-ministries, agencies or representative bodies that perform a public mission in the interest of the diaspora. substantive infrastructure, on the other hand, refers to the existence of policies in the area of social protection by which sending states provide rights and services that address diaspora's social risks. as we show below, an extensive substantive infrastructure can be measured not only by the diaspora's ability to benefit from some level of coverage from the home country's welfare state, but also by the capacity of sending states' authorities to provide practical support to nationals abroad who are in need. of course, having an extensive descriptive infrastructure does not necessarily mean that states also adopt extensive policies through which they actively respond to diaspora's social protection needs, as specific diaspora institutions may be created only symbolically while still veiling a rather superficial sending states' responsiveness to the concerns of nationals abroad. alternatively, states may still be able to ensure a comprehensive substantive infrastructure for nonresident populations even in absence of a widespread institutional network formally working in the interest of the diaspora. yet, the mere existence of an extensive public structure of institutions can still carry an important symbolic weight, as it may be considered as a formalised recognition of diaspora's importance for the homeland. an extensive descriptive infrastructure is thus expected to be correlated with an extensive substantive infrastructure, although it is not a sufficient, nor a necessary condition, for the latter. from an empirical viewpoint, our assessment of descriptive and substantive diaspora infrastructure relies on two large-n datasets designed in the framework of the erc-funded project "migration and transnational social protection in post (crisis) europe" (mitsopro). the diaspora policy dataset was created by collecting a large amount of data on national policies, using a standardized questionnaire filled by experts on consular and diaspora policies across countries (including the eu member states analysed here). in our description of substantive infrastructure, we also use some data on welfare entitlements of citizens abroad from a second mitsopro dataset on access to social protection, drawing on a second survey on national social protection policies with social policy experts across the same countries (see vintila and lafleur for further details). http://labos.ulg.ac.be/socialprotection/. accessed march . the surveys were conducted between april -january and several rounds of consistency check were centrally conducted by the mitsopro team. given the period in which the surveys were conducted, the country chapters included in this volume focus mainly on the policies in place at the beginning of . in some countries (spain, italy, germany, portugal or belgium), sub-national level authorities also develop policies towards the diaspora. while this research focuses on national-level policies, examples of such sub-national policies are provided for illustrative purposes in the respective country chapters. as previously mentioned, we operationalise sending states' descriptive infrastructure as the institutional framework that comprises home countries' public institutions at the national level which meet both conditions of having a mandate to engage primarily with the diaspora and being active in the adoption or implementation of social protection policies that benefit this population. institutions that form the descriptive infrastructure can have either direct relations with the diaspora (e.g. when an institution provides the diaspora with a specific service/benefit) or indirect ones (i.e. when it only participates in the design of diaspora policies). similarly, some of these institutions can be solely present physically in the home country, while others can operate in (all or selected) countries of residence. regardless of the intensity of their interactions with the diaspora or the main location of their activities, all the institutions that compose a country's descriptive infrastructure however share the characteristic of performing a public mission that contributes to addressing diaspora's social protection needs. the use of this specific definition of descriptive infrastructure has two important implications for assessing how protective states are towards their non-resident populations. first, by focusing on public institutions with a legal mandate to govern or administrate states' relations with the diaspora, the limited number of eu member states, such as ireland, that usually fund non-state actors (e.g. migrant associations) to perform missions of assistance to the diaspora may appear as less engaged. similarly, because we focus on national institutions, the limited number of subnational institutions that exist in some eu countries are also excluded from our measurement of descriptive infrastructure. however, when relevant, both regional actors and state-funded non-state actors are discussed in the country chapters for illustrative purposes. drawing on this definition and the information provided by the country chapters in this volume, fig. . shows a comparative overview of the descriptive infrastructure that eu countries put forward for their diaspora. the figure captures three types of institutions that are analysed below: a) consulates; b) governmental institutions (covering ministry and sub-ministry level institutions for non-residents) and; c) interest-representation institutions (either at the legislative or consultative level). as observed, there is substantial variation across eu countries in the repertoire of institutions they create to engage with the diaspora. some member states (especially romania, italy, portugal, croatia, france, greece, and spain) show a higher variety of institutions dealing with non-residents when compared to other countries (particularly estonia, finland, luxembourg or sweden), which return a very limited descriptive infrastructure for nationals abroad. as noted previously, consulates perform different missions for citizens abroad that are relevant for their access to welfare. these missions range from the delivery of indispensable documents to access certain benefits (e.g. life certificate to continue receiving a home country pension while abroad), direct provision of benefits (e.g. consular financial assistance in case of exceptional hardship), information provision on home and host countries' welfare systems (e.g. on their website, via brochures or information sessions) and, more exceptionally, assistance to access benefits (see below). the country chapters included in this volume provide details that point towards an important variation between eu member states in the type of services they offer. some also discuss how certain eu countries have engaged in the deterritorialization of their consular services by offering mobile consular services (i.e. physical movement of consular staff to locations where no consulate is present) or by allowing some consular services to be delivered electronically without the need for citizens to move. figure . identifies the "physical presence" of consulates in destination countries, defined as the total number of consulates that each eu member state has in the top five residence countries of their diaspora. although some honorary consulates also offer limited administrative services to citizens abroad, we excluded them from the analysis, thus focusing exclusively on consulates offering the widest range of consular services in each member state's consular law. this approach of focusing on the five largest destination countries of eu member states' diaspora populations is in line with our concept of "descriptive infrastructure" whose core idea is that the presence of homeland institutions should be reflective of the presence of citizens abroad. of course, this approach also faces certain limitations. for instance, there may be reasons to open a consulate-such as the desire to increase trade, cultural or political relations with a particular country-that are not necessarily related to the presence of the diaspora. also, when a large share of the diaspora in a particular destination country already holds that country's nationality or shows high levels of socio-economic integration, the incentive of sending states to open/maintain consulates in that specific destination country may be weaker. lastly, the geographic size of destination countries and diaspora's concentration in the territory of those receiving states can further influence the presence of home country consulates. honorary consulates frequently perform a symbolic role in representing a state's interests abroad and are often run by non-professional diplomats. in certain cases, they also offer limited administrative services to citizens abroad. it should also be noted that, in certain countries, what we refer here with the generic term of honorary consulate is called differently (e.g. royal consulates in denmark). ; and limited (red) when the number of consulates is lower than . regarding the network of governmental institutions for the diaspora, we consider it as extensive (green) for countries with at least a ministry for the diaspora; moderate (yellow) for countries with only sub-ministerial institutions; and absent (red) for countries that have neither type of institutions. interest-representation institutions are measured as extensive (green) when a country has at least reserved seats in the national parliament for diaspora representatives; moderate (yellow) when it has only consultative institutions for nationals abroad; and none (red) when neither of these interest-representation institutions exist bearing in mind these limitations, fig. . (and the part on consulates in fig. . ) allow us to distinguish three clusters of eu member states according to their consular presence. first, a group of seven member states have at least consulates in total in the top-five destination countries of their diaspora and can therefore be considered as returning an extensive consular presence. this group includes five countries from south and south east europe with a long tradition of large scale emigration (spain, italy, portugal, greece, and croatia), romania (which started to experience substantial migration outflows especially since the s), and one large former colonial power which has one of the most sizeable diaspora populations in absolute terms (france). a second cluster includes north western and central and eastern european countries that return a moderate consular network (between and consulates in top destination countries). the third cluster comprises nine member states with more limited consular presence (less than consulates in top destination countries). this group concentrates smaller eu countries (less than eight million inhabitants). overall, while this classification gives us an indication of sending states' willingness to be physically present where their diaspora concentrates, it does not tell us whether such presence is adequate considering the size of the diaspora in those countries. in fig. . , we propose an estimation of the adequacy of such consular presence by highlighting how many potential individuals the consular network of each eu member state has to serve in the top five destination countries. for clarity purposes, the data is presented according to our typology of consular presence (extensive, moderate, limited, as explained above). two important patterns emerge. first, among the states with moderate or extensive consular networks, a group of four member states (romania, france, germany, and poland) have to serve potentially much more citizens per consulate than other countries in these clusters, this questioning their ability to face a particularly high demand of services. second, among states returning a limited consular presence, we unsurprisingly find a majority of countries with limited diaspora presence in top five destinations, which somewhat justifies the rather small number of consulates they set up. yet, we also find two member states (slovakia and finland) whose nationals abroad concentrate mostly in one destination country, hence the demand of consular services in these specific states is much higher. the second category of institutions that are part of eu member states' descriptive infrastructure are governmental institutions for the diaspora. in line with the definition of agunias and newland ( ) , these are homeland public institutions at the ministerial and sub-ministerial level whose legal mandate primarily consists in engaging with the diaspora and which design or implement policies aiming to (c) member states with limited consular network (less than consulates in top destination countries) source: own elaboration based on mitsopro data. there is no consular representation of cyprus in turkey, hence this case appears with value " " respond to the perceived social protection needs of nationals abroad. to distinguish between ministry and sub-ministry level institutions, we rely on their criteria of "hierarchical independence" according to which only ministry-level institutions have stable financial means and can manage the diaspora portfolio in all its dimensions (agunias and newland ). sub-ministry level institutions, in turn, are executive-level agencies or departments hierarchically dependent on ministries (typically, the ministry of foreign affairs or the ministry of labour), but whose missions go beyond basic consular services set by the vienna convention. however, differences in the level of autonomy enjoyed by these institutions are not always reflected in their names. state secretaries, for instance, are autonomous from ministries in some countries, while being directly associated to or dependent on this criterion allow us to exclude ministry of foreign affairs' consular affairs departments that are present across all eu member states. certain ministries in others. hence, institutions with similar names sometimes belong to different categories of governmental institutions. in fig. . , we considered member states that have at least a ministry for the diaspora (which means that they can also have sub-ministerial institutions in addition to the ministry) as returning a strong network of governmental institutions. this choice is also justified by the fact that ministry-level institutions are undoubtedly an indication of the greater visibility that some eu countries wish to grant to the diaspora population. following this approach, states that have only sub-ministry level institutions are considered as having a moderate offer, while those who have neither type as having no network of governmental institutions for nationals abroad. our comparative analysis reveals that, at the time of data collection ( ), romania-which also represent one of the eu countries with the fastest growing emigrant population in recent years-was the only member state with a ministerial body in charge of engaging with the diaspora. as explained by nica and moraru (this volume), the ministry for romanians abroad was recently institutionalised (ten years after the country joined the eu), thus further extending the institutional network that the romanian government has started to design for its diaspora even before the large emigration wave during mid-late s. however, as noted in different country chapters, such ministries for the diaspora often tend to appear and disappear as new governments take power. this is the case of italy and france, which had such ministry-level institutions in the past, but no longer do. although most member states have not specifically created ministries aiming to address the needs of nationals abroad, the majority of them do have sub-ministerial institutions to represent diaspora's interests. such institutions are present across eu member states (fig. . ) , including countries with a long-standing emigration history such as greece, ireland, italy or spain, but also more recent emigration countries such as poland or bulgaria. these sub-ministerial institutions however enjoy varying levels of autonomy. as explained in the country chapters, some member states have departments tasked with engaging with the diaspora, which are located within the ministry of foreign affairs (e.g. italy's directorate general for italian citizens abroad and migration policies) and, occasionally, the social affairs ministry (e.g. spain). such institutions usually benefit from less autonomy than adhoc agencies set up in a number of member states. lastly, only three states have sub-ministerial institutions in the form of political positions that grant their holders larger room for manoeuvre to design policies, while being hierarchically dependent on another ministry (see the special envoy for expatriates of the czech republic, ireland's ministry of state for the diaspora and latvia's ambassador for the diaspora). moreover, our findings also show that seven eu countries (belgium, denmark, estonia, finland, luxembourg, the netherlands, and sweden) still consider that their bureaucratic dealings with the diaspora should be limited to basic consular services. consequently, these countries have not designed ministerial or sub-ministerial institutions for their nationals abroad. the third type of homeland institutions considered for our operationalisation of descriptive infrastructure are interest-representation institutions, i.e. home country public institutions with a legal mandate to voice diaspora concerns in the home and/ or host country. many chapters show how frequent it is for eu member states to have institutions that officially allow representatives of the diaspora to communicate (in a non-binding way) their concerns in the homeland via assemblies, councils or forums. yet, a handful of member states also have interest-representation institutions organized at the destination country level, such as the committees of italians abroad organized at the consular level to act as a link between the diaspora and consular authorities. by definition, interest-representation institutions are expected to cover a wide range of issues relevant for the diaspora (e.g. passport delivery, dual citizenship, access to culture, etc.), but they are also likely to include more niche welfare-related interests into the domestic political agenda of the homeland, as long as this is a relevant issue of concern for nationals abroad. we distinguish between two types of interest-representation institutions. first, legislative-level institutions represent diaspora's interests in the national parliament (in either or both chambers, when applicable) through members of the parliament (mps) elected by voters residing abroad. in fig. . , we considered that eu member states offering such legislative representation for the diaspora put forward an extensive infrastructure. as observed, five member states currently allow their nonresident citizens to elect their own mps (croatia, france, italy, portugal, and romania) . this presence of elected mps for the diaspora is an indication of the electoral visibility that states give to their nationals abroad, but the limited number of seats available for external constituencies also reveals the limited capacity that these constituencies actually have to influence the legislative process (see also vintila and soare ) . second, interest representation can also take the form of specific representative institutions whose role of defending diaspora's interests is officially acknowledged in public policies adopted by homeland authorities. when compared to parliamentary seats for the diaspora, these representative bodies have far less visibility in homeland politics and policies, although they usually enable a dialogue between diaspora representatives and a multiplicity of homeland actors. for this reason, eu member states that only have this type of bodies for their nationals abroad are considered to return a moderate type of interest-representation institutions in fig. . . the members of such bodies are either appointed by homeland authorities or elected by citizens abroad. while they are homeland public institutions, their mission of interest representation may be oriented towards the homeland and/or the countries of residence. our results indicate that this type of representative bodies are present across eu member states in total; in of them (see the cases marked in yellow in fig. . ) , such bodies constitute the only interest-representation institutions that states make available for non-residents. our findings also show that, overall, eu member states do not count with any type of interest-representation institutions for their diaspora. this cluster (marked in red in fig. . ) includes austria, belgium, cyprus, denmark, estonia, finland, germany, luxembourg, the netherlands, slovakia, and sweden. in addition to the consular, governmental and interest-representation institutions already captured under our umbrella concept of descriptive infrastructure, several chapters also mention other institutions that are still relevant for the diaspora populations of eu member states. however, they have not been included in our definition of descriptive infrastructure as they fail to meet the double condition of having a primary mandate to engage with nationals abroad and participate in the design/ implementation of policies aiming to respond to diaspora's social protection needs. among these institutions, some have prerogatives in the area of welfare, such as the presence of representatives of the spanish ministry for social affairs in specific consulates abroad. others-quite common across all eu countries, except for belgium, malta, and slovenia-are cultural institutions aiming to provide services abroad related to cultural, educational, linguistic or religious affairs of the home country (language courses, school networks supported with homeland's funds, or general promotion of cultural activities abroad). finally, several chapters also discuss the relevance of homeland parties operating abroad with the aim to defend diaspora's interests in origin countries. in this section, we question the assumption that the existence of diaspora institutions is a sufficient condition to determine states' engagement with nationals abroad in the area of social protection. we argue that descriptive infrastructure offers only a limited picture of how protective states are of the diaspora; and that a comprehensive assessment of their engagement with non-residents should also consider the content of homeland public policies that enable nationals abroad to deal with social risks, regardless of the characteristics of the institutions implementing such policies. we define the later as substantive infrastructure. we operationalise this concept via two dimensions: on the one hand, the role of sending states as social protection providers (i.e. provision role) and on the other hand, their function of facilitating access to welfare for non-resident nationals (i.e. facilitation role). we define sending states' provision role as their ability to maintain a form of state-sponsored solidarity with the diaspora, either by allowing non-resident nationals to remain eligible from abroad for homeland-based social protection schemes or by creating special schemes specifically designed to address the welfare needs of this population. in volume of this series (lafleur and vintila a), we demonstrated that, within each one the five policy areas analysed here (i.e. unemployment, health, family, old-age, and economic hardship), there are important variations in the array of specific social benefits that member states make available to different categories of (mobile and non-mobile) individuals. we further showed that the eligibility criteria for accessing such benefits often vary even within the same policy area. to enable the comparison between member states' policies towards their diaspora, we have therefore chosen in table . to focus on one core benefit per policy area. our analysis thus covers the following benefits: unemployment insurance benefits (depending on a qualifying period of contribution); contributory pensions (for individuals who reached the retirement age and/or sufficient years of contribution); family benefits (or "child benefits", covering the costs of bringing up children); health benefits in kind (access to doctors, hospitalisation, treatment) and social assistance (means-tested benefits aiming to prevent poverty). for each benefit, we consider that member states that allow nationals residing abroad to access home country benefits regardless of where they live (in the eu, the european economic area (eea) or in third countries) put forward an extensive form of engagement with the diaspora. at the opposite pole, countries that strictly restrict access to welfare entitlements to residence in their territory, thus automatically disqualifying non-residents from receiving such benefits, show no engagement with the social protection of their diaspora. finally, member states that do allow benefit exportability for non-resident nationals, but condition it to specific categories of individuals (such as those residing in particular countries) or to certain periods of time (only during short stays abroad), show only a moderate type of engagement. for this intermediary category, it is important to note that the eu legislation has pushed all member states to adopt at least a moderate type of engagement with their diaspora. indeed, the eu social security coordination framework made member states more engaged with their nationals abroad in terms of recognition of the possibility to export certain benefits when leaving one's country of nationality. this applies for almost all benefits analysed here, except for social assistance; although it is restricted only to nationals of eu member states who move to other eu/eea countries. as explained above, mobile eu citizens can continue to receive unemployment benefits for a short period when moving to another eu country with the purpose of finding a job. similarly, they can receive medical treatment during short stays in another member state based on the ehic. the eu legislation also allows intra-eu migrants to receive contributory pensions from abroad, as well as family benefits in their eea countries of residence, although the child resides in another eea country. all these different situations in which eu nationals continue to enjoy social protection when moving abroad due to the eu legislation are categorized in table . as moderate engagement, as they are always restricted in scope by covering only those moving to another eu/eea country. yet, some states have decided to take a step further in this regard by implementing diaspora-oriented social protection policies that go beyond this eu framework, thus putting forward an extensive engagement with their non-resident populations. in addition to the provision role, the second important function that makes up sending states' substantive infrastructure is the facilitation role, which refers to policies by which homeland authorities support citizens abroad in the administrative procedures to access home or host country welfare entitlements. it is therefore a policy-based commitment to facilitate access to social protection and an explicit recognition by homeland authorities that holding formal welfare rights in the home or host country is often not sufficient to access those rights in practice. three important remarks need to be made regarding this definition of the facilitation role. first, unlike the previous sections of this chapter that looked exclusively at benefits delivered by the homeland, in this section we acknowledge that homeland authorities can play an active part also when it comes to helping nationals abroad to access welfare schemes granted by their residence countries. for this reason, table . distinguishes between the facilitation role to access home country and host country benefits. second, our analysis of the facilitation role focuses on the same benefits previously discussed for the provision role: unemployment benefits, health care, family benefits, social assistance, and pensions. third, we consider as support the array of activities conducted by homeland authorities beyond mere information provision. as discussed in the country chapters, providing information on home/host countries' welfare systems via websites and brochures, in person at consulates or even the facilitation of contacts of local ngos and institutions active in the field of welfare is a very widespread practice eu member states. in our view, active support however entails an intervention in citizens' individual cases by providing personalized assistance and/or representation of interests in administrative dealings with welfare authorities. from this perspective, the delivery of life certificates by consulates or providing information on pensions on the consulates' website, for example, cannot be considered as active support, but actual assistance to submit paperwork and ensure communication with pension authorities does qualify in this category. to operationalise the level of support offered by homeland authorities to their diaspora, country experts examined the policies that define the missions of all institutions that compose each country's descriptive infrastructure to determine if such support is part of their missions. similarly to other indicators used to measure sending states' substantive infrastructure, we identified three levels of engagement in the facilitation role. sending states with policies that identify a specific responsibility of any institution to support nationals abroad in applying for any host/home country benefits are considered to offer extensive support. sending states whose policies only mention a general principle of support in the area of welfare are considered to offer moderate support as this usually leaves significant room for discretion to actually implement such active assistance. lastly, sending states whose policies do not even mention a principle of welfare-related support are considered to have a low level of engagement. keeping in mind these remarks, table . compares eu member states according to the benefits they provide for non-resident citizens (column on provision role) and their engagement in facilitating diaspora's access to welfare in home or host countries (column on facilitation role). as observed, when it comes to the provision role, eu countries seem quite reluctant to extend welfare rights to their non-resident nationals. this goes in line with our previous findings (vintila and lafleur ) according to which, regardless of diaspora's size or its economic and electoral leverage, eu member states subscribe to a restrictive pattern that disqualifies nonresidents from in-kind or cash benefits, as entitlement to most of these benefits remains conditional upon residence in the country. when benefit exportability is possible, this is generally driven by the eu legislation. as mentioned, thanks to the implementation of eu social security regulations, all member states currently put forward at least a moderate level of engagement with their nationals abroad when it comes to the type of benefits granted to the diaspora. as shown in table . , with the exception of pensions which are generally exportable worldwide (with few exceptions of countries which allow pension exportability only to eea countries, unless otherwise stipulated in bilateral agreements), very few member states went beyond the eu legislation in granting social rights to non-resident populations. interesting examples of pro-active diaspora engagement initiatives come from france and belgium in the area of health care. as explained in the country chapters, these two member states have set up special insurance schemes for their nationals moving to non-eu countries, allowing them to receive medical treatment either abroad or at home. it is also interesting to note that, in the area of social assistance -which is not covered by the eu social security legislation-, most member states have not implemented any financial assistance scheme for nationals abroad who are facing strong economic hardship beyond mechanisms of consular cash advances (sometimes nonreimbursable) usually designed to help citizens facing emergencies while temporarily abroad (e.g. tourists). yet, france, italy, spain, austria, and portugal also offer some conditional type of economic support for citizens permanently abroad to help them deal with unpredictable medical issues and/or economic hardship. this type of support usually takes the form of (either recurrent or non-recurrent) non-reimbursable financial help, although it varies substantially in its scope, aims and claim procedure. for instance, recurrent non-contributory benefits can be delivered by consular authorities, as it happens with austria's fund for the support of austrian citizens abroad or france's fixed-term social allowance. in some cases, only specific groups qualify for such exceptional financial assistance. as illustrated in this volume, this is the case of portuguese pensioners abroad who do not meet minimum subsistence levels and can apply for the "social support for the deprived elderly of the portuguese communities". as for the facilitation role, table . demonstrates that france, italy, and spain represent the eu member states that have assumed the most pro-active stance in facilitating the access of their nationals abroad to home or host country's welfare benefits. the normative framework in these three countries clearly identifies an obligation for sending states' authorities of different types to take an active role in the delivery of some homeland benefits. in the respective country chapters, this commitment is identified in the mission of france's consular council, italy's welfare advice agency and spain's departments of employment and social security at the consular level. on the other hand, romania, bulgaria, and croatia put forward a more moderate engagement in this regard, as their consular policies only state a general commitment to support the diaspora to exercise social rights, without further details on the extent or content of such mission. finally, lithuanian authorities also provide assistance to nationals abroad to access welfare schemes from the home country, but not from the host. the other member states do not provide any specific type of active support for facilitating non-residents' access to welfare, apart from mere information on eligibility conditions for different types of social benefits. finally, although eu states' policy responses towards their diaspora populations in the context of the covid- pandemic fall outside of the scope of this volume, it is also important to note that many member states have adopted an array of emergency measures for their citizens abroad in situation of need during this pandemic. some of these measures were specifically intended to provide practical help to nationals abroad affected by the covid- crisis (see examples of repatriation initiatives ), whereas in others, such measures focused on facilitating consular assistance and/or providing information regarding the social protection schemes of home and host countries. at the outset of this introductory chapter, we postulated that existing research on diaspora policies does not take into consideration benefits and services deriving from the eu membership that protect eu citizens in situation of international mobility. when it comes to social protection, we showed in volume of this series (lafleur and vintila a) that, unlike other migrant groups, mobile eu citizens benefit from advanced access to their eu host countries' welfare systems. with the concepts of descriptive and substantive infrastructure, this chapter therefore aimed to identify institutions and policies that-beyond the eu framework-provide an additional layer of protection for diaspora populations of eu member states, whether they live inside or outside the eu. figure . summarizes our main findings regarding member states' performance in terms of descriptive and substantive infrastructures, thus aiming to generate a typology of sending states' engagement with nationals abroad in the field of social protection. the figure allows us to draw several important conclusions. first, almost half of eu member states return a limited descriptive and substantive diaspora infrastructure. this seems to indicate a strong disengagement with their non-resident populations, as these countries combine a limited institutional network for the diaspora with limited engagement in providing or facilitating their access to welfare. yet, a closer look at the geographical distribution of their diaspora allows us to nuance this conclusion. to begin with, for six of those member states (austria, cyprus, (fig. . ) . the vertical axis captures states' substantive infrastructure, calculated as an average of their active engagement in the provision role and the facilitation role (table . ) belgium, finland, luxembourg, and slovakia), most of their nationals abroad (up to more than % in some cases) concentrate in the eu. hence, these countries may not perceive themselves as having global responsibilities towards their diaspora, especially since, by virtue of the eu citizenship status, most of their nonresident nationals are already protected in terms of access to welfare by eu regulations. accordingly, these six member states in particular are solely disengaged with a minority of their diaspora, namely those residing in non-eu countries. of the remaining states in this first cluster, the country chapters demonstrate that some, which have a majority of non-resident nationals living outside the eu, are not necessarily less engaged. for instance, both denmark and sweden have norway as a top non-eu destination for their diaspora and cooperate closely in the area of welfare with this country in the framework of the eea and the nordic agreements. similarly, over one third of the estonian and latvian diaspora populations concentrate in the russian federation and are special minority groups with a particular status detailed in the respective country chapters. lastly, malta returns a limited descriptive and substantive infrastructure, although it has concluded advanced bilateral cooperation with the main non-eu destination countries of its diaspora. for instance, more than % of maltese nationals abroad reside in australia, but a bilateral agreement signed with this country ensures pensions payment abroad. second, at the opposite end of the spectrum, a group of five eu member states, including france, italy, spain, portugal, and romania, show a very strong engagement with their citizens abroad. all five countries combine extensive descriptive and substantive infrastructures for the social protection of non-resident nationals. in general, this position reflects a domestic political discourse about the importance of keeping ties with populations across the globe. of these countries, romania stands out as the eu member state that, despite its relatively recent history of large-scale emigration, has put forward the most extensive network of descriptive infrastructure for its citizens abroad, which currently represent more than % of the country' total population. however, unlike france, italy or spain, romania returns a more moderate engagement in the facilitation of its diaspora's access to homeland benefits, although this might be partially explained by the fact that most romanians abroad (up to %) reside in other eu member states where they already have access to social protection due to the eu citizenship status. similarly, france also stands out in this cluster as the country with the strongest substantive infrastructure that allows its nationals abroad to keep accessing welfare benefits from france while residing outside europe (see the discussion on the special insurance scheme for non-resident french in the corresponding country chapter). a third cluster of countries combines a strong descriptive infrastructure with rather limited provision and facilitation role of sending states in ensuring nonresidents' social protection. the eu member states included in this cluster seem to confirm the importance of the symbolic dimension of state-diaspora relations. in this case, a strong level of institutionalization of diaspora relations does not automatically lead to an extensive array of policies and services for citizens abroad. country chapters on the czech republic, greece, lithuania, poland, and slovenia demonstrate clearly that the development of diaspora institutions has not been guided by welfare concerns, but rather by the desire to promote homeland identity abroad. in that strategy, social protection appears with a low priority, especially when compared to culture, education or citizenship. ireland seems to be an outlier of this third cluster as despite its relatively high level of institutionalisation towards the diaspora, it has limited diaspora-oriented social protection policies. as discussed in the country chapter, this position can be explained by the fact that ireland subcontracts its welfare missions to non-governmental actors in the main destination countries of its diaspora. country chapters also illustrate the existence in other member states of this kind of policy of funding migration organizations whom, in some cases, perform services of relevance to the diaspora in the area of welfare. their activities, however, fall outside of the scope of our study on policies since, by definition, such organizations are not part of the sending states' policy framework (i.e. not set in official norms) and cannot therefore be considered as a sending state response to the needs of the diaspora stricto sensu. also, due to the fact that their funding is often limited in time and activities are oriented towards specific destination countries, it becomes difficult to draw any meaningful generalization from the observation of such activities. finally, this comparative overview also allows us to conclude that there is no eu member state which has implemented extensive social protection policies for its diaspora without also having a well-developed institutional framework to engage with, consult or represent this population. this is visible in fig. . by the absence of cases combining a strong substantive infrastructure with a limited descriptive infrastructure. in other words, states that aim to go beyond the eu framework in their diaspora protection policies tend to be those that have institutions that allow dialogue, contact and representation with this population. lastly, the peculiar position of lithuania at the centre of the graph deserves a word of explanation. like most other member states, lithuania has a moderate substantive infrastructure with a dedicated institution at the sub-ministry level and a consultative body for diaspora affairs. similarly, its engagement policies in the area of social protection are broadly limited to the eu framework. yet, unlike in other member states, the lithuanian consular code identifies clear (but limited) responsibilities of its consulates in assisting citizens abroad to apply for some home country benefits. the rest of the chapters included in this volume provide an in-depth analysis of eu member states' responsiveness to the social protection needs of their diaspora populations, by providing rich empirical examples of the repertoire of policies and programmes through which eu countries engage with their nationals residing abroad. after providing a short overview of the main characteristics of the diaspora of each eu member state, country chapters critically examine the network of institutions that home countries authorities have designed for their nationals abroad. by highlighting their key engagement policies to address diaspora's needs and by comparing the content of policies/services available to non-resident nationals, country chapters thus provide a detailed assessment of the centrality of social protection issues in the overall policy framework by which eu member states dialogue with their populations abroad. open access this chapter is licensed under the terms of the creative commons attribution . international license (http://creativecommons.org/licenses/by/ . /), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license and indicate if changes were made. the images or other third party material in this chapter are included in the chapter's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the chapter's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. the vienna convention in consular relations: a study of rights, wrongs, and remedies sending states and the making of intra-diasporic politics: turkey and its diaspora(s) developing a road map for engaging diasporas in development: a handbook for policymakers and practitioners in home and host countries. geneva: international organization for migration and migration policy institute evaluating 'diaspora': beyond ethnicity? social security regimes, global estimates, and good practices: the status of social protection for international migrants the political representation of immigrants and minorities: voters, parties and parliaments in liberal democracies revisiting "the 'diaspora' diaspora mexico and its diaspora in the united states: policies of emigration since from here and there: diaspora policies, integration, and social rights beyond borders diasporas consular and diplomatic protection: legal framework in the eu member states (final report of the care (citizens consular assistance regulation in europe human geopolitics: states, emigrants, and the rise of diaspora institutions portability regimes of pension and health care benefits for international migrants. an analysis of issues and good practices adventures in infrastructure: making an african hub in paris migration and social protection in europe and beyond (volume ). comparing access to welfare entitlements migration and social protection in europe and beyond free movement and discrimination: evidence from europe, the united states, and canada arrival infrastructures: migration and urban social mobilities diaspora policies, consular services and social protection for romanian citizens abroad connecting with emigrants: a global profile of diasporas change in consular assistance and the emergence of consular diplomacy. the hague: netherlands institute of international relations 'clingendael diaspora policies, consular services and social protection for spanish citizens abroad emigrant policies in latin america and the caribbean migrants' access to social protection in the netherlands the politics of presence: the political representation of gender, ethnicity and race the concept of representation political representation in comparative politics a comparative analysis of diaspora policies introduction: integration as a three-way process migration and access to welfare benefits in the eu: the interplay between residence and nationality report on political participation of mobile eu citizens: romania. globalcit political participation reports acknowledgements this chapter is part of the project "migration and transnational social protection in (post) crisis europe (mitsopro)" that has received funding from the european research council (erc) under the european union's research and innovation programme (grant agreement no. ). in addition to this chapter, readers can find a series of indicators comparing national social protection and diaspora policies across countries on the following website: http://labos.ulg.ac.be/socialprotection/. we wish to thank angeliki konstantinidou for her assistance in compiling the international migration data used in this chapter. source: own elaboration based on mitsopro data. regarding the provision role, the type of engagement for each benefit is categorised as follows: (a) unemployment benefits (extensiveworldwide exportability; moderate-exportability only for short periods when moving to eea countries; none-no exportability); (b) health care (extensive-beyond eu legislation, additional scheme allowing non-residents to maintain homeland health insurance to cover medical treatment abroad or at home; moderate-medical treatment during short stays in the eu based on ehic; none-no in-kind benefits for non-residents); (c) pensions (extensive-worldwide exportability; moderate-exportability in the eea or based on bilateral social security agreements; none-no exportability); family benefits (extensive-worldwide exportability; moderate-exportability in the eea or based on bilateral agreements; none-no exportability); social assistance (extensivegranted to nationals abroad, regardless of their host countries; moderate-conditional financial help in situation of economic hardship; none-no assistance for non-residents) key: cord- -pv fb d authors: imtyaz, ayman; abid haleem,; javaid, mohd title: analysing governmental response to the covid- pandemic date: - - journal: journal of oral biology and craniofacial research doi: . /j.jobcr. . . sha: doc_id: cord_uid: pv fb d abstract background and aims covid- , which started as an epidemic from china in november , was first reported to who in december . it had spread to almost all countries globally by march . the pandemic severely affected health and economy globally, prompting countries to take drastic measures to combat the virus. this study aims to analyze different governments' responses to the pandemic to gain insights on how best to fight the coronavirus. methodology various data analysis operations like clustering and bivariate analysis were carried out using python, pandas, scikit-learn, and matplotlib to clean up, consolidate, and visualize data. insights were drawn from the analysis conducted. results we identified that the mortality rate/case fatality rate is directly proportional to the percentage of elderly (people above years of age) for the top thirty countries by cases. countries in western europe showed the highest mortality rates, whereas countries in south asia and the middle east showed the lowest mortality rate (controlling for all other variables). conclusion lockdowns are effective in curbing the spread of the virus. a higher amount of testing resulted in a lesser spreading of the virus and better control. in most regions, countries that were conducting a large number of tests also seemed to have lower mortality rates. in december , doctors in the hubei province of china started reporting cases of a new type of viral disease that they found hard to treat. the disease seemed to have originated in the city of wuhan. within a few weeks, the disease spread like wild fire across many provinces in china, prompting the authorities to effectuate a complete shutdown of economic, commercial, social, and cultural activities, to quell the spread of the virus .within the span of to months, the virus had made landfall in europe and america, spreading rapidly with the help of air travel and unrestricted movement of people across open borders (in europe). by mid-march, the virus had landed in almost all of the un member states and was declared a pandemic. countries most affected by it had enacted some form of a lockdown or the other to stop its spread. efforts were made to enforce social distancing in the early stages to various degrees in different countries to stop the growth rate from exponential. however, thus far, only a handful of countries have had success in curbing the virus. as of st june : - . million cumulative cases have been reported globally, with deaths and recoveries numbering at thousand and . million, respectively. this study aims to establish a basis for the causal relationship between the severity of the pandemic in a country and the government's handling. if such a relationship can be established, it can give governments vital insights that can be used to enact effective policy and legislation against the pandemic. this study will focus on drawing insights from publically available data and statistics on the coronavirus. the data that will be considered for the study are aggregated covid- patient statistics like daily cases, deaths, recoveries, testing data, etc. python has been used for carrying out the analysis. the study's depth will be limited to some exploratory data analysis, data analysis for correlation and cause-and-effect relationships, bivariate analysis, data visualization, and some k-means clustering. data from the worst affected countries (by cases) are considered in this analysis. the data used in the analysis conducted were obtained from publically available, and the government reported statistics on covid- patients in their countries. the primary dataset used is sourced from the john hopkins university center for system science and engineering (csse). the dataset consisted of aggregated data from various sources such as the who, european center for disease prevention and control, the united states cdc, and various other governmental and non-governmental organizations. the raw form data consisted of total cases segregated at city and district levels for every country. the cases were grouped by country in the analysis. link to the data source (github): https://github.com/cssegisanddata/covid- . testing data was collected from ourworldindata.org. link to the data source (ourworldindata.org): https://ourworldindata.org/grapher/number-ofcovid- -tests-per-confirmed-case. the analysis is based on data up to st june . statistical analyses were carried out on the data using well documented and practised methods. the software used is ubiquitous, open-source, and unquestioned in their accuracy and mode of operation. the data's sample size was big enough to consider the data to represent the population, and as such, generalizations could be made for the whole population using the insights obtained from analyzing the data. countries were separated into groups based on the percentage of their elderly population, and the covid- mortality rate (total deaths/total cases). the method is used to divide the countries into groups is the k-means clustering method, based on the elkan algorithm . the k-means method aims to reduce intra cluster variance while maximizing inter-cluster variance. feature scaling was not needed as both the features were on a similar scale from the start, and both features were given equal priority in the clustering. the number of clusters and number of dimensions/features did not warrant giving any aforethought to considerations of computational costs and complexity. the initial centroids were selected at random from the dataset. five clusters are identified as they seemed to stratify the data in the most convenient and explanatory manner, without sacrificing too much in terms of the sum of the squared distance of all the clusters (loss/error function). the analysis was carried out on the jupyter notebooks platform, using the python programming language. • pandas -used for storing data; pandas is a data storage, handling, and manipulation package used with python. • matplotlib -charts and graphs were generated using the pyplot library from matplotlib, a popular data visualization package for python. • scikit-learn -k-means clustering was done with the help of the sklearn. cluster library from scikit-learn, a popular machine learning, and data preprocessing package used with python. link to the code for this analysis: https://github.com/aymanimtyaz/covid- government response to the coronavirus pandemic can be divided into two parts: • efforts in curtailing the spread of the virus (i.e., flattening the curve) • efforts in the handling and treatment of covid- positive patients one metric to gauge the efficacy of government response in handling covid- positive patients is the mortality rate/case fatality rate. the mortality rate is the total number of deaths attributed to the virus divided by the total number of covid- positive cases. analysis of early cases in china led to the observation that the virus poses a more considerable danger to the elderly and people with some underlying comorbidities such as hypertension, diabetes, and heart disease , . this trend continued as the virus spread around the world. it has been established that the coronavirus poses an enormous amount of danger to the elderly. more than per cent of the deaths attributed to the virus are in elderly patients, considering a worldwide average. as we can see from the chart below, there seems to be a linear relationship between the mortality rate and the percentage of older people (people above the age of ) in a country. the variance in the chart may/can be attributed to other factors, such as handling of covid- positive patients, methods of data collection and reporting, other population demographics like genetic makeup, trends in disease, disabilities, and malnutrition, competency, scale, and accessibility of the country's medical apparatus, economic status of the country (gdp, ppp, poverty levels, etc.). the countries on the chart in figure have been clustered into five groups using the k-means clustering algorithm. we shall examine each group below. the cluster towards the upper right-hand corner of the chart is the one with the countries having the highest percentage mortality and the highest percentage of older people compared to the other clusters apart from the cluster containing germany and portugal. the prime reason for the high mortality is evident from the chart itself, a more significant number (by percentage) of older people in these countries. all these countries belong to western europe, except sweden. however, sweden's mortality rate has been increased owing to other reasons which we shall discuss further. more than half of belgium's covid- deaths are in care homes for older people. belgium comes third in place in europe for the number of people in old-age homes per . it, coupled with belgium having among the highest percentages of people above , may have increased the rate. one point to note is how belgium counts deaths due to the virus. a significant percentage of the counted deaths have not been tested positive for the virus. almost all of the people, in this case, resided in old age homes. the justification given for counting them in the deaths is that if there is even one confirmed case in an old age home, and if a significant amount of people die in a short period close to the diagnosis of the confirmed case, showing similar symptoms. there is a high probability that those people also died due to the virus. this method may have resulted in a small number of false positives, which may have wrongly increased the rate. unlike other countries in the top cases list, sweden did not implement a lockdown. it merely encouraged its citizens to stay indoors. public places like restaurants, bars, businesses, schools, and universities were allowed to remain open. it may have contributed to the increased mortality rate; however, how much the decision against a lockdown influenced the mortality rate remains to be seen. apart from their decision to not implement a lockdown, a large proportion of sweden's elderly also resides in nursing homes, just like belgium. unlike belgium, however. sweden only attributes deaths to the virus after a positive test has been confirmed. this cluster consists of the united states, canada, switzerland, germany, and portugal. in this group, germany and portugal seem to be doing very well concerning the percentage of elderly in their population. up until late april, germany had a case fatality rate of %- %. this has been attributed to the amount of testing the germans had been carrying out, unlike other european countries having similar age demographics. germany was testing at a much higher rate. they were even testing young people with mild symptoms. the number of cases is directly proportional to the testing level, and as these two stats increased, the mortality rate started to drop. germans also have a large amount of trust in their government, which, throughout the pandemic, has maintained a very high level of transparency and communication with the public, giving updates to them on the daily. as such, social distancing norms given by the government were rarely broken by the german public. portugal's low mortality rate is accredited because they started responding to the pandemic well before it spiralled out of control. portugal declared a state of medical emergency when they had a few or so cases, compared to spain, who declared an emergency when the growth had already gone exponential, and they had around cases. portugal is also unique because, unlike other european countries, it only has one land neighbour through which inter-country road-based transmission of the disease was possible. it had also managed to isolate more than % of the cases to of its cities, lisbon and porto. people with mild symptoms were instructed to stay at home, while series cases were admitted in hospitals. the united states currently leads the charts in cases in deaths by a wide margin. lockdowns were imposed on varying levels across the country, and different states have handled the pandemic differently. the situation was also highly politicized, with different media outlets giving a different spin to how the situation is. much misinformation is being spread, resulting in sections of the public flouting social distancing norms. this group consists of the latin american countries of peru, brazil, ecuador, and mexico. along with iran, china, and turkey. the clustering algorithm seems to have clustered these countries together based on the elderly's percentage, as the intra-cluster variance in mortality rate is very high. mexico warrants a little discussion here. it has an unusually high case fatality rate of %. one of the prime reasons for this is that mexico has one of the lowest testing rates globally, at around . tests per confirmed case. this means that they are not testing enough-the who recommends a testing rate of - tests per confirmed case for most countries. since the testing rate is so low, that the mortality rate gets inflated, low testing rates may result in improper handling of the spread of the virus , . more the number of people tested, more the number of positive cases isolated, and a lesser amount of untested, covid- positive people who can go around spreading the virus. the cluster towards the lower-left corner consists of those countries, which show a low mortality rate and have the lowest percentage of the elderly among all the countries. the cluster can be further divided into three groups. the first group consists of saudi arabia, qatar, and the united arab emirates, which are the gcc's three foremost countries. these countries have large immigrant worker populations that mostly consist of young males who reside in large dormitories, much like singapore. these countries also have many monetary resources that they can utilize in treating covid- positive patients with a high standard of care. as such, they all boast mortality rates of less than %. the second group consists of the countries in the indian subcontinent: -india, pakistan, and bangladesh. they have mortality rates between % and %, in the early stages of the epidemic. these countries had implemented among the strictest lockdowns in the world. india and bangladesh have only just lifted their lockdowns. the lockdowns have had a definite impact on curtailing the cases' spread, as both india and bangladesh have seen record increases in the number of new cases daily after the lockdowns were lifted. the only remaining country in this group in south africa has also implemented a lockdown a few weeks after detecting its first case. much like other countries in africa, south africa also has a large proportion of young people who may help offset the mortality rate. however, health conditions like obesity, hypertension, etc. are prevalent there. according to some statistics, over half of all south africans are considered to be overweight. the result of this comorbidity seems to be reflected in the age distribution of deaths, two-thirds of deaths due to the virus are in people below . this group consists of singapore, chile, russia, and belarus. about the percentage of elderly in these countries, the deaths seem to be less. if we follow the graph's linear trend, these countries should have a mortality rate of % to %. singapore has among the lowest covid- mortality rates in the first infected countries by cases. this can be attributed to the fact that over % of the confirmed cases are those of young migrant workers living in large, tightly packed dormitories where the virus's probability is high. an overwhelming majority of these workers show no to very mild symptoms, if at all. singapore is also one of the world's wealthiest countries, and as such, it can allocate a large number of resources towards combating the virus. russia has the third-highest number of cases globally; however, it reports one of the lowest mortality rates. the russian government attributes the low mortality rate to the late emergence of the virus compared to europe and north america, which gave it time to set up the infrastructure to handle the virus and gave it some precedent in what to do and what not to do. russia also has a high per capita testing rate. russia, belarus, and chile are accused of manipulating statistics related to the pandemic. this study identifies significant findings as: • european countries were found to have the highest case fatality rates, may be because of age demography and comorbidity • variance in the chart can be explained as being a result of government response to the pandemic • countries like germany, portugal, and singapore seem to have implemented reasonable measures against the virus, as their mortality rates are lower than in other countries with similar age demographics • countries like mexico and brazil need to increase their testing rate in terms of both per capita testing and several tests per positive case this analysis makes the following major inferences: • a relationship exists between the case fatality rate and the percentage of elderly in a country • a high testing rate (tests per capita) and a test per confirmed case rate of - help reduce the virus's spread and reduce/give a more accurate value of the case fatality rate • standardized testing and data collection protocols are needed across the globe for ensuring that the data being used in these kinds of analyses is worthwhile this research infers specific issues which are given below. we can say that government response to the pandemic can affect the pandemic's severity in a country. steps like enforcement of lockdowns and social distancing norms effectively curt the virus's spread, as we have seen in countries like india. smaller countries with less distributed population centres and good travel infrastructure are mediums through which the virus can rapidly spread (see: -europe). social distancing norms and lockdowns would have to be enforced with a higher stringency level to bring about any meaningful containment of the virus. testing is of paramount importance when it comes to combating the virus. it is through testing that statistics related to the pandemic are obtained. keeping this in mind, governments should allocate a more considerable amount of resources towards testing. the effect of other factors that may be related to the pandemic should be explored. this study has not covered any kind of forecasting. the topic of the study (covid- pandemic) is currently an evolving situation. the insights drawn from this study may not apply down the road. the data being considered is publically available; the government reported patient data from th january to st june . a problem like covid- cannot be modelled accurately in a bivariate system. thus, such a complex problem is almost certainly dependent on a host of other factors, apart from the elderly's percentage in a country. every country follows its protocols for reporting data and statistics related to the covid- pandemic. furthermore, the protocols may be different for subdivisions in the country. different states, districts, jurisdictions, etc. may have different methods of counting. this problem gets exacerbated by developing countries where there are not any protocols for data counting and reporting at all. this lack of consistency in reporting protocols may result in inaccurate data, which imparts inaccuracy to the analyses that use that data. russia, belarus, chile, china, etc. have been accused of manipulating their testing and patient data. other factors that can affect the mortality rate, apart from %age elderly are: • genetic makeup. • trends in disease, disabilities, and malnutrition • competency, scale, and accessibility of the country's medical apparatus • vaccination history • the economic status of the country (gdp, ppp, poverty levels, etc.) these factors should be taken into consideration in future analyses. a more in-depth study of the effects of lockdowns has to be done. lockdowns are harder to implement for poorer countries as their economy starts to shake. studies must be done to determine if these cycles of lockdowns are a viable option in fighting the covid- pandemic. moreover, if so, how to time and size different cycles of lockdown. none coronavirus disease in elderly patients: characteristics and prognostic factors based on -week follow-up using the triangle inequality to accelerate k-means covid- : how to fight disease outbreaks with data covid- -virtual press conference contentious issues and evolving concepts in the clinical presentation and management of patients with covid- infection with reference to use of therapeutic and other drugs used in co-morbid diseases clinical considerations for patients with diabetes in times of covid- epidemic key: cord- -uxtaw u authors: chowdhury, anis z.; jomo, k. s. title: responding to the covid- pandemic in developing countries: lessons from selected countries of the global south date: - - journal: development (rome) doi: . /s - - -y sha: doc_id: cord_uid: uxtaw u reviewing selected policy responses in asia and south america, this paper draws pragmatic lessons for developing countries to better address the covid- pandemic. it argues that not acting quickly and adequately incurs much higher costs. so-called ‘best practices’, while useful, may be inappropriate, especially if not complemented by effective and suitable socio-economic measures. public understanding, support and cooperation, not harsh and selective enforcement of draconian measures, are critical for successful implementation of containment strategies. this requires inclusive and transparent policy-making, and well-coordinated and accountable government actions that build and maintain trust between citizens and government. in short, addressing the pandemic crisis needs ‘all of government’ and ‘whole of society’ approaches under credible leadership. test for the 'international community' since the un's formation. he urged developed countries to immediately help less developed countries to bolster their health systems and capacity to check disease, especially covid- transmission. failure to do so, he warned, would contribute to 'the nightmare of the disease spreading like wildfire in the global south with millions of deaths and the prospect of the disease re-emerging where it was previously suppressed'. early precautionary measures in much of the rest of china and east asia, and in places such as kerala state in southwest india, were largely successful in containing the spread of the epidemic, at least thus far. but most national authorities outside of east asia did not take adequate early precautionary measures speedily enough to contain the spread of the outbreak, typically by promoting safe 'physical distancing', obligatory use of masks in public areas, and other measures to reduce the spread and likelihood of infection. societal vulnerability to infection and capacity to respond depend on many factors, including health care system preparedness, leadership experience and ability to manage specific challenges posed. government capacity to respond depends crucially on system capacity and capabilities-e.g., authorities' ability to speedily trace, isolate and treat the infected-and available fiscal resources-e.g., to quickly enhance testing capacity and secure personal protective equipment (ppe). funding cuts, privatization and other abuses of recent decades-in the face of rising costs, not least for medicines-have further constrained and undermined most public health systems, albeit on various different pretexts. of course, socio-cultural factors, such as more cooperation due to greater 'trust' in the authority, less individualistic and narcissistic cultures, and even the shared memory and experience of past outbreaks such as sars and nipah, have also been important. this review seeks to draw pragmatic lessons for developing countries to better address the covid- pandemic. it begins with a brief discussion seeking to understand distinctive characteristics of the pandemic infecting a large share of the world's population. it then evaluates the principal strategies adopted to address the health crisis, especially to enable national health systems to cope with the emergency. it is followed by reflections on the causes and implications of public health capacity vulnerabilities in developing countries. finally, it draws some implications of different policy responses in east asia, southeast asia-especially vietnam, and india's kerala state-argentina, brazil and peru, that are relevant for other countries. it argues that the costs of not acting quickly and adequately are higher. it further argues that so-called 'best practices', while useful, may be inappropriate, especially if not complemented by effective and suitable socio-economic measures. high degrees of public support and cooperation are critical for successful implementation of containment strategies without having to resort to wasteful and self-defeating draconian measures. this requires inclusive and transparent policy-making, and well-coordinated and accountable government actions that build and maintain trust between citizens and government. in short, addressing a pandemic crisis of this scale needs 'all of government' and 'whole of society' approaches under credible leadership. the covid- pandemic, caused by the sars-cov- virus, is now widely considered more infectious than other viral epidemics in last century following the spanish flu pandemic, especially since the deadly asian flu of the late s and hong kong flu of . the covid- fatality rate is lower than for the first severe acute respiratory syndrome (caused by sars-cov- ) in [ ] [ ] and is not more infectious than the h n virus, but has infected many more people nonetheless. several factors have made covid- more dangerous than other recent viral epidemics. first, its symptoms and consequences are rather diverse and can be quite severe, varying with age. for example, while covid- primarily affects the respiratory system, causing pneumonia, it has also been associated with gastrointestinal and neurological manifestations (christakis ) . those infected may also mistakenly attribute their symptoms to influenza or other health conditions. importantly, those infected with the sars-cov virus may be infectious well before showing any symptoms, seven coronavirus varieties have infected humans thus far: four caused sniffles, one caused the deadly mers outbreak in the middle east, first reported in saudi arabia in , with two others causing major international epidemics. the first caused sars, which petered out quickly, despite its high fatality rate, while the other causes according to the who, a total of , people in countries had sars; died between november and july , i.e., a death rate of . %, whereas the covid- death rate was . %, when it was declared a pandemic (woodley ) . consider two pathogens, x and y. for every thousand people, both cause people to become seriously ill, killing two each. but the second pathogen y also infects more people, only making them mildly or moderately ill, i.e., not killing them. so, the 'case fatality' rate (number of deaths per infected person) for x is % ( out of ), whereas for y, it is % ( out of ). but although this rate is lower for the second pathogen, y, it is no less lethal (christakis ) . 'transcript of the un secretary-general's virtual press encounter to launch the report on the socio-economic impacts of covid- ′. united nations https ://www.un.org/sg/en/conte nt/sg/press -encou nter/ - - /trans cript -of-un-secre tary-gener al%e % % svirtu al-press -encou nter-launc h-the-repor t-the-socio -econo mic-impac ts-of-covid - . accessed august . while as many as half of those infected, and hence infectious, may be asymptomatic, i.e., not show any symptoms of illness. hence, reliable new cheap and rapid tests for covid- infection promise to be a major 'game-changer'. r is the average number of individuals that an infected person infects when no interventions have been implemented; this number does not change. the 'reproduction rate'-referred to as r t or r e depending on preference or convention-will likely change as interventions are put in place, while the number of those susceptible changes due to infection and possible immunity. major variations due to 'super spreader' episodes further complicate understanding of the significance of average rates and of variations. while 'super-spreader' episodes have received much publicity, they have been exceptional with a lower variation in r t and hence less important for explaining contagion than 'normal' networks of viral transmission of covid- . again, with a lower fatality rate-the probability of a person dying-covid- has been particularly hard to contain as there are more infectious people around than if it were more deadly. hence, movement restrictions, physical distancing, self-isolation and other precautionary and preventive measures are important. the virus can spread from person to person during close direct or indirect contact with an infectious person (even before they have symptoms), contact with aerosol-or droplet-borne virus from an infected person, either directly or indirectly. infection, via mucous membranes in the mouth, nose or eyes, starts in the upper respiratory tract, typically in the throat or upper airways. elderly persons and people with other health issues, such as asthma, diabetes, obesity, hypertension, etc. are more vulnerable, and likely to face complications and death. improved understanding of covid- has been critical for designing and improving policy responses. the sars-cov virus was considered novel as it had never been seen in humans before. thus, initial responses in east, including southeast asia were drawn from known 'best practices' for testing, contact tracing, isolation and treatment. but, for various reasons, even these were not done in most countries outside asia. once the virus had spread widely, it was no longer practical or even possible to belatedly implement best practices effectively as case-loads not only overwhelmed hospitals, but also public health systems. differences with earlier viruses and epidemics meant that simple emulation of past containment measures have not always been appropriate, let alone optimally effective for containing covid- . government policymakers need to consider the general nature and specific variations of the covid- pandemic and its uniquely changing and varied implications in particular contexts. a standardized set of interventions, even ostensible best practices, is unlikely to be universally applicable, as the covid- pandemic has different ramifications in varied circumstances over time. the incubation period will require corresponding periods of quarantine or 'self-isolation'. the varied duration of 'mismatches'-e.g., due to incubation exceeding, or lasting longer than latency periods -imply that countries need to urgently acquire the ability to rapidly and reliably test as widely as necessary. as this has not been affordable for many, especially in poorer countries, the development of cheap, quick and reliable tests promises to be crucial. once widely available and used, such improvements in the speed, reliability and affordability of testing will have significant consequences. no one can be exempted from preventive or containment measures until it is definitively medically confirmed that all those once infected can be neither infected or infectious again. for the time being, face masks and shields, physical distancing and hand hygiene remain vital to containment efforts. the long-term health and economic impacts of covid- imply that public health and social protection systems should be well prepared to manage them. unfortunately, persuaded by the most influential, early western discourses, many politicians and others everywhere did not take the contagion threat seriously enough initially covid- appears to have lower r variation than sars, for example. this explains why the ebola epidemics with a terrifying fatality rate - % waned reasonably quickly. the period between becoming infected with a pathogen and showing symptoms is called the 'incubation period'. the 'latency period' is the time between becoming infected and being able to spread the disease to, i.e., infect others. there can be mismatches between the virus incubation period and the latency period. when the latency period is longer, an infected person may only display symptoms after they have actually become infectious, i.e., capable of infecting others. the sars-cov virus incubation period is generally longer than the latency period. thus, an infected person can spread the virus before symptoms of having covid- are visible. a saliva-based laboratory diagnostic test developed by researchers at yale to determine whether someone is infected with the novel sars-cov- virus was granted emergency use authorization by the us food and drug administration (fda) on august . with the technique made available on an open access basis, the cost and speed of testing can be radically reduced for all, with major implications for current precautionary and preventive practices and requirements. https ://news.yale.edu/ / / /yales -rapid -covid - -saliv a-test-recei ves-fda-emerg ency-use-autho rizat ion. accessed august . since june, south africa has been conducting trials for a -min covid- breath test, while israeli scientists claim to have developed a -s coronavirus breath test. https ://www.the-scien tist. com/news-opini on/in-south -afric a-covid - -breat h-test-trial -set-forjune- ; accessed august ; https ://medic alxpr ess.com/ news/ - -israe li-firm-secon d-coron aviru s.html. accessed august . for various reasons. these include not only cultural prejudice, but also misinformation and confidence in alternative approaches, such as 'herd immunity', all facilitated by the greater influence of social media. if and when an effective vaccine becomes available, there is no guarantee that it will be affordable and available to all without a strong multilateral commitment to ensure that it quickly becomes universally accessible. furthermore, there are likely to be significant populations who may refuse to be vaccinated en masse, e.g., where civil libertarian ideologies and mistrust of vaccines and authorities are pervasive. without such a shared commitment to universal access, it may be impossible to completely eradicate the covid- threat in the foreseeable future. recent us actions have not been encouraging for a concerted global response to the pandemic. as the largest financial contributor, the us decision to formally withdraw from the who will certainly hamper its efforts, not only for dealing with the current pandemic, but also for preventing or preparing for the next viral epidemic (mckeever ). earlier in april, president trump, using a korean war-era law, sought to redirect surgical masks manufactured by the us transnational firm m in other countries to the us, and to stop exporting masks manufactured by the company in the us (swanson et al. ). the us confiscated , us-made face masks bound for germany in bangkok, and redirected them back to the us for use there, a move the german minister condemned as 'modern piracy'. us buyers also offered three times more to secure face masks from china destined for france (willsher et al. when the who declared covid- a 'pandemic' on march , more than % of cases were in four countries (china, iran, italy and south korea), with new infections declining significantly in china and south korea, countries reporting no cases, and reporting cases or less (world health organization a). then, the who director-general (dg) expressed the hope that countries could still check the pandemic by mobilizing resources to detect, test, isolate, trace and treat those infected, quarantining them while they remain infectious. however, only a handful of east and southeast asian economies and kerala state in southwest india acted early, urgently and adequately, thus avoiding highly disruptive total lockdowns and associated human and economic costs. they also secured greater community support for containment, while minimizing draconian enforcement measures. had far more countries done so, while requiring safe physical distancing, mask wearing and other precautionary measures, the contagion could have been contained. and where communities or clusters had significant infection rates, urgent, targeted measures could have helped 'turn the tide' on covid- with decisive early actions, as in china, korea and vietnam, without imposing nationwide 'stay in shelter' or 'shelter in place' lockdowns, or restrictions on movements of people within its borders. lulled into complacency, most others were slow to respond, with some hoping or expecting the virus would bypass them, or believing that 'herd immunity' would protect most exposed to the virus. a few headstrong, but very influential government leaders refused to acknowledge the severity of the covid- threat, distracting many with conspiracy theories and 'blame games', instead of quickly learning from and correcting policy errors made as new knowledge became available. in the uk, developing 'herd immunity' in the population, by allowing the epidemic to spread, prevailed as official policy until the first imperial college of london (icl) study was issued on march. much harm could have been avoided if early precautionary actions had been taken. more than world leaders and experts signed an open letter before the world health assembly (wha) began on may, calling on governments to commit to a 'people's vaccine' against covid- , also calling for all vaccines, treatments and tests to be patent-free, mass produced, fairly distributed and available to all, in every country, free of charge https ://www.unaid s.org/en/resou rces/press centr e/ press relea seand state menta rchiv e/ /may/ _covid -vacci ne. accessed august . although the leaders of china, germany, france, norway and italy pledged at the wha to make vaccines developed in their countries a global public good, the usa remains non-committal. the united nations secretary-general also emphasized that everybody must have access to the vaccine when available. the wha unanimously acknowledged that vaccines, treatments and tests are global public goods, but was vague on the practical implications of the declaration. since then, the us, the uk, australia and other countries have signed up with the developers of 'candidate vaccines' to secure supplies for their own countries. 'ceasing all export of respirators produced in the united states would likely cause other countries to retaliate and do the same, as some have already done', m said. 'if that were to occur, the net number of respirators being made available to the united states would actually decrease. that is the opposite of what we and the administration, on behalf of the american people, both seek' (swanson et al. ). https ://www.bbc.com/news/world - . accessed august . the who maintained that physical distancing, 'effective' hand washing and related sanitary practices were the most effective, practically 'do-able' and affordable, and apparently did not want to distract from such 'non-pharmaceutical interventions'. one problem has been that many people believe that wearing masks is sufficiently protective in lieu of physical distancing and hand washing. but the use of protective face masks was actively discouraged by some national authorities, citing the very same who as the policy authority. the ostensible reason was to ensure adequate personal protective equipment (ppe) for 'frontline' workers, a view first associated with us presidential adviser, anthony fauci, as panic buying exhausted supplies and raised prices. thus, new infections and deaths quickly rose exponentially as the epidemic rapidly spread to other countries, especially to advanced countries in the west, better connected by passenger air travel. as developing countries struggle with inadequate vitally needed resources, many developed countries have acted in a jingoistic way by restricting exports of vital medical supplies, in contravention of the ihr and who recommendations. the principal strategy adopted by most governments is to 'flatten the curve', so that countries' health systems can cope with new infections by tracing, testing, isolating and treating those infected until an approved vaccine or 'cure' is available to all. but this is easier said than done. if testing, contact tracing and other early containment measures had been adequately done in a timely manner to stem viral transmission, nationwide lockdowns would not have been necessary, and only limited areas would have had to be locked down for quarantine purposes. the effectiveness of containment measures, including lockdowns, are typically judged primarily by their ability to quickly reduce new infections, 'flatten the curve' and avoid subsequent waves of infections. however, lockdowns can have many effects, depending on context, and typically incur huge economic costs, unevenly distributed in economies and societies. most 'casual' labourers, petty businesses reliant on daily cash turnover, and others in the 'informal' economy typically find it especially difficult to survive extended lockdowns. hence, success should not be measured by lockdown duration, enforcement stringency or even temporary declines in new cases. governments must be mindful of costs, including disruptions, and also of how policies affect various people differently. lockdowns have undoubtedly set back economic and social progress and people's welfare, but public policy should be directed to make such setbacks reversible, and to ensure they do not deliver economic 'knockouts' to the vulnerable. good planning, implementation and enforcement of movement restrictions, as well as adequate provisioning for those adversely affected, are crucial, not only for equity, efficacy and compliance, but also for transitions before, during, and after lockdowns. physical distancing, mask use and other precautionary measures, besides mass testing, tracing, isolation and treatment, have been able to check the contagion without resorting to draconian 'stay in shelter' lockdowns. such measures have been quite successful so far in much of east asia, vietnam and kerala. precautionary measures must be appropriate and affordable. those living in crammed conditions, e.g., urban slums, cannot realistically be expected to consistently practice safe distancing, but can nonetheless be enabled to sustainably take other precautionary measures within their modest means, e.g., by using washable masks or reusable shields in public areas. to minimize the risk of infection, authorities can encourage and enable, if not require, changes that demand 'physical distancing' in social interactions, including work and other public space arrangements, e.g., for offices, factories, shops, public transportation and classrooms. health systems in most developing countries are unevenly inadequate, even in normal times. despite several pandemics in recent years, most countries have remained poorly prepared, even for the specific challenges posed by covid- . even many health systems in europe and north america have faced major shortages of doctors, respirators/ventilators, basic infection prevention (bip) gear, ppe and testing kits. https ://apps.who.int/iris/bitst ream/handl e/ / /who-ncov-ipc_masks - . -eng.pdf?seque nce= &isall owed=y. accessed august . owing to the critical shortage of medical masks, the who's initial advice was to prioritize the use of face masks for people with covid- symptoms, those looking after those infected and other 'frontline' personnel. the who revised its policy with new interim reccomendations on june , https ://www.who.int/publi catio ns/i/ item/advic e-on-the-use-of-masks -in-the-commu nity-durin g-homecare-and-in-healt hcare -setti ngs-in-the-conte xt-of-the-novel -coron aviru s-( -ncov)-outbr eak. a recent survey of the availability of four bip and four ppe items in seven poor countries (afghanistan, bangladesh, democratic republic of congo [drc], haiti, nepal, senegal and tanzania) found less than a third of clinics and health centres in bangladesh, the drc, nepal and tanzania had any face masks (gage and bauhoff ) . in all seven countries, clinics and health centres, often the first point of public contact with the health system, had, on average, just . (of four) bip items and two (of four) ppe items. most countries also scored poorly on health workers' preparedness with reference to the ihr to prevent disease spread. while the us has about intensive care unit (icu) beds per , population, the ratio is around per , in india, pakistan and bangladesh in south asia. in sub-saharan africa, the situation is even more dire: zambia has . icu beds per , , gambia . , and uganda . (malley and malley ) . in of africa's countries, total icu beds number less than , or about beds per million, compared with about per million in europe. there are also serious respirator shortages in africa, with african countries together having fewer than as of mid-april, and ten with none at all, while the us had , respirators in mid-march (maclean and marks ). the average low-income country has . physicians and . nurses per thousand people, compared to . and . respectively in high-income countries (gage and bauhoff ) . global markets for crucial who designated covid- products are highly concentrated (espitia et al. ). the eu, us, china, japan and korea-account for % of total imports. the import shares of products needed for case management and diagnostics are even higher, close to %. import shares for ppe and hygiene products are somewhat lower, around - %, requiring countries to compete on the basis of their respective means, regardless of need. developing countries are also extremely vulnerable to changes in exporter policies, such as export restrictions on covid- tests, treatments and ppe. besides affecting availability, export restrictions-supposedly due to domestic shortages-have pushed up world prices. espitia et al. ( ) estimate that current export restrictions could initially increase prices of medical masks by . %, venturi masks by . %, and protective equipment, such as aprons and gloves by % and % respectively. if exporting countries tighten export restrictions in response to domestic price rises, prices of such covid- relevant goods could rise by % on average; most affected would be ppe, such as aprons ( % increase) as well as goggles and masks ( % increase) (espitia et al. ) . therefore, as high-income countries scramble to secure crucial supplies such as face masks, low-income countries face much tougher choices. their budgets are far more limited, and they typically lack local producers for most ppe, relying on donors and multilateral organizations for procurement in the face of unreliable supply chains. the covid- threat to frontline health workers in lowincome countries has been largely ignored. only a small fraction of needed ppe has gone to them. the who has dispatched . million ppe sets, while unicef has dispatched , n masks, . million gloves and other ppe. billionaire philanthropist jack ma has donated , masks and protective suits each to every african country and . million masks to asian countries (gage and bauhoff ) . in recent decades, developed economies, through the imf and world bank, have used aid conditionalities to demand fiscal cuts and neoliberal health reforms, e.g., by imposing user fees in developing countries (lister and labonté ) . instead of improving efficiency, quality and coverage, these reforms have had deleterious implications for public health, besides exacerbating inequalities in access to health care (stubbs and kentikelenis ; forstera et al. ; sobhani ) .their structural adjustment programmes in developing countries, particularly in africa, have resulted in underinvestment in health care systems, causing them to be poorly prepared to respond to the ebola epidemic (nkwanga ) . besides imf and world bank programmes, such underinvestment was also due to compromised fiscal capacities and regressive fiscal priorities (sanders et al. ; scott et al. ). with no known effective treatment for the infection, as the deadly nature of the virus became clear, many countries, even the world's most 'advanced' and richest, have adopted draconian measures, such as total or nationwide 'stay in shelter' lockdowns, often in panic and ignorant of other options. accustomed to adopting supposed 'best practices' prescribed by the rich and powerful, all too many developing country governments are implementing such measures without sufficiently taking into account country-specific circumstances and other challenges. besides the obvious differences between developed and developing countries, especially in terms of resources, demography, governance and other institutional capacities, there are significant differences among the developing countries themselves. in most slums and villages, many people often live together in one or two rooms, sharing common facilities. safe physical distancing is virtually impossible in such circumstances. even basic hygiene and other prescribed sanitary measures are not easy when even clean running water is scarce. most of the population in many developing countries is in the informal sector, earning meagre, typically daily incomes, and with paltry savings. all too many developing countries do not have enough fiscal space to provide sufficient relief for vulnerable populations and small businesses for very long. hence, extending strict lockdown measures and causing an economy to be locked down for too long may erode public support, even if high at the outset. but as it is often too late to rely solely on early preventive and precautionary measures, authorities typically see no choice but to implement strict and effective contagion containment at the expense of disrupting livelihoods. this dilemma is often misrepresented as choosing between life and the economy. transmission patterns are determined by many factors, some social, local and intimate. international and even national public health decision makers are often oblivious to some such factors, which community members know all too well. therefore, joint learning, involving both experts and affected communities, can be vital for effective responses. brazil and peru are two of the worst hit countries in latin america, but for different reasons. while the failure in brazil has been due to complacency, denial and lack of national/ social solidarity, the peruvian setback has been due to poor design of relief measures. despite life-threatening risks, brazil's president bolsonaro chose to emulate us president trump, infamously comparing the covid- threat to a 'little flu' or 'cold', even dismissing it as a media-hyped 'fantasy (borges ) . he also dismissed preventive measures as 'hysterical' and repeatedly demanded that state governors withdraw their physical distancing and stay-in-shelter lockdown orders. displeased by his public remarks on the need for lockdowns and physical distancing, bolsonaro fired his health minister, causing outrage across brazil. lockeddown citizens of brazil protested, even charging 'bolsonaro murder' (quinn ) . instead of an 'all of government' approach, bolsonaro also started disputes with brazil's congress and supreme court (oliveira ; santos ; bbc news ) . peru, on the other hand, acted early and as decisively as argentina, but met with different outcomes. peru imposed lockdowns, closed schools and borders, cancelled international flights, and introduced relief measures. but its response was flawed as the government had not sufficiently considered the country's socio-economic conditions. for example, most poor peruvians living in slums do not have bank accounts, and had to stand long hours queuing for cash relief grants. ironically, this became a major cause of contagion (ghitis ) . the government's relief and preventive public health measures did not address the needs of the most vulnerable sectors of society, including the poor, self-employed, informally employed, indigenous communities and indebted middle-income households. rather, the government targeted its subsidies at large companies, who were presumed to be the major employers. its safety-net programmes were based on census and municipality records, suffering serious data deficiencies. hence, government measures barely reached those in greatest need (martínez ) . more than % of peru's population live in extreme poverty, with around % in the informal sector depending on daily work for their livelihoods. while poor people, especially in cities, find it almost impossible to comply with lockdown restrictions as they struggled to survive, officials and much of the media portrayed them as 'irresponsible'. trust and community support for government measures were undermined with the revelation of corruption scandals in the procurement of sanitary, protective, testing, medical and other supplies (martínez ) . other resource constrained developing countries, like vietnam and argentina, and india's kerala state have tackled the pandemic far more effectively, at low cost and with impressive results. some key features of their policy responses are highlighted below: the kerala state government invited religious leaders, local bodies and civil society organisations (csos) to participate in policy design and implementation. it refused to use the term 'social distancing', which has caste and class connotations, and instead emphasized 'physical distancing' as part of a more socially inclusive approach to more people-centric development practices based on social solidarity. it carefully crafted political messages, such as 'break the chain', with larger political connotations, e.g., breaking the chains of oppression and popular emancipation. instead of using the pandemic for political advantage against argentina's long history of fiercely divisive politics, president alberto fernandez invited and stood together with leaders from across the political spectrum when he announced lockdown measures on march in a rare display of national political consensus (gillespie and do rosario ) . social, religious and business groups partnered to deliver food cartons to more than two million people in buenos aires and the surrounding areas (alcoba ) . the argentine national government has worked closely with opposition party state governors, as well as private and union-linked health providers to secure private cooperation without nationalization (who c). fernandez organized another display of national unity to announce that argentina would not pay external creditors while dealing with the pandemic, demanding favourable debt-restructuring terms, a bold approach which appears to be working. the kerala state government mobilized more than , volunteers to help implement various infection control measures. it successfully mobilized csos to support its 'break the chain' awareness campaign, and got numerous micro-enterprises to produce hand sanitizers and face masks, while distributing interest-free loans worth billion rupees to needy families (krishna ) . in vietnam, citizens were encouraged-via social media, text messages and tv broadcasts-to donate to the campaign to buy medical and protective equipment for doctors, nurses, police and soldiers in close contact with patients, and for those quarantined. both the kerala and vietnam governments took measures to prevent stigmatization. the kerala government organized hundreds of community kitchens with the help of csos and local-level leaders to discreetly deliver free meals to those infected with the virus, without publicly identifying them to avoid possible social stigmatization (krishna ) . in vietnam, the identities of those infected were protected by only referring to them by their case numbers. when local businesses were reportedly ostracizing foreigners, vietnam's prime minister spoke out against such discrimination. such measures encouraged people to be more open and cooperate fully in contact-tracing, testing and treatment. administrations that have successfully managed the pandemic have mobilized the all of government and demonstrated effective coordination among government departments and between their various layers. for example, the kerala government set up inter-departmental committees involving all branches of government, which meet daily to evaluate the situation. vietnam's national steering committee for covid- prevention and control was nicknamed the 'general headquarters'-a reference to a military coordinating body in existence until the war ended in . in argentina, the chief of the cabinet of ministers has responsibility for the 'general coordination unit of the comprehensive plan for the prevention of public health events of international importance'. the kerala government organized daily press conferences, when the state health minister and chief minister calmly explained what was going on and what her department was doing. communities were provided with essential epidemiological information to better understand the threat and related issues, to ensure compliance with prescribed precautionary measures and to avoid inadvertently causing panic. vietnam has not shied away from broadcasting the seriousness of the covid- threat, with the ministry of health's online portal immediately publicizing each new case with details including location, mode of infection and action taken. exceptionally, vietnam's communist partyled government published the identity and itinerary of a prominent party figure who had tested positive (vinh le and nguyen ). instead of communicating in traditionally formal ways, the government has been creative, e.g., by teaming up with two famous pop singers to produce, promote and broadcast an effectively educational song about the threat. it has also commissioned artists to create posters, and mobilized influential youth figures to broadcast supportive messages to raise the morale of those quarantined and others as appropriate (bui ). some governments and other authorities designed effective relief measures with consideration of challenges posed by specific conditions, including urban slum environments. for example, argentina's president alberto fernández ensured that no essential services-electricity, gas, water, mobile services, fixed landlines, internet and cable television-were cut for retirees, social welfare recipients and low-income households on account of non-payment of bills (sugarman ). argentina's government has devoted over us$ million for food assistance alone. at national, provincial and municipal levels, the government has supported public kitchens, while the president has promised those in desperate circumstances the food and other resources needed to survive (alcoba ) . in a similar vein, the kerala state government has organized the physical delivery of food, medicine and other essentials as well as necessary services to those under lockdown (krishna ) . it took immediate actions to reduce the risk of hunger and starvation of the poorest segments of the population by organizing free rations for all for a month, distributing food kits, consisting of items for every household, irrespective of income status (pothan et al. ) . kerala and vietnam have been internationally acclaimed as role models, especially as they are both considered poor, and suffering resource constraints. by acting early, decisively and inclusively, kerala and vietnam successfully avoided highly disruptive total lockdowns as well as associated human and economic costs. they achieved a high level of buy-in and popular support for their governments' covid- containment measures. as they achieved a high degree of voluntary compliance, draconian enforcement measures to 'flatten the curve' did not have to be imposed. while covid- crisis challenges are undoubtedly unique, they are not exceptional insofar as such challenges all have unique characteristics. nevertheless, the challenges have probably been far greater than for other recent epidemics, raising questions about earlier tested modes of response. full social mobilization is undoubtedly needed, but such exceptional 'emergency' or even 'wartime-like' measures must not be abused, e.g., by the temptation to skew implementation for despotic, political or pecuniary advantage. hence, success can be greatly enabled by legitimate, credible and exemplary leadership, government and otherwise. countries can have less disruptive and less costly, but yet very effective containment strategies, especially if they act early, quickly and adequately. the ability to trace and test as many suspected cases as possible, e.g., those who have recently come into close physical proximity with an infected person, is also crucial. effective containment depends heavily on voluntary compliance, and hence, community acceptance and trust, helped by transparency and shared understanding of what needs to be done. all these require state capabilities working together ('all of government') as well as credible and inclusive leadership to mobilize and co-ordinate the 'whole of society' for effective containment of contagion, as in the southwest indian state of kerala and vietnam. bbc news. . brazil. federal court prohibits government from running campaign against social isolation a little flu': brazil's bolsonaro playing down corona virus crisis trump's trade policy is hampering the us fight against covid- . peterson institute for international economics aggressive testing and pop songs: how vietnam contained the coronavirus. the guardian fighting covid- by truly understanding the virus. the economist trade and the covid- crisis in developing countries public health experts: coronavirus could overwhelm the developing world - d f- ea-a - b cdb _ story globalization and health equity: the impact of structural adjustment programs on developing countries health systems in low-income countries will struggle to protect health workers from covid- why even peru's top-notch plans failed to stop the coronavirus pandemic argentina sacrifices economy to ward off virus, winning praise india's kerala is combating covid- through participatory governance. the bullet globalization and health: pathways, evidence and policy african countries have no ventilators. the new york times when the pandemic hits the most vulnerable: developing countries are hurtling toward coronavirus catastrophe peru passes coronavirus risk to working class here's what we'll lose if the u.s. cuts ties with the who covid- will hit the developing world's cities hardest. here's why the ebola crisis in west africa and the enduring legacy of the structural adjustment policies alexandre de moraes suspends section of mp that changed rules of the access to information law. policy controlling covid- will carry devastating economic cost for developing countries. conversation local food systems and covid- ; a glimpse on india's responses. fao, april bolsonaro fires brazil's health minister as infections grow. foreign policy ebola epidemic exposes the pathology of the global economic and political system judge suspends bolsonaro decree that takes churches and lottery out of quarantine. conjur newsletter critiquing the response to the ebola epidemic through a primary health care approach from privatization to health system strengthening: how different international monetary fund (imf) and world bank policies impact health in developing countries international financial institutions and human rights: implications for public health argentina is showing the world what a humane covid- response looks like, the nation trump seeks to block m mask exports and grab masks from its overseas customers. the new york times how vietnam learned from china's coronavirus mistakes. the diplomat us hijacking mask shipments in rush for coronavirus protection. the guardian covid- will hit developing countries hard. financial times how does coronavirus compare with previous global outbreaks? the royal australian college of general practitioners service availability and readiness assessment (sara) world health organization (who). a. who director-general's opening remarks at the media briefing on covid- world health organization (who). b. rational use of personal protective equipment (ppe) for coronavirus disease (covid- ) argentina: there is no economy without health. who the article is based on authors' opinion pieces in inter press service (ips) news agency, which can be assessed at https ://www.ipsne ws.net/autho r/anis-chowd hury/; and https ://www. ipsne ws.net/autho r/jomo-kwame -sunda ram/. the authors would like to thank professor mj cardosa for her advice, comments and suggestions to improve the readability of the article, and lim siang jin for his editorial advice, but implicate neither in the final version. key: cord- -xndrlnav authors: granozio, fabio miletto title: comparative analysis of the diffusion of covid- infection in different countries date: - - journal: nan doi: nan sha: doc_id: cord_uid: xndrlnav the sudden spread of covid- outside china has pushed on march the world health organization to acknowledge the ongoing outbreak as a pandemic. it is crucial in this phase to understand what should countries which presently lag behind in the spread of the infection learn from countries where the infection spread earlier. the choice of this work is to prefer timeliness to comprehensiveness. by adopting a purely empirical approach, we will limit ourselves to identifying different phases in the plots of different countries, based on their different functional behaviour, and to make a comparative analysis. the comparative analysis of the registered cases curves highlights remarkable similarities, especially among western countries, together with some minor but crucial differences. we highlight how timeliness can largely reduce the size of the individual national outbreaks, ultimately limiting the final death toll. our data suggest that western governments have not unfortunately shown the capability to anticipate their decisions, based on the experience of countries hit earlier by the outbreak. italy is presently the hardest hit country. its death toll seems bound to rapidly overcome the chinese case. other western countries follow the same route. it is crucial in this phase to understand what countries presently lagging behind in the spread of the infection can learn from countries where the infection spread earlier. the first question we address is: which are the relevant numerical signatures to be monitored to check how effectively a country is acting, compared to other countries, in containing the infection? here we show that an answer to this question can be given not relying on specific epidemiological expertise, but based on a simple numerical analysis of public data available on the internet. it is widely acknowledged that comparison of curves from different countries is made difficult by the different ways the detection of the virus is addressed. in particular, the ratios of the tested population to the total population, among the countries addressed in this paper, range from about . /million in the case of south korea, to . /million for italy to less the /million in the case of usa . therefore, not only the real number of infected people might largely exceed the registered cases, but such ratio (registered/total cases) might change country by country. this difference is partly mitigated by two observations: -in the specific spirit of this work, we will compare countries in the same stage of the epidemic. considering the delay of the outbreaks (korea is grossly days ahead of italy and days ahead of the states, as will be discussed later in detail) italy is grossly following the same testing curve as korea while the usa lag behind by less than one order of magnitude. -we should assume that in advanced countries most symptomatic patients are counted among the registered cases within a few days. these are exactly the cases we mostly want to focus on. the hidden background of asymptomatic patients, though playing a role in determining the disease spread, is a less relevant datum in foreseeing the final death count. at the end of this analysis, remarkable similarities are found, especially among western countries, together with some minor differences. the extent and relevance of the observed similarities for the case of western countries will justify, ex post, the adopted approach. epidemiological curves are typically believed to follow the stochastic logistic model. nevertheless, this assumption cannot take into account situations in which the infected population reacts by drastic changes of its collective behaviour, thus changing the virus reproductive number, in the course of the outbreak. a general model for covid- diffusion would require knowledge of all the specific virus containment measurements adopted in each single country, their dates, and their quantitative effect on the reproductive number. this is so far beyond our present understanding. the choice of this work is to prefer timeliness to comprehensiveness. by adopting a purely empirical approach, we will limit ourselves to identifying different phases in the plots of different countries, based on their different functional behaviour, and to make a comparative analysis. for more complex approaches, the human data analysis time could easily exceed the obsolescence time of the dataset, which is of the order of a couple of days. the case of countries beyond the initial phase of the outbreak the source of data for this work is the csse covid- dataset . we analyse here the data of three of the countries that registered at the date of march the highest cumulative number of registered cases, i.e. china, italy, and south korea. we neglect iran, also because of the lack of information about the number of tested people. the three countries are at different stages of the outbreak. china exceeded the number of registered cases in the hubei province on january and presently reports few new cases per day. korea exceeded the number of registered cases on february and presently reports few new cases per day. italy exceeded the number of registered cases only a few days later but, in spite of a recent slowdown, the end of the exponential phase, if confirmed, is happening in the present days. the chinese plot shown in fig. a stops on february . this is due to the change of criterium adopted in the counting of infected patients performed in china on february . the reported data are fortunately widely sufficient for the purpose of this work. as for italy, last data are aligning to a linear curve, which might well be the inflection point, anticipating a smooth transition to a sublinear behaviour. the absolute number of the new daily cases in the country, about . on march , is still very high. by comparing the linear coefficient of the italian and korean blue curves, we observe in fact that the former exceeds the later by a factor . the comparison of the plots shows that, in spite of the extremely fast growth rate ( = . d, corresponding to a doubling time of one day) the rapid response of the korean society allowed to switch the growth to a slower rate before reaching registered infected people. this rapidity is confirmed by the observation that at the time when only infections were found, on february , the republic of korea had already tested over citizens . italy had instead registered cases by the time it reached the same number of tests on february . the perduring fast growth rate in italy rises major concerns and suggests that the cumulative final number of cases might exceed the chinese case. comparison between western countries. the italian case seems to correspond to the worst-case scenario among the ones analysed above. it suggests that while korea implemented a faster reaction than china, profiting of the lesson learned by the experience of the neighbour country, italy apparently showed a longer response time than both asian countries, in terms either of diagnosis, or of governmental decision, or else of change of individual habits. it is of great importance to verify how well the italian lesson was learned by other western countries. the plots reported in fig. a this timescale seems to be characteristic of the covid- "free expansion" in all these countries or, to state it more prudently, of the rate at which they are detected. we remind in this context that, in absence of large-scale screening programs, most infected people are tested after showing symptoms, i.e. about to days after infection. therefore, the registered cases curves map the history of the past behaviours of the infected population. we observe that, still at the date of march , the spanish evolution is correctly described by the red exponential curve. the us curve shows a minor deviation, which might well indicate a switch to phase # . france has switched to the second phase, with exponent  = . d. germany has also switched to the second phase, with exponent  = . d. the plot in fig. gathers all the curves above in the same plot, comparing them with the italian curve. among the possible ways to plot the data together, the most significant one, by far, was found to apply a relative shift in time, in order to "synchronize" the different starting times of the outbreak. we remark that, by normalizing the number of infected people to the overall population, the us plot would have been shifted backwards by - days. when plotted with the appropriate relative time scale (it reference, de, fr - d, es - d, us - d), the data show how early or late the different countries deviated from the red exponential "phase # " curve with  ~ . d, d ~ . d. the violet curve fitting the italian "phase # " is also shown. it can be qualitatively deduced that france, germany and probably the united states, on this particular conventional time scale, have switched to the violet curve grossly at the same time as italy did. spain is potentially running towards a worse scenario, although the last points hint to a possible alignment to the same violet curve, albeit a factor two above. the plot in fig. graphically highlights the importance of the early reactions. the numerical history of the outbreak in korea is compared to the hypothetical outbreak evolution (dotted lines) in case a two-day delay in the transition from the red to the violet curve, rigidly reflected in a twoday shift in the transition to the blue curve, would have taken place. according to the estimation in fig. , the transition to phase # would have taken place on march with an infected population of about . people, about , times higher than the actual number of registered cases at the real transition, happened on march st . the same scale factor would be applied today, within our hypotheses, to the actual infected population. we attempted an elementary, real-time analysis of the covid- diffusion data updated at march . timeliness was preferred to comprehensiveness. important information has been extracted by the data, but major caution is needed in deriving general and far-reaching conclusions. both the inhomogeneity in data acquisition rate in different countries and the huge background of undetected, presumably asymptomatic, infected patients, are two major sources of uncertainty. the criterion applied in the plot in fig. is highly instructive but, to some extent, arbitrary. with all due prudence related to the uncertainties above, we believe the present analysis is an excellent and timely starting point for further studies on the delayed effects on the curves of the response adopted by different countries. such response includes both individual changes of habits (hands hygiene, social distancing by own choice) and restrictions imposed by the governments (closing of schools, constraints to the mobility of citizens). the korean example clearly shows that early diagnosis of the first infected patients and timeliness in the response can largely reduce the size of the outbreak, ultimately limiting the final death toll. our data suggest that western governments have not shown the capability to anticipate their decisions based on the experience of countries hit earlier by the outbreak. our hope is that this work can contribute to triggering early and appropriate responses to the covid- pandemic. how many tests for covid- are being performed around the world? our world in data coronavirus cases: statistics and charts -worldometer quanti test per il coronavirus abbiamo fatto key: cord- -xp uoj z authors: das, s. k. title: spread of covid- : investigation of universal features in real data date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: xp uoj z we present results on the existence of various common patterns in the growth of the total number of patients affected by covid- , a disease acquired through infection by a novel coronavirus, in different countries. for this purpose we propose a scaling model that can have general applicability in the understanding of real data of epidemics. this is analogous to the finite-size scaling, a technique used in the literature of phase transition to identify universality classes. in the disease model, the size of a system is proportional to the volume of the population, within a geographical region, that have been infected at the death of the epidemic or are eventually going to be infected when an epidemic ends. outcome of our study, for covid- , via application of this model, suggests that in most of the countries, after the `onset' of spread, the growths are described by rapid exponential function, for significantly long periods. in addition to accurately identifying this superuniversal feature, we point out that the model is helpful in grouping countries into universality classes, based on the late time behavior, characterized by physical distancing practices, in a natural way. this feature of the model can provide direct comparative understanding of the effectiveness of lockdown-like social measures adopted in different places. understanding of the pattern in the spread of an epidemic [ ] [ ] [ ] [ ] is of immense importance. this helps minimize damage via optimal imposition of lockdownlike physical distancing (pd) measures [ ] , before medical solutions are found. a well-known theoretical result predicts exponential behavior for the natural spread of an epidemic [ , , , ] , viz., n = n exp(mt), ( ) where n is the number of people infected till time t, with n and m being constants. there exist other expectations as well [ ] . power laws or even slower rates [ , ] may not be surprising outcomes in real situations. even if exponential, it can last only for a limited period. the late time deviation from eq. ( ) can occur due to natural reasons as well as because of imposed social restrictions. advanced methods of analysis [ , ] are needed to obtain accurate picture of the overall real trend. there should be search for techniques that can help, for a given epidemic, identify the existence of common features, in the global scenario, for periods of 'actual' natural spread as well as spread during social restrictions. this is in line with the investigation of universality that is observed in phenomena associated with growth during phase transitions in materials [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . accumulation of such information has immense importance in tracking deficiencies in facilities related to medical testing as well as in identifying inadequacies in social measures. these are relevant for fighting both current and future catastrophes. here we present results on the spread of covid- [ , , - ], by applying one such model to the real data [ ] . the model can have general applicability in the studies of epidemic and is related to the finite-size scaling [ , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , a technique used in numerical [ , , ] studies to identify universality in phase transitional anomalies [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ] . the motivation behind the choice is more clearly sketched below. like in materials, concepts of phase transitions and universality exist in lives and societies [ , ] as well, which are, in a sense, part of the currently popular area concerning biologically "active matter" [ ] [ ] [ ] [ ] [ ] . universality emerges from the fact that, if there exists some basic similarity, microscopic details do not matter [ ] [ ] [ ] [ ] [ ] ] . in the societal context also, as long as there exists interaction among individuals, there should exist universality in the quantitative outcomes of various phenomena, including the spread of infectious disease. this is despite differences in cultures and governments across boundaries. it is of utmost importance to quantify such feature. a key point behind the universality in anomalous behavior is the divergence of appropriate characteristic length scale with the approach to certain fixed point [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . in finite systems there is scaling of these lengths with the size of the systems, in a limiting situation [ , , , ] . this fact is exploited in numerical studies with finite systems [ , , [ ] [ ] [ ] [ ] to identify the anomalies in various quantities. such a strategy should work for the real data on the spread of epidemic as well. in this problem, countries can be identified with materials as well as finite systems, given that the populations are nondivergent. however, unlike the standard scenario of studies in computers, where the size of a system is a priori assigned, here the issue is not straight-forward, particularly for an ongoing epidemic. outcome of our study, using real data [ ], suggests that, for a large number of countries, the early time growth can be described by a prolonged "universal" exponential form, varying from country to country only via a metric factor. various effects, including those from the practices of pd, modify this growth at late times. this is analogous to the emergence of finite-size effects [ , , ] . it is shown how from the shape or form of such pd affected parts of the overall scaling function the countries can be grouped into classes in a natural way, thereby suggesting the change that may be needed in future to strengthen the pd. from academic as well as practical points of view, it is extremely encouraging and interesting to observe that the scaling concepts of statistical physics work for real data of epidemic. in the equilibrium context, say, in critical phenomena, anomaly in a property x, thermodynamic or dynamic, is quantified as [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] where ǫ is typically the deviation of the temperature of the system from the critical value and x is a critical exponent. the value of x is same for vastly different materials, implying universality. note that ξ diverges as ξ ∼ ǫ −ν , for thermodynamically large systems [ ] , so that x ∼ ξ x/ν . in finite systems such divergences get restricted. this is because [ ] ξ cannot grow beyond l, the size of the system. for ξ = l, "true" at finite-size criticality, one writes the singularity as [ , ] x ∼ l x/ν . this is the expected behavior when x is estimated at the "finite-size" critical points [ , ] . the l = ∞ and l < ∞ behavior are bridged by the introduction of a scaling function y (y) as [ , , ] x = y (y)l x/ν . here y (= (l/ξ) /ν ) is a scaling variable that provides information on the deficiency of the size of a system with respect to the thermodynamic limit. y is a constant in the y = limit. for y → ∞, one has y ∼ y −x , that is consistent with the divergence of x for l = ∞. in the finite-size scaling method, correct behavior of a quantity is identified by observing collapse of data [ ] , along with the satisfaction of the limiting behavior, from different system sizes, for y . in the case of power-laws, one treats the values of the exponents as adjustable parameters in the collapse experiments. similar analyses [ , , , ] have been performed for quantifying the singularities in the nonequilibrium domain. the current problem is more closely related to this. here we briefly discuss the case of ℓ. this quantity diverges as ℓ ∼ t α , where α is the growth exponent. in the long time limit ℓ = l and one writes for the scaling ansatz [ , ] y is a constant in the other limit. as already mentioned, for the spread of epidemic, a simple theory predicts exponential growth [ ] . even for such a growth a finite-size (type) scaling equation can be constructed. note that in the literature of coarsening also growths other than power-laws are discussed [ , ] . for an epidemic, the size of a system should be n , the volume of the population that is infected when the spread stopped, i.e., the epidemic died. this number should not necessarily be proportional to the total population of a country. this statement is justifiable if the spread of covid- is carefully followed [ ] (see fig. ). it is clearly recognizable that the rate of infection is different in different countries. thus, the final numbers may not have connection with the total population. if the rates of infection are different, one may, of course, raise question on the validity or usefulness of the approach. however, despite the differences in rate, there may still be uniqueness in the overall functional form, perhaps differing only in certain metric factors from one country to the other. the growth in eq. ( ), with differences in m, is one such example. for the form in eq. ( ) one may need to adjust the constant m, if different for different countries, to obtain collapse of data. here the scaling ansatz is the scaling variable being in the limit y → ∞, y should behave as and it must approach a constant when y → . in case an analysis is being performed prior to the death of an epidemic, the value of n cannot be known. it is also not expected that the finite-size behavior, i.e., the growth in the presence of pd, after the knowledge of the disease has adequately spread, will be same for all the countries. this non-unique feature will lead to lack of data collapse. however, both uniqueness and non-uniqueness in this context can provide useful information. the issues on the choice of n in the case of analysis prior to the death and non-universality in m will be discussed later. one can, of course, introduce an exponent, to check for the stretched or stressed character in the exponential function. however, we will not travel this path. we have worked with data for more than countries. however, for the sake of brevity, we present . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. in fig. (a) we show n versus t plots for the considered countries, the unit for the latter being a day. the times in these plots are counted from the dates on which the first confirmed cases were reported [ ] . these plots are shown on a semi-log scale. it is clearly appreciable that n and its rate of change vary drastically from country to country [ ] . even though bending is visible, for some early period the spread may be exponential. however, confirmation of this from fitting exercise is ambiguous, particularly because of the lack of confidence in the choice of regimes, in the presence of pd effects at late times. from the plots in fig. (a) , it is also clear that in none of the countries the "instability" has set in, i.e., infections within the countries have truly started, until beyond t= . please see the parts put inside the box. up to certain times, from t = , the growths that are visible occurred essentially due to arrivals of patients from abroad. it took time for the confirmations of the infections spread by these patients. this says that it is appropriate to start counting time from the day the infections from "within" a country have started getting reported. for the rest of paper, these appropriately chosen onset times (usa: ; rus: ; ind: ) have been subtracted from those used in fig. (a) . in the following we have also normalized n by n , the number at the onset. that way, for each country the depicted growth implies spread by starting from a single patient. this puts all the countries on fair footing at the beginning. these transformed data sets are shown on a semi-log scale in fig. (b) . the results in fig. (b) convey the message that the rate of spread of the disease in each of the countries is very different from the others. if the behavior is really exponential, the factor m can significantly differ among the countries. the deviations from the exponential-like behavior, at n/n = n d , after certain times, are primarily because of pd, that includes the effects of lockdown, and this fact is analogous to the appearance of the finite-size effects [ , ] . in a standard phase transition problem, the characteristic length at the departure of a quantity from the thermodynamic limit behavior, i.e., the length at the onset of finite-size effects, is proportional to the system size [ , , ] . thus, instead of the actual size n/n of the system, here one can work with n d , value of which is country specific. since the death of covid- has not arrived yet, this is the only option we have. in fig. we have presented results from our scaling model. here we have shown y as a function of y, by including data from all the considered countries. the collapse of data appears good. the corresponding coordinates of (best) parameters, (n d , m), for usa, rus and ind are ( , . ), ( , . ) and ( , . ), respectively. in the inset we have shown the same results on a double-log scale. here also the collapse looks nice. the solid line in the inset is a powerlaw with exponent − . a simple exponential growth will imply consistency of the data with this exponent in the large y limit. however, there is deviation by about %. while this can be due to statistical error, we do not discard the possibility of an exponential behavior with a slightly nonlinear argument. for the late time behavior, it is not expected that the data sets from all the countries will overlap with each other. this is because, the success of pd depends upon several factors, including economic prosperity and population density. even if good overlap is not observed in this regime, a fair idea about relative country-wise deficiency in the effectiveness of lockdown-like social measures [ ] can be obtained. this is because of the fact that the analysis has the potential of getting data from all the countries overlapped at the very least till the appearance of the effects of pd, if the natural growth in different countries are described by a unique function, apart from non-universal [ , ] metric factors, which is 'm' for eq. ( ). such a collapse cannot be obtained via a simple scaling by the metric factors and thus, the relative knowledge of the effectiveness of pd in different countries will remain largely unexplored. for the presented countries, of course, we obtain . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . very good collapse of data over the whole range. the disparities in the economic and similar parameters among these countries are well known. nevertheless, similarity or universality in a robust way, as implied by the collapse throughout, is quite interesting, even if within a limited set of countries. in fact more countries should belong to this class. an interesting point to notice here is the following. the value of m for each of these countries is different from the others. a near perfect overall collapse of data, nevertheless, implies that in the post-pd regimes also these countries are consistently maintaining same discrepancy from each other as the pre-pd regimes. these are interesting facts and understanding needs attention. we have identified classes other than this. in one of those belong south korea, australia and few other countries. another class is formed by most of the large west european countries. the correctness of the numbers quoted above for n d and m, obtained via the optimum collapse of data from different countries, can be judged from fig. (a). there we have re-plotted the data sets of fig. (b) and compared them with the exponential form of eq. ( ) after inserting the scaling numbers for m. values of n d for each of the countries can be read out from the departure points of the exponential functions from the data sets represented by symbols and compared with the above quoted numbers. the agreement is rather good. this further justifies the scaling method and the functional form for the "natural" spread of the disease. we performed the following exercise for further confirmation of the latter. we have calculated β i , defined as [ , , [ ] [ ] [ ] β i = dln (n/n ) dlnt , the logarithmic time derivative of the growth data in fig. (b) . from eq. ( ) it is appreciable that the purpose of the quantity is to provide information on power-law [ , ] , and so, β i is referred to as the instantaneous exponent. nevertheless, this quantity is helpful in identifying other possibilities as well [ , ] . in fig. (b) we have presented a plot for β i , for ind, as a function of t. the pd affected region has been carefully removed. for the behavior in eq. ( ), the presented data set is consistent with this linear expectation, with the scaling value of 'm' being a near perfect number for the slope. a nonlinear fit (β i ∼ t c ) provides a value of the exponent close to unity, viz., c ≃ . . the deviation from the linearity perhaps again suggests that the actual growth is slightly shifted towards a case where the argument inside the exponential is marginally nonlinear. finally, our study is suggestive of "prolonged" exponential growth, in all practical sense, in the natural spread of the epidemic [ , ] . despite differences in population density and economic parameters, it seems . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint there is universality in the growths and the effects of physical distancing practices. even if there exist multiple universality classes, the proposed scaling model is useful. in addition to identifying the pre-pd growth, the relative deficiencies in the measures related to pd can be well captured in the outcome. very late time outcomes of lockdown cannot be tested by our model now. such second order effects can be included in future. exponential growth is commonly related to an ideal picture of spread of rumours, where, say, every knowledgeable person spreads a hoax to one more individual every next day. but in the case of an infectious disease, various factors can resist such a spread, even before any strict social measures have been implemented. e.g., beyond a certain time either the patients get cured or they die, thereby leave the gang of spreaders. thus, even the natural spread can be slower. if the above picture is true, from the duration of expo-nential growth it appears that the patients remain ill over long period. this is consistent with the medical observation. nevertheless, we do not discard possibilities other than the above mentioned ideal picture. continuing with the above reasoning, one should note that the patients are put under surveillance immediately after being tested positive beyond which they typically do not infect others. we expect the time gap between being infected and being tested positive to be less than the duration of exponential spread, the latter being significantly larger than days in many countries. in that case, there may as well be further reasons behind this fast growth. population dynamics of infecctious diseases: theory and applications the physics of foraging: an introduction to random searches and biological encounters terface focus a guide to monte carlo simulations in statistical physics phase transition dynamics phase transformation of materials kinetics of phase transitions medrxiv computer simulation of liquids understanding molecular simulation: from algorithms to applications key: cord- -yyh kikb authors: hossain, liaquat; karimi, faezeh; wigand, rolf t.; crawford, john w. title: evolutionary longitudinal network dynamics of global zoonotic research date: - - journal: scientometrics doi: . /s - - -y sha: doc_id: cord_uid: yyh kikb at global and local levels, we are observing an increasing range and rate of disease outbreaks that show evidence of jumping from animals to humans, and from food to humans. zoonotic infections (i.e. hendra, swine flu, anthrax) affect animal health and can be deadly to humans. the increasing rate of outbreaks of infectious diseases transferring from animals to humans (i.e. zoonotic diseases) necessitates detailed understanding of the education, research and practice of animal health and its connection to human health. these emerging microbial threats underline the need to exploring the evolutionary dynamics of zoonotic research across public health and animal health. this study investigates the collaboration network of different countries engaged in conducting zoonotic research. we explore the dynamics of this network from to based on large scientific data developed from scopus. in our analyses, we compare several properties of the network including density, clustering coefficient, giant component and centrality measures over time. we also map the network over different time intervals using vosviewer. we analyzed publication records. we found united states and united kingdom as the most collaborative countries working with and other countries in and cases, respectively. our results show increasing close collaboration among scientists from the united states, several european countries including united kingdom, italy, france, netherland, switzerland, china and australia with scientists from other parts of the world. united states, several european countries including united kingdom, italy, france, netherland, switzerland, china and australia with scientists from other parts of the world. background zoonosis can be referred to as the transmissible diseases between vertebrate animals and humans (who ) , which comprises % of emerging infectious diseases (taylor et al. ) . therefore, successful management of zoonotic diseases risks and outbreaks require the understanding of the complex interaction network of humans, animals and their living environments (who b) . previous bibliometric studies on relevant topics either investigated specific infectious diseases such as acquired immune deficiency syndrome (aids) (patra and chand ; uthman ) , tuberculosis (ramos et al. ) , and malaria (garg et al. ) or examined infectious diseases in general (bliziotis et al. ; ramos et al. ramos et al. , takahashi-omoe and omoe ) . the latter studies examined the research productivity and contribution of different countries and regions of the world in infectious diseases showing a gradual increase in research on infectious diseases in the us, the eu and other regions in the world. our investigation focuses on the contribution and collaboration of countries in exploring the intersection between animal and human health. we provide an investigation of the dynamics of zoonotic research networks over years by constructing and using large scientometric data. the study first explains the process of developing scientometric data for exploring research collaboration on this topic. these data are based on the extracted publication information from elsevier's scopus in the span of - . it proceeds with exploring these data by extracting a bibliometric networks (i.e. countries network). several social network measures such as network density and centrality are employed to analyze this network. the countries collaboration trend, network maps and measures, and their dynamics over this period of time are then discussed. elsevier's scopus (www.scopus.com) as one of the main sources of bibliometric data covering the greatest number of journals romo-fernández et al. ) is used to build the database of this study. the search for publications has been carried out with search queries using combinations of keywords including ''coordination, collaboration, cooperation, communication, preparedness, surveillance, emergency response, crisis management, containment, recovery, zoonotic, zoonosis, animal human, disease outbreak, illness outbreak, epidemic, pandemic and social network'' occurring in the articles' titles, abstracts and keywords. this initial set of keywords was selected after consulting with two experts in the field. the focus of the keywords was on three concepts including coordination, zoonotic diseases, and disease outbreaks at the various stages of disease prevention, detection, effective response and elimination. the publications information [e.g., author(s), document title, year, source title, citation count, source and document type, affiliations, publisher] were extracted using scopus export option. the publications used in the subsequent analysis were restricted to the ones in english. it is theoretically possible to miss out certain publications in the search process explained earlier. in order to minimize any missed out document and to account for any important keyword that was not included in the first stage, another set of keywords were identified to run a second round of search. as such, in the second stage, the keywords used in the extracted publications from the first stage were analyzed for their frequency. the frequency analysis of the keywords included identifying the most frequent ''single word'' and ''multiple words'' keywords. the latter keywords were the original keywords used by the authors and the former keywords were produced by splitting the ''multiple words'' ones. table shows the top ten most frequent ''single and multiple words'' keywords. another set of keywords including ''avian influenza, west nile virus, h n , control, risk'' were used in combination with ''coordination, collaboration, cooperation, communication, preparedness, surveillance, emergency response, crisis management, containment, recovery, outbreak, epidemic, pandemic and social network'' for a second round of search for publications ( search queries). the keywords that were too generic or used in the previous stage such as virus were not included in this round of search. the extracted publication data from this round was added to the previous results. the search span in both stages consisted of the period from to . the search for the publications was conducted in july . the two rounds of search resulted in publications of different types (e.g., article, conference paper, review) after filtering the publications with the same title. an application program was developed to extract bibliometric networks from these data, discussed in the next section. at least four bibliometric networks can be built using the database of publications developed in this study including networks involving authors, keywords, countries, and affiliations. figure shows these networks. in order to build these network (i.e. identify the links between the nodes) from the information available in the database, an application program is written in matlab. the algorithm of this application is explained here for the co- authorship network. the process of building the other networks including co-word, countries, and affiliation uses the same algorithm. there is a co-authorship relation between two authors if they wrote a document together. as such, in social network terms, there is a link (edge) from node a (author a) to n ode b (author b). to map the data exported from scopus into a co-authorship network, the following algorithm was developed where its variables are presented below: • max-no-papers maximum number of papers in the database with known authors • max-no-aut-paper maximum number of authors in a paper in the database • max-no-authors maximum number of authors in the database • list-all-authors a list containing the name of all the authors in the database • list-max-no-authors-per-paper a list indicating the maximum number of authors for each paper in the database • list-all-papers-with-all-their-authors a list of all authors for each paper in the database • co-authorship-initial a matrix with the size of (max-no-papers, max-no-aut-paper) that its cell (i,j) indicates whether author j in list-all-authors participated in writing paper i in the database • weighting a matrix with its cell (i,j) indicating the number of papers wrote by authors i and j in list-all-authors • co-authorship a matrix with its cell (i,j) indicating whether authors i and j in list-all-authors wrote a paper together or not in order to build the network of collaborating countries, the affiliation records of each publication were processed to extract the countries cited. in table below, we show some examples of the affiliation records in the database. the name of the countries, when reported, appears at the end of the record. in order to extract the countries associated with each publication, the steps explained below were followed: • reverse the affiliation record string, • count the number of characters till the first occurrence of a space (e.g., x characters), • extracting the first ''x'' characters identified in the previous step from the reversed string, • reverse the string extracted in step three which gives the name of the country reported. publications contained no affiliation information. these publications were excluded from the countries network analysis. further data cleaning process in this stage included identifying the variations in the name of the countries reported (e.g., united states, usa, us, united kingdom, uk) and unifying them. if an affiliation entry did not include the name of the country or useful information (e.g., the name of an institution) to search for the correct country of origin, it was excluded from further analysis ( publications). some other cases of data cleaning included finding the relevant country associated with a university, institution, company, state, or city where the name of the country was missing. this resulted in publications to carry out the data analysis. in this study, we apply the following network measures to perform our analysis: the density measure ''describes the general level of linkage among the points in a graph'' (scott , p. ) . in social network analysis terms, this is the number of links in a network, expressed as a proportion of the maximum possible number of links (scott ) . the density of a network increases as the number of linkages between its nodes grows. the densest network (with all its nodes linked together) has a density of and the least dense network (with no node linkage) has a density of . degree centrality- freeman ( ) defined degree centrality of a node as the number of its adjacent nodes. two nodes are adjacent if an edge links them together. therefore, degree centrality of a node counts the number of other nodes that are directly connected to it. the closeness centrality of a node is the sum of the graph-theoretic distances of that node to all other nodes in the network. the distance of a node from another is the length of the shortest path (geodesic path) between them (borgatti ; freeman ). normalized closeness centrality value of a node is calculated by dividing the number of all other nodes in the network by the sum of the distances of the node to all others (freeman ; leydesdorff ). the betweenness centrality of a node is defined as the frequency with which it settles in the shortest path connecting any other pair of nodes in the network (freeman ) the giant component in many cases, large and complex networks are seen to have a connected component that includes a substantial portion of the nodes in those networks. this connected component is referred to as the giant component. if a network has a giant component, it is usually only one (easley and kleinberg ) . the clustering coefficient of a node (e.g., node a) refers to the probability that two randomly selected adjacent nodes of a are adjacent to each other. in other words, it is the fraction of the pairs of a's adjacent nodes that are linked together (easley and kleinberg, ) . clustering and mapping vosviewer . . is used for displaying the structure of countries network. vosviewer provides both mapping and clustering of networks (especially bibliometric networks) in a unified approach as an alternative to combing the mapping and clustering techniques with different assumptions. its clustering technique is based on a weighted and parameterized variation of modularity-based clustering, and it uses visualization of similarities (vos) as its mapping technique . vos is a distance-based mapping technique rather than a graph-based one. while in the latter technique the distance between two nodes is not necessarily meaningful, in the former technique this distance represents the strength of their relationship (van eck and waltman ). vosviewer provides different visualizations of networks. in the label views, the size of a nodes' circle and label portray its importance. larger circles and labels represent more important nodes in terms of their weight (van eck and waltman ). the weight of the nodes in the countries networks in our study are determined based on the number of other countries associated with them and the strength of the associations. the color of the circles also depicts the cluster the node belongs to (van eck and waltman ) . the density view is helpful for identifying the most important areas of a map. in this view, the nodes are represented with the same label structure as the label view. the color of the point a node is placed in depends on the number of nodes around that point and their weights (i.e. their density). more nodes with greater weight neighboring a node lead to greater density for that node. according to the default color scheme used by vosviewer, three color (redgreen-blue) represent density where red and blue are assigned to the highest and lowest densities respectively (van eck and waltman ). as shown in fig. , the trend of publications on zoonotic research has been increasing since . while before , the number of extracted publications is constantly low, an increasing trend starts after that. this increase in the number of publications continues gradually and accelerates after . this observation provides three time intervals to examine detail changes in the collaboration networks including - , - , and - . the dynamic analysis in this study focuses on the last two time intervals as the number of publications in the first period is limited. another interesting point of time in fig. is . up to this year the number of publications is increasing but this upward trend halts here with occasional rises. to have a better understanding of the possible underlying reasons for such a trend in the zoonotic research output, the frequency of zoonotic research publications and who's disease outbreak news per year (who a) since are depicted in fig. . three highest points of disease outbreak news occurred in [due to suspected severe acute respiratory syndrome (sars) pandemic], (due to avian influenza pandemic) and (due to h n pandemic). after , with sars and avian influenza pandemics, the publications on zoonotic research grew rapidly, and then started to decline after , but again raised in with the spread of the h n pandemic to decrease again with the reduction in the disease outbreak incidences. it seems that the output of scientific research in the zoonotic disease outbreaks have reached a saturation level since and only occurrence of global disease outbreaks triggers increases in quantity of the related publications. as such, the changes of zoonotic research collaboration networks will also be examined for another two periods including - and - . table also shows the top ten journals publishing on this topic over the years examined in this study, in which emerging infectious diseases, veterinary record, euro surveillance: european communicable disease bulletin, and plos one hold the first three positions. countries collaboration trend figure below illustrates the changes in collaboration among the countries over time in terms of the number of collaborating countries, distinct collaboration links between them, and total number of collaboration links per year. the first instances of international collaboration start from and steadily increase although the number of collaboration links among countries experiences some rises and falls over the years. the highest amount of collaborations ( distinct links and total occurrences) takes place in among countries. in , the amount of collaborations drops to distinct collaboration ties while the number of participating countries increases to . since - the collaborating countries consist of - countries which are nearly % of all the countries ( ) in our database. in other words, the countries collaboration network at its most collaborative status comprises half of the publishing countries. in addition, the trend of recruiting more collaborating countries each year although is overall growing; its pace slows down after . however, the number of collaboration links between the present countries and the frequency of such collaborations shows fast increase (with occasional declines). as such, it seems that after the community of collaborating countries is more focused on having more collaboration with other existing countries in the community and strengthening these collaborative relationships. countries network measures and maps over time table demonstrates the measures of countries network in different periods. in the first period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , the density of the network is very low ( . %) indicating that a limited number of all possible collaboration links among countries are realized (see fig. a ). in addition, the high clustering coefficient ( . %) implies the high possibility of collaboration among two adjacent countries of a third country. figure a , pertaining to this period, illustrates this implication in the form of several triangles in the network. the network also has a giant component and several other small components. the network's degree of centrality is average ( . %). as shown in fig. a , the countries are gathered around a few central nodes in the network including the united states and united kingdom. they also possess the largest fig. countries network map during ( - ) and ( - ) . a label view of countries network ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , b label view of countries network ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) labels. south africa, germany, and italy (overlaid by germany in the map illustration), and france are the next countries with large labels which indicate their importance in the zoonotic research in this period. there is also a split evident in the map which separates countries around united states from countries around united kingdom. in other words, there is low density between the two areas. this is an implication of less collaboration among these two important areas of the network. in the second period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , the density of the network has improved (almost doubled) although it is still low. there is also a slight improvement in the clustering coefficient value ( . %). the degree centrality shows considerable improvement ( . %). as shown in fig. b , the countries are coming closer together compared to the previous period. the network closeness and the betweenness have decreased. the high value of closeness ( . %) and low value of betweenness ( . %) measures implies the low distance between the countries. the network measure for the whole period of time is similar to the second time period, which is expected given that most of the publications belong to this period. similar trend in the values of the network measures are observed in the other two periods ( - and - ) . the interesting observation here together with the information from fig. is the high value of clustering coefficient ( . %), density ( . %) and degree centrality ( . %) in - period which indicates the high probability that two collaborators of a country will be collaborating with each other and countries having more collaborations and collaborators. these values are higher than the seven years before . in other words, in the recent years, the countries were putting more effort in strengthening their relationship with more other countries (see figs. a, b) . the label views of the network in the whole period (fig. a) shows that united states and united kingdom are the major collaborating countries. italy, france and netherlands are the next main countries. as evident in the density view (fig. b) , united states and united kingdom are depicted in red indicating their high density; although united kingdom is nearer to other moderate density areas of the map while united states is placed farther from this part of the map. these countries as well as the others shown in red or orange comprise the important part of the world in terms of research, publication, and collaboration on zoonotic research. top collaborating countries table lists the countries with or more total collaborations and the corresponding number of countries they collaborated with. according to this list, united states and united kingdom are the first and second most collaborative countries working with and other countries in and cases, respectively. in addition, the number of countries they collaborate with exceeds the others. italy, france and netherland are the next most collaborative countries; although france's collaborating countries ( ) are slightly more than italy ( ). this result complements previous studies on the output of infectious disease research community. previous studies show that the united states and the western european countries productivity exceed the other countries in terms of publication on infectious disease research (bliziotis et al. ; takahashi-omoe and omoe ) , and united kingdom, france, and germany lead the european countries in terms of number of publication on this topic (ramos et al. (ramos et al. , ). our results show a similar pattern in terms of collaboration efforts on zoonotic research. the united states, united kingdom, france, italy and netherlands are the leading collaborative countries in zoonotic research. table presents the list of the strongest collaboration links among the countries. strength of a collaboration link is defined as the frequency of its occurrence during the years. - and - - - dynamic analysis during the period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , united states, united kingdom, germany, italy, and south africa are the top collaborating countries. in the second period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , the number of collaborators and frequency of collaborations increase. while the united states and united kingdom still hold their position at the top of the list of most collaborative countries, some changes are observed in the countries that follow them. south africa is no longer among the top countries. italy, france and netherlands have progressed further up the list. china, australia and switzerland also managed to appear among the top ten collaborating countries (see table for further details). to identify their collaboration growth rates, first the average amount of collaboration for each country in each of two time periods (av = total collaborations/years) are calculated which is presented in table . the growth rate is then obtain as the quotient of the second and first periods' average collaborations (growth rate = av /av ). if a country did not have any collaboration in the first period its average collaboration for the second period is considered as the growth rate. the collaboration growth rates of the countries are identified for the - and - periods as they represent more recent data compared to the other time periods ( - and - ) examined in this study. nigeria, mexico, portugal, egypt and singapore collaboration growth rates exceed the other countries. this study provides longitudinal analysis of countries networks of zoonotic research during - based on large scientific data developed from scopus. the overall properties of these networks as well as their dynamics over these years are examined in detail. the countries network shows steady increase in collaboration among different countries. the united states is the most collaborative country having links with countries and total instances of collaborations. several european countries including united kingdom, italy, france, netherlands, switzerland, germany and belgium are among the top ten collaborating countries. china and australia are also among the ten most collaborating countries. nevertheless, the density of the network is still low which means that limited numbers of countries are collaborating. however, this trend is improving such that almost half of the countries had at least one collaboration link in the recent years. in addition, in spite of the recent lower rate of addition of more countries into the network, within the current network, the countries are increasingly initiating new collaborations as well as enhancing these collaborating relations (strengthening them). conflict of interest none. investigating attachment behavior of nodes during evolution of a complex social network: a case of a scientific collaboration network evolutionary dynamics of scientific collaboration networks: multi-levels and cross-time analysis worldwide trends in quantity and quality of published articles in the field of infectious diseases networks, crowds, and markets: reasoning about a highly connected world centrality in social networks conceptual clarification bibliometrics of global malaria vaccine research betweenness centrality as an indicator of the interdisciplinarity of scientific journals hiv/aids research in india: a bibliometric study. library and information science research publication of european union research on infectious diseases a bibliometric overview of infectious diseases research in european countries a bibliometric analysis of tuberculosis research indexed in pubmed co-word based thematic analysis of renewable energy social network analysis: a handbook worldwide trends in infectious disease research revealed by a new bibliometric method risk factors for human disease emergence software survey: vosviewer, a computer program for bibliometric mapping vosviewer manual a unified approach to mapping and clustering of bibliometric networks zoonoses and the human-animal-ecosystems interface no. key: cord- -jx xpbjl authors: alsan, marcella; bloom, david e.; canning, david title: the effect of population health on foreign direct investment inflows to low- and middle-income countries date: - - journal: world dev doi: . /j.worlddev. . . sha: doc_id: cord_uid: jx xpbjl this paper investigates the effect of population health on gross inflows of foreign direct investment (fdi). we conduct a panel data analysis of industrialized and developing countries over – . our main finding is that gross inflows of fdi are strongly and positively influenced by population health in low- and middle-income countries. our estimates suggest that raising life expectancy by one year increases gross fdi inflows by %, after controlling for other relevant variables. these findings are consistent with the view that health is an integral component of human capital for developing countries. the effect of population health on foreign direct investment inflows to low-and middle-income countries the world health organization's report of the commission on macroeconomics and health (cmh, ) asserts: ''a healthy workforce is important when attracting foreign direct investment (fdi).'' many international agencies have made similar statements regarding the effect of health on fdi inflows. such claims have bolstered the position of health on the global development agenda. to date, however, a relationship between population health and fdi has not been established in the empirical literature. the aim of this paper is to investigate whether population health encourages inflows of fdi after controlling for other relevant variables. this study is important for two main reasons. first, developing countries continue to face severe resource constraints. placing budgetary priority on health interventions at the expense of competing claims merits a strong evidence-based foundation. second, the expanding role of fdi in the global economy has made understanding its determinants a priority for both researchers and policy makers. there are several reasons for why population health might be important for attracting fdi. a growing body of evidence has shown that health is an integral component of human capital that raises worker productivity and spurs economic growth. high levels of human capital in the workforce are likely, other things being equal, to make a country more attractive to foreign investors. on the other hand, high rates of absenteeism or worker turnover due to morbidity and mortality can raise production costs and deter fdi. a large burden of infectious diseases might also dampen fdi inflows to a given locale if investors fear for their own health or that of their staff. to investigate if health status of a population affects fdi inflows, we conduct a panel data analysis of industrialized and developing countries over the period - . our main finding is that fdi inflows are strongly and positively influenced by population health among the sample of low-and middle-income countries. our estimates suggest that raising life expectancy by one year increases fdi inflows by % in these countries, after controlling for other relevant factors. these findings are consistent with the view that health is an integral component of human capital for developing countries. the remainder of the paper is organized as follows: section presents stylized facts regarding fdi and its relationship to developing countries and human capital; section reviews empirical evidence and theoretical arguments for considering health as a form of human capital; section describes the theory of fdi inflows and the empirical model used in the analysis; section details the data used and our sources; section presents our empirical results; and section concludes. to the best of our knowledge, this represents the first empirical investigation evaluating whether health directly affects fdi, ceteris paribus. fdi has become an increasingly important source of financing worldwide. during the past two decades, global inflows of fdi have soared: from $ billion in to $ billion in (unctad, ) . attracting fdi is important for countries at all stages of development. it has been argued, however, that inducing greater fdi inflows is of more importance to developing countries given their lower savings rates and income levels. indeed, fdi now represents the largest component of net resource flows to developing countries, surpassing official development assistance (oda), portfolio investments, and bank loans (miyamoto, ) . in addition to providing much needed capital, fdi has other attributes of particular relevance for developing economies. these attributes include expanding access of domestic firms to global markets and facilitating the transfer of technology. fdi may also increase tax revenue for the host economy and enhance the competitiveness of the domestic market through spillover effects (loungani & razin, ; unctad, a) . these potential benefits of fdi have been widely publicized. leaders gathered at the international conference on financing for development (icfd), held in mexico in , characterized fdi as an engine for economic growth and an integral component of poverty alleviation. the monterrey consensus, adopted at the icfd, stated, ''a central challenge, therefore, is to create the necessary domestic and international conditions to facilitate direct investment flows . . . to developing countries'' (united nations, ) . this challenge has not yet been met. global fdi inflows are not distributed evenly. industrialized economies are the most likely destination for fdi; and some developing countries receive much greater inflows than others. african countries in particular have struggled to attract foreign investors (see morisset, ) . in , africa attracted only $ billion in foreign investment; far less than central europe ($ . billion), latin america ($ billion), or asia ($ . billion) (unctad, ) . asiedu ( ) , empirically investigating the determinants of fdi to developing countries, found that sub-saharan african (ssa) countries were less likely to attract investors than non-ssa countries, despite the fact that us investment into ssa had a higher rate of return than investment in other developing regions. furthermore, factors proven to promote fdi to non-ssa countries (such as infrastructure and return on capital investment) did not have a clear impact on fdi to ssa countries. a survey conducted by the united nations conference on trade and development (unctad) of the leading multinational enterprises supported asiedu's results. only one out of every five respondents expected higher inflows to african countries over the next two years, and two-thirds believed that the current level of flows would remain unchanged (unctad, b) . under standard neoclassical assumptions (where output is produced by capital and labor), capital is predicted to flow from wealthy to poor countries until capital-labor ratios equalize across countries. the observed pattern of fdi, with most capital flowing from one wealthy country to another, is thus an apparent paradox. lucas ( ) argues that differences in human capital could explain this paradoxical pattern. recently, there has been renewed interest in the idea that human capital might play a role in encouraging foreign investment. to the extent that physical capital and skills are complementary inputs, the presence of a healthy and more highly educated workforce can increase the productivity of capital. this is driven in part by economic activity shifting first from the primary goods to manufacturing sectors and then toward services, which are successively more knowledge intensive. for example, in the early s, the services sector accounted for only % of the world fdi stock. by , services had risen to about % of the total stock (unctad, a) . fdi geared to knowledge-and skill-intensive industries may imply that countries with higher levels of human capital are more attractive to investors (blomströ m & kokko, ; miyamoto, ; noorbakhsh, paloni, & youssef, ) . most cross-country studies investigating this idea identify human capital narrowly with education, ignoring strong reasons for considering health as an integral component of human capital. therefore, in a natural extension of the literature, we investigate whether the health status of the population encourages inflows of fdi. in section , we review empirical evidence establishing health as a form of human capital and summarize circumstantial evidence suggesting a link between health and fdi. in addition to the importance of health as a consumption good, health can also be viewed as a form of human capital that enhances economic performance both for the individual and at the level of the macroeconomy (bloom, canning, & jamison, ) . a substantial body of evidence has demonstrated that population health is a robust predictor of growth in per capita income (barro, ; barro & sala-i-martin, ; bhargava, jamison, lau, & murray, ; bloom, canning, & sevilla, ) . however, countries may benefit to different degrees from health. bhargava et al. ( ) argue that economic growth resulting from health improvements is more pronounced in developing countries than in industrial countries. health can affect economic performance through direct and indirect mechanisms. health has a direct effect on the productivity of workers. healthy workers are generally more physically and mentally robust than those afflicted with disease or disability. furthermore, they are less likely to be absent from work, or suffer low productivity in work, due to personal or household illness. poor health can lead to low wages, which in turn keeps health and nutrition levels low, thereby creating a poverty trap. microeconomic analyses using anthropometric measures (such as the onset of menarche, nutritional status, and stature) and indices of morbidity (such as work days lost due to illness) have consistently shown that health affects worker productivity (knaul, ; ribero, ; savedoff & schultz, ; schultz & tansel, ; strauss & thomas, ) . health can also affect economic performance through indirect mechanisms; for example, improved health can increase the return to education and worker experience. healthier children have enhanced cognitive function and higher school attendance, allowing them to become better educated, higher earning adults (bhargava, ; bloom, ) . healthier workers, who have lower rates of absenteeism and longer life expectancies, acquire more job experience. better health also improves the prospective lifespan of workers. in countries with low life expectancies, the prospect of retiring is remote. once better health becomes more common, retirement seems more attainable. increased longevity, therefore, can generate the need for retirement income and set off a savings and investment boom (bloom, canning, & graham, ) . health improvements may also affect the age structure of populations. initially, such improvements tend to reduce mortality rates among infants and children, since interventions to reduce childhood mortality are usually neither costly nor complex. as parents come to expect more of their children to survive to adulthood, fertility rates fall. this change produces a baby boom generation. the fall in birth rates, coming as it does after a fall in mortality rates, means that the large baby boom generation is unique, with much smaller cohorts before and after it. as this generation enters the workforce, it may provide a boost to productivity leading to economic growth (bloom & canning, ) . health, viewed as a form of human capital, could affect fdi through several mechanisms. as the cmh report suggested, a healthy workforce could enhance worker productivity and attract fdi inflows. however, health may also encourage fdi via other mechanisms. firm profitability may suffer if health-related costs are high. companies operating in countries where health infrastructure and personnel are lacking may need to develop or significantly subsidize a health care system for their employees. sick leave, funeral costs, and low workforce morale represent additional burdens for investing firms. in addition, for fear of endangering their own health and that of their expatriate staff, foreign investors may shun areas where disease is rampant and where access to health care is limited. foreign investors and their managerial staff may lack resistance to disease, either acquired or inherited, that the host country population enjoys. for example, a significant portion of the population in africa carries the sickle cell trait. this condition confers protection from severe malaria and is much less common among european descendants (pasvol, weatherall, & wilson, ) . a similar reduction in disease severity has been observed with certain types of thalassemia (clegg & weatherall, ) . indeed, these inherited hemoglobinopathies are thought to persist among certain african and asian populations because natural selection favors alleles offering protection against malarial illness. a classic instance of disease interfering with investment occurred during the building of the panama canal. yellow fever and other pathogens claimed the lives of , - , workers during - , forcing ferdinand de lesseps and the french to abandon the construction project (jones, ) . more recently, the outbreak of severe acute respiratory syndrome (sars) has highlighted fears that new infectious disease outbreaks could undermine global integration and deter foreign investment. preliminary evidence seems to support this view. a global business survey on hiv/aids sponsored by the world economic forum (bloom, bloom, steven, & weston, ) found that half of all business leaders in low-income countries believe that hiv affects their country's access to fdi. as well as affecting the costs of production, health may also affect the level of demand. healthy populations are more productive, earning higher incomes and creating a larger market for goods. in addition to this effect on aggregate demand, health may also have consequences on the pattern of demand, with direct effects on the demand for health services and more indirect effects on sectors such as tourism. even though circumstantial evidence suggests a link between health and fdi, empirical findings are noticeably absent. the gap in the literature is not without consequence. as competition for oda rises and questions about the effectiveness of foreign aid are raised, developing countries are increasingly looking to fdi to promote technology transfers and economic growth. we now turn to the model. firms invest in foreign countries, instead of exporting to them or licensing to a local company, to satisfy one of two strategic objectives. they may seek to better serve the local market, producing locally to avoid transportation costs, trade barriers, or production delays and speed information flow. this is market-seeking or horizontal fdi. alternatively, they may seek to produce for the global market but select this location to minimize production costs through lower-cost inputs. this is export-oriented or vertical fdi (shatz & venables, ) . in principle, health can affect both vertical and horizontal fdi. local production allows a firm to avoid transportation costs and import duties; but this is only attractive if the domestic market is sufficiently large to cover the fixed costs of setting up production and any country-specific cost disadvantages. asiedu ( ) and blonigen and wang ( ) conjecture, reasonably, that horizontal fdi will be driven largely by domestic demand (market size). along the same lines, other investigators have traditionally found that host market size, usually measured in terms of real gross domestic product (gdp) per capita and population size, is a positive determinant of fdi inflows (chakrabarti, ; schneider & frey, ; wheeler & mody, ) . by contrast, ceteris paribus, vertical fdi will flow to countries that possess cheap, productive inputs and have the fewest restrictions on trade. the presence of highly educated, healthy workers, available at low wages, may be a large inducement for vertical fdi. we can formalize this. let us begin with a model of export-oriented or vertical fdi. assuming constant returns to scale, profit maximization, and competitive markets, the profits earned by a unit of fdi can be expressed in the form of a profit function given by where p y is the world price of the output produced, p k is the local cost of capital, p x is the local cost of an input (in general, there will be many inputs into production), and z represents the per unit costs due to factors such as transportation, tariffs, and corruption in the host economy. in this model, all fdi will flow to the country with the highest profit rate. now suppose that the cost of investment rises as the volume of fdi (which we denote by i) expands depending on s, the absorptive capacity of the country with a quadratic adjustment cost would be according to the idea is that as aggregate fdi increases some resources become scarce, increasing the cost of investing. note that this model applies to gross inflows of fdi, since it is the gross inflows and not the net balance of fdi flows that has to be absorbed. the price of capital facing an individual company undertaking fdi depends on the aggregate volume of fdi and is investment of fdi in each country will take place up to the point where the profitability of investment is equalized across countries p ¼ f ðp y ; p k ðiÞ; p x ; zÞ. solving this as an implicit function for i gives the terms with the superscript refer to worldwide variables that are the same for each country (though they may vary over time), while the other variables are country specific. we proxy s, the absorptive capacity of the economy for fdi, by population size and income per capita. we do not have local prices for each input in our model. the profit function f of the firms involved in fdi implies an underlying production function. however, the aggregate production function of the economies these firms are investing in may be quite different. suppose the aggregate production function for the domestic economy is cobb-douglas and is given by where y is output, k is capital, l is labor, x is some other input (e.g., health), and a is total factor productivity. profit-maximizing firms will choose input levels for x so that the marginal product of x equals its real price (in output units) p x . this implies that and hence, it follows that we can regard the per-worker level of an input that is available in an economy (for a given level of income per capita) as a proxy for its price, with higher levels of an input per worker associated with lower input prices and lower input levels associated with higher prices. the level of output per worker is also a proxy for the general level of input prices. we can control this by including the level of income per capita in the regression. in this framework, countries with a high level of income per capita are likely to have high factor prices which will deter investment, while countries with high levels of a particular input per capita, given their income level, will have low prices for that input, which will encourage investment. we also include a number of variables, such as corruption and distance to major markets, that may add to costs of production. note that the production function for firms undertaking fdi implicit in the profit function f (eqn. ( )) may be quite different from the existing aggregate production function for the economy (eqn. ( )) that determines the link between domestic factor availability and factor prices. this allows for the possibility that fdi firms have different technology from the existing firms in the economy. our model does not, however, allow for the possibility that fdi firms are interested only in some specialized factors of production that are not captured accurately by broad aggregates. however, using national averages makes the empirical investigation tractable, since data on the availability and cost of inputs at the local level are not readily available for many developing countries. the model set out here is one of exportoriented or vertical fdi. for most low-and middle-income countries, we think this is the appropriate model. to construct a model of horizontal fdi, the appropriate price level of output is the local price of the good, not the world price. while input prices have the same effect for horizontal fdi as for vertical fdi, the coefficients on factors that produce trade barriers may now change. trade barriers such as import tariffs, distance to major markets, or lack of access to the sea may act as a deterrent to export-oriented fdi but may actually attract horizontal fdi, since many features that reduce the competitiveness of imports may give fdi that produces for the host economy an advantage. this implies that the coefficients on these variables must again be interpreted with care, since they may be the result of two competing forces. however, for most low-and middle-income countries we expect that fdi will be predominately exportoriented and that the deterrent effect of trade barriers dominates. in our empirical work, we model the gross level of fdi inflows at time t in country i as follows: where the subscript i refers to a country, while t refers to the time period. we include log population (pop) and log gdp per capita as scale variables. following our theory, we also include measures for worker health and education levels as productive components of human capital. further input per capita measures are included in the vector x, while vector z represents barriers to trade that may deter fdi. we include time dummies, d t , to capture changes in the volume of global international investment flows over time (due to changes in the world price or rate of profit), and e represents the error term. we predict that higher levels of health and education inputs are (after controlling for income per capita) associated with lower input costs, p x , according to ( ) above. note that gdp per capita now has two effects in our model. it can not only be considered as a scale variable that captures market size and capacity to absorb fdi, but can also act as a proxy for the overall level of input costs (assuming the cobb-douglas specification above). the two effects of income per capita on fdi can be thought of as generating a coefficient b = (b + b ) on income per capita in our regressions where b represents its scale effect on absorptive capacity and b represents its effect on average input prices. provided the model is correctly specified, there is no problem in estimating the total effect of income per capita (b + b ) though we cannot identify the individual parts of this effect. while this will not affect the validity of our estimation, the coefficient on gdp per capita should be interpreted with caution because it may reflect both the market size and the cost effect that tend to move in opposite directions. note that the market size effect is usually associated with horizontal fdi, while in our model a positive effect of market size on vertical fdi may be due to the economies' ability to absorb fdi inflows without pushing up the price of capital. although our theory is a model of vertical fdi, in practice the estimation is more general and some of the scale effects we detect may reflect horizontal fdi. our estimation approach measures the effect of health on fdi conditional on a number of other factors, such as the scale of the economy and education levels. we therefore estimate only the direct effect of health. there may also be indirect effect. for example, if high levels of population health raise income levels, and reduce mortality, then both income and population numbers will rise. health may also encourage school attendance and education. however, these indirect effects will already be captured by the relevant variables in the model and are not attributed to our health variable. our fdi measure is gross inflows. many researchers use other measures, for example, net inflows, but we prefer gross inflows for three reasons. first, this measure seems more appropriate for investigating what characteristics of a particular country attract investors. second, from eqn. ( ), a capacity constraint on fdi will raise the price of investment as gross inflows increase and some inputs become scarce. third, in terms of knowledge spillovers, which may be a central benefit of fdi, it is the gross inflows that matter and not the net inflows. the literature commonly normalizes fdi flows by dividing by some scale variable, for example, population or gdp. we prefer not to impose a particular normalization or scale factor, instead estimating a relationship. our log formulation allows for normalization by population or gdp as special cases. for example, in the case of population we can transform our equation as follows: it follows that we can test if normalizing by population is a valid method of measuring the scale effect by estimating the original equation and testing the restriction that a = . similarly, normalizing fdi by total gdp gives it follows that our estimated coefficients on health are unchanged by such normalizations. we use life expectancy at birth to proxy the health of a country's population. we would prefer a measure of health that explicitly accounts not only for mortality rates, but also for the morbidity effects of ill-health. however, murray and lopez ( ) demonstrate that higher life expectancy is associated with lower morbidity and overall better health status. furthermore, shastry and weil ( ) report that the survival rate of adult males is linearly related to adult male height, which is often used as a measure of health human capital in microeconomic studies (e.g., savedoff & schultz, ; schultz, ) . these findings establish a relationship between mortality and morbidity measurements. however, health is a multidimensional concept and it is likely that our life expectancy measure does not capture the full complexity of population health. different dimensions of health may have differing economic consequences (e.g., gallup & sachs, , show that endemic malaria affects economic growth, even after accounting for life expectancy). we leave the study of the effects of different components of population health on fdi to future research. we use as our educational stock measure the log of the percentage of the population aged or above who have completed secondary schooling (cohen & soto, ) . we follow the literature with respect to the inclusion of other control variables, including openness of the economy, infrastructure, quality of governance, and distance to major world markets. openness of the economy to trade is especially important for firms seeking to export products from the host country to the global market, as tariffs, quotas, and other forms of capital controls will diminish firms' profits (asiedu & lien, ) . openness is required not only with respect to exports, but also for imports, because many fdi ventures may require the purchase of intermediate inputs from abroad. we employ the ratio of trade (imports + exports) to gdp as our measure of openness. governance is increasingly being identified as a key factor that firms evaluate when choosing to invest abroad (gastanaga, nugent, & pashamova, ; miga & deloitte & touche, ) . in particular, the quality of bureaucratic institutions affects fdi inflows (globerman & shapiro, ; stein & daude, ) . wei ( ) finds that corruption has a strong negative impact on the location of fdi. we use knack and keefer ( ) indexes of bureaucratic quality and corruption in government. note that in both cases a higher value of the index is ''better;'' in particular, a high value of the index indicates less corruption. good infrastructure in the form of transportation and communication networks can increase firm productivity and help attract foreign investment. we employ telephone mainlines per , population as a proxy for host country infrastructure. however, this measure has its limitations, as it only accounts for the availability and not the reliability of the infrastructure. this could be particularly problematic in poor countries where support for infrastructure may be lacking (asiedu, ) . furthermore, telephone mainlines are quickly being replaced by mobile networks. although mobile networks were not sufficiently developed over our study period to be significant, there is evidence to suggest that this is quickly changing (williams, ) . rapid technological changes of this type mean that studies like ours based on historical data need to be treated with caution for policy purposes. we also investigate whether geography affects the distribution of fdi inflows. transportation costs and distance from the home country are commonly included in gravity models of international investment and may affect a firm's decision about where to locate abroad (brainard, ; yigang, ) . although hausmann and fernández-arias ( ) find that distance to major markets is not a robust fdi determinant, we include air distance from major markets as a possible control variable in our analysis. in addition, gallup, sachs, and mellinger ( ) argue that the economies of coastal regions, with their easy access to international trade through sea lanes, should outperform the economies of inland areas. while inland areas can access markets through rail or road links, these are often much more expensive forms of transportation. thus, we include a dummy variable for whether a country is landlocked with the stipulation that the country is not located in western or central europe (countries in western and central europe have close proximity to a major market and the absence of sea routes may not matter). we also include a variable for the proportion of population within km of the coast or an oceannavigable waterway as an alternative to having access to the sea. a weakness of the cross-country approach that we employ is that it relies on national averages. for large countries with major difference across states or provinces, such as india or china, fdi inflows may be responding to local, not national, conditions. in other instances, analysis at the regional level might be more appropriate. for example, parts of southern africa demonstrate a distinctive disease epidemiology partly due to shared ecological and historical characteristics (bloom & sachs, ) . our results therefore carry the qualification that the cross-country approach we employ may need to be supplemented by more detailed local or regional studies to obtain a fuller understanding of the determinants of fdi inflows. the empirical analysis employs panel data for a set of countries observed over the last two decades. a list of countries included in the analysis is provided in appendix a. a summary of data sources and variable descriptions is provided in appendix b. we use all countries for which data are available, but exclude major petroleum exporters, because for these countries our measure of openness (trade flows) may not reflect a lack of trade barriers and gdp per capita is unlikely to proxy labor costs (unctad, ) . the dependent variable, gross fdi inflows, is based on annual data averaged over each decade. we constructed gross fdi inflows using data from the world development indicators (world bank, ) . the world development indicators does not include data on gross inflows directly, but does provide data on total gross flows (the sum of gross inflows and gross outflows) and on net inflows (gross inflows minus gross outflows), from which gross inflows can be derived. we calculated gross fdi inflows using the following two relationships: we multiply this by gdp (constant us$) to obtain gross fdi inflows. all explanatory variables are taken at the beginning of the relevant time period. summary statistics for the full sample are presented in table . the correlation coefficients for the full sample of countries are presented in table . life expectancy ranks second only to gdp per capita in strength of raw correlation to log gross fdi inflows. table shows that life expectancy is highly correlated with income per capita (a correlation coefficient of just above . ). however, while this correlation tends to increase the size of the estimated standard errors in our regressions, it does not undermine the consistency of the estimates or the validity of the inference we can draw assuming that the functional form of our model is specified correctly. table reports our panel data estimates for the full sample of countries with up to two observations per country, one for - and one for - . all reported regressions passed ramsey's regression specification error test (reset) for model misspecification. we estimate using heteroskedasticity-consistent standard errors. column ( ) of table reports results for an ordinary least squares specification that is representative of the fdi literature. the coefficients on income per capita and total population, our indicators of market size, are positive and strongly significant, and this remains true for all our specifications. the coefficients on each are usually not significantly different from unity in our regressions, indicating that in practice normalizing fdi flows by total gdp is valid. corruption is not significantly different from zero in our specifications, yet the other gover- nance measure, quality of bureaucratic institutions, is both significant and positive in the model. adding life expectancy in column ( ) demonstrates that health is a statistically significant predictor of gross fdi inflows at the % level and is robust to adding education in column ( ). the results indicate that every additional year of life expectancy increases fdi inflows by about % among the full sample of countries. the other component of human capital, education, has a positive coefficient, but is not statistically significant. this finding is consistent with the conflicting evidence on the importance of education in determining the inflows of fdi. root and ahmed ( ) , as well as schneider and frey ( ) , report that education does not significantly affect fdi flows to developing countries. more recently, however, noorbakhsh et al. ( ) and globerman and shapiro ( ) argue that education does have a positive and significant impact on foreign investment and that its effect has been increasing over time. the reason for the poorly determined coefficient on secondary schooling in our model could be measurement error in the data on education that biases the estimated coefficient toward zero (see krueger & lindahl, ) . we also tried other measures of education, such as the number of accumulated years of education in the population aged - and school enrollment rates, but did not find any measure that produced a statistically significant effect. we further test for robustness by adding infrastructure and geographic variables that are also postulated to be determinants of fdi inflows. the results reported in column ( ) indicate that the coefficient on life expectancy is robust to these alternate specifications, though many of the controls do not themselves appear to be statistically significant. recent evidence suggests that pooling data from industrial and developing countries in empirical fdi studies may yield misleading coefficient estimates (blonigen & wang, ) . we might expect that developing countries are more dependent on export-oriented fdi, while industrial countries are more attractive for market-seeking fdi (shatz & venables, ) . of particular relevance to the current study, we noted a gap in average life expectancy between income groups: . years for high-income countries versus . years for low-and middle-income countries. diminishing returns to health might well make it a more important investment in low-income countries. we therefore analyze the model using two restricted samples, one of low-and middle-income countries and one of high-income countries selected on the basis of the world bank's income classification. the results for low-and middle-income countries are reported in table . the model being estimated in table is identical to that reported in table , the only difference being the sample. the results are broadly similar to those listed in table . the coefficient on openness is somewhat larger than before, which is consistent with foreign investment to developing countries being mainly export-oriented. life expectancy once again has a positive and statistically significant effect on fdi. the large decrease in the coefficient on gdp per capita when we add life expectancy to the model indicates that when health is excluded from the model, gdp per capita is, to some extent, serving as a proxy for health in low-and middle-income countries. the effect of population health on fdi inflows is robust to adding education and other control variables. our results suggest that every additional year of life expectancy is associated with a % increase in gross fdi flows to lowand middle-income countries. the index of corruption is now significant, but of the ''wrong'' sign. the results suggest that higher levels of corruption are associated with higher levels of fdi in low-and middleincome countries. this finding, although perhaps surprising, agrees with stein and daude's ( ) and wheeler and mody's ( ) results. it is also consistent with alesina and weder ( ) , who argue that the relationship between corruption and economic performance is complicated. some types of corruption may allow the relatively efficient provision of services to foreign firms, its main effect being on the distribution of domestic economic gains, with little distortion of productive activities. table uses the same specifications as table for a sample restricted to high-income countries. the sample size now becomes quite small and may lead to some variables becoming statistically insignificant simply because of a lack of power; therefore, these results should be treated with caution. unlike the results reported from the previous two samples; openness, gdp per capita, and bureaucratic quality are not statistically significant. the lack of significance of openness is consistent with the idea that fdi going to industrial countries is mainly to access their markets rather than to export. even though gdp per capita does not have a significant association with fdi inflows, the other proxy for market size, total population, is highly significant at the % level. the lack of significance of gdp per capita could be due to a balancing of the market size effect with the cost of production effect, which should work in the opposite directions. reduced corruption does appear to have a positive and significant impact on fdi in this sample; indicating that the type of corruption, or the way it affects the economy, may differ between industrial and developing countries. health is not statistically significant in any specification among high-income countries. this is consistent with the idea that the worker productivity effects of health differentials appear mainly in developing countries; however, we hesitate to emphasize such an interpretation due to the small sample size. our results are consistent with those of blonigen and wang ( ) , who argue that the underlying factors that determine the level of fdi activity vary systematically across countries at different stages of development. this split of the sample is supported by the fact that we can reject parameter equality between the two sub-samples in some specifications. for example, taking regression , the f-test (distributed as a v ( , )) yields a statistic of . . this leads us to reject the hypothesis that the coefficients reported in the two sub-samples are the same at the % significance level. we also reject the commonality of coefficients in regression specification . although we fail to reject the null hypothesis of equality for regression specifications and , it seems preferable to consider the two sub-samples separately. this paper provides empirical evidence that health is indeed a positive and statistically significant determinant of gross fdi inflows to low-and middle-income countries. our results remain robust to adding many control variables, such as education, governance, infrastructure, and income per capita. although we have tried to ensure that our results are robust, there is always the possibility that some hidden variable is the real determinant of fdi. the positive coefficient on life expectancy may be due to factors correlated with health that we could not control for in the model. future studies should confirm the robustness of our findings and attempt to disaggregate the health effect we have identified. it may be that certain diseases have a greater impact on fdi inflows than others. for example, diseases that afflict the working-age population (e.g., hiv/aids) or are easily transmittable (e.g., tuberculosis) may deter fdi inflows more than chronic, non-communicable diseases. perhaps diseases with a high morbidity affect fdi differently than those with a high mortality. it is difficult to carry out this type of detailed analysis at the cross-country level, but it may be possible in more local settings. despite these qualifications, our main result is that a one-year improvement in life expectancy is associated with a % increase in gross fdi inflows to low-and middle-income countries, and this result seems fairly robust. these findings are consistent with the view that health is an integral component of human capital for developing countries and suggest that the payoff to improved population health is also likely to include an elevated rate of fdi inflows. notes . globerman and shapiro ( ) do regress fdi on the human development index (hdi), which is a composite of gdp per capita, educational literacy and enrollment, and life expectancy at birth. we directly investigate the effect of health on fdi. . in , the five highest fdi-receiving countries attracted % of the total inflows to the developing world (cho, ) . . for example, debswana, anglo american, and coca-cola are a few companies now subsidizing hiv medicines (anti-retroviral therapy) in southern african countries (the economist, ) . . more generally, acemoglu, robinson, and johnson ( ) show that historically infectious disease burdens have had a profound impact on the pattern of colonial settlement while glaeser, la porta, lopez-de-silanes, and shleifer ( ) emphasize that one effect of such settlement was the transfer of human as well as physical capital. . the profit function assumes that all factor inputs are chosen to maximize profits given the price vector. in our case we examine the profits earned by a unit of fdi, allowing all other inputs to be chosen optimally. . adding multiple inputs in the same cobb-douglas function does not change any of the results. . the estimates of life expectancy are based on agespecific mortality rates for high-income countries but are usually constructed from life tables based on infant mortality rates from national demographic and health surveys in developing countries (see bos, vu, & stephens, ) . . williams ( ) finds that mobile phone penetration rates are a significant and positive predictor of net fdi inflows to developing countries. however, these results are only observed for the period - . a similar relationship is not found if data from to are included in the analysis. williams interprets these findings as evidence that mobile networks were not sufficiently developed during the earlier period to affect fdi. . the sea distance may be a better indicator than air distance to major markets for trade purposes, though this leaves open the issue of how to deal with landlocked countries. . the major petroleum producers are algeria, angola, bahrain, brunei darussalam, republic of congo, gabon, indonesia, islamic republic of iran, iraq, kuwait, libyan arab jamahiriya, nigeria, oman, qatar, saudi arabia, syrian arab republic, trinidad and tobago, united arab emirates, venezuela, and yemen (based on the classification by the united nations conference on trade and development-see http://www.unctad.org/templates/webflyer.asp?intite-mid= &lang= ). . because data are not available for , we used the earliest available data (during - ) for the index of corruption and quality of bureaucratic institutions over both time periods. the data for the variable, ''percent of population kilometers from the coast or an ocean-navigable waterway,'' are estimated using geographic information system (gis) technology, which does not date back to . despite this limitation, the variable was included in the model as a determinant of trade costs. we also tried other geographic variables (e.g., land area in the tropics) but none were significant. . neither the share of the population near the coast nor being landlocked were significant if entered separately. . in the world bank ( ) categorization, the lowand middle-income group (all developing economies) includes those countries in which the gross national income per capita was us$ , or less, as measured in current us dollars. the 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( ) key: cord- -c aw jkz authors: privor-dumm, lois; vasudevan, prarthana; kobayashi, kana; gupta, jaya title: archetype analysis of older adult immunization decision-making and implementation in countries date: - - journal: vaccine doi: . /j.vaccine. . . sha: doc_id: cord_uid: c aw jkz the global population of adults over years of age is growing rapidly and is expected to double by . countries will face substantial health, economic and social burden deriving from vaccine-preventable diseases (vpds) such as influenza, pneumonia and herpes zoster in older adults. it will be essential that countries utilize several public health strategies, including immunization. understanding the different approaches countries have taken on adult immunization could help provide future learnings and technical support for adult vaccines within life-course immunization strategies. in this study, we describe the priorities and approaches that underlie adult immunization decision-making and implementation processes in high-and-middle-income countries and two territories (“ countries”) who recommend adult vaccines in their national schedule. we conducted an archetype analysis based on a subset of two dozen indicators abstracted from a larger database. the analysis was based on a mixed-methods study, including results from key informant interviews in six countries and a landscape review of secondary data from countries. we found four distinct archetypes: disease prevention-focused; health security-focused; evolving adult focus; and, child-focused and cost-sensitive. the highest performing countries belonged to the disease prevention-focused and health security archetypes, although there was a range of performance within each archetype. considering common barriers and facilitators of decision-making and implementation of adult vaccines within a primary archetype could help provide a framework for strategies to support countries with similar needs and approaches. it can also help in developing context-specific policies and guidance, including for countries prioritizing adult immunization programs in light of covid- . further research may be beneficial to further refine archetypes and expand the understanding of what influences success within them. this can help advance policies and action that will improve vaccine access for older adults and build a stronger appreciation of the value of immunization amongst a variety of stakeholders. the global population of adults over years of age is growing rapidly and is expected to double by . countries will face substantial health, economic and social burden deriving from vaccine-preventable diseases (vpds) such as influenza, pneumonia and herpes zoster in older adults. it will be essential that countries utilize several public health strategies, including immunization. understanding the different approaches countries have taken on adult immunization could help provide future learnings and technical support for adult vaccines within life-course immunization strategies. in this study, we describe the priorities and approaches that underlie adult immunization decision-making and implementation processes in high-and-middle-income countries and two territories ('' countries") who recommend adult vaccines in their national schedule. we conducted an archetype analysis based on a subset of two dozen indicators abstracted from a larger database. the analysis was based on a mixed-methods study, including results from key informant interviews in six countries and a landscape review of secondary data from countries. we found four distinct archetypes: disease prevention-focused; health security-focused; evolving adult focus; and, child-focused and cost-sensitive. the highest performing countries belonged to the disease prevention-focused and health security archetypes, although there was a range of performance within each archetype. considering common barriers and facilitators of decision-making and implementation of adult vaccines within a primary archetype could help provide a framework for strategies to support countries with similar needs and approaches. it can also help in developing context-specific policies and guidance, including for countries prioritizing adult immunization programs in light of covid- . further research may be beneficial to further refine archetypes and expand the understanding of what influences success within them. this can help advance policies and action that will improve vaccine access for older adults and build a stronger appreciation of the value of immunization amongst a variety of stakeholders. Ó elsevier ltd. all rights reserved. older adults are a heterogeneous group in the second half of life [ ] . studies demonstrate that vaccine-preventable diseases (vpds), including influenza, pneumonia and herpes zoster, account for a substantial portion of premature death and disability in older adults [ , ] . vpds also have the potential to cause disability that may lead to additional issues, such as declines in functional ability and quality of life [ ] . the economic burden of vpds is also substantial [ , [ ] [ ] [ ] [ ] [ ] [ ] . the global population of adults over the age of is growing rapidly and is expected to double by [ ] . although adults are expected to live longer, they are not necessarily living in good health [ ] . to be prepared for this demographic change, countries must establish plans and infrastructure that support healthy aging. aging populations will impact countries' economies, social security policies, and health systems, as well as affect many aspects of daily living for both the individual and broader society [ ] . at a national level, the consequences of an aging population extend beyond the health sector and solutions must be viewed across the life course [ , ] . it will be essential that countries utilize several strategies to ensure that their older populations age in a healthy manner, including adult immunization [ , ] . as they have for children, vaccines have the potential to significantly reduce burden of disease and disability, dependence, healthcare costs, and more in older populations [ ] [ ] [ ] [ ] [ ] [ ] . given the imminence of a growing, worldwide adult population, anticipation of increased health costs has spurred multiple global, https://doi.org/ . /j.vaccine. . . - x/Ó elsevier ltd. all rights reserved. regional and national calls for action for policymakers and practitioners to prioritize adult immunization programs and improve uptake [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] . many high-and middle-income countries have adopted influenza vaccines [ ] , however few have adopted more than one vaccine for older adults or have comprehensive adult immunization strategies. countries that have adopted adult vaccines appear to have taken different pathways to policy adoption [ ] [ ] [ ] [ ] [ ] . further, to be prepared for healthy aging, countries must think holistically. they will need systems and an appreciation for prioritizing health in older adults to support delivery of vaccines and other crucial interventions [ , , ] . particularly in the context of covid- , preventing further strain on the health system is paramount [ ] . the global vaccine action plan [ ] and the immunization agenda [ ] call for a life-course approach to immunization, which some countries have begun to implement. despite similarities in disease burden, demographic profile, and geographic proximity, these countries have taken different approaches and achieved different results in adult vaccine adoption. to understand those differences and explain the factors influencing country decision-making and uptake, we conducted an archetype analysis. this analysis aims to describe the country priorities and approaches that underlie adult immunization decision-making and implementation. by characterizing groups of countries by features other than disease burden, geography or demographics, the analysis seeks to support global efforts to address country needs in strengthening processes for vaccine decision-making and implementation; facilitating sharing of best practices amongst countries with similar characteristics; and providing evidence, system or advocacy support to help countries succeed within their specific context. the archetype analysis does not replace the need for individual country strategies, but groups needs in a way that enables the global community to provide meaningful support across a broader group of countries. thirty-two countries and two territories (herein referred to as countries) were selected for analysis. countries selected had high proportions of older adults, were geographically diverse, and represented a range of potential archetypes based on their adult vaccine adoption status, financing models, degree of health system centralization, and vaccine coverage. all countries were included in a literature review and data abstraction. six countries (argentina, australia, canada, germany, japan, and the united kingdom (uk)) were selected for further qualitative research to provide additional depth in a diversity of contexts, approaches and performance. the insights gained in each case country helped characterize archetypes. each case country, to some degree, prioritizes adult vaccination and recommends and finances one to three adult vaccines, but varies in terms of government and/or healthcare system centralization and adult vaccine coverage rates. the united states (us) was not selected as a case study country, due to ivac's working knowledge of the american public immunization system and the abundance of publicly available peerreviewed articles and government documentation on older adult immunization. the study plan was reviewed by the johns hopkins bloomberg school of public health institutional review board and deemed to be non-human subjects research. domains (table ) were identified as part of a framework of potential barriers and facilitators for adult vaccine decisionmaking: country characteristics, adult vaccine/aging policies and decision-making, health immunization systems, uptake, and stakeholders and champions. these domains were the subject of key informant interviews conducted in six case countries and a concurrent landscape analysis of the countries. a series of indicators were subsequently identified, informed by previous research [ ] , an adult vaccine situational analysis [ ] , and the case study interviews. a team of abstractors conducted the indicator research. we searched peer-reviewed and grey literature, including government and professional society websites, disease burden and vaccine introduction and program status databases, reports from countries, the world health organization (who), non-governmental organizations (ngos), and media articles. we reviewed minutes from national technical advisory groups on immunization (nitags) as well as official recommendations and policies for both key informant interviews were conducted in in argentina, australia, canada, germany, japan and the uk. informants included vaccine experts, government and former government officials, healthy aging advocates, economists, and civil society. respondents were selected using a snowball approach. one-hour face-to-face interviews were conducted by - people using an interview guide. for each respondent type -technical respondents, economic respondents and health advocacy-focused respondentsunique guides were prepared to ensure the focus of the questions was on their area of expertise. a combination of open-ended questions and probes were used. topics included respondent background; country health priorities; key players and stakeholders; robustness of the process; drivers of decisions and uptake. we used scales of very important, moderately important, not important, and don't know/not sure to ascertain respondents' perceptions about drivers or degree of agreement with certain statements and to map responses. interviews were transcribed and entered into atlas.ti for mac os x (a qualitative data analysis software) to conduct a thematic analysis. no identifiers were included to keep the identities of respondents confidential. descriptive categories of their function (e.g., technical, economic, civil society organization, etc.), were included instead. based on the case study findings, we selected indicators that most differentiated countries and created a scoring of - to rate each country, with meaning that it fit the criterion well and that it did not fit the criterion and/or there was no data available to assess fit ( table ). each indicator was ascribed a score based upon a qualitative description. following validation, we found some of our scoring was insufficient in describing qualitative nuance and added an intermediate score of . to one indicator and . to four indicators. we scored all countries on indicators related to decision-making ( indicators) and implementation ( indicators). each country received a score and a ranking for both domains (i.e., decision-making and implementation). we recorded the scores in a table, organizing countries by pneumococcal vaccine coverage (high to low). we mapped all countries on a grid using graph pad prism version . . we used the case study insights to identify characteristics that could describe the primary driver of a country's approach to decision-making and implementation (the ''archetype"). based on the qualitative insights, we found four distinct archetypes and placed each country into one archetype. although countries could fit in more than one archetype, we selected the archetype that most closely fit each country's primary driver. thus, country performance does not define each archetype's description. we transcribed each country's data into individual country profiles, providing the qualitative description associated with each quantitative score. we asked respondents to indicate their level of agreement (agree/disagree) with each score. we requested the respondents to identify missing data or inaccurate scores, that if corrected, could substantially move a country's score higher or lower. if there was disagreement, we asked respondents to provide an explanation and publicly available source(s) that support the change they suggested. we reached out to - experts per country, including a ministry of health representative, wherever possible. we provided a slide set describing the project, including objectives, methodology and the archetype map to enable countries to provide meaningful input. countries that responded are listed (table ). thirty of the countries analyzed had more than % of their total population adults over years of age. twenty-four countries had over % of their population over years of age. high-income countries and upper middle-income countries, had older populations than lower-middle and low-income countries (table ), but the age of populations did not predict the number of vaccines adopted for their adult populations nor uptake of influenza or pneumococcal vaccine (fig. ). one hundred and twenty key informant interviews were conducted in the six case countries, including a range of respondents covering health, immunization, government policy, aging and economics. overall, respondents in australia and the uk had the greatest degree of confidence in their country's ability to make decisions about new vaccines for adults and implement programs. the uk respondents attributed their country's ability to make decisions on the broadest variety of factors and only the influence of advocacy and bringing a variety of perspectives into decision-making was ranked lower. respondents in canada expressed a high degree of confidence in their country's ability to make decisions but reported lower confidence in their government's level of priority for adult vaccines, access to providers and financing. germany had similar perceptions to canada in that the decision-making process was strong, but respondents questioned the ability to implement, ease of access and the variety of advocacy efforts. argentine and japanese respondents had lower composite ratings on their perception of their country's capability to make decisions and implement adult immunization than the other countries but rated their country's commitment to adult health and the variety of perspectives highly. argentine respondents also rated their nitags as capable. both argentine and japanese respondents had less confidence in ease of access, financing, surveillance for adults. we also noted varying approaches to how cost-effectiveness (c-e) data were used both amongst case study countries and other countries that the respondents described. a few countries, including the uk, used c-e thresholds in their adoption decisions. other countries considered c-e data but did not use it. in some countries, childhood vaccination was viewed as a higher priority, particularly for funding. some respondents in germany even went as far as to state that putting adult health before child health would be unethical. in japan, we saw no evidence of c-e studies used in their nitag decisions, although safety studies were a requirement (fig. ). similar to decision-making, factors influencing implementation varied by country (fig. ). in the case countries, we saw table scoring. early or late adopter of adult vaccines = no or late decision-making and adoption of either pneumococcal or herpes zoster vaccine = follower in decision-making and adoption of at least one vaccine = leader in decision-making and adoption of one or more vaccines country-specific policy requirements of manufacturers = multiple = one = none disease burden surveillance = no surveillance = some surveillance (mostly of flu and pneumococcal disease) = national surveillance of flu, pneumococcal disease, and herpes zoster nitag's prioritization of health security in decision-making = small to no priority on health security, or no evidence available = nitag considers health security, but it is not a main driver of decisions = nitag considers health security as a main driver of decisions nitag's utilization of cost-effectiveness (c-e) data in decision-making = small to no focus on c-e, or no evidence available = nitag considers c-e data, but it is not a main driver . *= nitag mostly considers c-e data as a main driver = nitag considers c-e data as a main driver nitag has adult vaccine working group(s) = such working groups . * = nitag has such working groups, but is involved in other recommending bodies where government is engaged = such working group = multiple such working groups (as part of a broader vaccine-specific working group or a standalone) public policy -pneumococcal vaccination for older adults = pcv or ppsv not recommend, unknown if considered by nitag = pcv or ppsv considered by nitag, but not recommended . * = pcv or ppsv was recommend by nitag, but not yet implemented = pcv recommended by nitag public policy -herpes zoster vaccine (hzv) for older adults = hzv not recommended, unknown if considered by nitag = hzv considered, but not recommend by nitag . *= hzv recommended by nitag, but not yet implemented = hzv recommended by nitag publication of health aging strategies = no healthy aging strategy publicly available = aging strategy available at the sub-national or national level . *= sub-national or national aging strategy available that mentions adult immunization, but is over ten years old = national aging strategy available that mentions adult vaccines publication of national immunization strategies = no immunization strategy publicly available = only pediatric immunization strategy publicly available = national immunization strategy published and covers both pediatric and adult vaccines vaccine financing -level of public financing (for each vaccine) = older adults must pay out of pocket = vaccine covered by private insurance, requires co-pay, or limited coverage is provided in certain geographic areas or at-risk populations . *= mixed system of payment (covered) = vaccine is fully funded by the government for all vaccine registry (for pediatric and adult populations) = countries were assessed on their adult vaccine implementation and decision-making. decision-making was scored upon indicators and implementation upon indicators. each indicator was ascribed a quantitative score, as described above. recommendations were not universally implemented (particularly in canada and germany). the exceptions were the uk, which has a very centralized immunization program, and australia, which was decentralized but took a more centralized approach to monitoring and promotion. access to immunization was a factor reported to influence older adult immunization uptake. lower uptake may be due to limited mobility or lack of awareness of the need for adult vaccines. in some countries, such as germany and japan, respondents stated that vaccines were still viewed as something only for children. additionally, health system complexity was reported as an important factor contributing to access, and ultimately uptake, with some respondents describing receiving vaccination as an older adult as an overly cumbersome process. in canada, respondents' general perception was that there are not many places or providers of adult vaccination. restrictions on who could administer vaccines was also reported as a perceived barrier. improvements in access were described in japan, where nurses can now vaccinate; in france, where pharmacists can offer influenza vaccines; and in the uk, where pharmacists were allowed to administer influenza and pneumococcal vaccines. despite some countries expanding their range of adult vaccine providers, respondents noted that uptake does not always correspondingly increase. this gap offers a role for advocacy efforts in improving uptake. the influence of advocacy can be difficult to assess and is sometimes subjective. nonetheless, we used the number of national advocacy organizations as a proxy for influence in database countries. in case countries, we were able to gather insights. each respondent was asked about advocacy efforts in their country, yet there was a wide range of level of familiarity of country efforts. australia is a clear leader and uses a variety of approaches to advocate for adult immunization. australian respondents described influential advocacy efforts that impacted both the national adult vaccination decision-making and implementation processes. for example, in the country citizens, government, medical societies, and health aging specialists have organized large groups to advocate for better recommendations and financing as well as influence uptake and equal access to vaccines. in japan, respondents were not familiar with any major advocacy effort, although could describe small-scale patient-advocacy groups or activism against the government regarding vaccine injuries. based on the findings from the case studies, ten indicators emerged as descriptors of countries' older adult immunization decision-making capacity, specifically whether countries: were early adopters; had country-specific barriers such as requirements for technology transfer (brazil, india, japan, korea); preferences for indigenous product (china, indonesia, brazil, india, russia); halal vaccines (malaysia); safety study requirements (japan); or c-e requirements (uk, netherlands); prioritized surveillance on vpds in older adults (emerging as a factor in many of the countries concerned about health security); were prompted in their vaccine decisions by health security concerns; considered c-e a major driver in vaccine decisions; had working groups in their national immunization technical advisory groups (nitags) specific to adult vaccine issues; adopted pneumococcal conjugate vaccine (pcv) ; adopted herpes zoster vaccine (hzv); published a national healthy aging policy (including whether there is a mention of vaccines); and included adult vaccines in their national immunization policy. for implementation and uptake, indicators that emerged included whether there was government financing for influenza vaccines, pcv and hzv; centralized vaccine registries for children and adults; coverage data for all three vaccines; advocacy (measured by the number of advocacy organizations); documented influence of organizations or leaders; access (easy to get vaccinated by expanded list of providers or lack of bureaucracy or cumbersome process); equity focus; centralization of the adult vaccine program; and centralization of the health system. few countries that had strong decision-making also had strong uptake and vice-versa. further, the scoring table shows that countries varied significantly in the indicators that drove their performance on adult vaccine decision-making (table ) and implementation (table ). to determine how composite scores corresponded to performance, we ordered countries based on their pneumococcal vaccine uptake and compared that to rankings of the composite score on both decision-making and implementation/uptake. countries with the highest coverage of pneumococcal vaccines did not always perform the highest on decision-making, with the exception of australia, us, uk, and canada. we did a similar exercise for influenza vaccine uptake and found that top ten countries with highest influenza coverage were similar to those with the highest decision-making and implementation scores. the us had the highest ranking, compared to other countries, and scored points when assessed for the robustness of policies and decision-making. australia (score: . ), the uk (score: . ) and italy (score: ), had the next set of highest scores. countries with the least robust policies and decision-making were denmark, table countries responding to validation survey. received survey results responded with feedback the results of the archetype analysis was shared with experts representing all countries. countries responded and participated in the validation process. india, peru, the philippines, switzerland, and saudi arabia (all ranking last; scoring: ) (see table ). when assessed for the promotion of implementation and uptake, the uk (score: out of a possible ), new zealand ( ), and australia ( ) had the highest rankings compared to other countries. in contrast, russia (score: ), peru ( ), and india ( ) had the lowest ranking (see table ). based on a synthesis of case study data, we found four distinct archetypes with unique characteristics: ''disease preventionfocused"; ''health security-focused"; ''evolving adult focus"; and ''child-focused and cost-sensitive" (fig. ) . some countries could belong to multiple archetypes, but we selected the archetype most closely aligned with primary driver of approach. we also noted that the highest performing countries in terms of both decision-making (australia, us, uk, canada, italy, netherlands, germany and mexico) and implementation (uk, new zealand), australia, us, korea, canada, italy and norway) belonged to either the ''disease prevention-focused" or ''health securityfocused" archetype (see fig. ). disease prevention-focused: countries in the ''disease prevention" archetype included canada, france, germany, netherlands, uk, and us. these countries valued the use of data and process. most countries' nitags in this archetype had considered most of the adult vaccines and performed fairly high on decision-making. we noted use of their own disease burden/impact evidence in decision-making, as well as use of other countries' data. most of these countries had their own adult surveillance and formal adult vaccine working groups on their nitag. the uk and the netherlands also placed high importance on economics. most countries considered economics, but it was not a primary driver. germany, and to a lesser extent the us, considered economics, but disease burden was the primary driver in decisions. there was significant variation in implementation performance. reasons varied within this archetype, and included lack of national adult registries, equity focus, sufficient advocacy and centralization. health security-focused: the ''health security" archetype was the largest of the four and also the most diverse in terms of performance. it included argentina, australia, china, greece, hong kong, italy, japan, mexico, new zealand, saudi arabia, taiwan, and turkey. the characteristic of this archetype is that outbreaks (h n in australia and argentina; pneumonia in japan), vpd threats (due to migration or in refugees), and natural disasters (tsunami in japan) were viewed as an important country motivation for action. we saw wide variation of performance within this archetype, with australia, italy, new zealand and mexico performing highest and china, japan, hong kong, taiwan and greece lagging behind. degree of centralization and registries contributed to performance. australia, for example, reported that data use was strengthened during the h n outbreak in . in argentina, surveillance and epidemiologic response was also strengthened as a result of an h n outbreak. it also led to strategies to establish mass vaccination centers to improve access to vaccines more widely. in , the great east japan earthquake struck northeastern japan and destroyed the local healthcare system. at the time, pneumococcal vaccine coverage in japan was only % and many healthcare workers feared the occurrence of pneumonia outbreak at evacuation shelters [ ] . to avoid future outbreaks, pneu-mococcal vaccine was provided free of charge in the three prefectures most affected by the earthquake. in , they reached record levels of uptake with miyagi and iwate at %, and fukushima at % coverage [ ] , leading to significant reduction in deaths attributed to pneumonia in the area [ ] , and eventually to the ministry of health, labour, and welfare's decision in to include pneumococcal vaccine to the routine immunization schedule for adults aged and older. the national coverage increased from % in to % in [ ] . evolving adult focus: countries in the ''evolving adult focus" archetype include belgium, brazil, colombia, ireland, korea, spain, sweden and malaysia. these countries had moderate to strong systems and decision-making ranged from weak (denmark, malaysia) to moderate (korea, belgium). many of the countries in this archetype lack a strong nitag for adult vaccine decisions, but exhibit some elements of the ''disease prevention" archetype. some have healthy aging policies or immunization strategies, but only brazil has both. some countries were early adopters for some adult vaccines, including pcv in ireland and belgium, and hz vaccine in uae and norway. belgium has published an adult immunization strategy recently [ ] . financing for recommended adult vaccines, varies as well. although vaccines were recommended in some countries, they were not always publicly financed or financed for risk groups. child-focused and cost-sensitive: finally, some countries, including russia, peru, india, switzerland and the philippines remain ''child-focused and cost-sensitive" in their public markets. the countries in this archetype have not prioritized adult immunization programs and have generally lacked focus on decisionmaking for older adults. we found no adult vaccine working groups on the three vaccines analyzed (influenza, pneumococcal and herpes zoster) or policies around adult immunization at the time of our study. in terms of implementation, these countries may require patients to pay out of pocket for adult vaccines (russia, india) although there were some exceptions for influenza vaccine like the philippines and switzerland (although in switzerland vaccines were covered through insurance). we did not find a focus on implementation. these five countries have no registries or policies around adult health or adult immunization. additionally, advocacy for adult immunization was not strong and, in most cases, seemed to have little influence on the outcomes of the government. lastly, for most countries in this archetype, there is a cost-based argument: given limited resources, public investments in child health and vaccines are prioritized, as they are seen as necessary to further national economic development (russia, peru, india, philippines). we were able to validate our data and scoring in of countries ( %) ( table ) . where there was disagreement and documented sources, we corrected data and in five instances, adjusted scoring to reflect a more accurate picture of the parameters which had to do with timing of decisions or policies, the importance of c-e data in decision-making, nitag working groups, and a mixed financing system. importantly, the act of classifying countries into a primary archetype has its own set of limitations. firstly, there is a level of subjectivity that comes with archetyping, which we have tried to ameliorate by taking an evidence-based approach. secondly, archetyping elevates a certain set of common characteristics above others and there are variations between and within countries that get under-accounted. countries may not fit perfectly in an archetype and may actually belong to other archetypes simultaneously; we therefore classified countries into primary archetypes, according to the indicator that they scored the highest on. our analysis was also limited by data availability and quality. in some cases, a zero score was given due to a lack of data or clarity on an indicator. we tried to address this through the validation process, but little additional information was provided. additionally, each indicator's scoring was based only on data that was publicly available through october (unless otherwise provided by experts during validation) and may be impacted by timing. changes in scoring of - points is unlikely to impact score mapping, but larger changes may shift archetype categorization. archetypes can be useful in identifying factors that are most influential in improving decision-making and implementation for adult vaccines in the context of a country's approach and priorities. this will enable various countries to learn from experiences amongst countries within the same archetype. there has been some use of archetypes, mainly in health technology assessment [ ] [ ] [ ] [ ] [ ] , but experiences have not yet been widely documented. the archetype describes the primary driver of decisions and implementation as well as country priorities or approach rather than performance. there can be significant variation in perfor- mance within an archetype, which we saw in this exercise. top performing countries belonged to two different archetypes, which were ''disease prevention-focused" (us, uk, canada) and ''health security-focused" (australia, italy), suggesting that there are multiple ways to achieve adoption and uptake. it is likely that countries within the ''evolving adult focus" archetype could improve their performance by learning from countries in the ''disease prevention" or ''health security" archetypes. the improvements needed within the ''child-focused" archetype may require both stronger advocacy as well as additional data. while we provide broad-based archetypes, we also saw different approaches within the archetypes; this is important as each country will need to take lessons based on what works for them. understanding the success factors of the highest performing countries within a particular domain (e.g., decision-making) can also help other countries move up their performance in the context of their structure and priorities. the countries in the ''disease prevention" archetype all value data and its use, albeit to different levels and strategies can focus on data use and advocacy for disease prevention. at the one extreme of this archetype is the uk, where data use permeates through the process of both decision-making and implementation. decisions are evidence-based, with little influence of advocacy or champions. on the implementation side, there was also strong use of data with information on the immunization status of individual patients, which is all mapped to their general practitioner (gp). for countries who will consider a centralized approach, the uk provides a good model. however, many countries have decentralized systems, including the us and canada, who also have strong use of data for decision-making. they also have greater degrees of advocacy, which could perhaps also ensure certain groups have a voice in the process. use of data for implementation in decentralized settings may also benefit from learnings from table for score descriptors. generally, the higher the score the better that country meets the indicator; scores either mean the country doesn't meet the indicator or no data were found. countries that have centralized registries in a decentralized system (e.g., australia, although a different archetype). health security concerns provide countries with an opportunity to overcome a wide array of issues, from financing to barriers that may slow down decisions (e.g., tech transfer requirements as seen in brazil or requirements/strong preference for local products such as in china or india, requirements for local studies as in japan, etc.) and may be a motivator to strengthen surveillance, use of data, communications and platforms. the current context of covid- highlights likely opportunities to leverage the importance of developing a strong system. in doing so, it is important for countries to consider how all people, including older adults and/or marginalized populations such as migrants or refugees, can access vaccines. for example, in the us, adult immunization access increased as a result of the influenza an h n pandemic, with states granting pharmacists the authority to vaccinate against influenza [ ] . also, during that pandemic, a study demonstrated that american indian and alaska native persons have a higher risk for death from the h n influenza [ ] supporting prioritization of seasonal influenza vaccines amongst native americans that year [ ] . we saw wide variation of performance within this archetype and note that while emergencies may provide motivation to take action, other table for score descriptors. generally, the higher the score the better that country meets the indicator; scores either mean the country doesn't meet the indicator or no data were found. contextual factors must be taken into account. degree of centralization of adult immunization is one important factor that influences success of implementation. registries and stronger use of data are an important element in both ''health security" and ''disease prevention" archetypes, but the motivator to get them done may be different -in times of emergency, data are essential, but it is prior to an emergency that data are needed [ ] . after the severe acute respiratory syndrome (sars) epidemic, china was challenged to improve its public health emergency management systems (phems) [ ] . the system was significantly improved within ten years after the outbreak [ ] . more recently, china was able to contain covid- within the country [ ] , but the virus has caused more than . million cases and , deaths worldwide and continues to spread as of early april [ ] . there is now more than ever a strong need for systems to detect risk, transparently communicate the risk, and have infrastructure in place to address both existing and emerging infectious threats [ ] . engaging civil society and building accountability mechanisms can help motivate action more urgently. this current pandemic provides a window of opportunity to build urgency for the need for adult immunization and systems to deliver them. efforts, however, must not focus solely on covid- , but on the platforms needed to build strong health systems for all ages, including older adults. in countries that have taken action in the face of an emergency this message will resonate; for others, particularly without the resources or capacity to address older adults, different approaches may be needed to build focus on the needs of this group. in countries with an evolving adult focus, a strategy could be to emphasize nitag strengthening and sharing experiences with the ''disease prevention" and/or ''health security" archetypes. this will be particularly important should a vaccine become available for covid- and in considering vaccines that can address vpds in an older population now. in countries who follow other countries' recommendations, stronger global guidance is needed to emphasize preparedness, highlight the importance a growing adult population, and the consequences of doing nothing. in countries that need to improve uptake, access, financing, registries, and monitoring are all important. one factor that correlates to uptake is expansion through pharmacists [ ] , although with covid- , perhaps other ways of delivery that don't require contact with people could be considered. additional provider-focused strategies could be implemented to improve uptake of current vaccines, such as financial incentives to vaccinate older adult patients. proactive outreach (e.g., actively sending reminders to patients to get their vaccines) may also be important post-pandemic to remind patients of vaccines' importance. finally, even in the ''child-focused and cost-sensitive" archetype there may be opportunities to take advantage of synergies and address immunization through broader issues such as universal health coverage and antimicrobial resistance. central to these opportunities is building the links between child and adult health, and economic development [ ] . the economic pressure placed on countries through covid- may make adult immunization seem unreachable and studies that capture the broader value of vaccines may help in justifying investments [ , ] . stronger global guidance synthesizing healthy aging, universal health coverage, antimicrobial resistance and immunization recommendations and agendas can also be helpful. importantly, strong individual champions, coalition building across the vaccine and aging communities, and more resonant messaging could all help elevate routine older adult vaccination as a priority [ ] . a critical, momentumbuilding milestone would be when global institutions, like who, commit to leading the coordination of implementation [ ] , empowering countries to think about implementing older adult immunization in a more timely manner. combining two separate analyses, this graph plots countries' performance in implementation and decision-making as a point estimate, overlaid with each country's primary archetype denoted by a symbol (within an archetype, countries share similarities around vaccine decision-making; (see table ). countries are plotted according to their adult vaccine implementation score (see table ) on the x axis and their adult vaccine decision-making score (see table ) on the y axis. for example, the uk scored in implementation and . in decision-making, and is plotted at ( , . ) . some countries share the same coordinate, with two names next to a single point. countries with the highest implementation and decision-making scores appear in the top right corner of the graph. primary archetype (disease prevention focused; health security focused; evolving adult focus; or cost-sensitive and child focused) is designated by the color of the country's name and the symbol overlaid each point. most countries (n= ) belong to the health security primary archetype. within and across all four archetypes, vaccine confidence plays a role as both a facilitator and barrier of countries' performance. although fear of side effects, spread of misinformation, lack of provider recommendation, and reduced belief that vaccines are valuable are common reasons for hesitancy across all ages, a recent review of the literature yielded few insights into describing how adult vaccine hesitancy varied from that for children [ ] . this is an area of further research that may help explain country uptake and better address implementation gaps. specifically, once the research gap is more clearly described, tailored communication and outreach strategies could be developed that encourage older adults to seek immunization services. countries take different approaches to adult immunization. drivers and facilitators of primary adult immunization archetypes should be considered when developing global guidance for countries. experiences and lessons learned should be shared within archetypes to improve performance of countries falling behind on decision-making or implementation. the results of this study may inform strategies in countries with similar contexts and priorities. further research may be beneficial to further refine archetypes and expand the understanding of what influences success within an archetype. this can help advance policies and action that will improve vaccine access for older adults and build a stronger appreciation of the value of immunization amongst a variety of stakeholders. the authors declare the following financial interests/personal relationships which may be considered as potential competing interests: lpd has received grants from glaxosmithkline, merck and pfizer and an honorarium from pfizer. the other authors declare no competing interests. the world report on ageing and health: a policy framework for healthy ageing global, regional, and national disability-adjusted life-years (dalys) for diseases and injuries and healthy life expectancy (hale) for countries and territories, - : a systematic analysis for the global burden of disease study estimated human and economic burden of four major adult vaccine-preventable diseases in the united states t-cell immunity to influenza in older adults: a pathophysiological framework for development of more effective vaccines herpes zoster epidemiology, management, and disease and economic burden in europe: a multidisciplinary perspective cost-effectiveness of adult vaccinations: a systematic review modeling the economic burden of adult vaccine-preventable diseases in the united states cost-effectiveness of adult pneumococcal vaccination policies in underserved minorities aged - years compared to the us general population cost of shingles: population based burden of disease analysis of herpes zoster and postherpetic neuralgia a review of the cost-effectiveness of adult influenza vaccination and other preventive services united nations department of economic and social affairs population division population ageing in europe. facts, implications and policies. brussels: european commission directorate-general for research and innovation socioeconomic sciences and humanities adult vaccination as part of a healthy lifestyle: moving from medical intervention to health promotion vaccines for the elderly: current use and future challenges the public health value of vaccination for seniors in europe moving beyond traditional valuation of vaccination: needs and opportunities influenza vaccination in older adults: recent innovations and practical applications effectiveness of influenza vaccination on hospitalizations and risk factors for severe outcomes in hospitalized patients with copd report on who meeting on immunization in older adults the full benefits of adult pneumococcal vaccination: a systematic review identifying barriers to adult pneumococcal vaccination: an nfid task force meeting adult vaccination: now is the time to realize an unfulfilled potential national vaccine advisory c. a pathway to leadership for adult immunization: recommendations of the national vaccine advisory committee: approved by the national vaccine advisory committee on focusing on the implementation of st century vaccines for adults european geriatric medicine society (eugms) and the world association for infectious diseases and immunological disorders (waidid) first mexican consensus of vaccination in adults adult vaccination: a key component of healthy ageing -the benefits of life-course immunisation in europe a global review of national influenza immunization policies: analysis of the who/unicef joint reporting form on immunization adult immunization policies in advanced economies: vaccination recommendations, financing, and vaccination coverage variation in adult vaccination policies across europe: an overview from venice network on vaccine recommendations, funding and coverage challenges in adult vaccination vaccine myopia: adult vaccination also needs attention what isn't measured isn't done -eight years with no progress in aboriginal and torres strait islander adult influenza and pneumococcal vaccination a blueprint for improving the promotion and delivery of adult vaccination in the united states the world health organization. the global vaccine action plan the world health organization. immunization agenda : a global strategy to leave no one behind evidence-to-policy gap on hepatitis a vaccine adoption in countries: literature vs. policymakers' beliefs situational assessment of adult vaccine preventable disease and the potential for immunization advocacy and policy in low-and middle-income countries an activity report of physicians of the department of general medicine, juntendo university school of medicine against the great east japan earthquake relationship between public subsidies and vaccination rates with the -valent pneumococcal vaccine in elderly persons, including the influence of the free vaccination campaign after the great east japan earthquake pneumococcal vaccine (ppsv ) advies -basisvaccinatieschema development of archetypes for non-ranking classification and comparison of european national health technology assessment systems different paths to high-quality care: three archetypes of topperforming practice sites segmentation of seven asia-pacific health technology assessment (hta) agencies into different evolutionary hta archetypes integrating pharmacies into public health program planning for pandemic influenza vaccine response deaths related to pandemic influenza a (h n ) among american indian/alaska natives - states prevention and control of influenza with vaccines: recommendations of the advisory committee on immunization practices (acip) the public health emergency management system in china: trends from evaluation of the effectiveness of surveillance and containment measures for the first patients with covid- in singapore coronavirus resource center early response to the emergence of influenza a (h n ) virus in humans in china: the central role of prompt information sharing and public communication covid- : too little, too late? pharmacy-based interventions to increase vaccine uptake: report of a multidisciplinary stakeholders meeting life-course immunization: building the consensus for adult vaccination in ifpma generation of political priority for global health initiatives: a framework and case study of maternal mortality characterizing global vaccine hesitancy: how adult and pediatric hesitancy may differ glaxosmithkline (gsk) biologicals, belgium provided funding for the archetype analysis. merck and gsk provided funding for the landscape analysis and case studies. the authors thank nina martin, geervani daggupati, nobutoshi nawa, so yoon sim, dexter waters, and gatien de broucker, for their valuable contributions; members of the international council on adult immunization (icai) for their review and input; the in-country experts who participated in case study interviews and provided input in the validation process; and haley budigan for her careful proofreading. key: cord- -zb ih dl authors: chongsuvivatwong, virasakdi; phua, kai hong; yap, mui teng; pocock, nicola s; hashim, jamal h; chhem, rethy; wilopo, siswanto agus; lopez, alan d title: health and health-care systems in southeast asia: diversity and transitions date: - - journal: lancet doi: . /s - ( ) - sha: doc_id: cord_uid: zb ih dl southeast asia is a region of enormous social, economic, and political diversity, both across and within countries, shaped by its history, geography, and position as a major crossroad of trade and the movement of goods and services. these factors have not only contributed to the disparate health status of the region's diverse populations, but also to the diverse nature of its health systems, which are at varying stages of evolution. rapid but inequitable socioeconomic development, coupled with differing rates of demographic and epidemiological transitions, have accentuated health disparities and posed great public health challenges for national health systems, particularly the control of emerging infectious diseases and the rise of non-communicable diseases within ageing populations. while novel forms of health care are evolving in the region, such as corporatised public health-care systems (government owned, but operating according to corporate principles and with private-sector participation) and financing mechanisms to achieve universal coverage, there are key lessons for health reforms and decentralisation. new challenges have emerged with rising trade in health services, migration of the health workforce, and medical tourism. juxtaposed between the emerging giant economies of china and india, countries of the region are attempting to forge a common regional identity, despite their diversity, to seek mutually acceptable and effective solutions to key regional health challenges. in this first paper in the lancet series on health in southeast asia, we present an overview of key demographic and epidemiological changes in the region, explore challenges facing health systems, and draw attention to the potential for regional collaboration in health. southeast asia consists of the ten independent countries located along the continental arcs and off shore archipelagos of asia-brunei, singapore, malaysia, thailand, the philippines, indonesia, vietnam, laos, cambodia, and myanmar (burma) (fi gure )-collectively known as the association of southeast asian nations (asean). the region contains more than half a billion people spread over highly diverse countries, from economic powerhouses like singapore to poorer economies such as laos, cambodia, • the diversity of geography and history, including social, cultural, and economic diff erences, have contributed to highly divergent health status and health systems across and within countries of southeast asia. • demographic transition is taking place at among the fastest rates compared with other regions of the world, whether in terms of fertility reductions, population ageing, and rural-to-urban migration. rapid epidemiological transition is also occurring, with the disease burden shifting from infectious to chronic diseases. • rapid urbanisation, population movement, and highdensity living raise concerns about newly emerging infectious diseases, but these outbreaks have stimulated regional cooperation in information exchange and improvement in disease surveillance systems. • southeast asia's peculiar geology contributes to it being the most disaster-prone region in the world, more susceptible to natural and man-made disasters aff ecting health, including earthquakes, typhoons, fl oods, and environmental pollution. climate change along with rapid economic development could exacerbate the spread of emerging infectious diseases. (continues on next column) (continued from previous column) • health systems in the region are a dynamic mix of public and private delivery and fi nancing, with new organisational forms such as corporatised public hospitals, and innovative service delivery responding to competitive private health-care markets and growing medical tourism. • the health-care systems are highly diverse, ranging from dominant tax-based fi nancing to social insurance and high out-of-pocket payments across the region. there is a greater push for universal coverage of the population, but more needs to be done to ensure access to health services for the poor. • private health expenditure is increasing relative to government expenditure, where new forms of fi nancing include user charges, improved targeting of subsidies, and greater cost recovery. health-care fi nancing could be further restructured in response to future demographic shifts in age-dependency, as in introduction of medical savings and social insurance for long-term care. • there is potential for greater public-private participation with economic growth through asean integration and further regional health collaboration, despite the current division of the region under two who regional offi ces. and myanmar (table) . [ ] [ ] [ ] [ ] [ ] [ ] [ ] by comparison with india and china, southeast asia is less visible in global politics and economics. the same is also true of global health. in the fi rst paper in this lancet series on health in southeast asia, we analyse the key demographic and epidemiological transitions of the region to delineate the challenges facing health systems and to emphasise potential for regional collaboration in health. this regional overview sets the scene for more detailed discussion of specifi c health issues presented in the fi ve subsequent reports in this series, profi ling maternal and child health, infectious diseases, non-communicable diseases, health workforce challenges, and health-care fi nancing reforms. southeast asia contains about million people, or % of the world's population, with indonesia having the largest population (and fourth largest in the world) and brunei the smallest (see table) . nearly half ( %) of the region's population live in urban areas, which is less than the world average, but there is much variation between countries, from % in cambodia to % in singapore. the region's average population density of people per km² also masks substantial intercountry and in some instances intracountry diff erences. population densities range from a low of people per km² in laos to a high of per km² in singapore. population densities in southeast asia's only two megacities, jakarta and manila, are much higher, at more than people per km². although their population sizes are similar (around million), the greater sprawl of manila and jakarta make them less densely populated (ranked th and th in the world) than mumbai and delhi (ranked st and th, respectively). the next largest city in southeast asia, bangkok, is ranked th. although urbanisation is expected to continue to rise in the region, urban slum populations seem to be less deprived than they are elsewhere, with about a quarter living in extreme shelter deprivation (defi ned by un habitat as a slum household lacking three or more of the following conditions: access to water, access to sanitation, access to secure tenure, a durable housing structure, and suffi cient living space). , although life expectancy in all countries in the region has improved, there have been signifi cant variations in the rate of progress. most countries have enjoyed continuous rises in life expectancy since the s, and these are converging. in some cases (myanmar, cambodia) political regimes and history of confl ict have aff ected progress, as has hiv in thailand (fi gure ). where life expectancy gains have slowed, this trend has been mainly attributable to slow progress in reduction of adult mortality. there has been little progress towards reduction of intercountry diff erence in life expectancy during the past years, with the gap remaining at around years. as elsewhere, decreased fertility has been the main factor contributing to ageing of the populations in these countries. the speed and timing of fertility reduction has varied widely across the region (webappendix p ). singapore had the earliest and sharpest reduction-the total fertility rate fell from more than six children per woman in to · in the mid- s, and since , it has ranked among countries with ultra-low fertility (table). thailand's fertility decrease mirrors that of singapore, although beginning somewhat later; it is currently the only other country in the region with we used quantitative and qualitative data from academic and grey literature to review the health situation in southeast asia. search terms used were "health", "health statistics", "health systems", "socio-economic development", and "southeast asia". data were gathered after a call for information from regional experts on selected subthemes related to health (geography, history, demography, epidemiology, and health systems rapid socioeconomic development and strong family planning programmes are likely to have driven this reduction. interestingly, this statement was true for indonesia, but less so for brunei and malaysia, although all three countries share a common dominant religion, islam. malaysia adopted a pronatalist policy in the late s under the then prime minister mahathir mohammad. catholicism has been a major contributing factor to the slow uptake of family planning programmes in the philippines, alongside the persistence of cultural norms that support large family sizes. the high fertility rates recorded in cambodia and laos are related to low educational levels, as refl ected in their low proportion of enrolment in secondary school- - % compared with - % elsewhere in the region (including % in vietnam). according to cleland, although literacy confers cognitive abilities to use contraception, the social and psychological skills conferred by higher education probably enable people to "translate the desire to postpone or limit childbearing into contraceptive practice… [and] they are also more likely to use allopathic health services for a range of needs including ante-and natal-care, child immunization and curative care [that lead to better child survival]". economic and demographic developments have prompted the movement of people across the region, mainly for short-term employment, but also for settlement. rapid economic growth and the slowing of domestic population and labour force growth due to fertility reduction have prompted countries such as singapore to open its doors to in-migration of foreigners at all skill levels for employment, with the option of permanent settlement for the highly skilled. the philippines, indonesia, and vietnam are major labour-exporters, whereas malaysia and thailand both receive and send nationals abroad. besides this internal labour market, countries in southeast asia also send and receive migrants from outside the region. since the s, however, destinations within asia have replaced labour migration to countries such as the usa and to the middle east. there is signifi cant undocumented or illegal migration as well as movement of displaced people in the region. , these groups are particularly vulnerable since "[u]ndocumented migrants are disproportionately more exposed to health risks due to inadequate working conditions and irregular movements, but are unlikely to seek medical attention because of their status, and are also often left out of assistance programmes in times of disasters and emergencies". population age structures of countries in the region vary widely as a result of past diff erences in fertility, mortality, and migration trends (fi gure ). these trends are in turn aff ected by economic, social, cultural, and political developments. singapore and thailand have among the fastest ageing populations in the world, with the proportion of elderly residents projected to double from % to % in and years, respectively-shorter than the years expected for japan - because of more rapid fertility reduction in these two countries. with increasing longevity, the pace of increase in numbers of the oldest old, aged years and older, in southeast asia is projected to exceed that of east asia over the period - . the other major factor contributing to population ageing has been the decrease in mortality. figure shows estimated trends in risk of child death (ie, between birth and age years) in countries of the region during the past four decades. child survival has improved substantially in all countries, but particularly in indonesia, vietnam, thailand, malaysia, brunei, and singapore, where the risk of child death is now typically less than about · %, compared with - % in the s. measured by the risk of dying between ages and years, regional diversity in levels of adult mortality is even greater than for child mortality (fi gure ). typically, the risk of dying at these ages for men is - %, and is higher ( %) in cambodia, laos, and myanmar ( - %), and signifi cantly lower in singapore, where the level is similar to those in australia and japan ( - %). this regional diversity in risk of adult death is similar for women, but with rates typically - % less than those for men. increasing longevity is a result of diminishing burden from communicable, maternal, and perinatal diseases (group diseases; webappendix p ), whereas countries with aged populations have a higher burden of noncommunicable diseases (group diseases). interestingly, mortality rates from these two groups of diseases, as well as from injuries, are correlated. countries with high mortality rates from communicable diseases also have high death rates from chronic diseases (webappendix p ). deaths from communicable diseases are still prominent in cambodia, myanmar, and laos. injuries are an important cause of death in all countries, but less so in singapore and brunei. few countries in the region have complete cause of death data systems to inform health policy and planning, and of those that do only singapore has reliable cause of death certifi cation and coding. although not representative of present health conditions in neighbouring countries, understanding of how leading causes of death have changed in singapore during the past years or so can provide important insights into what other countries of the region could expect to achieve, provided there is a similarly strong public health commitment to disease control and injury prevention. figure summarises trends in selected causes of death for both sexes in singapore since . in the early stages of transition, striking reductions in infectious diseases such as tuberculosis were achieved, off set by increases in non-communicable diseases including cardiovascular diseases and cancers, as well as injuries. although deaths due to road traffi c accidents have subsequently decreased and cardiovascular diseases seem to have reached a plateau, breast cancer has continued to rise. except for stomach and cervical cancer, mortality from all other cancers is still rising (data not shown). these data illustrate the success of singapore in reducing mortality from the diseases of poverty, as well as the eff ects of inadequate chronic disease control programmes, although there is evidence of some success in control of lifestyle-related diseases in recent years. as other countries in the region succeed in bringing communicable diseases under control, the importance of injury prevention and chronic disease control programmes will become increasingly pressing. the region as a whole does not have reliable longitudinal data for disease trends. however, evidence from studies of disease prevalence shows a strong inverse association with national wealth, which can be largely attributed to the social determinants of health, including the provision of more effi cient health systems with greater population coverage. the fi gure provided on p of the webappendix shows the relation between prevalence of tuberculosis and per head income (log-log scale). the regression equation (not shown) suggests that a doubling of per head income is associated with a reduction in tuberculosis prevalence of %. for diabetes mellitus prevalence, countries can be roughly divided into three groups that are positively correlated with income, although the eff ect tapers off at higher levels of per head income, (webappendix p ), possibly because of more eff ective disease control programmes with greater coverage. hiv was introduced into the region in the s. transmission peaked in the early s in thailand, followed by myanmar and cambodia. hiv/aids has been a major cause of death in some countries of the region (eg, thailand), although its spread has been partly controlled by the promotion of condom use. in the early s, more eff ective antiviral therapies emerged, followed by the introduction of compulsory licensing. although universal access to treatment has been attempted, patient compliance and losses to follow-up care are still prevalent. , aids mortality in southeast asia has stabilised since the mid- s, although prevalence remains high in myanmar, laos, and cambodia. the environment continues to be an important contributing factor to disease and mortality in the developing world, including countries in southeast asia, accounting for up to a quarter of all deaths. regular monsoons and typhoons occur in southeast asia. the el niño and la niña phenomena also intensify the annual variation of the hot and wet climate, leading to droughts, fl oods, and the occurrence of infectious diseases such as malaria and cholera. countries in the northern part of the region such as the philippines and vietnam are badly aff ected by seasonal typhoons that have increased in intensity over time. the philippines and indonesia are located on the pacifi c ring of fire, a zone of earthquakes and volcanoes where around % of the world's earthquakes occur. southeast asia is one of the most disaster-prone regions in the world; the indian ocean earthquake off the coast of sumatra in caused a devastating tsunami in aceh, indonesia, and countries on the fringe of the indian ocean, one of the worst natural disasters ever recorded. uncontrolled forest fi res raged in the indonesian states of kalimantan and sumatra in . the severity of the fi res was also closely linked to the occurrence of the el niño southern oscillation, which has historically brought severe drought conditions to southeast asia, creating conditions ripe for fi res. in , the severity and extent of haze pollution was unprecedented, aff ecting some million people across the region. the health-related cost of the haze was estimated to be us$ million. the health eff ects of the haze in southeast asia have been well documented. , an increase in concentration of particulate matter with diameter μm or less from μg/m³ to μg/m³ was signifi cantly associated with increases of % in upper respiratory tract illness, % in asthma, and % in rhinitis from public outpatient care facilities in singapore. time-series analyses in people admitted to hospital in kuching, malaysia, showed that signifi cant fi re-related increases occurred in respiratory hospital admissions for chronic obstructive pulmonary disease and asthma. survival analyses suggested that people older than years who had been previously admitted to hospital for cardio respiratory and respiratory diseases were signifi cantly more likely to be readmitted during the haze episode. climate change could exacerbate the spread of emerging infectious diseases in the region, especially vector-borne diseases linked to rises in temperature and rainfall. southeast asia has been identifi ed as a region that could be vulnerable to eff ects of climate change on health, because of large rainfall variability linked to the el niño and la niña oscillation, with attendant consequences for health systems. southeast asia's rich history and recent industrialisation and globalisation have raised new challenges for the region's health systems. modern medical technology is available in the world market but at costs higher than most of the region's population can aff ord. many traditional health practices persist alongside the use of new medical technologies and pharmaceutical products, presenting regulatory problems in terms of safety and quality. with increasing educational levels, ageing populations, and growing consciousness of human rights in the recently developing democratic environment, the demand for better care is increasing. health systems in the region face more serious adjustment problems than ever before. health services have become an important industry, with a mix of public and private non-profi t and for-profi t actors, along with the growth of trade and medical tourism. the provision, fi nancing, and regulatory functions of the public sector have to adapt accordingly to these transformations. the need to restructure healthcare delivery and fi nancing systems becomes crucial to balance new demand and supply equilibriums. , countries in southeast asia and their health system reforms can thus be categorised according to the stages of development of their health-care systems. a typology of common issues, challenges, and priorities are generated for the diverse mix of health systems of southeast asia at diff erent stages of socioeconomic development (see webappendix pp - ). the pressures placed on national health-care systems by the recent demographic and epidemiological transitions that we have described are amplifi ed by the growing demands of an increasingly educated and affl uent population for high quality health care and the supply of the latest medical technology. before the east asian fi nancial crisis in - and the recent global economic recession, an expanding middle class in the urban populations of the larger cities pushed their demand for high quality care into a booming private sector. as a result, market forces have turned many aspects of health care into a new industry in countries such as singapore, malaysia, and thailand, contributing to labour-force distortions for the production and distribution of health workers both within and across countries. the s began with the opening up of socialist states and rapid growth among market economies in the region. while they were each fi nding ways to reform their health systems, the asian fi nancial crisis in - posed more challenges for countries of the region. the depreciation of local currencies resulted in increased costs of imported drugs and other essential supplies, at the same time as access to basic health care was reduced for the most vulnerable population groups. however, reported spikes in suicides and mental illnesses in the other aff ected east asian economies such as south korea, taiwan, and hong kong were not as signifi cant in southeast asia. following the lessons learnt from the past fi nancial crisis, most countries have strengthened their social protection mechanisms and essential health services. there is a greater push among countries to increase universal coverage of basic health services, especially to vulnerable and disadvantaged populations. , throughout the region, many innovative pro-poor fi nancing schemes were implemented, such as the health card and -baht schemes in thailand, the health fund for the poor in vietnam, health equity funds in cambodia and laos, and, even in affl uent singapore, the medifund, a meanstested hospital fees subsidy scheme for indigent patients. so far, the health-care systems with dominant tax funding are fairly stable, in view of the strong role of governments and eff ective controls by health agencies to overcome inequity problems. however, crucial issues involve rising costs, future sustainability of centralised tax-fi nanced systems, effi ciency and quality of the public services, and higher public expectations. in both malaysia and singapore, the health-care systems are changing from government-dominated health services towards greater private-sector involvement. attempts to privatise public hospitals have been controversial, thus resulting in many hybrid forms of corporatised entities that continue to be controlled or subsidised by governments. [ ] [ ] [ ] [ ] some of the most innovative and advanced forms of publicprivate mix in health services have developed within the region, for example the restructuring or corporatisation of public hospitals in singapore from as early as and the later swadana (self-fi nancing) hospitals in indonesia. with the anticipated rise in the ageing population and future problems of intergenerational funding through pay-as-you-go mechanisms, there are experiments with new health-care fi nancing such as compulsory medical savings and social insurance for long term care. [ ] [ ] [ ] some countries such as the philippines, vietnam, and indonesia have radically decentralised their health-care systems with the devolution of health services to local governments, a restructuring that has aff ected aspects of systems performance and equity even though the impetus for cardiovascular diseases excluding rhd breast cancer tuberculosis road traffic accidents decentralisation was mainly political. consequently, to ensure increased fi nancial coverage and aff ordability, many governments have passed laws to establish national health insurance systems and mandated universal coverage, although implementation is problematic. with existing policies of decentralisation and liberalisation, equity issues and poor infrastructure will continue to challenge the development of the health sector. , the severe acute respiratory syndrome (sars) epidemic has emphasised the need to strengthen regional health collaboration. this cooper ation has occurred via two channels-direct bilateral collaboration by individual countries (ministries of health and foreign aff airs) and those under the aegis of asean. the mekong basin disease surveillance project is an example of successful health cooperation. it was established under the collective agreement of each ministry of health of member states of the greater mekong subregion to share important public health information. the emergence of infl uenza a h n and h n outbreaks has led to common eff orts to strengthen epidemiological surveillance and stockpiling of antiviral drugs. enthusiasm for regional economic collaboration continues to grow, evident from the explicit goal of the asean free trade area to increase the region's competitive advantage as a production base geared towards the world market. asean leaders have identifi ed health care as a priority sector for region-wide integration. from an economic perspective, opening of health-care markets promises substantial economic gains. at the same time, however, this process could also intensify existing challenges in promotion of equitable access to health care within countries. it could also lead to undesirable outcomes whereby only the better-off will receive benefi ts from the liberalisation of trade policy in health. health and trade policy can and do appear to contradict each other. tobacco use is the major preventable cause of non-communicable disease and death among the populations of asean countries. all asean members except indonesia have embraced the framework convention on tobacco control (fctc) and all countries endorse some form of tobacco control policy. however, most of these states are, to varying degrees, still involved in investment in or promotion of the tobacco industry, often using the justifi cation of poverty alleviation. there are clear contradictions inherent in the state seeking to prevent tobacco use in the interests of health, while actively promoting tobacco for the economic benefi t of its population, resulting in both substantial and symbolic harm to eff orts to implement the fctc. for example, tobacco production is legitimised; rational policy principles are violated, and direct cooperation between the state and multinational tobacco corporations is made possible by modifi cation of control policies. tobacco exports within asean also threaten the group's health solidarity. divestiture of state ownership of capital in tobacco corporations and a much stronger commitment by states to control the use and promotion of tobacco are urgently required in asean countries. issues of intellectual property rights surrounding products such as essential pharmaceutical drugs as public health goods are also of concern to countries. thailand started compulsory drug licensing in . indonesia has called for the urgent development of a new system for virus access and a fair and equitable sharing of the benefi ts arising from the use of the infl uenza virus in research (now commonly referred to as viral sovereignty). additionally, indonesia has pressed for the development of medical products to replace the existing patent system in global health governance. with globalisation, ensuring of accessible health services for citizens is no longer the sole responsibility of the state; health care in southeast asia is fast becoming an industry in the world market. the private sectors in singapore, thailand, and malaysia have capitalised on their comparative advantage to promote medical tourism and travel, combining health services for wealthy foreigners with recreational packages to boost consumption of such health services. patients from elsewhere, including the developed countries, are choosing to travel for medical treatment, which is perceived to be high quality and value for money. because of poor local economic conditions, the philippines had a policy to export human resources for health to the world and to richer countries in the region as an income-generating mechanism. although the fi nancial returns from this strategy seem substantial, equity issues have surfaced concerning the negative eff ects of international trade in health services and workforce migration on national health systems, especially in widening disparities in the rural-urban or public-private mix. regional collaboration in standards of data collection and health systems analysis is hampered by who's division of the asean region into two areas under separate regional offi ces: the south-east asia regional offi ce, encompassing indonesia, myanmar, and thailand, and the western pacifi c regional offi ce, consisting of the remaining countries. potential benefi ts from enhanced who regional cooperation include improved health surveillance, information-sharing, and health systems strengthening in all asean countries. southeast asia is a region characterised by much diversity, including public health challenges. social, political, and economic development during the past few decades has facilitated substantial health gains in some countries, and smaller changes in others. the geology of the region, making it highly susceptible to earthquakes and resultant tsunamis, along with seasonal typhoons and fl oods, further increases health risks to the population from natural disasters and longterm eff ects of climate change. public policy in these countries cannot ignore such risks to health, which could have important social and economic consequences. regional cooperation around disaster preparedness and in the surveillance of and health systems response to disease outbreaks has obvious advantages as a public health strategy. concomi tantly, all countries in the region are faced with large or looming chronic disease epidemics. even in the poorest populations of the region, non-communicable diseases already kill more people than do communicable, maternal, and perinatal conditions combined, with many of these deaths occurring before old age. greatly strengthened health promotion and disease prevention strategies are an urgent priority if the impressive health gains of the past few decades in most countries of the region are to be replicated. further growth and integration of the asean region should include as a priority enhanced regional cooperation in the health sector to share knowledge and rationalise health systems operations, leading to further public health gains for the region's diverse populations. all authors contributed to data collection, interpretation, writing, and revision of the report. we declare that we have no confl icts of interest. population division of the department of economic and social aff airs of the un secretariat maternal, neonatal, and child health in southeast asia: towards greater collaboration emerging infectious diseases in southeast asia: regional challenges to control the rise of chronic non-communicable diseases in southeast asia: time for action human resources for health in southeast asia: shortages, distributional challenges, and international trade in health services health-fi nancing reforms in southeast asia: challenges in achieving universal coverage neonatal, postneonatal, childhood, and under- mortality for countries, - : a systematic analysis of progress towards millennium development goal a systematic analysis of progress towards millennium development goal worldwide mortality in women and men aged - years from to : a systematic analysis world population prospects: the revision population database city mayors statistics. the largest cities in the world by land area human development and urbanisation state of the world's cities / : the millennium goals and urban sustainability ultra-low fertility in pacifi c asia: trends, causes and policy issues the global family planning revolution: three decades of policies and programs ethnicity and fertility diff erentials in peninsular malaysia: do policies matter? in: un department of economic and social aff airs population division. completing the fertility transition regional overview: east asia and the pacifi c education and future fertility trends, with special reference to mid-transitional countries. in: un department of economic and social aff airs population division. completing the fertility transition the future of labor migration in asia: patterns, issues, policies. research and seminars social policy in asean: the prospects for integrating migrant labour rights and protection social issues in the management of labour migration in asia and the pacifi c. un economic and social commission for asia and the pacifi c graphics bank: aging, speed of aging in selected countries population ageing and population decline: government views and policies. paper prepared for the expert group meeting on policy responses to population ageing and population decline the second demographic transition in asia? comparative analysis of the low fertility situation in east and south-east asian countries population ageing in east and southeast asia: current situation and emerging challenges aids: where is the epidemic going? thailand's national death registration reform: verifying the causes of death between seroprevalence of hiv among female sex workers in bangkok: evidence of ongoing infection risk after the compulsory licensing in canada and thailand: comparing regimes to ensure legitimate use of the wto rules late hiv diagnosis and delay in cd count measurement among hiv-infected patients in southern thailand excellent outcomes among hiv+ children on art, but unacceptably high pre-art mortality and losses to follow-up: a cohort study from cambodia preventing diseases through healthy environments el niño and health implementing the road map for an asean community earthquake glossary: ring of fi re air quality in malaysia: impacts, management issues and future challenges fires in indonesia: causes, costs and policy implications indonesian fi res: crisis and reaction health consequences of forest fi res in indonesia impact to lung function of haze from forest fi res: singapore's experience cardio respiratory hospitalizations associated with smoke exposure during the southeast asian forest fi res climate change and mosquito-borne disease impact of regional climate change on human health health impacts of rapid economic change in thailand comparative health care fi nancing systems, with special reference to east asian countries towards a comparative analysis of health systems reforms in the asia-pacifi c region east asian economic crisis on health and health care in indonesia was the economic crisis - responsible for rising suicide rates in east/southeast asia? a timetrend analysis for japan children and the economic crisis promoting health and equity: evidence, policy and actioncases from the western pacifi c region. manila, philippines: who western pacifi c regional offi ce privatization and restructuring of health services in singapore the growth of corporate private hospitals in malaysia: contradictions in health system pluralism constraints on the retreat from a welfare-oriented approach to public health care in malaysia the politics of privatization in the malaysian health care system innovations in health service delivery: the corporatization of public hospitals saving for health the savings approach to long term care fi nancing in singapore western pacifi c regional offi ce and south-east asia regional offi ce for who east asia decentralizes: making local government work south-east asia regional offi ce and western pacifi c regional offi ce for who measuring the accumulated hazards of smoking: global and regional estimates for global health, equity and the who framework convention on tobacco control the political economy of tobacco and poverty alleviation in southeast asia: contradictions in the role of the state the framework convention on tobacco control and health promotion: strengthening the ties pandemic infl uenza preparedness: sharing of infl uenza viruses and access to vaccines and other benefi ts this paper is part of a series funded by the china medical board, rockefeller foundation, and atlantic philanthropies. key: cord- -o zpu authors: anser, muhammad khalid; yousaf, zahid; khan, muhammad azhar; sheikh, abdullah zafar; nassani, abdelmohsen a.; abro, muhammad moinuddin qazi; zaman, khalid title: communicable diseases (including covid- )—induced global depression: caused by inadequate healthcare expenditures, population density, and mass panic date: - - journal: front public health doi: . /fpubh. . sha: doc_id: cord_uid: o zpu coronavirus (covid- ) is spreading at an enormous rate and has caused deaths beyond expectations due to a variety of reasons. these include: (i) inadequate healthcare spending causing, for instance, a shortage of protective equipment, testing swabs, masks, surgical gloves, gowns, etc.; (ii) a high population density that causes close physical contact among community members who reside in compact places, hence they are more likely to be exposed to communicable diseases, including coronavirus; and (iii) mass panic due to the fear of experiencing the loss of loved ones, lockdown, and shortage of food. in a given scenario, the study focused on the following key variables: communicable diseases, healthcare expenditures, population density, poverty, economic growth, and covid- dummy variable in a panel of selected countries from through . the results show that the impact of communicable diseases on economic growth is positive because the infected countries get a reap of economic benefits from other countries in the form of healthcare technologies, knowledge transfers, cash transfers, international loans, aid, etc., to get rid of the diseases. however, the case is different with covid- as it has seized the whole world together in a much shorter period of time and no other countries are able to help others in terms of funding loans, healthcare facilities, or technology transfers. thus, the impact of covid- in the given study is negatively impacting countries' economic growth that converts into a global depression. the high incidence of poverty and social closeness increases more vulnerable conditions that spread coronavirus across countries. the momentous increase in healthcare expenditures put a burden on countries' national healthcare bills that stretch the depression phase-out of the boundary. the forecasting relationship suggested the negative impact of the coronavirus pandemic on the global economy would last the next years. unified global healthcare policies, physical distancing, smart lockdowns, and meeting food challenges are largely required to combat the coronavirus pandemic and escape from global depression. is spreading at an enormous rate and has caused deaths beyond expectations due to a variety of reasons. these include: (i) inadequate healthcare spending causing, for instance, a shortage of protective equipment, testing swabs, masks, surgical gloves, gowns, etc.; (ii) a high population density that causes close physical contact among community members who reside in compact places, hence they are more likely to be exposed to communicable diseases, including coronavirus; and (iii) mass panic due to the fear of experiencing the loss of loved ones, lockdown, and shortage of food. in a given scenario, the study focused on the following key variables: communicable diseases, healthcare expenditures, population density, poverty, economic growth, and covid- dummy variable in a panel of selected countries from through . the results show that the impact of communicable diseases on economic growth is positive because the infected countries get a reap of economic benefits from other countries in the form of healthcare technologies, knowledge transfers, cash transfers, international loans, aid, etc., to get rid of the diseases. however, the case is different with covid- as it has seized the whole world together in a much shorter period of time and no other countries are able to help others in terms of funding loans, healthcare facilities, or technology transfers. thus, the impact of covid- in the given study is negatively impacting countries' economic growth that converts into a global depression. the high incidence of poverty and social closeness increases more vulnerable conditions that spread coronavirus across countries. the momentous increase in healthcare expenditures put a burden on countries' national healthcare bills that stretch the depression phase-out of the boundary. the forecasting relationship suggested the negative impact of the coronavirus pandemic on the global economy would last the next years. communicable diseases are not novel for the world; governments have learned from different infectious diseases in the past, such as human immunodeficiency virus (hiv), tuberculosis (tb), ebola, and spanish influenza a century before. the history of communicable diseases dates back much further, however we have only reported on the past years. the influenza pandemic is considered to be one of the most deadly epidemics in recent history, which affected about one-third of the world's population, with a death toll of at least million people globally. the list of communicable diseases is long, as more than infectious diseases across the globe have been reported to date. the united states was largely affected by hemagglutinin type and neuraminidase type (h n ) virus, where the death toll exceeded , people ( ) ( ) ( ) . four decades later, the world was again hit by another communicable disease in with a new mutant influenza a, which is caused by an hemagglutinin type and neuraminidase type (h n ) virus that spread from east asia, also called "asian flu." asian influenza -a is different from hini virus, as it is comprised of two different genes, i.e., hemagglutinin genes (h ), and neuraminidase (n ) genes. the virus was reported in singapore first in february , and hit the us in the summer of the same year; the world death toll from this virus was . million people, out of which the death toll around , in the us, making it the worst hit affected country [( - ), etc.]. the pandemic did not end as its mutation, caused by influenza -a ( pandemic), caused by a hemagglutinin type and neuraminidase type (h n ) virus. this virus was comprised of h hemagglutinin and contained the n neuraminidase from asian influenza . it was reported in the us in september , and largely affected the older population; the median age was years and above. the worldwide death toll exceeded million and about % of the death toll was reported in the us alone. this virus continued to move worldwide as a seasonal flu that led to severe illness [( - ), etc.]. this virus did not end, as in the spring of , a new mutant influenza -a caused by h n virus was detected in the us and quickly spread around the world. an estimated range of , - , people globally died from this pandemic virus infection in the first year. it is a seasonal virus that causes serious illness and increases hospitalizations and mortalities [( , ), etc.]. on may , , a(h n )pdm pandemic was detected in two imported cases in thailand, which increased up to cases by the end of the month, and by july the virus had been transmitted and detected in all thai provinces, which increased the death toll up to . the pandemic waves followed two irregular interval periods, which started from may , maxing out in july and falling in december, while the second wave began in early january , maxing out in february and ending in april. in between the year time period, around , registered influenza cases were reported in the country, , of which were confirmed virus patients with a(h n )pdm infections, and the death toll reached ( ) . the ebola outbreak that was experienced in west africa in march , affected a number of affiliated bordering countries. more than , cases were registered and more than , deaths were reported with this virus. however, with unified healthcare policies and strengthening response capacities, the affected countries limited the transmission of the deadly disease in a given course of time [( , ) , etc.]. unified healthcare policies are desirable to improve countries' economic growth ( , ) . in late december , wuhan city in china detected a novel coronavirus (covid- ) that threatened human lives; to date ( th april, ) covid- has affected , , people across countries. the death toll exceeds , people, while the recovered cases are , across the globe ( ) . the who has declared an alert about this global pandemic, which represents a large family of viruses and causes serve respiratory problems like sars, mers, etc. the covid- virus is a mutant strain of the coronavirus family, known as sars-cov- . figure shows the total death tolls reported in the five most affected countries by covid- for easy reference. since the emergence of coronavirus, a great amount of scholarly writing has been done on the given issue. for instance, lai et al. ( ) collected a cross-sectional data of , healthcare workers working in different chinese hospitals and analyzed their mental health states after handling coronavirus patients. the results suggested that, as healthcare workers are directly exposed to the coronavirus, there is a high need for physiological support and interventions to take care of frontline workers to reduce the symptoms of distress, insomnia, depression, anxiety, etc. phelan et al. ( ) argued that coronavirus was spreading all over the world from china, thus there was a need to handle this outbreak with global healthcare governance and strategies, including surveillance, testing, treatments, cooperation, technology transfers, and healthcare information. wang et al. ( ) discussed the early transmission channel of coronavirus in wuhan city in china by considering a single center case study of patients infected with novel coronavirus ( -ncov). the statistics show that the rate of patients administered to the intensive care unit (icu) were % of the total, while the death toll was . %. the hospital associated human-to-human transmission rate was suspected to be %. the study concludes that the risk of transmission of coronavirus could not be analyzed as it was becoming increasingly dangerous as the weeks progressed. livingston and bucher ( ) concluded that the coronavirus pandemic spread with an enormous rate despite aggressive control efforts. the study argued that the case-fatality ratio is higher in the elderly population, with a median age of more than and equal to years. italy is highly infected with coronavirus, which is an issue that needs to be taken seriously and controlled with effective interventions and surveillance. torales et al. ( ) reviewed the coronavirus associated studies and confirmed the psychological illnesses that were reported in the healthcare workers, suspected patients, and the general public. the results derived that the coronavirus outbreak is leading to additional health problems, including fear of death, anxiety, depression, insomnia, anger, etc. the need for efficient psychotherapy in suspected patients and counseling to the general masses would have a positive impact on reducing the risk of transmission of this disease. table shows the recent pieces of literature on the interlinkages between the coronavirus pandemic and economic activities all across the globe. the study is important in the given circumstances, where coronavirus fear and depression have appeared around the world, creating chaos among community members as they seek remedial actions to get rid of the pandemic ( ) . a few policy actions have been derived by the international community to prevent the epidemic, including maintaining physical/social distancing among community members, increasing healthcare expenditures, and reducing poverty and hunger. this study has included all these factors and has examined their impact on the country's economic growth, which considers a proxy for economic suffering leads to a depression. the epidemic proportionally affected developed and developing countries, therefore, the current studies included both developed and developing countries in a panel of selected countries during - . the outbreak of coronavirus creates many healthcare issues, including inadequate healthcare equipment, patents' facilitation centers, quarantine issues, fear, depression, and many other sanitation issues that cause the situation to worsen. the global depression phase becomes lengthier if these critical issues are unresolved. this study intended to explore the answers to the following critical questions: do communicable diseases, including covid- , exert a greater magnitude of stress in terms of negatively affecting countries economic growth which then converts into global depression? the second question is whether high population density and poverty incidence may increase the length of the coronavirus pandemic around the globe? and finally, how may we reduce human suffering and death tolls from the coronavirus plague across countries? knowing the answers to these questions will aid in helping the world with the coronavirus outbreak and stabilize the world from depression. in a given context, the study prepared a set of research objectives to analyze global depression through some policy instruments, including healthcare expenditures, population density, and poverty incidence in a panel of countries. the research objectives are: (i) to examine the impact of communicable diseases, including (covid- ), on a country's economic growth. and % in the us and eu, respectively, is likely due to coronavirus. economic growth is expected to further decrease growth by . and . % in the us and the eu, respectively. hasanat et al. malaysia e-business online business is affected by the coronavirus pandemic due to lockdown, low sales and purchase, less buying intensions, supply chain issues, fear, etc. odhiambo et al. kenya agriculture services, and the manufacturing sector due to the coronavirus outbreak, the agriculture sector decreased the share of . % in total gdp, subsequently, tourism, construction, infrastructure development, and manufacturing dropped their share at around . , . , . , and . %, respectively. it is predicted that in the mild scenario, economic growth will drop in the range of between and %, depending upon the country's profile, while in the given sample of countries, the median drop in gdp is expected to be − . % in . the service sector is also affected due to breakdowns in the supply chain process, which tends to decrease economic growth in the crisis period as expected between . and % per month. huang et al. china smes business due to the coronavirus pandemic, the smes sector has been badly affected and is highly dependent upon government support in terms of tax rebates, reduction in tax duties, provision of subsidies, flexible repayment of loan schedules, low interest rates, liquidity support, etc. wolf ( ) worldwide economic growth macroeconomic policies would largely support country's economic growth during the crisis period associated with coronavirus bandyopadhyay ( ) global evidences general discussion on economy the closure of educational institutions, travel restrictions, hospitality industry, financial, and related markets has caused economic declines across the globe. rodela et al. developing countries the coronavirus outbreak increases the high out-of-pocket healthcare expenditures that increases poverty incidences across countries. nseobot et al. nigeria trade due to the coronavirus outbreak, a unit decrease in oil price put a stress on the economic growth by . units. the death toll from coronavirus has not exceeded . % globally, whereas the death rate increase by air pollution was about . % in worldwide. due to lockdown, many polluting industries were temporarily shut down, which decreased n o emissions and carbon emissions by and %, respectively. (ii) to investigate the role of healthcare expenditures in reducing the coronavirus outbreak (iii) to observe the changes in poverty rates and population density due to the coronavirus pandemic on economic growth across countries (iv) to determine the inter-temporal relationship between the coronavirus pandemic and economic growth over a time horizon. these objectives have been set and analyzed by using sophisticated econometric techniques in order to reach some conclusive findings. the study used the following key factors that affect a country's economic growth and which turn into economic losses during the outbreak of communicable diseases, including covid- . economic growth (denoted by eg) is used as a proxy variable for analyzing economic losses due to an emerging epidemic, which served as a response variable. the data of gdp per capita in constant us$ is used in the given analysis. the explanatory variables are as follows: poverty incidence (denoted by pi) is used to get an insight into the "mass panic" among the country's residents during the coronavirus pandemic, as poor populations are directly exposed to communicable diseases caused by a lack of knowledge, low/no direct income, persistent unemployment, and inadequate healthcare facilities. this restlessness then creates more panic during the emergence of the epidemic that negatively affects the country's economic growth. the headcount ratio in percentage form is used for this reason. covid- (denoted by covid-dum) is used to assess the magnitude and the intensity of coronavirus that largely increases due to high social contact between the population members, as this virus easily spreads through close contact in the community, like, handshaking, sneezing, coughing, touching, etc., hence it is highly possible to get infected with the virus when people per square km of the land area are living in compact places. thus, the covid-dum is formed and assigned values of and . the covid-dum value represents the likely occurrence of coronavirus when the population density is in triple digits (i.e., people per square km of land area) and represents otherwise. the covid-dum data is extracted from the data set of population density (denoted by pd), which is further included in the regression estimates to get more insight into social distancing. the data of deaths caused by communicable diseases (denoted by cd) as a percentage of total deaths and per capita healthcare expenditures (denoted by he) as in us$ is added to the study to minimize the probability of omission bias problems in the given model. further, both the variables have important policy implications on the country's economic growth that can be used to assess global depression caused by insufficient healthcare expenditures, which links to the increasing cause of deaths by communicable diseases including . table a in the appendix shows the list of sample countries used in the study, which covered a period of - . the data is taken from world bank ( ) and povcal net database. the strong viability of regressors and regressand in the given context need an empirical model that would facilitate answering the causes of global depression associated with high communicable diseases including covid- . the study utilized a traditional solow growth model that considers a starting point for any growth-specific modeling, i.e., where y shows economic output, l shows labor stock, k shows capital investment, t shows technology, i and t show crosssections and time period, and ε shows error term. equation ( ) shows the conventional style solow growth model that comprises labor, capital, technology, and their resulting impacts on economic output. further, the moderation effect of technology with labor and capital stock shows the labor-augmented technology and capital-augmented technology that would increase many times to the output through a multiplier effect. equation ( ) is modified and extended by the given set of parameters in order to get fresh insight into the real-time issue faced by the world regarding the coronavirus pandemic, i.e., where eg shows economic growth, comd shows communicable diseases, he shows healthcare expenditures, pd shows population density, pi shows poverty incidence, covid-dum shows covid dummy, i and t show countries and time period from to . equation ( ) shows that it is likely that communicable diseases, including covid- , will increase economic suffering in the form of decreasing a country's economic output that will have a negative impact on the globalized world, which causes global depression. the other factors, including healthcare expenditures, population density, and poverty incidence, would likely place more pressure on economic output because of insufficient healthcare resources, highly-dense populations, and poverty and hunger. these factors are crucial and need a fair assessment in order to devise strong policies to reduce economic suffering caused by the coronavirus and other factors to lessen global depression through economic opportunities. figure shows the research framework of the study. figure shows the different causes of global depression that are interconnected with poverty incidence, communicable diseases, population density, and healthcare resources. the blend of efficient healthcare, economic, social, and environmental policies are largely desirable to escape from this pandemic with the adoption of curative and preventative policies across the globe. the stated objectives need to be checked by sophisticated econometric techniques to get fresh evidence about global depression due to the outbreak of coronavirus. the study employed a differenced panel gmm estimator. this technique is utilized on longitudinal data sets where the cross-section identifiers are greater than the time period that is used in this study, i.e., cross-sections consist of selected countries while data is used from to . the second reason is that the differenced gmm estimator controls for possible endogeneity issues and serial correlation issues from the model. third, it includes the dynamic nature of the regressand in the list of regressors, where the regressand is included with the regressors to analyze the initial convergence in the growth model. fourth, the list of regressors can be further utilized as instrumental variables added by their first lagged, hence it can control for possible endogenous issues and autocorrelation issues in the model, and finally, the validity of using regressors as an instrumental variable by their first lagged is a real challenge to check whether the given instruments are reliable or not. for this purpose, the j-statistic and instrumental ranks are used to determine its validity. these features give clear distinctions from the rest of the instrumented techniques, for instance, simple ols, two-stage least squares, three-stage least squares, and simple gmm estimates with fixed and random effect. further, the study benefits from using the innovation accounting matrix that consists of two basic inter-temporal techniques, i.e., impulse response function (irf) and variance decomposition analysis (vda). the technique is based upon both the var specifications and determined by the shocks pertaining to the regressand by their set of regressors over a time horizon. thus, it specified the nature and magnitude of the explanatory factors to the outcome variable in forecasting apparatus. the statistics clearly show that the panel consists of all the representatives of the countries across the globe where highincome to low-income countries have been included in the given model to give equal rank to all of them without any special attention. this uniqueness gives reliable estimates and provides evidence for both sides of the coin. the maximum count of deaths caused by communicable diseases is about . % of total deaths, with a mean value of . %. poverty incidence shows the maximum value of . % with a mean value of . %. the data of covid- dummy is extracted from the population density data, as population density shows that the selected panel of countries has a high to low dense population data; the highest value is . people per square km of land area while the lowest value is . . thus, on the basis of ranking the population density data, the covid-dum is assigned a value to those countries where the population density is more than and equal to three digits, i.e., , while is assigned otherwise. the mean value of covid-dum shows . , which depicts that on average % of the countries in the selected panel have a population density that is more than or equal to three digits, while % of countries have a population compactness that is limited to two digits. table shows the differenced panel gmm estimates and found that communicable diseases other than coronavirus increase the country's economic growth in the form of receiving aid and other technology transfers from the rest of the world. this aid has controlled or reduced the intensity of some infectious diseases, like ebola, hepatitis, flu, tuberculosis, measles, rabies, zika, etc. however, the novel coronavirus has largely affected the whole world and the world's biggest economies, including the united states and other european countries that [ the results of this study further show that healthcare expenditures enormously increase in a given scenario that after obtaining the parameter estimates of the studied coefficients, there is a greater need for exploring the forecasted (inter-temporal) relationship between the stated variables for the next years. for this purpose, the study used innovation accounting matrix, which is based upon two innovative functions, impulse response function (irf) and variance decomposition analysis (vda). the irf estimates assist to identify the direction of the stated variables that could be seen by various economic and healthcare shocks over a time horizon. on the other side, the vda estimates showed the magnitude of the candidate variables on the response variable over time. thus, both innovation estimates help to determine future preventive strategies to minimize the covid- pandemic across countries. table shows the irf estimates for easy reference. the estimates show that communicable diseases and healthcare expenditures will likely increase countries' economic growth over a time horizon, whereas population density and covid- will mainly increase economic suffering in the form of decreasing economic output for the next years. the poor income group experience decreased economic growth up to however, after it countries' economic growth begins to increase due to increased income inequality across countries. the rest of the effects can be seen in figure for easy reference. table shows the vda estimates and suggests that population density will exert a greater magnitude on countries' economic growth with a standard error shock of %, followed by healthcare expenditures, covid- , and communicable diseases, while poverty incidence will have the least effect on countries' economic growth over a time horizon. the complete description can be visualized in figure . the world has been relentlessly affected by the outbreak of this deadly coronavirus, even though it is still only developing. in this study, a number of important factors have been identified, which might help researchers and policy makers to understand the emerging global depression. this study has selected a panel of developed and developing countries in order to examine the vulnerabilities caused by coronavirus across all the segments of society. the overall results come to the following policy conclusions: (i) communicable diseases, including covid- , largely increase economic suffering through the increased demand for healthcare infrastructure, exacerbated by poverty incidence and social compactness. thus, the need for healthcare technology transfers from developed to developing countries, fund allocation for poor nations to reduce global inequality which would help them out from poverty, hunger, and diseases, and smart cities planning with them about symptomatic treatment and immunity boosters to get an increased chance of early recovery from this infectious disease. (viii) population mixing is the main transmission route of spreading coronavirus from one person to another, thus there is a high need to raise awareness among community members to avoid massive gatherings. the government should have to take some initiatives for providing homebased jobs and given them enough salary to convince the massive population to stay at their homes. (ix) extreme physical distancing options, including school closures, business closures, and travel restrictions, may result in a few early achievements as they raise awareness in the community about how to avoid this infectious disease, however, if these strategies are delayed, these activities should be substituted by other options, like online teaching, work at home, meetings conducted online, risk management, online training programs, and other social programs that a person can be engaged with and learn new things to resettle his/her self quickly in a new mode. (x) the lower-income strata group will largely suffer from this pandemic due to low awareness, inadequate healthcare resources, unemployment, illiteracy, the absence of social safety net programs, a lack of voice, etc., and all these vulnerabilities will largely victimize poor people more than non-poor. thus, there is a greater need to support poorer countries through cash transfer programs. the provision of basic food material, basic healthcare services, sanitation facilities, and proper counseling and guidance would minimize the risk of spreading infectious disease. it is a reality in a given context that social/physical distancing and smart lockdowns exert a positive health effect, but these measures have potentially caused more economic suffering that will lead to a global depression. the disruption of the supply chain, fear of business losses, supply-demand production gap, and the global healthcare crisis will make this episode more painful. the need for joint global efforts, unified economic and healthcare policies, and subsidized economic sectors may decrease the intensity of the global depression and progress toward the eradication of the coronavirus. the basic limitation of the current study is inadequate data availability for covid- ; hence, the study selected given countries on the basis of the country's economic growth per capita. the impact of covid- on case per million and death per million is also important, which can be further explored in future studies. data is freely available at the world development indicators, published by the world bank. https://databank.worldbank.org/ source/world-development-indicators. mka: conceptualization, methodology, and supervision. zy: software and formal analysis. mk: resources. an: formal analysis, writing-reviewing, and editing. mmqa: visualization. kz: data curation and validation. all authors: contributed to the article and approved the submitted version. pandemic influenza: public health preparedness for the next global health emergency britain and the - influenza pandemic: a dark epilogue the origin and virulence of the "spanish" influenza virus an update on swine-origin influenza virus a/h n : a review avian influenza a (h n ) the next influenza pandemic: lessons from hong kong avian-to-human transmission of the pb gene of influenza a viruses in the and pandemics impact of influenza vaccination on seasonal mortality in the us elderly population h n influenza detection of molecular markers of drug resistance in pandemic influenza a (h n ) viruses by pyrosequencing lessons learned from influenza a (h n ) pdm pandemic response in thailand ebola viral disease outbreak-west africa the spread of the ebola virus disease and its implications in the west african sub-region health care expenditure and economic growth in saarc countries ( - ): a panel causality analysis modeling determinants of health expenditures in malaysia: evidence from time series analysis covid- coronavirus pandemic factors associated with mental health outcomes among health care workers exposed to coronavirus disease the novel coronavirus originating in wuhan, china: challenges for global health governance clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan coronavirus disease (covid- ) in italy the outbreak of covid- coronavirus and its impact on global mental health becker friedman institute for economics working paper the impact of coronavirus (covid- ) on e-business in malaysia modeling kenyan economic impact of corona virus in kenya using discrete-time markov chains economic effects of coronavirus outbreak (covid- ) on the world economy saving china from the coronavirus and economic meltdown: experiences and lessons covid- coronavirus and macroeconomic policy coronavirus disease (covid- ): we shall overcome economic impacts of coronavirus disease (covid- ) in developing countries covid- : a situation analysis of nigeria's economy the dramatic impact of coronavirus outbreak on air quality: has it saved as much as it has killed so far? does communicable diseases (including covid- ) may increase global poverty risk? a cloud on the horizon world development indicator europe: how do the outbreak patterns compare? the new york times us overtakes china as country with most covid- cases available online at what happens when it hits the poor ones? ( ) as coronavirus spreads to poorer countries, here's how the world can help covid- ): situation report, . world health organization ( ) duty to plan: health care, crisis standards of care, and novel coronavirus sars-cov- . nam perspectives. discussion paper prudent public health intervention strategies to control the coronavirus disease transmission in india: a mathematical modelbased approach covid- : how doctors and healthcare systems are tackling coronavirus worldwide an unprecedented global crisis! the global, regional, national, political, economic and commercial impact of the coronavirus pandemic available online at coronavirus: how some countries are keeping -or not keeping -people indoors. the straits times coronavirus: trump extends us social distancing guidelines -as it happened coronavirus crisis could double number of people suffering acute hunger -un. the guardian world hunger is still not going down after three years and obesity is still growing -un report. world health organization the economic impact of coronavirus could worsen food security for the world's hungry people disproportionately hurt the poor-and that's bad for everyone as coronavirus deepens inequality, inequality worsens its spread. the new york times researchers supporting project number (rsp- / ), king saud university, riyadh, saudi arabia. the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © anser, yousaf, khan, sheikh, nassani, abro and zaman. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord- - ofqm a authors: mate, kedar; bryan, caitlin; deen, nigel; mccall, jesse title: review of health systems of the middle east and north africa region date: - - journal: international encyclopedia of public health doi: . /b - - - - . - sha: doc_id: cord_uid: ofqm a this article is an updated version of the previous edition article by francisca ayodeji akala, volume , pp. – , © , elsevier inc. geopolitically, the middle east and north africa (mena) region is strategically situated, with more than half of the countries of the region contributing to a significant proportion of the world's energy production. despite this abundance of resources, there has been modest growth and poverty reduction in the region when compared to others. the region as a whole has, however, achieved significant progress in health outcomes in the past few decades as a result of improved health systems focused on strengthening health service delivery, public health programs, and application of new medical technologies. these achievements at a regional level mask significant disparities among and within countries; these disparities, along with ongoing demographic transitions and epidemiologic changes, pose significant equity and efficiency challenges for mena health systems. this article is an analysis of mena health systems and a review of issues facing them. it highlights the challenges that countries need to address to ensure more efficient and responsive systems. the world bank composition of the mena region will be used primarily in this article; the countries include algeria, bahrain, djibouti, egypt, iran, iraq, jordan, kuwait, lebanon, libya, morocco, oman, qatar, saudi arabia, syria, tunisia, united arab emirates (uae), west bank and gaza (wbg), and yemen. however, where reference is made to world health organization/eastern mediterranean office (who/emro) classification of mena in this article, it will also include data from afghanistan, pakistan, somalia, and sudan but exclude data from algeria. the article begins with a regional overview of the socioeconomic status and health systems achievement in past decades and then addresses current health patterns of the region. before going on to address the health-related challenges facing the region, the article reviews the organization of both biomedical and traditional medical services by detailing issues of access, staffing, and other key health resources, financing, and governance structures. in the last couple of decades, despite modest growth, the mena region has witnessed significant achievements in morbidity and mortality patterns and other measures of health status. these health achievements can largely be attributed to the expansion of health services and public health programs and to educational and socioeconomic developments. in comparison with other countries (in latin america and east asia) of similar per capita incomes, the world bank (iqbal, ) has demonstrated that the mena region has performed favorably on human development indicators in general and more specifically on health outcomes. while mena countries had worse health indicators (using child mortality and life expectancy as proxies) in than comparable countries, the gap had been eliminated by . the average infant mortality rate for the region has dropped from per live births in to per live births in ( table ) . the average life expectancy at birth for the region has increased to years in from years in . however, these regional achievements hide disparities among and within countries of the region. for example, by world bank estimates the infant mortality rate in ranged from per live births in kuwait to in yemen. in egypt in , infant mortality rates were per live births among the poorest-income quintile households and per live births among the highest-income quintile households in the country. mena countries are also diverse in economic terms, with per capita income ( ) ranging from us $ in yemen to us $ in qatar. mena countries can be divided into three main groups that differ in terms of their economic and health outcomes achievements: ( ) low-income countries (yemen and djibouti), which have the highest infant mortality rates and maternal mortality ratios in the region and are facing the greatest health-related challenges; ( ) middle-income countries (algeria, egypt, iran, iraq, jordan, lebanon, libya, morocco, syria, tunisia, and west bank and gaza), which have made significant progress in improving health outcomes although some of these countries continue to face rural/urban disparities in both health outcomes and gaps in health coverage; and ( ) high-income countries of the cooperation council for the arab states of the gulf (ccasg) (bahrain, kuwait, oman, qatar, saudi arabia, and united arab emirates), which have achieved good health outcomes as a benefit of oil revenues used to achieve universal access to health services. political conflicts across the region have had significant impacts on health outcomes achievements and health systems development for many countries (sen et al., ) . from up until , political uprisings, protests, and armed conflicts have affected tunisia, egypt, yemen, bahrain, syria, algeria, iraq, jordan, kuwait, morocco, sudan, and west bank gaza. most of the initial protests of the arab spring ended as of , while others like the large-scale conflict in syria, and between israel and gaza, continue to this day. like many other global governments, mena countries signed on to the millennium development goals (mdgs)a global effort to track key development achievements between and . the region continues to face development challenges, including rapid population growth, high unemployment particularly among the youth, water scarcity, gender inequality, and socioeconomic disparities among the rich and poor that threaten achievement of the mdgs. however, most countries of the mena region are largely on track to achieve the health-related goals including reducing maternal mortality, child mortality and hiv, tb, and malaria morbidity and mortality. as stated earlier, this aggregate regional picture is complicated by disparities in mdg achievement across countries and within countries plagued by significant income inequality. epidemiological and demographic transitions and their effects on morbidity and mortality patterns gaziano ( ) notes that the region as a whole is moving toward the third stage of epidemiological transition, characterized by degenerative and man-made diseases. still, a number of countries face dual burdens of disease characterized by decreasing, but still prevalent, communicable diseases and increasing rates of noncommunicable diseases (ncds). the who estimates that between and the burden of communicable diseases will decline from % to %, while the burden of ncds will increase from % to %. four main trends have driven changes in the leading causes of disability-adjusted life years (dalys) globally: aging populations, increases in ncds, shifts toward disabling causes and away from fatal causes, and changes in risk factors. figure shows that, among ncds, diabetes, anxiety, drug use disorders, low back and other musculoskeletal disorders increased the most in the middle east and north africa between and , while lower respiratory infections, diarrhea, and preterm birth complications decreased between and . (institute for health metrics and evaluation, human development network, the world bank, . the global burden of disease: generating evidence, guiding policy -middle east and north africa regional edition. figure . ihme, seattle, wa.) for low-income countries and rural areas in middle-income countries like egypt and morocco, communicable diseases co-exist with an increasing burden of ncds, dispelling previous notions that ncds mostly affect the affluent. middleand upper-income countries in mena, on the other hand, are mainly burdened by ncds, having largely eliminated communicable diseases. the effects of rapid urbanization ( % of mena's population live in urban areas) and changes in diet and lifestyle are significant contributing factors to the rising rates of ncds in the region. of public health concern is the increasing prevalence of tobacco use in the region, where tobacco-related deaths were projected by murray and lopez ( ) to increase from . % in - . % in . global smoking prevalence data presented by jha et al. ( ) reveal that the overall mena prevalence was %, less than the global average of %. data from who/emro for subsequent years ( ) ( ) ( ) ( ) ( ) indicate that the smoking prevalence rates in the mena region are increasing ( table ) , with prevalence rates among men ranging from . % in oman to % in yemen ( figure ) . the region is also experiencing a nutrition transition characterized by a high prevalence of stunting from undernutrition, particularly in low-income countries and certain geographic areas of middle-to high-income countries. there is also widespread iron-deficiency anemia and other micronutrient deficiencies, along with newer problems related to obesity from overnutrition and their links with ncds/chronic conditions. the adoption of western lifestyles, including decreased physical activity and significant increases in the consumption of energy-dense foods, has led to significant increases in the prevalence of overweight and obese populations. mena along with the pacific islands, southeast asia, and china face the greatest threat of increasing prevalence of overweight and obese children in the world. the rising numbers of road traffic accidents (rtas) is also becoming a major cause of premature mortality in the region and shows no signs of abating, with an increasing number of vehicles overcrowding limited infrastructure. according to who, there was a dramatic increase ( %) in the number of deaths due to rtas from to and the trend has continued since then. kopits and cropper ( ) indicate that in there were about road traffic fatalities in mena and predict that this number will be in , a % increase. peden et al. ( ) reported that at . road traffic deaths per population, low-and middle-income countries of mena have among the highest rates in the world (compared to a global rate of per ). more than people are killed yearly due to road traffic injuries in the mena region, with an estimated cost of more than % of the regional gni. the mena road network carries only % of the world's fleet, yet it contributes to % of the traffic fatalities. the global burden of disease estimates that car crashes are the leading cause of death in mena for the -to -year-old age group since , and will become the leading cause of death for the total population by . figure demonstrates road-crash-related death rates per population of selected mena countries, which are generally higher than the rate for the united kingdom. from to , mena experienced a . -fold increase in population, the highest population growth rate in the world ( figure ) and currently has the second highest annual population growth in the world (at % or nearly million additional people per year). at this rate, mena's population is projected to double in about years (population reference bureau, ) . much of this growth is among the young with % of the population less than years old (un, ) . countries of the region are however at different stages of the demographic transition, ranging from those in the early transition stage with both high birth and death rates, such as yemen and djibouti, right up to those considered to have essentially completed the transition with both low birth and death rates, such as bahrain, kuwait, qatar, and united arab emirates. migration to, from, and within the region is also a significant contributor to the population dynamics in menaboth migration for official employment purposes, as well as due to internal and regional displacement. the oil-exporting countries of the region have hosted millions of foreign workers since the oil boom of the s, with foreign workers constituting anywhere from % to % of workers in these countries. arabs from other mena countries and asians from pakistan, india, the philippines, and indonesia make up the majority of the foreign workers in the oil-exporting countries, which also have to provide services to address health concerns of the workers and their families. in addition, the region has the largest refugee population in the world. according to unhcr, the region experienced the largest growth in internally displaced people (idp) in , increasing % from with numbers expected to continue to rise in . the surge in refugees and idps is likely due to political conflict. countries with already burdened health systems face great difficulties in providing health services to these refugee and idp populations. like the rest of the world, newer diseases such as hiv/aids and highly pathogenic middle east respiratory syndrome (mers-cov) are emerging in mena and posing new challenges. according to the unaids ( ), hiv has been on the rise in the region since , though the overall prevalence remains low and largely limited to high-risk groups (who are also highly marginalized and difficult to reach). the mena region does, however, face the second-highest growth rate of hiv infection in the world. unless effective and timely preventive measures are implemented, the disease could have significant social and economic consequences. akala and el-saharty ( ) estimate that health-related expenditures on hiv/ aids could reach, on average, . % of the gross domestic product (gdp) of mena countries by . economic losses would result from rising mortality and morbidity, which would reduce labor productivity, reduce capital investments, and shrink the labor force. hiv/aids surveillance systems to track the epidemic are particularly weak in the region. the lack of data, combined with high levels of stigma and discrimination against high-risk groups and hiv-infected persons, provides an optimal context for the disease to spread silently. mers-cov, a strain of the coronavirus emerging in the arabian peninsula, has posed a challenging threat to health systems in the region since . cases have been found in saudi arabia, uae, qatar, oman, jordan, kuwait, yemen, lebanon, and iran and have spread to neighboring mena countries, western europe, and as far as the united states (cdc, ) . frequent travel through the region for commercial, religious, and tourism purposes increases the reach of the disease and the possibility of pandemic infection. by , nearly % of the roughly diagnosed mers-cov cases have resulted in fatality. the origin of the virus remains unknown, and human-to-human transmission through close contact is most frequently the source of infection. both biomedical and traditional medical systems exist in the region; while the former predominates, the latter also provides a significant but difficult-to-quantify quantity of services. the following subsections discuss the organization of both systems in mena. mena health systems were originally organized to provide primary health care (phc) services as a means to achieve who-supported "health for all" goals by the year . more recently, the emphasis has shifted to a more curative focus with large investments in acute hospital care. the current curative and hospital-based approach is accompanied by the demographic and health care changes documented above with rising burden of chronic disease. this represents a potential allocative mismatch, with diversion of resources toward acute care while population changes require greater investment in primary care. who assesses that mena will have to address a number of identified weak areas including limited intersectoral cooperation; poor community involvement in planning and provision; weak policy analysis, formulation, coordination, and regulation; weak health information systems; poor organization and management of health services at all levels; and inappropriate human resource policies. the provision of health services in mena had primarily been the role of the state, with centralized financing, regulatory, and delivery infrastructure. in recent years, many governments have begun to separate these functions in order to maximize efficiency and effectiveness of the health sector. governments most often retain the regulatory and policy-making functions. however, mena governments have in many instances shifted service delivery to independent management systems to operate the acute and primary health care delivery infrastructure. financing for health is still in large part via centralized funds, though there are a number of national health insurance schemes with tiered coverage levels and diverse expected sources of funds are on the horizon in the region. more recently, with many governments' inability to fully respond to the population's health service needs, the private medical sector has been expanding to fill gaps in coverage, with resulting concerns about equity, efficiency, and quality assurance due to inadequate regulation of this sector by the government. the private sector is now playing a dominant role in the health sector of many mena countries (including growth in the gulf countries). while historically these private providers focused on curative services and provision of hospital-oriented and capital-intensive services, there has been recent growth of private primary and specialty care services in countries like the united arab emirates among others. by the income groupings already described, low-income countries have developed two-tiered health systems characterized by government and privately provided services. although government services are subsidized and should be available to all citizens, in reality the quality is often suboptimal, with inexperienced staff and poor availability of medical supplies and drugs. in addition, public services on the one hand do not fully cover rural and remote areas of these countries, particularly in yemen where there are significant physical barriers to rural populations accessing these services. access to privately provided services, on the other hand, requires households to make direct out-of-pocket payments that can be impoverishing for the poor. as an example, in , . % of private health expenditures were out-of-pocket and public health expenditure accounted for only % of total health expenditures in yemen ( table ) . in middle-income countries of the region, governments have implemented reforms focusing on the financing and organizational aspects of health systems. social health insurance systems have been implemented to varying degrees among these countries, with many facing issues of population and service coverage particularly for workers in the informal sectors. the gaps in coverage have created the need for various providers, including the private (for-profit and nonprofit) sector and the voluntary sector, leading to fragmented health-care delivery and financing systems for these mena countries. a number of these countries currently have to deal with rising health-care costs and inadequate financial protection at the consumer level. new calls for universal health care coverage issued by global multilateral agencies, like the world health organization, are intensifying pressure on these governments to extend meaningful financial risk protection to all citizens. with significant oil revenues, the upper-income countries have been able to achieve comprehensive health coverage for their populations, either free of charge or at highly subsidized rates. evidence suggests however that this universal access, although generally affordable, could benefit from improved efficiency and quality reforms. although per capita health expenditures are higher among these countries (ranging in from us $ in oman to us $ in qatar), more recently the gcc governments have had to implement cost-containment measures and have begun to consider new financing strategies, including introduction of national health insurance schemes. they also face the challenge of providing health service coverage to foreign workers and their dependants. the system of traditional medicine (tm) in mena has a long history and is still available and used. the who terminology of tm is used here and is a comprehensive terminology that includes both tm systems as well as other forms of indigenous medicine. tm in mena is largely based on an ancient system that is an amalgamation of the tm systems of china, egypt, india, iraq, persia, and syria and is referred to as unani, or arab medicine. unani, according to who, is increasingly being used in the region despite the more readily available biomedical system. tm can generally be administered as medications or nonmedications, with the former mainly including herbal medicines and the latter comprising various techniques which can be performed with or without medications. traditional birth attendants (tba) are also an important part of the tm system in the region. they are patronized mainly by populations in remote and rural areas of most mena countries where, in addition to the age-old cultural practice of tba, there are also significant physical barriers to accessing biomedical services. surveys carried out by khattab et al. ( ) in saudi arabia indicate that significant numbers of women in remote areas continue to patronize tbas despite increasingly available hospital services. this suggests their continued importance in the provision of maternal and child health services in the country. in an environment in which the licensing of tm practitioners is generally absent or not well monitored, it is difficult to quantify clients that patronize tm practitioners. in many mena countries, practitioners provide services that are not regulated and that are mostly patronized by the poor due to easier physical and financial access. while tm is generally accessible and affordable in many mena countries, it is often insufficiently integrated into national health systems. who/emro has previously implemented a regional tm strategy , with the following four key objectives: . to integrate relevant tm with national health-care systems by developing and implementing national tm policies; . to promote safety, efficacy, and quality by expanding the tm safety, efficacy, and quality knowledge base, and by providing guidance on regulatory and quality standards; . to increase the availability and affordability of tm; and . to promote the rational use of tm by providers and consumers. the who released a new strategy for - to address challenges that member countries continue to face. it calls for each member country to build their activities in developing effective policies and regulations around these three strategic sectors: . build the knowledge base on traditional & complimentary medicine (t&cm) so that it can be managed actively through national policies. . strengthen the quality assurance, safety, proper use, and effectiveness of t&cm by regulation and education of products, practices, and practitioners. . promote universal health coverage by integrating t&cm services into health services by capitalizing on their potential to improve health and by ensuring that users are able to make informed choices about their health care. the human resource situation in the region varies among and within countries in terms of quality, quantity, and distribution. mena health systems also face the same global challenges of training, sustaining, and retaining health personnel. table includes the number of physicians per population in - and in - . the average for the region in - was . physicians per population, which is lower than would be expected for a region largely composed of middle-and high-income countries. yemen, morocco, wbg, iran, and iraq have the lowest number of physicians, while lebanon, jordan, and uae have the highest number per population. the quantity of other allied medical staff follows the same general trend as for physicians. the national and expatriate populations in mena countries are increasing rapidly, and the demand on the physical health system infrastructure needed for effective acute care is being pushed to the limits, demonstrated by the overall decrease in hospital beds per people. similar to international trends, most health staff in the region are concentrated in urban areas. rural areas often lack adequate staffing, not only in terms of numbers but also in terms of the required experience of available staff. there is also a shortage of female staff, which presents a major access problem as female health care workers are culturally required to attend to female patients. there are insufficient numbers of public health practitioners to address the ongoing epidemiological transitions in the region. rawaf ( ) notes that public health practitionersespecially physicianshave a low status and low incomes; this factor, along with underdeveloped public health capabilities and infrastructure, lack of structured training and career development opportunities, and lack of data, presents a significant challenge for the region. appropriate policies and management of human resource issues are essential for integrating preventative and health promotion services with curative services and should also be factored into strengthening the curricula of training institutions in the region. according to who/emro less than half of mena countries have adopted or are actively implementing national drug policies, and yet less than a third of the population has regular access to essential drugs. in the absence of functional pharmaceutical regulations, irrational drug prescribing and self-medication are still major challenges in the region, despite the availability of essential drug lists and an abundance of treatment guidelines. the availability of prescription medications in private pharmacies makes self-medication relatively easy. the use of brand name medications instead of generics is also relatively common, and this together with irrational prescription habits contributes to a high proportion of total health expenditure on pharmaceuticals in the region. developing more effective and better-regulated national procurement arrangements can also reduce pharmaceutical spending in countries. given the curative care focus described earlier, spending on medical equipment and technology in mena is also significant and inefficient. health transition-related challenges mena health systems are under increasing pressure to keep pace with epidemiological and demographic transitions. the growing population implies that the cost of providing health services will continue to increase because more people (refugees and foreign workers included) will require basic services, more women will require reproductive health services, more young people will require youth-friendly services, and the aging population will require more specialized care. mena health systems have to adapt to address all these transitions within an environment of limited resources. new approaches and paradigms are needed in the reorganization of the health-care delivery system, which should feature better partnerships by different stakeholders and providers; redistribution of skills mix and enhancing the knowledge of health professionals; better use of primary and acute care services; and the rationalization of existing pharmaceuticals and medical technologies and the appropriate introduction of new ones. with the current curative model of care focusing largely on acute care, mena health systems could greatly benefit from a more strengthened primary health-care approach that not only provides regular and extended care to patients, but integrates preventive and health promotion services together with curative services. patients and their households have a central role to play in the management of chronic conditions since they require daily lifestyle and behavior changes. health systems must be involved in empowering patients to play a more active role in own their care and to link patients to community services that can support their efforts. the emergence of new diseases such as hiv/aids and mers-cov has underscored the need for more effective surveillance systems as an important part of an overarching national monitoring and evaluation system needed to track not only these emerging infections but other existing conditions. a review of disease surveillance systems by who/emro notes that there is insufficient commitment to the systems, lack of practical guidelines, overwhelming reporting requirements, weak involvement of the private sector, lack of transparency, shortage of human resources, and poor data analysis. in the absence of efficient surveillance systems, it becomes difficult to effectively plan and implement measures that proactively curb the widespread transmission or the onset of diseases and to provide timely services for those who need them. along with the need to adapt mena systems to address health and demographic transition challenges is the need to concurrently address challenges related to the who's health systems strengthening building blocks: service delivery, health workforce, information, medical technologies, financing, and leadership (who hss, ) . to address these challenges, political commitment, resources, and management capacity are needed to strengthen existing public health functions or develop them where they are absent. the most critical of these functions include intersectoral policy making, public information and education, and quality assurance and improvement. the management of these functions can only succeed where transparent governance structures exist and where more complex coordination among the different entities beyond the health sector can take place. addressing prevailing service delivery concerns will require a shift from the current curative care model together with more comprehensive rationalization of health resources. in general, there are more hospital beds than needed in most countries of the region and particularly in the public sector, which has a regional average of % of the beds but less than % occupancy rates. maintaining this excess capacity has resource implications. instead of the current focus on expanding the hospital-based infrastructure, more critical is the need to reconfigure the mena health system to better integrate the provision of preventative and promotional services with treatment and support services. with the growing population, mena health systems require a stronger emphasis on services and functions aimed at reducing the population's level of exposure to existing risks of emerging challenges, rather than the more expensive option of treating them when affected. in addition, a surveillance and treatment infrastructure designed to swiftly address modern health care threats from epidemics of mers co-v and other dangerous pathogens needs to be developed in the near term. the health care workforce of the mena region is very diverse, with staff hailing from virtually every corner of the world in great numbers. this diversity is both an incredible asset to the health sector of the region, as well as one of its greatest vulnerabilities. recruitment and retention of the workforce is a key initial challenge. professional licensing and ongoing continuous medical and nursing education and recertification for all professionals is another key challenge. finally, a diverse health care workforce needs strong organizational culture with clear and easily understood standards and policies, values-based leadership, and a sense of accountability for performance. data collection, management, and reporting are increasingly a part of any modern health care delivery system. this is true in the mena region as it is elsewhere in the world. addressing systemic challenges will require more comprehensive health information systems that provide relevant data that are readily available for assessing priorities as well as for planning, managing, and implementing the required services. unfortunately, the region generally lacks available, reliable, timely data to guide these processes. many countries and large systems are investing substantively in electronic data capture and reporting systems; some are investing in electronic health records at the service delivery level. these systems afford the opportunity to produce data about system and clinical performance that could aid mena health system managers to make more rational and evidence-informed decisions about how to improve the health system in the future. availability of critical technologies, medical products, vaccines, and other technologies is increasingly challenging in a geopolitical region that is riddled with conflict, war, and geographic adversity, with rural populations that are spread across an enormous geographic territory. in addition to these challenges, rational procurement and importation issues will present mena countries with challenges in the near term. improving and sustaining achievements of national health systems in the region becomes even more challenging within the context of a growing population, especially one with a high economic dependency rate. with % of the population less than years of age and the highest unemployment rate, the proportion of the mena population that is economically active is the lowest in the world. this has implications for how health insurance schemes in the region (social and private) can be more efficiently managed and maintained. the high dependency ratio adds more fiscal pressure on limited government health budgets, which need to be better targeted at addressing the needs of the most vulnerable populations. governments can also take better advantage of the growing private health sector by fully regulating them and ensuring that private along with public investments are made in more cost-effective technologies. financing considerations will require extending financial protection to those who most need it. with the exception of a few countries (saudi arabia, oman, and uae), out-of-pocket expenditures accounted for at least % of private health expenditures in (see table ), which disproportionately affects the poorer populations, who can be further impoverished in the event of a catastrophic illness. mena governments are increasingly interested in extending financial protection and improving access to health services by using different risk-pooling mechanisms, including social and private health insurance, and could benefit from global experiences in achieving these. well-targeted social safety nets are needed to ensure adequate protection of citizens against the impoverishing effects of ill health. finally, leadership systems of many mena health care systems have undergone substantial turnover with changes to governments in the region. where leadership and governance have been relatively stable, leaders are often challenged by limited support beyond the top-most level of leadership, inadequate ongoing leadership skill development, incomplete information for management, and many competing priorities expressed by varied stakeholders in the system (patients, providers, and policy-makers, to name a few). these are not unique situations to leading health systems anywhere in the world, but combined with some of the other challenges noted above, mena health care system leaders are particularly challenged to deliver on the promise of providing high quality, effective, efficient, and equitable health care services to the populations of the mena region. the region clearly faces a multitude of challenges at various levels and scope, with some easier to address than others. governments have the complicated task of defining the priorities and determining the best options for addressing them within budget-constrained environments. to effectively and efficiently respond to these challenges, mena governments must also have the political will to involve key stakeholders in the planning, implementation, and management of health systems. the mena region is not alone in trying to keep pace with the current and future health-related transitions; all other regions have their own similar and yet unique sets of challenges. the beauty of globalization is that regions and countries can benefit from others and share their experiences and ideas in tackling these challenges together. public-health challenges in the middle east and north africa reducing the growing burden of cardiovascular disease in the developing world better governance for development in the middle east and north africa region: enhancing inclusiveness and accountability sustaining gains in poverty reduction and human development in the middle east and north africa estimates of global and regional smoking prevalence in , by age and sex the need for traditional birth attendants (dayas) in saudi arabia traffic fatalities and economic growth how arabs compare: arab human development report the global burden of disease: a comprehensive assessment of mortality and disability from disease, injuries and risk factors in projected to population trends and challenges in the middle east and north africa public health functions and infrastructures in mena/em region syria: effects of conflict and sanctions on public health world population prospects arab human development report : towards freedom in the arab world eastern mediterranean region country profile world development indicators. the world bank everybody's business: strengthening health systems to improve health outcomes: who's framework for action traditional medicine strategy world health organization patterns of belief and use of traditional remedies by diabetic patients in mecca, saudi arabia traditional healers in the qazvin region of the islamic republic of iran: a qualitative study hiv/aids in the middle east and north africa: the costs of inaction international migration: facing the challenge public health in the middle east and north africa: meeting the challenges of the twenty-first century. the world bank preventing hiv/aids in the middle east and north africa: a window of opportunity to act health : regional health-for-all policy and strategy for the st century. who/emro (original in arabic) the work of who in the eastern mediterranean region: annual report of the regional director the who strategy for traditional medicine: review of the global situation and strategy implementation in the eastern mediterranean region health and human security center for population and development studies at the harvard school of public health the authors would like to thank jane roessner for review, editing, and advice on this manuscript.see also: centers for disease control; nongovernmental organizations (ngos); southeastern europe, health systems of. key: cord- -v mz d authors: shearer, freya; walker, james; tellioglu, nefel; mccaw, james m; mcvernon, jodie; black, andrew; geard, nicholas title: assessing the risk of spread of covid- to the asia pacific region date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: v mz d during the early stages of an emerging disease outbreak, governments are required to make critical decisions on how to respond appropriately, despite limited data being available to inform these decisions. analytical risk assessment is a valuable approach to guide decision-making on travel restrictions and border measures during the early phase of an outbreak, when transmission is primarily contained within a source country. here we introduce a modular framework for estimating the importation risk of an emerging disease when the direct travel route is restricted and the risk stems from indirect importation via intermediary countries. this was the situation for australia in february . the framework was specifically developed to assess the importation risk of covid- into australia during the early stages of the outbreak from late january to mid-february . the dominant importation risk to australia at the time of analysis was directly from china, as the only country reporting uncontained transmission. however, with travel restrictions from mainland china to australia imposed from february , our framework was designed to consider the importation risk from china into australia via potential intermediary countries in the asia pacific region. the framework was successfully used to contribute to the evidence base for decisions on border measures and case definitions in the australian context during the early phase of covid- emergence and is adaptable to other contexts for future outbreak response. on december , , chinese authorities reported a cluster of cases of atypical pneumonia in the city of wuhan, hubei province, later identified to be caused by a novel coronavirus, sars-cov- [ ] . the disease caused by this virus is now known as coronavirus disease or covid- [ ] . the number of confirmed cases and geographical extent of covid- has increased significantly since december . as of february , , , cases had been confirmed in mainland china, including , deaths. a further , cases and deaths had been reported outside of china -and more than half of these cases had been reported in the asia pacific region. multiple countries outside of china had reported sustained local transmission [ ] . when a novel pathogen such as covid- emerges, governments are required to make critical decisions on how to respond appropriately, despite limited data being available to inform d r a f t these decisions. the extent of transmission of covid- in mainland china changed rapidly during the first month of the epidemic. from january , chinese authorities progressively implemented strict mobility restrictions on the people of wuhan, and on travel out of the a↵ected area to other parts of china. internationally, border screening measures were implemented, and travel restrictions were imposed by both governments and airlines [ ] . for example, australian authorities placed restrictions on all travel to australia from mainland china on february , in order to reduce the risk of importation of the virus. only australian citizens and residents (and their dependants) were permitted to travel from china to australia [ ] . these restrictions remained in place at the time of writing. the day before australia imposed these restrictions (january ), , cases of covid- had been reported in mainland china. australia had detected and managed imported cases, all with recent travel history from or a direct epidemiological link to wuhan [ , ] . a further cases had been confirmed outside of china, including cases in countries of the south east asia and western pacific regions [ ] . at that time (january ), models estimated that , individuals ( % cri , - , ) had been infected in greater wuhan up to january (with who reporting , confirmed cases for the same time period) and projected that the epidemic could peak in wuhan as early as late february [ ] . before the restrictions, australia was expecting to receive approximately , air passengers from mainland china during february [ ] . travel numbers fell dramatically following the imposed travel restrictions. prior models suggest that travel restrictions are unable to completely prevent the international transmission of viral respiratory illnesses [ , ] . screening methods are unable to identify all cases, due to limitations in the sensitivity and specificity. exposed travellers can complete a journey during the incubation period when they are undetectable, and some exposed travellers may never show symptoms at all [ , ] . furthermore, when applied early in an epidemic, screening methods that rely on detecting fever will identify many more cases of other respiratory diseases such as influenza than the target disease. while travel restrictions are highly unlikely to prevent the ultimate importation of covid- [ ] , they can reasonably be anticipated to delay the establishment of an epidemic in a country, buying valuable time for health authorities to establish response measures. analytical risk assessment is a valuable approach to guide decision-making on travel restrictions and border measures during the early phase of an outbreak [ , , ] . while importation risk into a country of interest from a source country is a general problem for emerging diseases, the specifics of risk assessment should consider the status of both the evolving epidemic and the local and global public health response. here, we consider the covid- importation risk to australia from countries other than china at a time when china was the only country reporting uncontained local transmission and limited cases had been reported in other countries. with air-travel restricted from china, and strict quarantine measures in place for those allowed to return, a key concern for australia was the epidemic status of other countries with large (and unrestricted) travel volumes to australia. we introduce a modular framework for assessing the risk of covid- being imported from a source country (here china) to a country of interest (here australia) via other intermediary countries in the region. we have focused on the risk of (potentially undetected) spread to countries in the south east asia and western pacific regions because they are highly connected to both china and australia, relative to the rest of the world. our analysis takes into account the covid- epidemiological situation and mobility restrictions imposed as of mid-february but is adaptable to the analyses required during later phases of the outbreak. the framework was developed to provide a rational basis for decision-making on border measures and case definitions in australia at a time when global transmission of covid- was not yet established, which was no longer the case at the time of writing. while the detailed analysis presented here is specific to australia and the south east asia and western pacific regions during the early phase of covid- emergence, the framework itself is adaptable to other contexts for future outbreak response. a framework was developed to assess the risk of covid- infections being imported by passengers travelling on flights from the south east asia and western pacific regions to australia as of february , . the framework includes a series of analyses based on current epidemiological evidence, patterns of air travel, and model components described in de salazar and colleagues ( ) [ ] and developed by the authors. our framework considered a single point of origin for all exported infections, as china was the only country reporting uncontained transmission at the time of analysis. each step of the analysis is outlined in figure and described in more detail below. probability of an outbreak outbreak size importation risk to australia step step step step step -importation risk from china to intermediary countries sars-cov- first emerged in china [ ] and hence the risk of importation for countries in the south east asia and pacific regions, in the early stages of the outbreak, was primarily dependent on travel from china. the expected numbers of imported cases in each intermediary country was estimated using an approach proposed by de salazar and colleagues ( ) based on air travel volume estimates from china since covid- emergence [ ] . their model estimates the expected number of imported cases in countries by regressing the number of imported cases reported by each country against their relative incoming travel volumes from china (under unrestricted travel). they assume that the expected case count would be linearly proportional to air travel volume. bootstrap sampling was used to estimate % confidence intervals. we fitted the model to reported cumulative case counts for each country extracted from who situation reports , , , , and (i.e., one per week from january ). step -number of potentially undetected cases in intermediary countries the number of potentially undetected introductions in each intermediary country was based on the discrepancy between expected (step ) and reported cases (noting that cases due to local transmission were excluded from these counts). under the assumption that all reported cases were e↵ectively isolated ( hours after symptom onset) with reduced risk to onward transmission, the di↵erence between the expected and reported numbers of cases per country provided a crude estimate of the number of unreported cases. we assumed unreported cases were undetected and therefore more likely to contribute to local transmission and potentially a large outbreak. step -probability of an outbreak in intermediary countries a branching process model was used to generate stochastic projections of the initial stages of an outbreak for each country. this model incorporates country-specific rates of covid- importation (as estimated in step ) and country-specific detection probabilities based on the ratio of reported cases to expected cases (with a maximum detection probability of ). we assumed an r of . (within the range estimated for covid- in wuhan in early january [ ] ), no individual-level variation in transmission and independence of all undetected introductions [ ] . the probability of local transmission was defined as the proportion of simulations with no locally transmitted cases weeks after simulation commenced (i.e., february ). details of this branching process model are provided in the supplement. step the stochastic transmission model described in step was also used to estimate the likely number of locally transmitted cases in each intermediary country, conditional on local transmission occurring. this model assumed no public health intervention, and that both importation rate and detection probability were constant over time. the transmission model was run from january , with epidemic curves (separated by imports and local transmission) projected forward by one week beyond the last data collection date (february ). step -importation risk from intermediary countries to a country of interest the likelihood that a passenger arriving in australia from a country in the south east asia or western pacific region would be infected by covid- will depend on the prevalence in that country, and the travel volume from there to australia. given the wide confidence intervals on estimated prevalence, and the multiple stochastic factors, there is considerable uncertainty involved in such estimates. for the purpose of this initial risk assessment exercise, we simply provided the prevalence estimates and travel volumes. travel volumes from countries within the south east asia and western pacific regions to australia were extracted from the australian bureau of statistics [ , ] . we present a ranked table of aggregate risk of covid- infections being imported into the country of interest (australia), based on sustained transmission occurring in the source country (china) by originating country of travel ( figure ). the table includes key quantities estimated . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint at steps to of the analysis outlined in the methods and depicted in figure . the potential number of undetected imported cases (as of february , ) in each country of the south east asia and western pacific regions (intermediary countries) is displayed in figure . projected epidemic curves for selected countries are shown in figure (curves for all countries considered are provided in the appendix), with reported imported and local cases also shown for context. all four countries shown have high levels of expected imported cases ( figure ). thailand and indonesia have fewer reported cases than expected, and hence a higher estimated number of undetected cases (figure ), leading to projection of considerable undetected local transmission. in contrast, malaysia and singapore both reported a number of cases equal to or greater than expected, and hence have a lower estimated number of undetected cases, leading to projection of more modest levels of local transmission. note that the projected levels of transmission in singapore are lower than the actual reported cases. these known local cases were not further incorporated into our analysis, but rather signalled to decision makers that the likelihood of further undetected transmission was relatively low. ( − ) ( − ) . ( − ) < . myanmar . ( − ) ( − ) . ( − ) < . laos . ( − ) ( − ) . ( − ) < . we developed a framework to assess the importation risk of covid- into australia during the early phase of the epidemic, from late january to mid-february . the dominant importation risk to australia at the time of analysis was directly from china, as the only country reporting uncontained transmission. with travel restrictions from mainland china to australia imposed from february , our framework was designed to consider the importation risk from china (source country) into australia (country of interest) via potential intermediary . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. countries. we focused on countries in the south east asia and western pacific regions as potential intermediary countries since they are highly connected to both china and australia, relative to the rest of the world. intuitively, intermediary countries that pose the highest overall risk of importation to a country of interest are those with high connectivity to both the source country and country of interest. high connectivity to china increases the probability of an outbreak of covid- in an intermediate country, and consequently, someone resident in that intermediate country and travelling to the country of interest has a higher likelihood of being exposed. the risk table (figure ) was developed for two purposes. first, to provide evidence of likely exposure over the preceding week to inform the epidemiological case definition, tailored to the source country and for use in near patient decision making for practitioners in the country of interest (here australia) caring for returned travellers. second, projection of the likely future epidemic course helped to inform travel advisories and the likely utility of border restrictions. the framework we have developed provides a risk assessment from solely from an epidemiological perspective. it does not consider the potential social, political and economic implications of future border measures and mobility restrictions which are both substantial [ ] and will exert an influence on epidemiology as people change their behaviour [ ] . this framework is therefore only one key element to be considered by decision-makers contemplating possible border policies and mobility restrictions, which are ultimately a political determination. a significant strength of our approach is in its transparency with respect to both individual factors that contribute to overall risk and the relationship between model projections and the reported epidemiology. this enables decision-makers to incorporate their own expertise when interpreting the outputs. even if limited or highly uncertain data is available to inform absolute estimates of risk associated with plausible importation routes, comparisons of relative risk using our approach are still possible and valuable. in addition, each analysis component has modest . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. data requirements and low computation cost, making rapid preliminary assessment across a range of countries feasible. as the outbreak progressed, mismatches between model projections and observed epidemiology could be readily observed and incorporated into decision making. a strength of our modular approach is that it enables individual components to be adapted as new data and models become available, or as information needs change in response to the evolving situation. the breakdown of our workflow (figure ) provides clear guidance on how . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint d r a f t to adjust the method. importantly, the framework itself still applies, but components of the analysis would need to be adapted. as implemented, our estimates of importation rates into countries only consider air travel (step ). several countries/regions have high volumes of land travel, for example mainland china and hong kong. not accounting for these would lead to an underestimate of importation risk to these countries/regions. furthermore, the estimated importation rates are relative to global reports of imported cases of covid- . if there was systematic under-detection of covid- across all countries at the time of analysis [ ] , this would lead to a systematic underestimation of importation rates. our approach was not able to estimate rates of import prior to january nd when case counts for countries started being reported by the who. our analysis framework is specific to a scenario in which a dominant source of infection is mitigated by border measures. once established outbreaks occur in countries other than the primary source, assessing importation risk becomes more complex. further to this, we primarily focused on identifying undetected epidemics -over the course of time emerging observed data from many countries became more influential in the risk appraisal. thus, as it stands, our analysis is only applicable in the early stages of an outbreak, a feature shared with many other models of global infection links. in detail, by the time of writing, substantial transmission has been reported in a number of additional countries, in particular iran, italy and south korea [ ] . in order for our tool's risk assessment to reflect the true risk of importation to the country of interest, components of the analysis, specifically steps and , would need to be adapted to account for high levels of known local transmission in countries other than the source country. returning to the exemplar study that motivated the development of our framework (risk of importation of covid- into australia), should a large outbreak occur in one or more countries in the south east asia and western pacific regions, additional intra-regional transport connections would be associated with importation risk to countries in the region. more detailed modelling that incorporates intra-regional travel and information on known local transmission could then be included (at steps and ) and updated to reflect emerging epidemic intelligence. this would allow the framework to be applied during such a phase of the outbreak. a further strength of our approach is its use of a stochastic model, including control e↵orts, for early epidemic response in intermediate countries. here, without access to detailed additional information on intermediate country's capacity to respond, we used a simple model of country response capacity. as outbreaks progress, di↵erences in how e↵ectively countries are able to respond, both in terms of their health system capacity, and their ability to implement population-based measures such as social distancing may introduce systematic e↵ects that are not captured by the framework. with additional information or dedicated further research in anticipation of future global events, this additional information could be incorporated into the framework (at steps and ) to improve predictive capabilities. it is also worth noting that here we used a stringent definition of outbreak control (truly no cases) compared to other approaches in the literature, which may define control as a substantially smaller number of cases compared to baseline [ ] . in conclusion, by developing a modular framework that describes not only the underlying mathematical models of transmission and control, but how each component integrates with the next to generate an overall assessment of importation risk of an emerging disease, we have provided a decision-making tool that is flexible to the analysis requirements at di↵erent phases of an outbreak. the framework provides an evidence base for decisions on border measures and case definitions, and it has been successfully used during the early phase of the covid- response in the australian context, when limited cases had been reported outside of mainland china. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint step -importation risk from china to intermediary countries sars-cov- first emerged in china [ ] and hence the risk of importation for countries in the south east asia and pacific regions, in the early stages of the outbreak, was primarily dependent on travel from china. the expected numbers of imported cases in each intermediary country was estimated using an approach proposed by de salazar and colleagues ( ) [ ] , based on air travel volume estimates from china since covid- emergence. full details are provided in [ ] . briefly, their model estimates the expected number of imported cases in countries by regressing the number of imported cases reported by each country against their estimated incoming travel volumes from china. they assume that the expected case count would be linearly proportional to air travel volume. bootstrap sampling was used to estimate % confidence intervals. for our analysis, the model was fitted to reported cumulative case counts for each country extracted from who situation reports , , , , and (i.e., one per week from january ) and incoming air travel volumes as estimated by lai and colleagues [ ] . we fitted the model in r (version . . ) using the glm function from the base stats package. for who situation reports , , and , the cumulative case counts for countries outside of china are separated by whether the likely site of exposure was within china or elsewhere. for our analysis, reported cumulative case counts were extracted from the column 'total cases with travel history to china' in table of who situation reports and , and the sub-column 'china' under 'likely place of exposure' in table of who situation report . we used estimates of incoming air travel volumes for each intermediary country extracted from lai and colleagues' global risk analysis, which accounts for changes in air travel volumes following travel restrictions within china and internationally imposed in late-january. full details are provided in [ ] . briefly, their analysis considered (i) internal travel from wuhan to other cities/regions in china, based on location-based mobility data; and (ii) international travel from mainland china to other countries, based on travel volume from wuhan and other high-risk chinese cities over the period from february to april, based on international air transport association data. travel volume was weighted over time to capture the impact of travel restrictions after lunar new year, following which there was assumed to be no further travel from wuhan and a % reduction in travel from remaining cities. the number of potentially undetected introductions in each intermediary country was based on the discrepancy between expected (step ) and reported cases (noting that cases due to local d r a f t transmission were excluded from these counts). under the assumption that all reported cases were e↵ectively isolated ( hours after symptom onset) with reduced risk to onward transmission, the di↵erence between the expected and reported numbers of cases per country provided a crude estimate of the number of unreported cases. we assumed unreported cases were undetected and therefore more likely to contribute to local transmission and potentially a large outbreak. step -probability of an outbreak in intermediary countries a branching process model was used to generate stochastic projections of the initial stages of an outbreak for each country. the model assumes individuals can be either exposed (e), infectious (i), recovered (r), or isolated (v ). the exposed and infectious classes are split into two compartments (giving them an phase-type distribution) and symptom onset is taken to correspond to the transition between exposed and infectious states (see figure ). imported cases are assumed to be in the first exposed class. at the time on symptom onset there is a probability, p(t), that the individual is detected (either from direct contact tracing e↵orts or enhanced case finding) and hence with probability p(t), the case is missed. this probability depends on the current workload and hence time. once the case is detected there is a -hour period before they are completely isolated during which it is possible for them to infect others. the probability of detection is related to the workload, x(t), by where p is the baseline probability of detection and w c is the workload capacity. so while the workload is less than the capacity, the probability of detection remains high, but decreases once the capacity is exceeded. other model parameters and assumptions: • mean incubation period is . days (time in e and e ) [ ] ; • infectious period is . days (time in i and i ) [ ] ; cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint • r is taken to be . based on estimates from the early epidemic phase in wuhan, china [ ] ; • no variation in individual-level transmission. model simulations (n= ) were performed in r (version . . ) [ ] using the gillespie algorithm [ ] for each country, the import rate is calculated as the weighted mean of daily expected cases, with weights set according to the time intervals between data points. the initial detection probability (p ) of each country was calculated as the mean of the ratio of cumulative reported cases to the cumulative expected cases starting from january . the maximum value of p was . . the workload capacity w c , used for updating the detection probability, was set to infected people/day. the probability of local transmission was defined as the proportion of simulations with more than zero daily locally transmitted cases weeks after simulation commenced (i.e., february ). step -estimated size of an uncontained outbreak in intermediary countries the stochastic transmission model described in step was also used to estimate the likely number of locally transmitted cases in each intermediary country, conditional on local transmission occurring. this model assumed no public health intervention, and importation rate was constant over time. the detection probability was calculated by using workload capacity w c and p at each time increment. if the workload w (the number of people currently being isolated) was smaller than w c , then the detection probability was equal to p . if the w exceeded w c , the health system was deemed to be under strain, and the detection probability was set to (p ⇥ w c )/w c . the transmission model was run from january , with epidemic curves (separated by imports and local transmission) projected forward by one week beyond the last data collection date (february ). manuscript figure was generated in r (version . . ) using functions from the package gridextra. manuscript figure was generated in r with % quantile bounds smoothed using functions from the package ggplot . projected epidemic curves for all intermediary countries are shown in figures , and , with reported imported and local cases also shown for context. step -importation risk from intermediary countries to a country of interest travel volumes from countries within the south east asia and western pacific regions to australia were taken from australian bureau of statistics arrivals data for march [ , ] . values shown are a sum of visitors arriving from each intermediary country, and australian residents returning from each intermediary country. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. figure : imported cases (left panels) and epidemic curves (right panels) from january using who data up to february , and projecting forward to march , for selected countries in the western pacific region. lines and shaded regions in each panel show median and % quantiles for the cumulative number of cases (imported or locally transmitted). black points show cumulative imported cases (left panels) and cumulative local cases (right panels) for each country, as reported by who. note that the decrease in cumulative local cases in japan from february to is due to a change in reporting formats within the who situation reports between these dates. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. figure : imported cases (left panels) and epidemic curves (right panels) from january using who data up to february , and projecting forward to march , for selected countries in the western pacific region. lines and shaded regions in each panel show median and % quantiles for the cumulative number of cases (imported or locally transmitted). black points show cumulative imported cases (left panels) and cumulative local cases (right panels) for each country, as reported by who. world health organization. novel coronavirus ( -ncov) situation report - . available at world health organization. novel coronavirus ( -ncov) situation report - . available at world health organization world health organization. novel coronavirus ( -ncov) situation report - . available at australian government department of health. australian health protection principal committee (ahppc) novel coronavirus statement on australian government department of health. -ncov acute respiratory disease world health organization. novel coronavirus ( -ncov) situation report - . available at nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study short-term movement, visitors arriving -selected countries of residence: original', time series spreadsheet e↵ectiveness of traveller screening for emerging pathogens is shaped by epidemiology and natural history of infection. elife, :e estimated e↵ectiveness of symptom and risk screening to prevent the spread of covid- . elife using predicted imports of -ncov cases to determine locations that may not be identifying all imported cases. medrxiv assessing spread risk of wuhan novel coronavirus within and beyond china preparedness and vulnerability of african countries against importations of covid- : a modelling study short-term movement, residents returning -length of stay and main reason for journey: original', time series spreadsheet an integrative review of the limited evidence on international travel bans as an emerging infectious disease disaster control measure nine challenges in incorporating the dynamics of behaviour in infectious diseases models quantifying bias of covid- prevalence and severity estimates in wuhan, china that depend on reported cases in international travelers. medrxiv the royal children's hospital world health organization. novel coronavirus ( -ncov) situation report - . available at using predicted imports of -ncov cases to determine locations that may not be identifying all imported cases. medrxiv assessing spread risk of wuhan novel coronavirus within and beyond china early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study r: a language and environment for statistical computing. r foundation for statistical computing a general method for numerically simulating the stochastic time evolution of coupled chemical reactions short-term movement, visitors arriving -selected countries of residence: original', time series spreadsheet short-term movement, residents returning -length of stay and main reason for journey: original', time series spreadsheet appendix to manuscript 'assessing the risk of spread of covid- to the asia pacific region' key: cord- - uvb qsk authors: tanveer, faouzia; khalil, ali talha; ali, muhammad; shinwari, zabta khan title: ethics, pandemic and environment; looking at the future of low middle income countries date: - - journal: int j equity health doi: . /s - - -z sha: doc_id: cord_uid: uvb qsk covid- which started in wuhan, china and swiftly expanded geographically worldwide, including to low to middle income countries (lmics). this in turn raised numerous ethical concerns in preparedness, knowledge sharing, intellectual property rights, environmental health together with the serious constraints regarding readiness of health care systems in lmics to respond to this enormous public health crisis. from the restrictions on public freedom and burgeoning socio-economic impacts to the rationing of scarce medical resources, the spread of covid- is an extraordinary ethical dilemma for resource constrained nations with less developed health and research systems. in the current crisis, scientific knowledge and technology has an important role to play in effective response. emergency preparedness is a shared responsibility of all countries with a moral obligation to support each other. this review discusses the ethical concerns regarding the national capacities and response strategies in lmics to deal with the covid- pandemic as well as the deep link between the environment and the increasing risk of pandemics. like the previous outbreaks of coronaviruses i.e. severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers), the ongoing pandemic covid- has characterized that the infectious diseases represent a problem that does not recognize borders, race, ethnicity, religion, caste or any other status quo. now known as "covid- ", "sars-cov- ", " -ncov", the virus has already made a huge impact on a global scale [ ] and changed human ways of thinking and characterizing the problem. covid- is an issue beyond borders, thus necessitates a globally coherent, combined, inclusive and holistic approach which can help in the reduction of transmission and overall risk mitigation, which otherwise, is predicted to impact entire human race. according to the who situational report on th april, , the total number of global cases surged up to , , [ ] , with almost every country affected or threatened by the geographical expansion of sars-cov- . the grand total of the total infections as of th sept, , is , , with death toll of , [ ] . a summary of the statistics taken from the who showing the data of th april and th september is indicated in inset fig. revealing the regional distribution of the sars-cov- cases and rate of mortalities. international regimes are on high alert to stop its spread, however, as far as the global scenario is concerned, countries and governments are clueless in stopping the expanding pandemic as not much is known about sars-cov- , while left only with implementing nationwide lock downs and curfews which opened new economic fronts and social challenges. one of the major challenges is the intermittent psychological burden on segments of the society who have not been well versed with the scientific knowledge. rumors and false information through social media brings enormous mental distress and singles out the need for responsible information sharing. similarly, the deepened cultural norms that people find difficult to abandon in lmics has created situations more favorable for transmission of sars-cov- , with the religious fundamentalists also playing their part. zoonotic origins of the coronaviruses and their circulation in the intermediate animal hosts presents another challenge of sustaining biodiversity and human-animal relationships. the primary reservoir of the sars-cov were bats while the intermediate source was civet cats that expanded across countries in - . mers-cov jumped to humans from camels and possessed an exceptional fatality rate of % in . now, sars-cov- has been proposed to jump to human beings from bats and pangolins [ , ] . the ongoing pandemic has resulted in a situation in which the scale of emergency is similar to world war ii (ww-ii), requiring decisiveness and commitment [ ] . in the developing and under developed regions, the risk management is extremely challenging because of the resource limitation as well as lack of basic health necessities and poor sanitation etc. [ , ] . it is now established that the oral-fecal route of transmission of sars-cov- is also possible beside respiratory droplets and person to person contact which further multiply the complexities of sars-cov- for less advanced regions [ , ] . apart from the lack of resources and technology, negligence due to the lack of awareness presents a grim picture. covid- has unleashed an enormous psychological burden that may have long term detrimental consequences. covid- has presented itself as a test case for the humanity in terms of global fraternity, decision making, technology and expertise sharing, rapid pandemic response mechanisms, stability, crises management and policy making. it is of paramount importance that the decisions regarding covid- pandemic should be strictly governed by ethical and moral principles. a shared threat cannot be defeated without a combined response. keeping in view the significance of the current situation, we have attempted to discuss various issues from the lens of ethics with special reference to the developing and under developing regions. covid- pandemic is an unprecedented situation facing the world in current times, with large, unimaginable socio-economic impacts. in such a situation, pandemic preparedness and response efforts require careful analysis of core ethical values and principles with an informed and evidence-based decision making. the ethical aspects that require special consideration include the greater need for public engagement, disease surveillance, clinical research and novel experimental interventions. the moral obligations in relation to "duty to treat" and "duty to plan" must consider the rights of health care workers and affected communities. moreover, necessary measures should be taken with respect to allocation of scarce resources, priority setting and social distancing [ ] . the decision making process for outbreak preparedness planning involves a number of stakeholders including governments, ngos, the military, commercial businesses, research funders, academic institutes, public health officials, researchers, ethicists, health care workers, volunteers, communities and families. all of them have different moral or legal obligations to fulfil [ ] . in a public health emergency, it becomes difficult to keep a balance between competing ethical principles i.e. need for necessary interventions in the interest of public health without compromising the public liberty. measures that limit individual rights must be reasonable, proportionate, least-restrictive, impartial, non-discriminatory, and in accordance with national and international regulations [ ] . when thoroughly implemented, home quarantine orders by government are legal and effective, as long as individual freedom and privacy is respected [ ] . the principal of equal respect must be implied by decision makers when a lock down or quarantine is imposed on the public. hereby restricting the public right to freedom is to be reciprocated by readily providing their basic needs, by ensuring effective risk communication through ethical and logical backing of this decision and giving easy access to latest information about the uncertain, ever changing risks [ ] . resource allocation should be ethical, transparent and based on scientific evidence. in this regard, the primary obligation is to protect front line health care workers as the entire health care systems depends on these individuals. furthermore, public health measures should focus on prioritizing the provision of resources when and where required e.g. to the public in confined settings which are prone to rapid spread of disease (such as homeless shelters, prisons, and slum areas), to areas with localized outbreaks to control community transmission and to high-risk groups such as older people, people with co-morbidities and weekend immune systems [ ] . health equity i.e. equal health opportunities for all should be the focus of all health policies planned by the state actors to better prepare a country's health system in the face of current pandemic or any health crisis that may come in future [ ] . during a pandemic, issues of resource scarcity can be mitigated to a large extent if early public health interventions are introduced e.g. through social distancing which is crucial in reducing pressure on the health system. this is particularly important with regard to resource constrained settings such as those in low to middle income countries (lmics). the failure to contain the spread at an early stage can severely constrain the health system's capacity in these countries. access to scarce resources which is considered reasonable in one country may be different in another such as in the case of developed and developing countries. particularly in developing countries, the public should be well informed about decisions regarding allocation of limited resources with clear communication of proper justification to gain trust and avoid chaos [ ] . resource scarcity may also be encountered at the global level. lower-income countries may face more scarcity than developed countries in countering covid- spread. hoarding of important medical supplies such as personal protective equipment and inaccessibility of vaccines and treatments when made available, should be discouraged by developed countries or the countries where they happen to be produced [ ] . ethical aspects must also be considered in covid- pandemic research policy and practice. it is an ethical obligation to conduct research in infectious disease outbreaks needed to address pertinent research questions that arise during such a health crisis [ ] . according to nuffield council on bioethics, the core values of ethical research include helping reduce suffering, demonstrating equal moral respect for the communities involved and fairness in terms of benefit sharing. the ethical principle of helping reduce suffering provides the basis for prioritization of more valuable and much needed research during a public health emergency such as covid- [ ] . for example, conducting rapid review of research proposals becomes all the more important during a pandemic. however the decision of ethics review committees (ercs) should not be too hasty so as to avoid approval of mediocre or non-pertinent research at the same time ensuring a speedy review to facilitate important research. in these circumstances, standard operating procedures (sops) could be introduced to form a multi-disciplinary sub-committee composed of members from erc who could be immediately called in times of emergency to conduct rapid reviews [ ] . to make the process more rapid, technological interventions should be encouraged. an erc in a chinese hospital used the video conference to review batches of research proposals. moreover, these conferences were held more frequently during the corona virus pandemic than they normally did. the mean time between receiving the application and initial review decision was . days [ ] . ethical principle of fairness entails the equitable sharing of benefits and the burdens of research between different actors involved in research i.e. the participating community as well as the collaborating partners from low and high resourced settings. similarly, the principle of equal respect emphasizes respectful relationships between researchers and the affected communities going through the emergency for meaningful community engagement. with respect to health care workers and researchers, the employers and the funders are responsible to make sure their needs are met as an equal moral obligation in exchange for their services [ ] . science and technology should be at the forefront of the outbreak research ranging from health sciences including risk assessment, risk management, vaccine development and modelling studies for improved data analysis to social sciences fighting discrimination/violence and promoting human rights [ ] . in contrast to research and development (r&d) focused on medical care and treatment, less attention is given to the improvement of coordination in assessment and modelling studies on data generated during an outbreak. integration of data analysis generated across disciplines is critical to provide support to decision makers during a pandemic in order to understand the course of the outbreak, the risk of its spread, and the potential effects of infection control measures [ ] . this should be given due share in research practice during a pandemic. ethical standards also advocate the notion of "duty to care" and "duty to treat" by health care professionals during pandemics. supporting arguments in relation to professional duty in the face of uncertainty and risk to life are guided by ethical principles of virtue, generosity and social utility [ , ] . besides, in dealing with this covid- crisis, health care workers may have to take difficult decisions based on a utilitarian approach when faced with ethical dilemma of managing critical care resource allocation. keeping in view the uncertainty surrounding this novel outbreak, rationing of resources might be required for a much longer time period and a far larger number of people. the response decision may require shifting from providing all the patients the maximum number of available resources to allocating minimal resources necessary for an individual's survival. so that the additional resources are left out for others who may have an equal chance of a good outcome [ ] . this is where governments and health care departments are obliged to guide and provide training to health care workers to handle difficult situations. furthermore, ethical practice emphasizes the duty to plan where proactive planning by the public health leaders and health professionals to prepare beforehand can help reduce morbidity and mortality in a worst case scenario. the aim is to have a system in place across all levels of health care to maximize benefits to the community in the time of need [ ] . besides being an expanding pandemic, sars-cov- is accompanied by huge chunk of information floating through the social, electronic and print media making it the surge for authentic information and news much harder, as iterated by the who and unicef [ ] . while people must rely on authentic data, the news spread through social media platforms often masks the original news/statistics. the tsunami of in-correct information and rumors has appeared as a major concern. the focus should be on awareness regarding sars-cov- and not on overburdening people with psychological distress which may lead our way to a psychological pandemic. one of the key steps to reduce the spread of misinformation is to automatically direct the users seeking information to who when keywords like coronavirus, covid- , pandemic etc. are searched on the online platforms. the only way in which traditional media will be helpful in fighting the expansion of the sars-cov- pandemic is through responsible reporting and sharing so that the information trickles down to common people. in pandemic of this global scale, media can be used as a source to mobilize communities to help the underprivileged segments of the society by keeping with the general safety protocols. team of social media experts linked to the official sources can be helpful in diffusing correct information across the social media platforms. evidence based information can be sought through the country specific official advisories and who. limiting ones information resources can be helpful. media giants must be adhered to strict norms of not to create panic but spread awareness. environmental ethics, climate crises and covid- : preparing for the worst covid- pandemic is an example of complex threat to humanity from emerging and re-emerging pathogens and signifies the need for a holistic and integrated one health approach for reducing their risk [ ] . one health approach is characterized by the inter dependence of human, animal and environmental health [ ] . both the animals and environment have a significant role in the emergence of infections with zoonotic origin in human population. several factors like climate crises, increased travelling, population explosion, urbanization, deforestation, animal trade and rapidly evolving pathogens have further amplified the threat of emerging zoonosis. due to evolutionary pressures and acquiring mutations, previously an animal pathogen, now gains the ability to cross the specie barrier, jumping and adapting to a new host i.e. human, which happened in case of sars, mers and now covid- [ , ] . circumstantial evidence suggest that the pandemic started in the seafood market which was a hotspot for buying and selling animals like bats, snakes, poultry etc. and provided sufficient humananimal interaction leading to spillover. initial studies on the genome of sars-cov- reveals . % similarity with bat coronaviruses leading to the conclusion that these viruses emerged from horseshoe bats [ ] . studies also revealed pangolins as one of the possible intermediate host [ ] . these converging evidences signify the need for one health approach. increasing demand for urbanization has led to human encroachment of more and more natural habitats, thereby, increasing exposure to novel exotic pathogens from the wild. a rapid consensus is building among the scientific community which infer the transition from holocene era to anthropocene era on the geologic time scale, in which human species are involved in changing the geology of the planet through anthropogenic activities [ ] . as a consequence of plastic pollution, distribution of radioactive material across the planet, co emissions, mining, deforestation and the sea level rise, the global ecosystem is becoming destabilized with time and threatens the animal species in the wild which may otherwise serve as a buffer between human and animals for harboring deadly infections. extinction of megaflora and megafauna signifies the need of exclusive one health strategies to combat this ever expanding threat. the emerging diseases and climate crises cannot be separated and requires extensive research, funding and attention of the international leaders. climate action cannot be shelved even in the pandemic as it is one of the tools for mankind to fight the emerging and re-emerging pathogens. figure indicates a holistic perspective of the sars-cov- pandemic while fig. illustrates the one health concept. adding more to the role of the environment, it is pertinent to mention that the developed countries are the major contributors towards the greenhouse gas emissions leading to global warming and climate change. this raises an ethical dilemma as most of the countries affected as a result of these changes are contributing negligible amount of green house gases (ghgs) but often become the adversely affected. the burden of responsibility regarding contributions to the climate change in relation to the pandemic needs significant discussions and dialogues. ethical issues concerning covid- outbreak: situational analysis in low to middle income countries (lmics) pandemic response should be guided by the ethical principles of fairness, respect and transparency. however, outbreaks are more often confronted with fear, discrimination, and interventions lacking evidence which raises public health concerns [ ] . in this section, we discuss the ethical challenges faced by low to middle income countries as they struggle to respond to the escalating spread of covid- . based on the idea that no "one size fits all", it is important to consider how the cultural and economic values in these countries impact approaches to address the corresponding ethical issues [ ] . figure indicates the issues in the lmics regarding global health emergencies using an ice berg analogy. various ethical dilemmas arising from the current situation are indicated in fig. . rapidly growing contagion in less developed countries mainly in africa, asia and certain parts of the americas is a global health emergency. different countries require a context-specific response depending upon their current situation whether there are no cases, infrequent cases, clusters or local transmission. overall, decisive actions necessitate effective social distancing, quarantines and if required even lock downs as well as massive testing and systematic contact tracing to stop further spread. developing and least developed countries are the most vulnerable to this crisis, many of which are affected due to war conflicts, are overly populated with urban areas and slums, lack access to basic health services and are thus at high risk of covid- spread [ ] . in lmics, the greatest challenge is how fast the gaps in early response to covid- outbreak are filled before the infection control goes out of hand. the best chance is to have the systematic containment measures in place and massive testing done before the virus overwhelms the weaker health care systems. a well-organized response should also incorporate scientific knowledge generation e.g. studies on changing disease epidemiology such as duration of incubation period between infection and appearance of first symptoms so the people are retained in quarantine no longer than it is necessary in order to keep the costs down [ ] . moreover, rapid and actionable research conducted at local level should be encouraged in lmics so as to deal with the pandemic more effectively. data generated from response activities can be utilized for research purposes to make foreseeable predictions in the local context [ ] and change the ongoing response strategies as and when required in order to minimize socio-economic impacts. response preparedness is weak in many low income countries as evident by preparedness assessments of countries, none of which were evaluated as ready to respond, making them predominantly susceptible to epidemics. it is due to the poor health and nutrition conditions, aggravated by co-morbidities and low average annual health spending of only $ per person in these countries. according to who, the regional readiness level is assessed to be only % with serious gaps in the response capacities for these countries to investigate disease spread alerts, treatment of patients in quarantine facilities and transmission control in both the health facilities and the public [ ] . south asia which holds a quarter of the world's population with currently covid- affected countries including afghanistan, pakistan, india, nepal, bangladesh, sri lanka are likely to face severe constraints in the management of the outbreak if it spreads uncontrollably. the current low number of reported cases may be due to less testing with limited resources in these countries. for example, india's testing rate is exceptionally low given its large number of population with an average of just over tests per million persons which is way less than advanced countries like south korea with more than and italy more than tests per million persons, as of march , [ ] . total cumulative corona cases in india were reported to be , , while the death toll has risen to , , as of th september [ ] . pakistan reported its first coronavirus case on february , . there were confirmed cases and deaths, as of april , . the weekly report of th to th september by who reveals a total of , cumulative cases of sars-cov- in pakistan, with cumulative deaths [ ] . initially, the country's response was appropriate and timely just when the virus was already spreading from china to its neighboring countries due to travel. the containment measures proved effective in preventing the import of virus from china. later, when a considerable number of people travelled back from neighboring iran which was badly affected by the virus, the whole dynamics changed for pakistan. partial or complete lockdowns were imposed throughout the country, and all businesses apart from those providing essential goods were closed [ ] . the government estimated that the number of cases were expected to rise up to , by april , in a national action plan report submitted to the supreme court [ , ] . however, the lockdown situation was gradually eased with implementation of "smart lockdowns" and reopening of the economy in stages. afghanistan, a war-torn nation started to feel the brunt of covid- just like its neighbors. controlling its spread in afghanistan is governed by a number of social and political complexities, including the incursion of afghan refugees from neighboring iran. less public awareness of the virus and lower health literacy is a major issue illustrated by an individual who was confirmed to have the virus, and people who were the potential suspects, left the quarantine facility, risking the virus transmission in the communities [ ] . the cumulative deaths in afghanistan have risen to while the total reported cases are , as of th sept. [ ] . iran faced the worst situation among lmics and was the epicenter of corona virus in asia with over , confirmed cases and over deaths as of april , . as of th sept. , the total number of reported cases are , and cumulative deaths are reported to be , in iran [ ] . the iranian government was criticized for failure to respond early which resulted in shear increase in the number of cases, affecting both citizens and several top officials [ ] . also, insufficient public awareness regarding risk of the virus, and poor public attitude in observing self-quarantine were attributed as reasons for higher rate of spread [ ] . in addition to resource limitations, us sanctions on iran even increased the difficulty in procurement of medical supplies from companies abroad. it is due to the stricter sanctions imposed by us since may, with severe penalties for non-us firms doing business with iran. this is a humanitarian crises and the global community must look at the impacts of such sanctions on humanitarian aid during a pandemic so that the sufferings of the public could be reduced [ ] . some countries also faced challenges in implementation of ongoing lockdowns due to religious or cultural values such as religious congregations [ ] . congregations in pakistan, malaysia and india were considered responsible for transmission of the virus. pakistan reported hundreds of cases directly linked with the congregation which was held in march at raiwind, lahore [ ] . developing and less developed countries also face several challenges in self-quarantine which might not be very effective where large families live together often in congested settings, sometimes three or more people sharing the sleeping quarters. households in sierra leone, tajikistan, guinea, pakistan, afghanistan, and senegal are the largest, with six or more members on average [ ] . in africa, the first case was confirmed in egypt on feb , . according to the recent data of who available on th sept. , the total number of cases has risen to , , with the death toll rising to , in african continent, with south africa affected the most [ ] . the covid- outbreak continues to spread across africa with a number of countries in the continent where community transmission is becoming established such as south africa. african countries are more vulnerable to faster spread of covid- due to weak health care systems, high occurrence of hiv and malnourishment among other factors such as scarcity of medical supplies for personnel and the patients [ ] . resource constrained countries in africa, should take steps for prepardeness and development of basic technological interventions for responding to health emergency [ ] . the who african regional office along with cdc immediately started taking measures to prepare african countries for covid- outbreak. the previous experiences from ebola preparedness came handy as coordination response mechanisms were already in place. over the past few years, the who has helped develop a national network of surveillance laboratories and health facilities in the african region amidst the previous outbreaks which could prove really helpful in current crisis [ ] . the rapid response measures taken in china and other countries like taiwan, hong kong, singapore and south korea ranged from strict quarantine measures, to detailed contact tracing, augmented with use of big data analytics. these measures helped the countries in keeping down the number of growing cases by breaking the chain of transmission. taiwan leveraged all the technological resources, integrating national health insurance and immigration and customs databases to generate big data for tracing potential cases or areas [ ] . the impacts of these early interventions for effective response towards covid is encouraging for the countries where covid- is spreading fast. effective public engagement should be made meaningful through gaining public trust and seeking cooperation instead of using the coercive measures especially in resource constrained settings with low level of literacy and social, religious and cultural complexities. only this way, the lockdowns or quarantine measures will be more effective [ ] . effective risk communication is mandatory in public health response measures taken in lmics ensuring the public's right of access to information. poor populations without access to information channels are the most vulnerable during health crisis and are most likely to ignore the government's warnings regarding the precautionary measures such as social distancing [ ] . a larger population of lmics is living without access to mass media in rural areas or some poor countries such as madagascar, nigeria, zambia etc. [ ] . awareness about the risk can be spread through simple health messaging and regular briefings by the government on television and radio; through public officials at the district level; or any other means deemed appropriate so as to provide access even to the poorer communities living without internet or communications channels. it is the government's obligation to keep the public well informed about the risk of covid- . it also means that governments may have to take difficult decisions given the uncertainty and time constraints surrounding this pandemic. therefore, it is important that information must be communicated in a transparent, honest and timely manner [ , ] . scarcity of resources including trained personnel, health centers, and protective gears is a major problem in lmics. even under normal circumstances, the poorest countries have acute shortage of icu beds in comparison to high income countries e.g. roughly us has icu beds per million people whereas countries such as india, pakistan and bangladesh have only beds per million people. the situation is worse in sub-saharan africa where zambia has . icu beds per million, gambia has . and uganda has . beds per million. so the fatality rate in these countries is estimated to be much higher in these countries than wealthier nations [ ] . during a pandemic, standard crises care protocols should be developed by public health institutions to establish a systematic and evidence based procedure which ensures fair distribution of health care resources. thus shifting the focus from prioritizing individual patient benefits to maximizing benefits to the community as a whole [ ] . priority decisions regarding resource allocation should not be discriminatory i.e. based on sex, race, religion, disability, wealth, citizenship, social status or connections [ ] . moreover, the ethical debate regarding allocation of resources in lmics must take into consideration a wider context where critical care resources may already be scarce or non-existent even in a normal situation as compared to developed countries. in such conditions, ethical justification encompasses social justice governed with locally adapted global approaches [ ] . ethical standards support the idea that state is responsible for compensating the public losses incurred upon them due to public health interventions such as the containment measures including social distancing, quarantine and isolation. this is particularly important for people residing in resource constrained regions. the state ought to make social policies with the aim to share some of their burdens and costs e.g. by protecting the employment rights of citizens [ ] , providing financial support to the poor and needy such as daily wagers who might suffer due to shutting down of several industries as a result of lock down orders. however, lack of resources could seriously defeat this argument of compensation in these countries which cannot even provide for the basic health care needs of the people [ ] . in pakistan, it was estimated that between . million to . million workers in various industries were at risk of losing their jobs. according to human rights watch, the government must tend to the poorer workers who might be further pushed into poverty and it may dissuade them from voluntary quarantine necessary to contain the spread of the virus [ ] . a multi-lateral response by international community has been previously seen against similar threats posed in by severe acute respiratory syndrome (sars), in by swine flu (h n ), in by middle east respiratory syndrome (mers) and in - by ebola. all these crises were contained well via multilateralism and current crises of covid- is yet to be further materialized by this strategy. the current covid- crisis presents challenges that are beyond and above the earlier outbreaks, hence it deserves a well-established multilateral response. any pandemic requires the weak links to be strengthened on individual basis i.e. at the hospital level as well as community basis, country basis and even globally. therefore, it is the urgent need to shore up the health care systems in order to handle the current flood of cases as well as the future waves of the same or other related viruses. efforts for developing and supplying medical devices, diagnostic tools, vaccines, therapeutics, and other medical technologies for covid- pandemic can be seen globally. even though medical and scientific urgency are building, the medical technologies need to be tested efficiently, ethically and urgently with equitable availability to everyone around the globe. therefore, a multi-lateral response strategy which can accelerate scientific discovery and technology development with ensured safety, efficacy and quality is essential. further, there is need to coordinate the world health organization (who) for operational implementations. technology pooling and benefit sharing as previously witnessed during influenza [ ] and sars epidemic [ ] will not only save lives of millions of individuals by response acceleration to pandemics but will also encourage powerful administration of the global solidarity for the future epidemics. to protect people against deadly infectious disease outbreaks, it is critical that scientists and governments rapidly share information about the pathogens that cause them. the genetic information of sars-cov- was shared immediately and openly [ ] that accelerated the initial stages of diagnostic tests development and novel therapeutic compounds exploration. likewise, many researchers immediately shared their research information via open source publication [ ] . scientist from different countries are sharing medical course and epidemiological data and collaborating for medical guidelines development in response to the current pandemic [ ] . such examples of sharing information and open science need be incorporated throughout research and development of covid- medical technologies. moreover, the scientific community need to share every progress, every success and even the negative data so the research can be continued with uppermost speed to obtain the best results. some of the current and early research by pharmaceuticals, universities and medical device companies are funded by charities and governments. it is therefore imperative that such funding agreements mandate full data sharing, open source publishing and open collaboration following ethical guidelines regarding identity of subjects. a data-sharing system needs to allow collaboration between stakeholders in the absence of pre-existing relationships and all collaborators must adhere to fundamental ethical principles of data use. above all, it must ensure that people in all affected countries benefit from timely access to evidence-based interventions in emergencies. the multi-lateral response needs to be opened to the wide range of intellectual property rights, technology blueprints, technology specification, copyrights, patent rights, cell lines, research and regulation rights, data rights and clinical trial rights. in simple words, no exclusive right has to stand in the way of response to covid- pandemic by global research community in order to prioritize public health. similarly, all the rights such as confidential business information rights and trade secret rights required for bio similars, vaccine development and medical technology need to be accumulated and distributed hence to accelerate access to the market. it is therefore important to enable fast track registration along with emergency access to new medical technologies and medicines around the globe. some of the regulatory barriers can be eliminated by access to regulatory data and fast-track registration, however, countries should ensure that producers can bring medical technologies quickly into the market with equitable access. competition between producers has always resulted in increased supply with lower prices. in response to current pandemic, facilitating competitive supply source can present more advantages. as coronavirus infection is exponentially increasing with life threating outcomes, there is need of utilizing every possible option to mobilize supply capacity with respect to diagnostics tests, therapeutics, protective equipment, vaccines and other medical devices as soon as possible. with expanding supply, necessary actions should be taken to limit the export of needed ingredients, medical technologies and hoarding of medical supply to other countries [ , ] . compulsory licensing is a useful tool to be used during public health emergencies such as the covid- crisis when a treatment becomes available. international organizations and pharmaceutical companies should encourage the developing countries to pursue this option in the time of a pandemic [ ] . it would be difficult to minimize the socio economic impacts of covid- in due time. it is the prime responsibility of the international community to take public health measures in best interest of the public with providing access to basic health care facilities, information and resources without discrimination, embodying the values of respectfulness and cultural appropriateness. in the long run, governments in 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remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we are thankful to the fellows of qau for providing valuable inputs. we are also thankful to ms. xanthine muller, from the radiobiology department of ithemba labs, cape town, south africa, for checking the manuscript for consistency and english language corrections. all authors contributed equally. the author(s) read and approved the final manuscript. this work is not funded. available on request.ethics approval and consent to participate not required. all authors agreed on publishing. authors declare no conflict of interest. key: cord- -yeucn x authors: altobelli, emma; angeletti, paolo matteo; profeta, valerio f.; petrocelli, reimondo title: lifestyle risk factors for type diabetes mellitus and national diabetes care systems in european countries date: - - journal: nutrients doi: . /nu sha: doc_id: cord_uid: yeucn x background. diabetes is increasing by . % per year in males and . % in females. lifestyle risk factors are related to diabetes. the aim of this work is to highlight within eu- countries the distribution percentages of some lifestyle risk factors and some components of diabetes health care. methods. a literature search was conducted to highlight the presence of diabetes registries, which are fundamental tools for disease surveillance and health planning; the presence of a national diabetes plan (ndp); the care setting; and methods used for reimbursement of drugs, devices, and coverage of any comorbidities associated with diabetes. a multiple correspondence analysis (mca) was carried out to evaluate the possible associations between the variables considered. results. the highest percentages of diabetes (> %) are registered in bulgaria, malta, and hungary. concerning the prevalence of overweight, no european country shows overall percentages of less than %. regarding obesity, % of countries show prevalence rates of %. the record for physical inactivity belongs to malta, with % of individuals being inactive. the percentage of physical inactivity for females is higher than for males across europe. in total, % of the countries have an insurance-based health system, while countries have public national health systems. further, % of countries have an ndp, while % of the eu countries have established a prevalence register for diabetes. conclusions. prevalence rates for type dm in the range of – % are noted in % of eu- countries. in total, out of eu countries show a high prevalence rate for overweight, while % of eu- countries have an obesity prevalence rate of %. diabetes treatment is entrusted to general practitioners in most countries. the results of this work highlight the differences between countries, but also between genders. type diabetes mellitus represents the paradigm of chronic diseases in which there is a close association between family and environmental factors. it is now a health problem with enormous global impact, with estimates of continuous growth [ ] . an important universally recognized risk factor is high calorie intake with limited intake of fiber, which results in an increased accumulation of visceral fat, an increase in body mass index (bmi), and increase in abdominal circumference [ ] . table and figures and summarize the information related to the income and distribution percentages of the following risk factors: overweight, obesity, physical inactivity, and type diabetes. data came from eurostat datasets [ ] and we used the map creator software to build the maps (figures and ) . a literature search was conducted to highlight the presence of diabetes registries as fundamental tools for disease surveillance and health planning ( a literature search was conducted to highlight the presence of diabetes registries as fundamental tools for disease surveillance and health planning ( table ). the keywords used were registries or incidence or prevalence and diabetes mellitus; insulin-dependent registries or incidence or population based and diabetes mellitus, insulin-dependent; "prevalence" or "registries" or "population based" and "diabetes mellitus, type " and "epidemiology"; considering publications from the last years, in english, over years of age. the prisma [ ] method was used to select bibliographic entries ( figure ). only references to type diabetes registries were selected. the data covered the type of health system, presence or absence of a national diabetes plan (ndp), presence of a population-based register, care setting, methods for reimbursement of drugs, devices and coverage of any comorbidities associated with diabetes, and the prevalence of and mortality from diabetes, gathered from the institutional sites of individual european countries to investigate the presence of national data and policies for diabetes control. furthermore, to ensure the completeness of the data, the following sources of information were consulted: eurostat [ ] , who diabetes country profiles [ ] , european commission (ec) [ ], international federation of diabetes (ifd) [ ], foundation of european nurses for diabetes (fend) [ ] , and the world bank [ ] . all data are reported in table . full-text articles excluded, with reasons n = type diabetes registries n= paper without studies included in qualitative synthesis (n = ) (n = eu- countries n = outside eu- countries) the data covered the type of health system, presence or absence of a national diabetes plan (ndp), presence of a population-based register, care setting, methods for reimbursement of drugs, devices and coverage of any comorbidities associated with diabetes, and the prevalence of and mortality from diabetes, gathered from the institutional sites of individual european countries to investigate the presence of national data and policies for diabetes control. furthermore, to ensure the completeness of the data, the following sources of information were consulted: eurostat [ ] , who diabetes country profiles [ ] , european commission (ec) [ ], international federation of diabetes (ifd) [ ], foundation of european nurses for diabetes (fend) [ ] , and the world bank [ ] . all data are reported in table . a multiple correspondence analysis (mca) was carried out in order to to evaluate the possible association between the variables taken into consideration, including eurostat data for the countries of the european union, data relating to mortality per , inhabitants and the mortality trend [ ] , the prevalence of diabetes [ ] , the organization of the health system [ , , ] , the presence of a national diabetes plan, the year of approval [ , ] , the general practitioners and diabetic centers involved, and the cost percentage of diabetes of the total health expenditure [ ] . the variables listed above were classified as follows: percentage of diabetes (≤ %, > %), diabetes mortality (≤ per , , greater than > per , ), mortality trend (growth, stable and in reduction), and percentage cost of diabetes of total health expenditure (≤ %, > %). the mca was conducted using sas statistical software. the graphical representation takes into account the variables that contributed most to the variance. countries belonging to the european union show high income rates, except for bulgaria and romania. the highest percentages of diabetes (> %) are registered in bulgaria, malta, and hungary. values for diabetes of between and % are shown for % of the countries, including the czech republic, croatia, estonia, france, italy, greece, lithuania, latvia, poland, portugal, romania, slovakia, slovenia, and spain; while values between and % are shown for austria, belgium, cyprus, denmark, finland, luxembourg, germany, ireland, sweden, the united kingdom, and the netherlands. regarding men, seven countries ( %) have a diabetes percentage rate higher than %: bulgaria, czech republic, estonia, hungary, malta, spain. regarding women, bulgaria shows a rate of %. concerning overweight individuals, no european country shows overall percentages of less than %. in fact, as many as out of countries ( % of european countries) show a high percentage of overweight of %; the remaining countries show percentages of between and %. overweight affects % of men in countries (czech republic, estonia, luxembourg, malta, spain, and uk) and percentages between - % are shown for states. only latvia has a percentage just below %. the figures for women are globally similar, with the exception of austria, where the percentage of overweight is slightly lower ( . %). in out of countries, the percentage of female overweight is between and %, while in countries the percentage exceeds % (czech republic, denmark, estonia, greece, latvia, lithuania, malta, poland, spain, uk). regarding obesity, % of european countries show values of obesity of %: bulgaria, croatia, czech republic, estonia, france, greece, france, hungary, ireland, latvia, lithuania, malta, poland, slovakia, slovenia, spain, uk). percentages in the range of . - . % are shown for cyprus, italy and romania. the remaining countries show obesity percentages ranging between and %. regarding gender, obesity rates are above % for men in countries (czech republic, estonia, luxemburg, uk), while the lowest values are recorded in austria, portugal, and romania. particularly relevant is that in some countries (czech republic, malta, estonia, and uk) the percentage of obese women is greater than %. instead, the percentage exceeds % in countries (bulgaria, cyprus, france, hungary, ireland, lithuania, poland, slovakia, slovenia, and spain). on the other hand, the percentages of physical inactivity are more variable from country to country. the highest value for physical inactivity belongs to malta with %, followed by countries in southern europe (italy, spain, portugal) and northern europe (belgium and the united kingdom). it is important to underline that the percentage of physical inactivity in females is higher than in males across europe. a total of , references were identified through database searching were, while were identified through manual searching. of these, references were excluded because they were duplicates. of the remaining papers, were selected as potentially valid for the systematic review. nutrients , , of a further papers were excluded for not containing the requested information. in total, papers were analyzed, of which covered type dm and covered type dm (figure prisma flow chart). of the latter , were eu- countries and were from outside the eu- . all results are described in table . european health systems vary from country to country, and even within individual countries. however, in most european countries ( %) there are insurance-based health systems, while in countries there are public national health systems. in % of countries, there are national diabetes plans. in total, % of the countries belonging to the european union have established a prevalence register for diabetes. diabetes care is mainly entrusted to the general practitioner in countries, while in the remaining countries it is entrusted to diabetes centers. in health systems where health care is totally managed by the state government, the latter provides coverage for drugs, devices, and associated comorbidities, except for latvia. in insurance systems, on the other hand, only in belgium is there full coverage for expenses relating to drugs, devices, and comorbidities, while in the remaining countries there are shares for different copayments. mortality is extremely variable; the lowest values are found in finland, while the highest values are present in the islands malta and cyprus. there are only two countries with values above / , , which are croatia and czech republic; while mortality values of between and / . are found in austria, portugal. and hungary. seven out of countries show mortality values of between and , including bulgaria, denmark, germany, italy, latvia, poland, and sweden. in total, % of european countries show mortality values of between and / , , including belgium, estonia, france, greece, ireland, lithuania, luxembourg, romania, slovakia, spain, uk, and the netherlands. the country and year of approval of each national diabetes plan represent the first dimension, which account for about % of the variance; the prevalence and mortality trends represent the second dimensions, which account for around % of the variance. all results are represented in figure . nutrients , , x for peer review of trend, and a health expenditure for diabetes < % of the total national health expenditure. the cloud of points represents the presence of an ndp, health expenditure for diabetes < %, and the presence of the national health service. the chronicity control system is represented by the chronic care model (ccm), which was developed in the mid- s by wagner [ , ] . this model covers the needs of health organizations and citizens. the ccm provides six levels of implementation: the organization of care systems with the removal of barriers; self-management with support from a caregiver; support for decisions on prevention or treatment strategies based on medical evidence; delivery of services; a system for recording and monitoring care and community and public health resources [ ] . for diabetes mellitus, this means a combination of programs the first quadrant includes the following countries and variables-finland, the united kingdom, ireland, sweden, belgium, austria, luxembourg, the netherlands, each showing a mortality rate below . , diabetes < %, stable mortality trend, and with diabetes care entrusted to general practitioners. in this quadrant, a cloud of points can be seen, showing mortality < / , diabetes < % for austria and netherlands, with diabetes care entrusted to general practitioners. the following countries and variables represent the second quadrant-estonia, bulgaria, poland, romania, lithuania, latvia, france, and germany, each showing health expenditure for diabetes > % compared to the total health expenditure, an increasing mortality trend, the absence of a national diabetes plan for diabetes, and health insurance. in this quadrant, an aggregation zone can be highlighted, which includes the absence of a national diabetes plan, a rising mortality trend, and health insurance. hungary, the czech republic, slovenia, greece, croatia, cyprus, malta, and the geographical area of eastern europe represent the third quadrant, each having a mortality rate greater than %, the approval after of the ndp, a % of diabetes > %, and the presence of diabetes services. it is important to underline that a point of clouds includes mortality greater than %, percentage of diabetes > %, and approval year of the ndp after . the fourth quadrant includes portugal, italy, spain, slovak republic, denmark, each showing the presence of a ndp, a ndp approved before , a national health system, a decreasing mortality trend, and a health expenditure for diabetes < % of the total national health expenditure. the cloud of points represents the presence of an ndp, health expenditure for diabetes < %, and the presence of the national health service. the chronicity control system is represented by the chronic care model (ccm), which was developed in the mid- s by wagner [ , ] . this model covers the needs of health organizations and citizens. the ccm provides six levels of implementation: the organization of care systems with the removal of barriers; self-management with support from a caregiver; support for decisions on prevention or treatment strategies based on medical evidence; delivery of services; a system for recording and monitoring care and community and public health resources [ ] . for diabetes mellitus, this means a combination of programs aimed at nutrition education, autonomous control of blood glucose with related strategies, psychological support, and personal empowerment [ ] . the growth estimates for diabetes in europe are quite clear-an increase from . million cases in to . million cases in [ ]. these data are even more alarming in light of the recent sars-cov pandemic, posing a problem to healthcare stakeholders. in fact, diabetics are more susceptible to lower respiratory tract infections due to the abnormal neutrophil function induced by hyperglycemia [ ] . data from clinical studies show the increased susceptibility of diabetics affected by atypical pneumonia [ ] . in this context, the enhancement of telemedicine services appears to be a priority in the control of chronic diseases, especially in lockdown periods. a recent meta-analysis has shown that telemedicine for diabetes treatment is cost effective for both retinal screening and telemonitoring [ ] . another work highlights how the control of the diabetic via telematics allows better control of glycated hemoglobin [ ] , which is the main marker of diabetes progression [ ] . an important aspect to consider is the organization of diabetes services. the economic crisis of the period - severely tested the health systems of individual countries, with progressive cuts to some services or increases in copayment quotas. some health systems, by virtue of their organization or recent reform, have been able to cope with these new economic scenarios, while others have found themselves in more difficulty; the effects of the recent economic crisis are still fully visible in terms of mortality trends [ ] . the close associations between the organizational and financial aspects can be deduced from the distribution of the variables obtained from the analysis of the reports. in fact, it is clear that the activation of a national diabetes plan can contribute to the reduction of the prevalence of mortality from dm and the containment of the global costs of diabetes. our results show that in countries where there is a national health system (uk, italy, spain, portugal) or an insurance system with high social protection (the netherlands, france), excellent performance is noted in the control of diabetic disease and its comorbidities. in fact, the guarantee of access to therapies and control and prevention of complications contribute to reducing mortality, while at the same time lead to significant savings. these results are most evident in countries where a national diabetes control plan has been in place for at least years. another aspect that emerges from our analysis is the care setting. in fact, it seems that the management of diabetes by practitioners compared to diabetic centers guarantees better results in terms of the prevalence of and mortality from t dm, as underlined by the aforementioned meta-analysis of gupta et al. [ ] . access to care or better delivery of care represents one of the cornerstones of the ccm model. in our opinion, a similar system should also cover obese individuals by actively involving them in prevention policies, emphasizing self-care by self-management [ ] . our data show that obesity and being overweight are closely related to physical inactivity, especially in females, representing a gender gap. an emphasis on this theme was noted for the women's football world championship [ ] . countries should make greater efforts to guarantee women access to sports activities, promoting the removal of sociocultural barriers and with ad hoc investments; for example, it has been shown that quality public transport and travel infrastructure for pedestrians could reduce the gender gap, allowing women to practice physical activity with greater ease and accessibility [ ] . this is a fundamental aspect, especially in light of the fact that physical inactivity is one of the determinants of non-communicable diseases [ ] and one of the main determinants of the increase in bmi, and therefore of obesity [ ] . in fact, it has been estimated that by , in eu- countries obesity will reduce life expectancy rates from . to . years and that . % of health budgets will be used to treat complications associated with obesity. moreover, the consequent economic effects of obesity directly reduce productive activities [ , ] . in conclusion, % of eu countries show type dm prevalence rates in the range of - %. in addition, of the eu- countries show a high percentage of overweight, while % of eu- countries have an obesity prevalence rate of %. the record for physical inactivity belongs to malta. in general, physical inactivity rates are higher for females than males. regarding care organizations, national public insurance is present in % of countries. diabetes treatment is entrusted to general practitioners in most countries. the results of this work highlight the differences between countries, but also between genders. the patterns identified could indicate cultural and gender trends to which future public health interventions should be addressed. greater attention should be given to the fight against risk factors for non-communicable diseases, particularly diabetes, considering its high prevalence. this must be a priority for citizens at higher risk. the authors declare no conflict of interest. the founding sponsors had no role in the design of the study; 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hengartner, nick; meadors, grant; ke, ruian title: change in global transmission rates of covid- through may date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: w u fq g we analyzed covid- data through may th, using a partially observed markov process. our method uses a hybrid deterministic and stochastic formalism that allows for time variable transmission rates and detection probabilities. the model was fit using iterated particle filtering to case count and death count time series from countries. we found evidence for a shrinking epidemic in of the examined countries. of those countries, have significant evidence for subcritical transmission rates, although the decline in new cases is relatively slow compared to the initial growth rates. generally, the transmission rates in europe were lower than in the americas and asia. this suggests that global scale social distancing efforts to slow the spread of covid- are effective although they need to be strengthened in many regions and maintained in others to avoid further resurgence of covid- . the slow decline also suggests alternative strategies to control the virus are needed before social distancing efforts are partially relaxed. since its initial outbreak in wuhan, china in late and early [ ] , covid- caused repeated rapid outbreaks across the global from february through april . the extremely rapid spread of covid- in china [ ] does not appear to be an anomaly: the disease has shown a short doubling time ( . - . days) outside of china as well [ ] . as of may , , the virus caused , , reported infections, and , deaths globally [ ] . in response, most affected countries/regions have implemented strong social distancing efforts, such as school closures, working-from-home, shelter-in-place orders. as a result, the spread of covid- slowed down substantially in some countries [ ] , leading to a flattening of the epidemic curve. as social distancing induces high costs to both society and individuals, plans to relax social distancing are discussed. however, changes in both the transmission rates and detection probabilities over time coupled with stochasticity due to reporting delays makes differentiating between truly subcritical dynamics and simply reduced transmission difficult. in this report, we developed a deterministic-stochastic hybrid model and fitted the model to case incidence and death incidence time series data from countries. following the a a a a a approach suggested by king et al. [ ] , we use a (partially) stochastic model and base our estimates on incidence rather than cumulative incidence data. using both case count and death count of data allowed us to disentangle changes in surveillance intensity from changes in transmission [ ] . we found evidence for large decreases in the country-level transmission rates, in several of the worst-affected countries. importantly, using data up to may , , we computed % confidence intervals to test whether or not the data were consistent with subcritical dynamics (i.e. the reproductive number r was below on may , ). most countries showed large decreases in transmission rates over time, and more than half of studied countries have transmission rates below the epidemic threshold. on the other hand, many countries still appear to be showing rapid exponential growth. given its highly contagious nature, covid- can spread rapidly when strong social distancing measures are lifted, even partially [ ] . alternative strategies that can effective control the virus are needed when social distancing measures are relaxed. case count and death data were downloaded from the johns hopkins github repository (https://github.com/cssegisanddata/covid- ) through may , . data included aggregate counts of reported cases and deaths at the country level and contained no identifying information. any country in the data that had more than cumulative cases and deaths by may , was included. to minimize the effect of repatriated cases we started each time series on the first day when the cumulative number of cases exceeded . all data processing and model fitting were otherwise done on the incidence scale. to address obvious bulk-reporting issues in the data (e.g. sudden zeros in the data followed by very large numbers), we smoothed the data using tukey's -median method. because several countries had days with a single death surrounded by days with no deaths, which the smoothing method would set to zero, days with a single death were not replaced with smoothed values. the original data and the smoothed data used for estimation are shown in s fig in s file. we model the spread of covid- as a partially observed markov process with real-valued states s (susceptible), e (exposed), i (infected), and r (removed) to describe the latent population dynamics, and integer-valued states c (to be counted), y (counted cases), d : (dying), and y (counted deaths) to model sampling into the data. we use multiple states to model the counted deaths to produce an erlang distribution with mean days and standard deviation days in the time to death based on previous estimates of the time to death [ ] . the model and all of its parameters (table ) have time units of days. the latent population model is governed by the following ordinary differential equations, where χ(t) is the time-variable transmission rate and n = s + e + i + r is assumed to be fixed over the run of the model. λ ei is the rate at which exposed persons become infectious and λ ir is the rate at which cases recover (i.e. are either no longer infectious or die). at every time interval, we sample persons moving from the e to i states into a stochastic arm of the model that is used to calculate the likelihood of the data. to relate the latent population model to data, we randomly sample individuals from the unobserved population into a stochastic process that models the random movement from infection to being either counted as an observed case or counted as an observed death. the number of persons sampled into the observation arm of the model over a time interval dt is given by and ω are the probabilities that an infected person will be counted or die respectively, ρ c (t) and ω c are the probabilities of being not sampled or not dying respectively, and g(u) is a stochastic function that maps from real-value u to integer g(u); it takes value buc with probability u mod and value due with probability − (u mod ). in plain english, the model tracks the random fate of each newly infected person as they move from the exposed to infected state with respect to eventually being observed as a case and/or a death in data. at each time step of length Δt, the change in state space is given by, where f t |c is a random variate from binðc ; À expðÀ l y dtÞÞ, and h it is a random variate from bin d iÀ ; À exp À dt À � À � . x i indicates the i th element of multinomial random variate defined above. the rate λ y determines the rate at which persons who will be counted are counted (i.e. lower values of λ y mean a longer delay in cases showing up in the data). the values of y : are set to zero at the beginning of every day such that they accumulate the simulated number of cases and deaths that occur each day. both the transmission rate and detection model probability are allowed to vary with time in the following way: where t f is the final time in the given dataset. in plain english, the transmission rate is constant up to some time, t ð Þ w , where it linearly increases or decreases to the value χ f by time t ð Þ w . the model is constrained such that t ð Þ w < t f À , that is, the transmission rate must be constant for at least days before the end of the data collection period. this constraint is in place to avoid overfitting the final transmission rate. the detection rate likewise has a linear increase or decrease beginning at time t ρ ; however, the increase or decrease continues to a fixed point that is days before the final datum. variation in the detection rate (i.e. the probability that an infected case will be counted in a fixed interval) over the course of the epidemic can strongly bias estimates of the population growth rate (derivation for the exponential growth case in s file); not allowing the detection probability to change over time could lead to discordance in the case count and death count time series. we assume that the data are negative binomial-distributed, conditional on the simulated number of cases and deaths that occur in a given time interval, i.e. the number of cases in the i th observation period has density negbin(y , � ) and the number of deaths in the i th observation period has density negbin(y , � ). the negative binomial is parameterized such that the first argument is the expectation and the second is an inverse overdispersion parameter that controls the variance of the data about the expectation; as � i becomes large, the data model approaches a poisson with parameter y i . both � and � were estimated from the data. parameter estimation had two distinct steps: model selection and computation of confidence intervals. in the model selection phase, the model was fit to the data using an iterated particle-filtering method, implemented in the pomp r library [ ] . to optimize the likelihood of the data, we used particles in iterations for each country. to determine whether or not particles was sufficient to minimize the variance in the estimated the mean likelihood at a given parameter value we ran independent particles filters on a single data set and found that the average deviation from the mean was less than . log units suggesting that we would be able to detect differences in the log likelihood greater than . log units. the reported likelihoods were measured using particles at the optimized maximum likelihood estimates (mles). for all fits, the initial state at time zero is computed by assuming there were i( ) infected persons, days before the first reported death (by definition time one). the number of initial number of susceptibilities was assumed to be the predicted population size of the given country [ ] . the model is then simulated forward for days, assuming exponential growth with transmission rate χ , which is taken at the initial state of the model at time zero. because the data were highly variable in the complexity of the patterns they showed, we considered three nested models of increasing complexity for each country. the first model (model ) assumed simple exponential growth with a constant sampling probability, i.e. ρ = ρ f and t ð Þ w ¼ t ð Þ w ¼ . this amounts to a period of exponential growth with transmission rate χ in the pre-data period and then a constant transmission rate χ f over the observation period. the second model (model ) allowed the transmission rate to vary but kept the detection probability constant, i.e. ρ = ρ f . the third model (model ) allowed both the transmission rate and detection rate to vary, i.e. all parameters estimated. we determined the best model for each country by a sequence of likelihood ratio tests first comparing model and model and then model to model . because we are using an optimization method, we do not have access to samples from the likelihood surface directly. therefore, to obtain estimates of the parametric uncertainly in the final transmission rate, χ f , we computed % confidence intervals using the profile likelihood method. for each country computed the profile likelihood by optimizing the model along a fixed grid with points every . units centered on the mle of χ f value from the previous fit. points were added to the grid until the measured likelihood on either side of the mle was greater than log units lower than the measured maximum likelihood. we then fit a local polynomial regression (loess in r) to those points and found the predicted maximum likelihood parameter value [ ] and the % ci by locating the points on either side of the mle that were . log units below the maximum likelihood. we fixed several parameter values based on published work and our scientific judgement. the probability that a case would eventually die, ω = %, is based on estimates of the case fatality ratio for both asymptomatic and symptomatic patients ( % ci . - %) [ ] . the latency rate, l ei ¼ , was initial set based on our general sense of what was consistent with the pre-print literature available at the time, however, that value is has proven to be consistent with later reports [ ] . the recovery rate, l ir ¼ , was similarly set to be consistent with the available literature when the model was being developed. likewise, longitudinal studies have shown that our assumption of an average infectious period of days is reasonably consistent with the clinical data [ , ] . although the clinical data paints a picture of the natural history of infection that is far more complex than our model can capture, the formulation of our model is consistent with the available data. our primary outcome of interest is the growth rate, r, at the end of observation period, which is derived from the transmission rate estimated from the data. using the equation in [ ] we can express the growth rate in terms of the model parameters we found that for most countries, the fraction of the population that was still susceptible at the end of the observation period was greater than %, therefore we omitted the term prðsÞ ¼ s between countries. from the same paper we also have the equation showing that r = when r = . we also compare predicted deaths due to covid- in each country through july th to the average number of deaths in a period of the same length (fig ) . predicted deaths were computed by simulating the number of daily deaths from the first observation though july th for each country and taking the mean value. confidence intervals were computed as the relevant quantiles of the sum over simulations. pre-covid- deaths were based on allcause death data were downloaded from the who mortality database (https://www.who.int/ healthinfo/mortality_data/en/) for each country for which it was available. using data from the most recent year, we computed the death rate and multiplied the death rate by the length of the interval from the first observation to july th for each country. we fit our model to data collected from countries. model fits are shown in fig , and parameter values are given in table . the model can capture the data well, with a few exceptions. the model was not able to find a robust fit to the data from bangladesh; in general, the upside down 'v' shape to the deaths could not be captured well in such a short time series. algeria had a similarly odd pattern in the deaths time series that the model could not capture in detail, although the overall trend in deaths was recovered. in previous versions of this paper, the model had a hard time fitting data from both italy and spain. however, given the longer time series and modifications to the model form, we now find that both italy and spain are well-captured by the model. overall, the model slightly overestimates the number of deaths around the time where deaths begin to decrease. however, this was generally corrected if the time series was long enough. including temporal heterogeneity in the time from infection to detection of a covid- death would likely correct this; however, it is not clear that this is advisable, as death counts are likely under-reported. all countries except japan and saudi arabia were found to have lower transmission rates on may , than at the beginning of the observation period, suggesting a global decline in the transmission of covid- though may , . however, the initial transmission rate should be interpreted cautiously, as we allowed a wide range of infected persons to exist days before the first observation. that is, the initial transmission rate parameter is rather a convolution of the unknown number of infected persons and initial growth rate consistent with the data. we found significant evidence for subcritical dynamics in countries ( countries had subcritical point estimates but their cis contained the epidemic threshold). fig shows the point estimates and cis of the final transmission rate on may , for all countries, stratified by continent [ ] . european countries had the highest probability of being subcritical ( of ) with asia ( of ) and the americas ( of ) having fewer subcritical countries. none of the countries in africa that met the inclusion criteria had subcritical dynamics. generally, countries that were found to have both variable transmission rates and variable detection probabilities (model in table ) show a pattern of level or increasing deaths coupled with a level or slightly declining incidence in number of reported cases. this pattern illustrates how viewing the case count data alone can be potentially misleading as declines in reported cases can be confounded by variation in the probability of detection (e.g. comparing canada to denmark). some countries were found to have detection probabilities lower than % on may ; however, these values should not be over-interpreted as the simple linear model for changing detection probabilities imposes strong assumptions that are focused on capturing the general trend. fig shows the predicted number of deaths projected out to july , assuming that all parameter values are constant over the period may through july . the average duration of the country-level epidemic in european countries is longer than in asia, leading to a higher level of death, despite asian countries having on-average higher growth rates. however, in the americas, the predicted deaths are higher with of countries having total predicted deaths greater than . % of the total population by july , . the model predicts , , total covid- deaths in all countries on july , ; of those deaths, % are predicted to occur in the us. the deaths due to covid- in europe are lower than the average number of reported deaths in a period of the same length for all countries in the data set that also had all-cause death counts from previous years. however, in the americas, the covid- death counts are approaching the all-cause death levels in several countries, suggesting that covid- deaths are approaching a doubling of all-cause deaths in those countries. our model found evidence for reductions in transmission rates of covid- in of examined countries. encouragingly, of those countries, we found statistical evidence that the size of the epidemic is decreasing in countries, i.e. the effective reproductive number is less than , using data up to may , . this suggests that, despite the highly heterogeneous populations represented by these countries, the growth of covid- outbreak can be reverted. although our model cannot attribute exact causes to the global decline in transmissions rates, most countries implemented sustained, population-level social distancing efforts over a period of weeks to months. these efforts are highly likely to play a major role in reducing the transmission of covid- [ ] . we estimated that in countries with decreasing transmission, the rate of decrease is in general less than . /day (average - . /day). based on data from european countries, the us, and china, we previously estimated that in the absence of intervention efforts, the epidemic can grow at rates between . - . /day [ ] . this means that the outbreak can grow rapidly and quickly wipe gains made though public heath efforts made if social distancing measures are completely relaxed. for example, if the rate of decrease under strong public health interventions is . /day and the growth rate in the absence of public heath interventions is . / day, then, the number of cases averted in two weeks of intervention will be regained in only one week. social distancing measures have their own social costs. our results suggests alternative strategies to control the virus are needed in place when social distancing efforts are relaxed. due to the uncertainties in the impact of each specific control measures, changes to policies should be made slowly because the signal of changing transmission can take weeks to fully propagate into current data streams as a result of the long lag between infection to case confirmation (as we estimated to be on average approximately weeks). our goal in this paper was to develop a model that could be applied very broadly to multiple countries and we have made assumptions that facilitate that goal. however, our model makes key assumptions that should be considered when thinking about where these results fit into the vast collection of covid- modeling papers. for example, we slightly privilege death counts over case counts in linking the population model to the data by assuming that the distribution of the time to death is known and that the probability of being a detected death is fixed over time. likewise, we assume that at the country level, the change in transmission rates can be modeled by a simple linear function, which we believe is reasonable as interventions implemented at the local level are likely to lead to a smooth change when aggregated up to the population level. our model produces reasonable fits to the global data, but out approach does not allow us to have unique models for each country that could almost certainly capture country-level trends with greater accuracy. our model also makes strong simplifying assumptions about the natural history of infection, about which we are continuously learning. for example, our model assumes that contagiousness is constant over the infection, which is possibly variable over time [ ] . we also assume that diagnosis does not affect transmission from infected persons. however, given that we are inferring broad, population-average parameters and allowing those parameters to change over time to reflect broad changes in the transmission dynamics, we believe that our results are are reasonable portrayals of reality despite using a simple model of the natural history of infection. overall, our results suggest that covid- is controllable in diverse settings using a full range of strong and comprehensive non-pharmaceutical measures, and that future deaths from the disease are avoidable. supporting information s file. (pdf) early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia early release -high contagiousness and rapid spread of severe acute respiratory syndrome coronavirus -emerging infectious diseases journal -cdc fast spread of covid- in europe and the us and its implications: even modest public health goals require comprehensive intervention an interactive web-based dashboard to track covid- in real time. the lancet infectious diseases - - -covid -report- .pdf avoidable errors in the modelling of outbreaks of emerging pathogens, with special reference to ebola high contagiousness and rapid spread of severe acute respiratory syndrome coronavirus . emerging infectious diseases pomp: statistical inference for partially observed markov processes maximum smoothed likelihood estimation severity of -novel coronavirus (ncov) temporal dynamics in viral shedding and transmissibility of covid- virological assessment of hospitalized patients with covid- clinical and virologic characteristics of the first patients with coronavirus disease (covid- ) in the united states estimating epidemic exponential growth rate and basic reproduction number countrycode: an r package to convert country names and country codes conceptualization: ethan obie romero-severson, nick hengartner, ruian ke. key: cord- - td a authors: lazcano-ponce, eduardo; allen, betania; gonzález, carlos conde title: the contribution of international agencies to the control of communicable diseases date: - - journal: arch med res doi: . /j.arcmed. . . sha: doc_id: cord_uid: td a although inequality is often measured through three critical indicators—education, income and life expectancy—health-related differences are also essential elements for explaining levels of equality or inequality in modern societies. investment and investigation in health also involve inequalities at the global level, and this includes insufficient north-south transfer of funds, technology and expertise in the health field, including the specific area of communicable diseases. globally, epidemics and outbreaks in any geographic region can represent international public health emergencies, and this type of threat requires a global response. therefore, given the need to strengthen the global capacity for dealing with threats of infectious diseases, a framework is needed for collaboration on alerting the world to epidemics and responding to public health emergencies. this is necessary to guarantee a high level of security against the dissemination of communicable diseases in an ever more globalized world. in response to these needs, international health agencies have put a number of strategies into practice in order to contribute to the control of communicable diseases in poor countries. the principle strategies include: ) implementation of mechanisms for international epidemiologic surveillance; ) use of international law to support the control of communicable diseases; ) international cooperation on health matters; ) strategies to strengthen primary care services and health systems in general; ) promotion of the transfer of resources for research and development from the north to the south. many obstacles to the improvement of global health persist in the st century, something that is evident in the large degree of health-related inequality between rich and poor countries. infectious diseases constitute the second cause of death worldwide, are an incalculable source of human suffering and cause immense economic loss at every level. in point of fact, % of all deaths worldwide and % of the global burden of disease can be attributed to infectious diseases ( figure ). unfortunately, not only are the majority of these deaths potentially preventable, but over % occur in developing countries, where poverty is often the common denominator. the three infectious diseases that cause the largest number of deaths are hiv/aids, tuberculosis and malaria. against this background, the need to achieve a greater degree of social justice and uphold the human rights of the populations of poor countries is the principle justification of north-south assistance related to emerging and re-emerging infectious diseases ( ) . in this context, there are a number of strategies that international health agencies have used in order to contribute to the control of communicable diseases in poor countries. this essay reviews these efforts, beginning with the mechanisms created to facilitate international epidemiologic surveillance. the use of international health law as a tool for global collaboration on the control of communicable diseases is also touched upon. next, international cooperation on a range of health matters and efforts to strengthen primary health care and health systems in general in poor countries are referred to. finally, a discussion is included about how international agencies facilitate the north-south transfer of resources for research and development and contribute to the implementation of these investments in the areas of research, surveillance systems and improvements to health. diseases that are rapidly spread, including a number of emerging and re-emerging infectious diseases, require surveillance systems with a high degree of sensitivity, which are also opportune. surveillance systems with these characteristics allow rapid decision making and action to stop an outbreak from growing or to control an epidemic. given the above, a new paradigm for global collaboration has been developed based on the establishment of surveillance networks at the international level. epidemics and outbreaks in local regions can represent an international public health emergency. although such situations require a global response, there is no single institution with the ability to guarantee health safety worldwide. therefore, collaboration by international agencies, national governments and individuals with pertinent expertise is required. collaboration in this area has included the establishment of the networks for surveillance of emerging infectious diseases, three regional structures operating in latin america with the support of the pan american health organization (paho) ( ) . these networks carry out epidemiologic and laboratory-based surveillance of emerg-ing and re-emerging infectious diseases in the amazon, central american and the southern cone regions and provide a forum for information exchange, cooperation on capacity building and collaboration on quality control mechanisms, all aimed at the prevention or control of epidemics ( ). another initiative in this area is the global outbreak alert and response network (goarn), which was established in under the guidance of the world health organization (who). goarn provides a technical, multidisciplinary response to outbreaks and epidemics with a global outlook. this network aims to improve coordination of international responses to situations involving emerging and re-emerging infectious disease by focusing its actions on technical and operational support for national or regional efforts. goarn assists countries in actions targeted at disease control by ensuring rapid technical support; investigation and risk calculation in epidemics; controlling outbreaks of diseases with the potential for spreading rapidly; providing technical advice and guidance; carrying out epidemiologic research; advising on clinical management issues; confirming laboratory diagnoses; handling dangerous pathogens; and giving logistic support and sending supplies (drugs, vaccines, reagents, medical equipment). goarn constitutes a global resource that guarantees rapid access to experts and necessary operational resources for infectious disease control (see box ) ( ). traditionally, international law has been a central tool in the global surveillance of communicable disease. throughout the th century, international law was decisive for coordinating quarantines in different european countries, which were not coherent from one nation to the next. international legislation and norms have contributed to the exchange of epidemiologic information about infectious diseases in diverse geographic areas, justification of the establishment of international health organizations, and support for epidemiologic surveillance systems for communicable diseases. as the world enters the st century, communicable diseases continue to stretch the limits of global health policy, carried out through the use of legally binding instruments and voluntary norms. such legislation is discussed and adopted within the framework of multilateral institutions such as the who, world trade organization (wto), food and agriculture organization of the united nations (fao) and the world organization for animal health (oie). international law has constituted an indispensable tool for the protection and promotion of health in the context of globalization. international legislation has also been useful in the application of global health policy aimed at reducing human vulnerability to mortality and morbidity due to communicable diseases ( ) . the international health regulation, and particularly global regulations related to the control of infectious disease, have not been significantly modified since its proposal in . therefore, the who and paho have been involved in coordinating the review and modification of the international health regulation, which constitutes a series of guidelines for cooperation by countries on the control of disease outbreaks ( ) . the recognition of the need for changes in the international health regulation grew out of the emergence of new infectious diseases such as severe acute respiratory syndrome (sars, see box ), ( ) as well as the resurgence of re-emerging infectious diseases which for the latin american region include cholera ( ) and typhoid fever ( ) , while in africa reemerging diseases that indicate the need for this modernization of health regulations include influenza, ( ) measles ( ) and cholera ( ) as well ( figure ). the efforts to modify the international health regulation proceed from an understanding of the issues raised by increasing globalization; specifically, public health emergencies with international repercussions. important in this respect is the need to take into account the potential for the international spread of an emerging or re-emerging disease while also measuring the repercussions for the free circulation of people and goods ( ) . the who proposal for modernization of the international health regulation includes the following: ) a mission with a stronger focus on control of infectious diseases, ) emphasis on broader health care coverage and better access to treatment schemes, ) global surveillance including data from official and non-official sources, ) strengthening of national public health systems through the establishment of comparable productivity indicators and outcome measurements, ) giving priority to the protection of human rights, ) guidelines for good health governance defined as adoption of the principles of impartiality, objectivity and transparency ( ). above all, who needs to ensure all geographic regions establish health norms and structures that facilitate the transfer to poor countries of economic and technical assistance related to health. the need for increased global capacity to deal with infectious diseases is what drives the creation of a collaborative framework for epidemic alerts and responses to public health emergencies that are of international concern. such a structure should guarantee the highest level of security against the spread of disease with the least possible interference in other globalized processes such as commerce or travel. the best way to prevent the international spread of diseases is through opportune detection of and intervention into public health threats, while the problem is still limited. this requires early detection of unusual events the largest ebola outbreak ever recorded was successfully controlled in uganda in through the efforts of the ugandan government and an international team coordinated by the global outbreak alert and response network (goarn). more than ebola cases were isolated and treated and , contacts were tracked. after initial containment of the outbreak, follow-up was carried out through a community-based early warning surveillance system, establishment a field laboratory and creation of an isolation ward. goarn provided logistic support and coordination in the field, which made quick and effective control of the outbreak possible ( ). through national epidemiologic surveillance and international coordination as part of an effective response to public health emergencies of international importance. when common challenges exist, common strategies are necessary to find solutions, as is sharing high-quality information in order to provide effective, evidence-based responses. globalization has had multiple repercussions on international health, including the dissemination of certain infectious and vector-borne diseases, greater reach for bioterrorism and new health behaviors, among others. against this global backdrop, cooperation among countries would seem the best way to ensure worldwide progress in public health matters ( ) . however, international-and specifically north-southcooperation on actions to promote greater health should not be limited to the control of communicable diseases. particularly in many poor countries, it is important to reduce the burden of illness or ill health related to malnutrition ( ) . at times this may imply the existence of conflicting health priorities. international agencies and national institutions and governments will have to decide how limited resources can best be invested to achieve the greatest gains in the fight against ill health, be they through the control of communicable diseases or in the fight against malnutrition ( ) . of course, international cooperation on health issues cannot be the sole responsibility of poor countries; instead, developed and developing nations must collaborate. developed countries should commit to resolving global problems, making an effort to recognize precisely their global qualities even when originally they are located (in geographic terms) in developing countries. on their part, the less-developed nations should work towards guaranteeing the sustainability of their health policies. a specific proposal for dealing with issues such as these is the establishment of a global research council, which would contribute to making action-research more efficient as well as promoting faster uptake of new applied knowledge in the public health field. in general, in order to reach these goals, north-south collaboration is essential ( ) . the initiative for global eradication of poliomyelitis in has various lessons to teach us about international cooperation. in the first place, each goal should be defined based on strategies that are technically feasible for large geographic areas. secondly, before a strategy is implemented, an informed, collective decision should be negotiated and a consensus reached. in addition, financial risk should be minimal while the possibilities for implementation in a short time period should be maximized. finally, global health interventions should take into consideration the available infrastructure within the local health systems and ensure sufficient resources-financial and in terms of health care systems-as was the case in the eradication of poliomyelitis ( ) . there is a lack of efficacy in existing measures for stopping the spread of communicable diseases among countries. in order to create a foundation upon which to build communicable disease control strategies, to start with, health system infrastructure in developing countries must be strengthened (table ). this will involve the continual development of institutional capabilities for early detection and efficient and opportune intervention in emergencies linked to epidemics. for too long, many international agencies have given priority to other matters, including managerial capacity. although these issues may be important, the end result has been the postponement of support for improving primary care. therefore, international support for the control of communicable diseases should begin to include resources for strengthening local health systems ( ) . although some aspects of health problems, priorities and policy have become global, most of the responsibility for communicable disease control continues to be exercised at the local level. therefore, a network for the ''global public good'' has been proposed to improve communicable disease control in developing countries. this initiative proposes that failures and omissions in collective efforts to control communicable diseases can be overcome through the following actions: a) providing additional or matching funds to those offered at the local level; b) promoting investment by developed countries in the health systems of less developed nations; c) offering joint strategies for the global control of communicable diseases; and d) guiding the political process that will establish mechanisms for financing global communicable disease control programs ( ) . in this context, an alliance of a number of agencies has been formed, including the united nations, the governments of developing countries, governmental donors in developed countries, private foundations and corporations and non-governmental organizations. the goal is to mobilize, manage and distribute additional resources for the control, to begin with, of hiv/aids, tuberculosis and malaria. one high priority in the use of funding is the purchase of vaccines. however, there is still no consensus on implementing a strategy for financing and improving the health services of poor countries ( ) , and this will be something that should receive priority in the near future. research, development and funding priorities in the health field vary greatly in different parts of the world (particularly developed vs. underdeveloped), something which is linked to the insufficient north-south transfer of investment in health. one of the reasons this situation exists is simply that communicable diseases make up a much larger proportion of the burden of disease in underdeveloped countries as compared to developed ones (see box ) ( ) . a related problem is that research priorities are different in richer countries where chronic diseases are a priority than in poorer nations where infectious diseases and malnutrition are of greater concern. even when chronic diseases constitute an important proportion of the burden of disease in developing (often middle-income) countries, research needs may be different from those in developed nations. specifically, interventions to prevent chronic diseases, or to improve adherence to treatment once acquired, which may be successful in developed countries can be either not feasible or inappropriate (in cultural, social or economic terms) in developing nations. in addition, the development of vaccines in developed countries, for the control of communicable diseases, can be of little use in poorer nations, where they may be ineffective given the existence of different viral strains or bacterium. quality of health care services is quite heterogeneous from one country to another, both when comparing developing countries with one another or with their developed country counterparts, which again implies different research and funding needs. finally, the high cost of patented medicines and medical technology limits their transferability from richer to poorer nations. the new health environment is highly complex and therefore the proposals being made to improve it are extremely heterogeneous ( ) . certain international agencies have contributed to successful inter-institutional and international collaboration on scientific capacity building, joint research programs and technology transfer. to establish the basis for north-south discussion and transfer of resources and technology, as well as south-south collaboration, these successful examples will need to be examined and learned from. the identification of the necessary conditions for developing sustainable research, control efforts and health services will also be essential elements in the control of communicable diseases. recently there has been growing interest in the study of how priorities for investment in health research are established in different parts of the world ( ) . there are a number of perspectives from which an analysis of these issues can be carried out, including a focus on the economic, health or human rights aspects of priority setting. in economic terms, there has been an increase in investment in health research, from billion usd in ( ) to . billion usd in ( ) . the health sector generates trillions of dollars at the global level; among the products and services to be invested in are prevention of disease and health promotion, as well as diagnosis and treatment. the world bank is the agency that provides the largest amount of health-related financing worldwide, at close to one billion usd each year. the world bank's principal health-related aims are to contribute to the improvement of the health of the poor and to the reduction of the impoverishing effects of disease, as well as increasing equitable access to health care and promoting sustainable financing for health systems ( ) . the . billion usd provided by the world bank for the fight against hiv/aids in recent years constitutes an example of how the emergence of a public health problem-specifically an emerging disease-can lead to the creation of new investment priorities in terms of health research, prevention activities and treatment. human development can be measured through three critical indicators: education, income and life expectancy, all of which interact in complex ways with health. the large north-south differences can be expressed in terms of these four elements and their reciprocal influences. these indicators would seem to indicate a lack of equity in the way health research priorities are established, which in turn translate into insufficient north-south transfer of applicable after antibiotics began to be used to treat tuberculosis patients in developed countries beginning in the s, the control programs for this disease underwent radical transformations in these nations and tuberculosis incidence and mortality rates declined steadily in the industrialized world. the developed nations began to ignore the disease, and resources available to developing countries for dealing with it dried up. the treatment options used in developed nations were unaffordable for developing countries, where instead strategies such as ambulatory care and passive case detection were preferred in order to lower treatment costs and avoid expensive mass screening. studies carried out in developing contexts produced useful schemes for other resource poor settings. investigation undertaken in india confirmed the effectiveness of treatment of tuberculosis in patients' homes and provided alternatives to costly mass screening. research supported by the ministry of health of tanzania provided the groundwork for the development of dots (directly observed treatment shortcourse), which is now the leading global intervention against tuberculosis. however, these research results were not applied in many poor countries, given the almost total absence of tuberculosis on the international health agenda and especially the lack of funding. it was not until tuberculosis incidence began to rise in developed countries such as the united states and a number of european nations in the s that international concern was again focused on this disease, including resources. at this juncture, the world bank made tuberculosis a priority and provided loans for the implementation of who-dots, after which countries adopted this scheme ( ) . health research results, technology and health investment. among the many reasons offered to explain this situation is that in rich countries most infectious diseases are not endemic, as opposed to the reality of many poor countries, where emerging infections (such as hiv/aids) and reemerging diseases (such as malaria, tuberculosis or cholera) are priority public health issues (see box ). perhaps the most heart-wrenching example of this is the fact that epidemiologic surveillance and especially therapeutic interventions for hiv/aids are not available in poorer countries, where the large majority of people living with the disease are concentrated ( % of people living with hiv/ aids reside in developing countries, and only % of the million people living with the disease in resource poor areas received antiretroviral treatment in ( ) . a communicable disease has been controlled if through public policy the spread of an infectious agent is restricted to its pre-epidemic status, which is to say that the epidemic has been reversed. on the other hand, a communicable disease is eliminated if it is sufficiently controlled to prevent the occurrence of an epidemic in a specific geographic area. control and elimination are achieved locally, but a disease is eradicated only if it has been eliminated in all geographic regions. thus, eradication is clearly the most difficult goal to achieve, although it has large advantages over control. the economic effects of eradication can be extremely favorable in that it not only reduces the infection but also eliminates the need for future vaccination efforts. eradication generally becomes feasible, from an economic point of view, when a disease is first eliminated in one or more of the richer countries. the incentives for participation by the poorer countries in eradication initiatives begin with the existence of an international control program, which allows them to take advantage of financial support for elimination efforts ( ) . to promote and facilitate participation by developing and developed countries in epidemiologic surveillance systems, as well as initiatives for the control, elimination or eradication of communicable diseases, poor countries need to develop their capacity for early detection, dissemination of precise and high quality information and a high degree of transparency ( ) . all countries should adhere to international regulations, including the international health regulation and those of the world trade organization. finally, developed countries should provide financial and technical support for countries undergoing emergencies linked to communicable diseases, because globally this is the only way they can guarantee the safety of their own populations and ensure the usefulness of their internal health-related investments. ultimately, developed countries should also share 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five key policy areas communicable disease control: a 'global public good' perspective a global health fund: a leap of faith? the burden of disease among the global poor public health. grand challenges in global health commission on health research for development. health research: essential link to equity in development global forum for health research. monitoring financial flows for health research. geneva: global forum for health research economics, health and development: some ethical dilemas facing the world bank and the international community resumen mundial de la epidemia del vih/sida: diciembre de eradication versus control: the economics of global infectious disease policies impediments to global surveillance of infectious diseases: consequences of open reporting in a global economy sars vaccine development after the initial efforts to eradicate malaria through the use of ddt beginning around the mid-twentieth century, although some areas achieved important reductions in malaria incidence and mortality, frequent resurgences of endemicity continued in a number of poor countries. the initial eradication strategies failed for a number of reasons, including the development of resistance to ddt, a lack of high quality epidemiological knowledge and managing capacity as well as the inadequacy of the health care systems that existed in less developed countries. although for at least two decades malaria ceased to be an international priority, research continued, including the development of antimalarial drugs and attempts at vaccine development supported by such international agencies as the who, the world bank, the united nations development programme (undp) and usaid. during the last decade of the twentieth century a different set of strategies was developed, including evaluation of national malaria situations by a number of african countries and joint efforts to strengthen malaria control programs by african governments and the who, which were financed primarily by the world bank but also with resources from g countries, the european commission and development banks. it was this transnational alliance of international agencies and national governments and a more complex and realistic appraisal of the work needed to control malaria (instead of relying on a single strategy, ddt use) that constituted perhaps the most important difference between these two phases in the fight against malaria ( ) . key: cord- -fs rx q authors: blasius, bernd title: power-law distribution in the number of confirmed covid- cases date: - - journal: chaos doi: . / . sha: doc_id: cord_uid: fs rx q covid- is an emerging respiratory infectious disease caused by the coronavirus sars-cov- . it was first reported on in early december in wuhan, china and within three months spread as a pandemic around the whole globe. here, we study macro-epidemiological patterns along the time course of the covid- pandemic. we compute the distribution of confirmed covid- cases and deaths for countries worldwide and for counties in the us and show that both distributions follow a truncated power-law over five orders of magnitude. we are able to explain the origin of this scaling behavior as a dual-scale process: the large-scale spread of the virus between countries and the small-scale accumulation of case numbers within each country. assuming exponential growth on both scales, the critical exponent of the power-law is determined by the ratio of large-scale to small-scale growth rates. we confirm this theory in numerical simulations in a simple meta-population model, describing the epidemic spread in a network of interconnected countries. our theory gives a mechanistic explanation why most covid- cases occurred within a few epicenters, at least in the initial phase of the outbreak. by combining real world data, modeling, and numerical simulations, we make the case that the distribution of epidemic prevalence might follow universal rules. covid- is an emerging infectious disease caused by the coronavirus sars-cov- . it was first reported on in hubei, mainland china on december , and has spread well outside china in a matter of a few weeks, reaching countries in all parts of the globe within a time span of three month. as of march , the disease has arrived in countries, with more than confirmed cases and deaths worldwide. despite the drastic, large-scale containment measures implemented in most countries, chaos article scitation.org/journal/cha these numbers are rapidly growing every day-posing an unprecedented threat to the global health and economy of interconnected human societies. one of the most powerful tools to understand the laws of epidemic growth is mathematical modeling, going back to bernoulli's work on the spread of smallpox in . epidemiological models can be roughly divided into two classes. the first class of models is focused on describing the temporal development of the epidemic within a localized region or country. these models are often variants of the well-known susceptible-infected-recovered (sir) model , and have recently been adapted to the situation of covid- , taking into account non-pharmaceutical interventions (e.g., quarantine, hospitalization, and containment policies) and allowing first predictions of healthcare demand. , , , the second class of models is concerned with the geographic spread of the epidemic around the globe. for these aims, spatially explicit models have been developed that leverage information on the topology of transport networks. for example, the global network of cargo ship movements was used to model the dispersal of invasive species. similarly, for infectious diseases, in a pioneering study, the spread of sars in the global aviation network was modeled. based on these approaches, conceptual frameworks have been developed to estimate epidemic arrival times as effective distances. , at the same time, these models have been refined to highly detailed simulation frameworks for predicting the spread of disease and are able to include factors such as vaccination, multiple susceptibility classes, seasonal forcing, and the stochastic movement of individual agents. , reacting rapidly to the emergent pandemic, spatial epidemiological models have been developed to describe and anticipate the spread of covid- . , , , these models allow us to predict the incidence of the epidemics in a spatial population through time, permitting to study the impact of travel restrictions and other control measures. despite this theoretical progress, not much is known about the biogeography of covid- , neither from empirical studies nor from mathematical models. this is astonishing, as one prominent characteristic of the pandemic is the huge variation in the number of cases that have been reported from different countries of the world. as of april , some countries-the epicenters of the pandemic-were already badly affected by the pandemic, while others at the same time had just confirmed the first few cases. this geographic variation in covid- prevalence might be explained by several arguments: a first obvious possibility would be that the variation is caused by the idiosyncratic circumstances of the individual countries which differ largely in their geography and population size, but also in the way they are combatting the disease. alternatively, parts of the variation could simply be due to reporting errors, reflecting disparate national testing regimes, with countries such as china, japan, south korea, or germany having high testing rates, in contrast to other countries with much poorer testing. here, we argue, however, that a dominant part of this variation may be a direct consequence of the dynamics of the spreading process itself. thereby, the epidemic prevalence in a country should be directly correlated to the arrival time of the disease: countries that were invaded very early by the virus have accumulated many cases in time, while countries with a late invasion naturally still have smaller prevalence. to test this hypothesis, we use empirical data to compute the country-level distribution, p, of confirmed covid- cases, n, at the end of march worldwide and find that it is closely approximated by a truncated power-law, over five orders of magnitude. power-law distributions characterize a large range of phenomena in natural, economic, and social systems, which is known as zipf-or pareto law. , , , examples range from the number of species in biological taxa, the number of cities with a given size, the number of different words in human language, the frequency of earthquakes, the distribution of wealth, the number of scientific citations, , the step length in animal search patterns, and the popularity of chess openings. our study shows that epidemic prevalence, at least in the emerging stage of a pandemic, is another system that falls into this class, suggesting that the spatial distribution of covid- case numbers is a fractal. the appearance of a power-law distribution often points to the nature of the underlying processes. it might, for example, be an indication that the system operates close to criticality, , and it might hint at the presence of a multiplicative stochastic process with certain boundaries , or a rich-get-richer process. , here, we provide a conceptual dual-scale model that explains the emergence of the power-law distribution by the "superposition" of two concurrent processes: large-scale spread of the virus between countries and small-scale snowballing of case numbers within each country. assuming exponential growth on both scales, the critical exponent is simply determined by the ratio of large-scale to small-scale growth rates. we confirm this theory in numerical simulations in a simple meta-population model, describing the epidemic spread in a network of interconnected countries. by combining real world data, modeling, and numerical simulations, we make the case that the distribution of epidemic prevalence, and possibly that of spreading processes in general, might follow universal rules. our research builds on the covid- data repository operated by the johns hopkins university center for systems science and engineering (jhu csse). the database contains information about the daily number of confirmed covid- cases and confirmed deaths in various countries worldwide. using these data, we computed the distribution p c (n) of confirmed cases and the distribution p d (n) of confirmed deaths at a given date (see appendix a). the country-level prevalence distribution on march , is shown in figs. (a) and (b). on that day, countries were invaded by the coronavirus and countries already had reported fatalities. the number of confirmed cases varied between cases in china (followed by cases in italy) and case in countries. the number of confirmed deaths varied between in italy (followed by in china) and one or zero deaths in many countries. a broad, long-tailed distribution that in very good approximation can be described by a power-law, spanning five orders of magnitude for the confirmed number of cases and four orders of magnitude for the confirmed number of deaths. to illustrate the robustness of our hypothesis to spatial scale, in figs. (c) and (d), we depict the same analysis for the distribution of confirmed covid- cases in us counties on march , . on this day, counties were invaded by the virus and counties reported at least on death. epidemic prevalence varied between confirmed cases and confirmed deaths in new york city and one confirmed case in counties and one confirmed death in counties. again, we find that the distribution of confirmed cases follows a power-law over several orders of magnitude. thus, although the two datasets differ greatly in spatial scale and resolution [ invaded countries in figs , we obtain somewhat larger slopes of µ c = . and µ d = . . a more accurate estimation of the critical exponent is provided by a maximum likelihood estimation (see appendix a). applying this approach to the country-level covid- distribution yields critical exponents ofμ c = . ± . andμ d = . ± . . for the us-county distribution, we obtain the valueμ c = . ± . andμ d = . ± . . these exponents slightly deviate from those obtained from the regression analysis, but are still in the same ballpark. given an unbounded power-law distribution p(n), the cumulative distribution function c(n) = ∞ n p(n )dn should also follow a power-law c(n) ∼ n −µ . as shown in the insets in fig. , this is not the case for the distribution of covid- cases, for which the cumulative fraction c(n) = n m=n+ p(m) of countries, or counties, with case number m > n do not really follow a straight line in a double logarithmic plot. instead, they are better described by the cumulative distribution function eq. (a ) of a truncated power-law, that is, a power-law distribution with an upper bound n max for the number of cases, eq. ( ) (see appendix a and fig. ). this indication for the presence of a truncated power-law distribution also conforms with our theoretical analysis below. however, we note that although the shape of the empirically obtained c(n) overall follows the curve of a truncated power-law distribution, there is a considerable wavering around the theoretical curve (compare blue circles and black lines in fig. insets) . thus, a rigorous hypothesis testing with monte carlo simulations, , which does not take disturbances due to additional irregularities (e.g., heterogeneities in country sizes or containment measures) fully into account, will always reject the hypothesis of a perfect truncated power-law as the true underlying distribution. the presence of a power-law distribution means that global covid- prevalence patterns are characterized by a small number of countries with huge epidemic prevalence (the long tail of the distribution) and a large number of countries that are (yet) barely affected by the disease. in between these two extremes, there is a smooth transition and this transition is scale-free, that is, the amplification in the number of countries (or counties) with decreasing number of cases is the same at all scales. in general, the obtained critical exponents are rather small. while for most natural power-law distributions critical exponents are around µ ≈ , here we estimate exponents that are clearly below two, µ < , indicating a very broad distribution for which in the absence of an upper bound, the mean value diverges. while the present analysis considers the distribution of case numbers at a temporal snapshot, in reality the pandemic is a dynamic process successively invading countries worldwide. in fig. , we investigate the temporal development of the covid- distribution. the figure shows that the country-level distribution of confirmed cases is formed already within a few weeks from the start of the outbreak and remains roughly stationary over the considered time interval of days. a closer inspection (see inset in fig reveals that the critical exponents in fact are not constant, but in general are decreasing functions of time, indicating that the case distributions tend to broaden over the course of the pandemic. figure (b) further investigates the spatial spread of covid- across countries worldwide more systematically. the figure plots the number of countries that were invaded by the coronavirus (i.e., having the first confirmed covid- case) at a particular day in the time span from january to april , . on january , the first entry in the database, six countries (china, japan, south korea, taiwan, thailand, us) were already invaded by the virus. from this day, within roughly two months, the pandemic spread to nearly every country in the world. interestingly, the invasion speed was not constant. instead, fig. scitation.org/journal/cha distribution. a first group of countries was invaded by the disease in the end of january. in the first three weeks of february nearly no new arrivals were reported. starting from february , a second wave of invasions appeared which lasted until the end of march, after which the number of new arrivals began to fall again, probably reflecting the fact that the pandemic had reached basically all countries of the world. as of april , a total countries were invaded by the coronavirus. there are several possible reasons why the disease arrival is not more evenly distributed. one explanation for the bimodal shape is related to the lockdown of airline transportation in china in the end of january . according to this hypothesis, after the first pandemic bubble in january, the further spread of the pandemic came to a temporary standstill with the onset of travel restrictions, only to resurface in a second wave, starting end of february. alternatively, it may be that many arrivals of the virus in countries all over the world simply went undetected during the first weeks of february and were detected only later with the increasing awareness and increased testing. this hypothesis is corroborated by the observation that end of february is also the time when the first pcr based tests became available. in general, the strong irregularity in the arrival time distribution points to the high level of stochasticity of the worldwide spreading process. c. mechanistic explanation of the power-law distribution figure would suggest that the temporal development of the pandemic is characterized by two complementary processes: the successive invasion of more and more countries and the increasing number of cases within each affected country. here, we argue that the emergence of the power-law distribution could be related to the concurrent "superposition" of these two processes. thereby, on a large geographic scale, the pandemic is driven by the spread of the virus in the network of interconnected countries. on a small scale, case numbers are snowballing within each country, once it has been invaded, thereby further increasing the epidemic imbalance due to different arrival times between countries. in the simplest approximation, at the begin of the pandemic both of these processes developed exponentially in time. a straightforward calculation shows that the combination of the two exponential processes generically yields a truncated power-law distribution in the number of cases in countries: consider an epidemic outbreak that started (the first case reported in a country) at time t = . we are interested in the case distribution at time t > . let us first assume that at this day, the probability distribution for a country to have been invaded by the virus at some former time τ grows exponential in τ with spreading rate s, this exponential growth in the geographic distribution of the pandemic would be the expectation if one modeled the spread in a network where nodes are countries (neglecting saturation when the pandemic has reached most countries). note that the distribution is truncated from two sides because arrivals of the disease can only have occurred after the start of the pandemic, τ ≥ , and in the past, τ ≤ t. second, we assume that in each country, the number of confirmed cases has grown exponentially with the time since invasion t − τ with growth rate r (neglecting containment measures and saturation after the epidemic peak), combining these two equations, the probability distribution of confirmed cases p(n) can be calculated as which is a truncated power-law with critical exponent, thus, the critical exponent is simply determined by the ratio of large-scale to small-scale growth rates. in the symmetric case that both growth rates are identical, s = r, we would expect a powerlaw with µ = . in the limiting case that the large-scaling spreading process is linear in time, s = , we obtain a border-line distribution with critical exponent µ = . note that from the truncation of τ in the arrival time distribution, eq. ( ), the admissible range of case numbers in the power-law distribution eq. ( ) necessarily is restricted between the lower bound n = (the epidemic prevalence in a newly invaded country) and the cut-off value n max ∼ e rt (the epidemic prevalence at time t in the country with the first confirmed case)-justifying the observation of a truncated power-law in the empirical data as shown in fig. . obviously, this simple theory far from accurately describes a real-word pandemic. first of all, the theory is valid only in the initial phase of the pandemic, while both geographical spread and within-country epidemic growth are still exponential. as soon as saturation processes set in, the derivation of the power-law breaks down. next, as shown in fig. (b) , the arrival time distribution during the covid- pandemic is not exponential, as discussed above. in gross oversimplification, we may nevertheless fit an exponential function p(t) ∼ e st through the data, yielding an "average" spreading rate of s = . d − [black dashed line in fig. (b) ]. finally, epidemic growth rates during the covid- pandemic have not been identical in all countries (even in the initial stages). they have also not remained constant in time, but in most countries have fallen in the course of the epidemic. furthermore, most countries were invaded multiple times, leading to different epidemic foci within countries. neglecting all these observations, for the sake of argument, let us assume an average doubling time of case numbers of t / = . d in all countries, yielding an exponential growth rate of r = log( )/t / = . d − and a maximal case number of n max = e . * = . × after days. then, according to our simple theory equation ( ), we would expect a critical exponent of µ = + . / . ≈ . , in rather good agreement to the fitted exponents in fig. . to test the theory of sec. ii c, we developed a dual-scale metapopulation model (see appendix b). the first level describes the chaos article scitation.org/journal/cha large-scale stochastic spread of the virus in a network of n interconnected countries. the second level describes the small-scale increase in case numbers within a country; it is started in each country from the time point of invasion by the virus and follows a simple deterministic sir-dynamics. the motivation for this model design was not to predict the worldwide spread of covid- , but rather to quantitatively test the emergence of heterogeneous case distributions in a conceptual model framework that incorporates the ideas from sec. ii c. figure shows a typical model outcome. the large-scale spreading process is captured in the arrival time distribution, which exhibits a unimodal dependency on time [ fig. (d) ]. correspondingly, the number of invaded countries grows stochastically and roughly follows a sigmoidal shape. in accord to our theory, eq. ( ), this arrival time distribution starts to grow exponentially in the build-up phase of the pandemic. the highest invasion rates occur after about days, while after a simulation time of days, out of the n = countries are already invaded by the virus. combining the large-scale and small-scale model components allows us to simulate the epidemic prevalence in each country as a function of time. figures (a) and (b) show the resulting distribution of cases and deaths after a simulation time of days [vertical red line in fig. (d) ]. again, the distributions are well characterized by a truncated power-law. comparison with fig. shows that the model is able to describe the characteristics of the empirical distribution of covid- cases rather well. the log-likelihood estimation of the critical exponents yields values ofμ c = . ± . andμ d = . ± . . these exponents can be compared to our theory equation ( ) . from fig. (d) , we estimate a spatial spreading rate of s = . d − in the build-up phase of the pandemic. the initial growth rate of infected in the sir-model equals r = . d − (see appendix b). thus, according to eq. ( ), we would expect a critical exponent of µ = + . / . = . , in good agreement to the estimated value from the numerical simulation. we want to note that the nearly ideal power-law scaling in the case distribution holds only in the initial phase of the pandemic and is lost when the spatial spreading starts to saturate. this can be seen in the simulated case distribution p(n) for different time instances [ fig. (c) ]. while p(n) remains roughly stationary for the first - days of the simulation, a first plateau begins to emerge at the left end of the distribution for larger times. this plateau reflects the fact that when the number of newly invaded countries is reduced, these countries with just a few cases are missing in the left end of the case distribution [reminiscent to the behavior exhibited in the empirical case distribution, fig. (a) ]. additionally, the estimated critical exponents are decaying in time [inset of fig. (d) ], similar to that of the empirical data [inset of fig. (b) ]. thus, the first sign that the outbreak has reached most countries in the network is the reduction in the scaling range and a simultaneous broadening of the case distribution. eventually, in the limit of large time, when the epidemic has come to an end in every country, scaling is lost and the distribution of cases must converge toward a delta function p(n) = δ(n − fn pop ), with f the fraction of susceptible out of a population of n pop individuals in a country that will be infected (or it would approach the country size distribution in a meta-population with heterogeneously distributed country sizes). interestingly, in our numerical simulations, we still obtained power-law distribution when the contact rate β was set to a large value, so that the dynamics within a country rapidly reach a stationary state. in this case, with increasing β (and thus increasing initial epidemic growth rates r), the critical exponents tended to µ → . it is well known from the literature , that caution is in order when trying to identify power-law distributions in real data and, in particular, that a straight line in a double-logarithmic plot does not suffice to prove the existence of a power-law distribution. for this reason, the aim of this study is not to prove that the covid- case distribution is a perfect power-law, an undertaking that would require sophisticated statistical analysis and a much larger sample size. we also do not intend to rule out other likely candidate distributions (e.g., log-normal or stretched exponential distributions). instead, our claim is merely to demonstrate that the empirical data are highly consistent with the hypothesis that the number of reported cases are taken from a truncated power-law distribution of the form equation ( ) . nevertheless, the scaling relations in the distributions shown in fig. are remarkably constant over the whole range of case numbers, stretching several orders of magnitude with no obvious signs of saturation for either the range of small or large case numbers. one might argue that the bend in the cumulative distribution function is a sign that the growth in some countries (e.g., china, korea) had already become sub-exponential. however, this is contradicted by the observation that a similar bend is also exhibited by the cumulative distribution function obtained from the meta-population model (fig. ) . thus, the most likely explanation is that the case distribution follows a truncated powerlaw (see also fig. ) , suggesting the hypothesis that the spatial distribution of covid- cases is a fractal. this is further corroborated by our simple theory, which provides a mechanistic explanation for why we would expect a truncated power-law in the first place. our finding of power-law distributions in the number of reported cases has important consequences for epidemiology. most notably, the small values of the estimated critical power-law exponents are related to the strong inequality of case numbers that was frequently observed all over the world in the initial phase of the covid- outbreak. following a power-law distribution means that this pattern prevails even as numbers grew and the scale of infection expanded globally. in particular, during the course of the pandemic, most cases were reported to have occurred in a few countries, sometimes even a single country-the so-called epicenters of the pandemic. the distribution of cases within countries followed a similar pattern. often covid- was peaking in a few localized foci (local regions or cities), while other parts of the country at the same time had experienced only a moderate number of cases. our theory provides a mechanistic explanation why this might have been the case. a graphical representation for the inequality of a distribution is given by the lorenz curve, which in the case of the covid- case distribution is a plot of the fraction of the total number of confirmed cases in dependence of the fraction of the most affected countries. this is shown in fig. for the number of confirmed covid- cases and confirmed deaths on march , . the lorenz curve shows that on this day, . % of confirmed cases and . % of the confirmed deaths had been reported in the % most affected countries (while the top % most affected countries had accumulated . % of all confirmed cases and . % of all confirmed deaths). with out of confirmed cases on that day, china alone had accumulated a fraction of % of all cases. the two most affected countries, china and italy, together had accumulated a fraction of % of the worldwide reported cases. this inequality can also be measured by the gini-coefficient g, power-law distribution with µ < , one would theoretically expect a gini-coefficient of g = . the emergence of power-law distributions with a small critical exponent and the associated inequality of the distribution, with gini coefficients close to one is also observed in the developed meta-population model. consequently, also in the model case numbers are mostly concentrated in a few countries. in the simulations, these epicenters of the pandemic, i.e., the countries with most cases, are always the countries in which the diseases originated or which were first invaded by the virus. in other words, the prevalence rank order among countries remains unchanged during the course of the pandemic. this is akin to the "rich-get-richer process" or "firstmover-advantage," , a well-studied process to generate power-law distributions. in the real covid- pandemic, this was not the case. during the beginning of the pandemic, most cases were observed in china, later the "leading role" changed next to italy and finally to the usa. this reflects different mitigation strategies and circumstances in different countries, a factor that is not considered in the simple model. nevertheless, despite these changes in the rank order, the distribution of cases in the empirical data was always closely represented by a power-law. we would like to remark that the available database only provides information on the reported covid- cases in each country. in all likelihood, the real number of cases will be much larger. not much is known about the reporting rates, but first estimates indicate that a substantial fraction (possible %) of infections might go undetected. reporting rates probably vary strongly between countries and may change in time with the awareness of national health institutions and available testing capabilities. further uncertainties arise because the criteria by which a person is classified as active case (and even more so for being classified as recovered) vary between countries and not uncommonly have been modified during the course of the pandemic within a country. remarkably, we obtained power-law distributions in the absolute number of cases in each country. at first guess, one might have expected such scaling only after case numbers have been normalized by population sizes. our preliminary investigations show that such normalized case numbers become even more unequally distributed, robustness of the algorithm for estimating parameters of a truncated power-law. the same as fig. but for random numbers n i that were generated from a truncated power-law distribution with µ = . and cut-off value n max = × . the estimated distribution roughly follows a straight line on the double-logarithmic plot with equally spaced bins. note that even though only random numbers were drawn, the estimated probabilities vary over many orders of magnitude (which is numerically possible since in order to compute the probability distribution, the histogram counts are divided by the variable bin sizes). log-likelihood estimation of critical exponent (appendix a) yieldsμ = . ± . in good agreement with the actually used exponent. in contrast, the estimator for an unbound power-law, eq. (a ), yieldsμ = . ± . , strongly overestimating the true exponent. the estimation by a regression line, yielding µ = . , also is slightly too large. the inset shows that the cumulative fraction is well described by the cumulative distribution function c(n) of a truncated power-law with critical exponentμ and n max = . × , the maximal n i value of the sample. with even smaller estimated values of the critical exponent, and the distributed values do not line up any more so well on a straight line on a double-logarithmic plot. thus, "folding" the distribution of population sizes over the covid- case distribution does not flatten, but rather tends to further increase, the inequality of the resulting distribution. this indicates that absolute (non-normalized) case numbers may be the natural variables to describe the patterns of the pandemic in its initial stage. in all likelihood, the role of country sizes and population numbers will become increasingly important with the further spread of the pandemic. we have shown that a simple conceptual model yields an accurate description of the covid- prevalence distribution in the initial phase of the pandemic. this is remarkable because many important epidemiological aspects of the spreading process are not captured by the model. most notably, the model takes into account neither variability in country sizes, population numbers, testing rates, heterogeneity of intra-and inter-country connectivity, nor the corresponding changes due to social distancing, lock-down measures, closing of airline connections and shut-down of borders. these simplifications leave much room for future investigations and model improvements. obvious model improvements would be to consider a meta-population with heterogeneously distributed country sizes or to make the initial number of infected individuals a random number, as would be a better description of what happened in many countries. one basic assumption of the developed model is the separation of the pandemic into two spatial scales, the large-spatial spread over a rather small number (n < ) of interconnected countries and the small-scale growth within a population of much larger size (n = × ). this separation obviously is somewhat arbitrary. for the virus, countries are, of course, quasi-arbitrary entities. therefore, it would be important to check whether both the data analysis ( fig. ) and the mathematical model are robust to arbitrarily subdividing or lumping countries. the very similar scaling observed among us counties [figs. (c) and (d)] lends credence to the model's generality. similarly, one can readily ascertain that the model result is not an artifact of artificial lumping. suppose a virus that is spreading in an all-to-all, or randomly coupled, network of a number of n · n pop individuals. if we would artificially subdivide individuals into a small number n of classes (or countries), at the time point when the disease has spread to all countries, within each country, we would still have only a few cases (of the order of n n pop ). thus, the assumed simultaneous spread on both spatial scales requires a real physical separation in the network structure. it would be an interesting perspective for future research to study the spread in multi-scale hierarchies or in more realistic models of interconnected societies. one important model application would be the simulation of interim covid- lockdown or containment measures, as were introduced in many countries in the world in march and april . such measures might inhibit the increase of case numbers within local regions (the small-scale part of our theory) but they would not necessarily suppress also the large-scale diffusion of infections across regions. thus, under the guise of suppressed case numbers during the mitigation period, there could be a dangerous "invisible" homogenization in the spatial distribution of the virus. this would have tremendous implications in a scenario where the measures are suddenly lifted in many places. in this case, our theory would predict the emergence of a very different case number distribution than shown in fig. . instead of the previous power-law distribution resurfacing, the most likely situation would be the synchronous initiation of increasing in case numbers everywhere. thus, situations as they appeared only in the epicenters during the beginning phase of the pandemic could be the rule in most parts where mitigation measures are lifted. in this sense, the long tail of the case distribution, characterized by the many regions with only mild epidemic prevalence, that was observed in the initial phase of the pandemic, could create a false sense of security. finally, we would like to remark that the model's strong simplicity is at the same time a strength: being rather generic, it should be applicable to very different systems, to describe the spread of commodities as a process with two spatial scales. the fact that the distribution of covid- resembles a model where only the initial infection "counts" reflects the intrinsic difficulty in containing epidemics at global and local scales when unilateral measures (e.g., travel bans and lockdowns) are impractical or non-enforceable, i.e., where other countries or regions will step up and continue the spread. thus, assessing how a well simple dualscale model predicts the early spread of epidemics, despite the huge contrasts between countries, could help identify critical temporal and spatial scales of response in which to mitigate future epidemic threats. the author would like to thank christoph feenders, thilo gross, alastair jamieson-lane, cora kohlmeier, james mclaren, and alexey ryabov for helpful comments regarding the article. assume a truncated power-law (or pareto) distribution of the random variable n with upper bound n max . normalization p(n)dn = yields . the cumulative distribution function reads in the limit n max → ∞ (a power-law distribution without upper bound), the cumulative distribution function also follows a power-law c(n) ∼ n −µ . a synthetic sample of the distribution (a ) can be obtained by the formula where u i are random numbers taken from a uniform distribution in the range [ , ]. the inverse problem is to estimate the parameters of the distribution given a random sample n( , n , . . . , n n ) of n data points. the log-likelihood for the distribution eq. (a ) can be defined as , , then, an estimator for the cut-off value is obtained byn max = max(n i ) and an estimatorμ for the critical exponent is obtained by maximizing l(µ), yielding a standard error in these expressions, the "hat" means that we refer to an estimated value. the maximization of l(µ) must be computed numerically (here, we use brent's method from the julia package optim.jl ). in the limit of an unbounded power-law distribution n max → ∞, the maximization can be calculated analytically, yielding μ (a ) to estimate the distribution p(n) of case numbers that vary over many orders of magnitude, we used a histogram with logarithmic binning. that is, we placed a discrete number of bins, k, at positions of integer powers of two n k = k (i.e., , , , , , etc.) chaos article scitation.org/journal/cha and for each bin counted the number h k of countries (or us counties) that under the day of investigation reported a number n of cases that was falling into this bin (n k ≤ n < n k+ ). to obtain the probability distribution, the resulting histogram counts were divided by the varying bin sizes p(n k ) = ch k /(n k+ − n k ) and the normalization constant c fixed so that k p(n k ) = . for visualization, we plotted the distribution on double-logarithmic axes, excluding bins without entries. to confirm the robustness of the histogram estimation, we also used an alternative algorithm, where we first computed the histogram of log-transformed case numbers ν = log(n) using equally spaced bins, which, after normalization, yielded the distributioñ p(ν). next, we used the back-transform p(n) =p(ν)/n to obtain the probability distribution p(n) of non-logarithmic case numbers. this procedure also yields a distribution with bins that are equally spaced on a logarithmic scale and the resulting distributions, shown in fig. in appendix c, are very similar to that from the logarithmic binning method described above. we have checked that the resulting distribution is largely independent to the choice and number of used histogram bins and other numerical parameters. we also computed the cumulative fraction c(n) = n m=n+ p(m) of countries with case number m > n. this was obtained by taking a rank-plot of case numbers and inverting axes, i.e., sorting the array of case numbers in descending order and plotting for each country the rank as a function of the sorted case number on double-logarithmic axes. to describe the spatiotemporal evolution of epidemic prevalence during the course of a pandemic, we developed a conceptual dual-scale meta-population model. the large-scale model component allows us to simulate the spread of the virus in a network of n interconnected countries (with average network degree k). the state of a country is given as a boolean value, being either invaded by the virus or non-invaded. the model starts with a single invaded country. the geographic spread runs in discrete time, each step corresponding to one day of the time-continuous small-scale model. in each time step, a non-invaded country becomes infected by neighboring invaded countries in the network with the transmission probability p. as soon as a country has been invaded by the virus in this process, the small-scale model for this country is initiated. this large-scale model corresponds to the well-known siepidemic spread on a network. the number of invaded countries grows stochastically and roughly follows a sigmoidal shape. neglecting saturation effects (that is, in the initial phase of the pandemic) and assuming a homogeneous degree distribution, the expected number of invaded countries x(t) grows exponentially in time, x(t) = x exp(st), with x = and exponent s = kp. then, the rate of newly invaded countries is given byẊ = s exp(st) and thus also the probability distribution p(τ ) for a country to have been invaded at some former time τ ≤ t, eq. ( ), grows exponentially, p(τ ) = c exp(st). here, the normalization factor is given by c = s n exp(st)/(exp (st) − ), which is determined by the condition that the time integral t p(τ ) dτ = x(t)/n. in our simulation, parameter values were taken as follows: number of countries n = , degree k = (fully connected network), and invasion probability p = × − . the small-scale model is time-continuous and deterministically describes the epidemic dynamics within a country. the model determines the time course of susceptible s, infected i, recovered r, and dead d from a standard sir-model, here, n pop is the constant population size in the country, β is the contact rate, /γ the infectious period, and m the case fatality rate. the total number of cases is determined as c = i + r + d. in the small-scale model, countries are simulated independently from each other and are only coupled by the unique invasion event for each country, which starts the epidemic growth in that country with initial values s( ) = × , i( ) = and r( ) = d( ) = . all infection state variables in a country are zero before invasion by the virus, i = r = d = . the resulting well-known sir-dynamics in a single country is shown in fig. . with the chosen parameterization, it takes roughly days until the epidemic peak is reached. after this time, the assumption of an exponential increase, eq. 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impact of non-pharmaceutical interventions on the outbreak of coronavirus disease complexity in human transportation networks: a comparative analysis of worldwide air transportation and global cargo-ship movements coronavirus disease (covid- ) situation reports the gleamviz computational tool, a publicly available software to explore realistic epidemic spreading scenarios at the global scale levy flight search patterns of wandering albatrosses on estimating the exponent of power? law frequency distributions a mathematical theory of evolution based on the conclusions of human behavior and the principle of least effort key: cord- - w z un authors: ahmed, shahira a.; karanis, panagiotis title: cryptosporidium and cryptosporidiosis: the perspective from the gulf countries date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: w z un the present review discusses the burden of cryptosporidiosis in the gulf cooperation council (gcc), which is underreported and underestimated. it emphasizes that the cryptosporidium parasite is infecting inhabitants and expatriates in the gulf countries. children under years are a vulnerable group that is particularly affected by this parasitic disease and can act as carriers, who contribute to the epidemiology of the disease most probably via recreational swimming pools. various risk factors for cryptosporidiosis in the gcc countries are present, including expatriates, predisposing populations to the infection. water contamination, imported food, animal contact, and air transmission are also discussed in detail, to address their significant role as a source of infection and, thus, their impact on disease epidemiology in the gulf countries’ populations. cryptosporidiosis is a significant diarrhoeal disease for both people and animals worldwide. several species of the protozoan parasite cryptosporidium can cause this disease [ ] , in which cryptosporidium oocysts have ubiquitous presence in the environment. cryptosporidium oocysts transmission can occur following direct or indirect contact with an infected host usually via the faecal-oral route. person-to-person contact, zoonosis, and the consumption of contaminated food or water are well known mechanisms for faecal-oral transmission [ , ] , with a significant risk of infection from the ingestion of a single oocyst [ ] . when the oocysts enter the gastrointestinal tract, the invasive cryptosporidium causes damage to the small intestinal epithelium. it disrupts the barrier function and absorption capability that leads to mild-to-severe diarrhoea and other abdominal symptoms. in immunocompetent adults, cryptosporidium infection is usually asymptomatic or mild, which is generally self-limiting. currently, cryptosporidium has reported species with more than valid genotypes [ ] . amongst them, species and genotypes have been identified in humans, out of which c. parvum and c. hominis are the most common pathogenic species, causing more than % of infections in humans. c. meleagridis, c. ubiquitum, c. cuniculus, c. muris, and c. andersoni are other pathogenic species that have sporadically emerged in human cases of zoonotic outbreaks, especially when there has been direct contact with infected animals [ ] [ ] [ ] [ ] [ ] . the disease-causing species and their associated subtypes have contributed to a substantial global burden of cryptosporidiosis and play a role in the severity of the disease [ ] . globally, diarrhoeal diseases have killed . million people in . one third of these deaths were children under years, and their highest mortality are from sub-saharan africa (ssa) and south asia. this was because int. j. environ. res. public health , , of challenges (water scarcity, water quality, desertification, and air and marine pollution) that require reconciliation of many conflicting priorities [ , ] . one of the most critical problems that affects public health in the gcc countries is the lack of renewable water resources. infrequent rainfall in the arabian peninsula has led to the overutilization of ground water resources that has consequently affected the qualitative and quantitative of ground water needed for agriculture, industry, and personal consumption [ ] . most of the demand for fresh water in the gcc countries relies on desalination of seawater, which is a process that requires an extensive pre-treatment and conditioning of seawater [ ] . due to this rigorous treatment of seawater, researchers typically do not suspect desalinated drinking water as a source of cryptosporidium contamination; however, it can happen. during the course of the water treatment process, contaminants and beneficial nutrients could be removed and of course some might be added [ ] once stored in tanks or used to fill swimming pools [ , ] . the burden of infectious diarrhoea in the countries of the gcc has been addressed in various reviews on the middle east and north africa (mena) and eastern mediterranean region (emr). infectious diarrhoea has been reported by the united states military after it experienced a significant burden from this disease in the mena campaigns of world war ii [ , ] . traveller's diarrhoea due to ingestion of bacteria, viruses, or protozoa has been reported to affect travellers to saudi arabia [ ] . diarrhoeal infections among mena children pose a significant public health challenge [ ] and has been indicated in many reports affecting children in the gcc countries [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the mortality from diarrhoeal diseases in the gcc countries has also been estimated in a study from the emr. it has been estimated that over , deaths have occurred in due to diarrhoea in the emr. the majority of these deaths ( . %) have occurred in children under years and the dalys/ , ranged from in kuwait to , in somalia [ ] . cryptosporidium has been reported to be the th leading cause among diarrhoeal aetiologies responsible for death in the emr population. approximately . death have resulted in children under years and . death from all age groups due to fatal cryptosporidiosis in the emr area. it has been noted that mainly uae and kuwait have the lowest prevalence-weighted risk for diarrhoeal infection [ ] . the wealth of the gcc countries has attracted many people to seek work opportunities that has notably increased the population in the region and subsequently increased the burden of infectious diseases, particularly gastrointestinal diseases [ , ] . the pattern of the parasitic infection has shifted to reflect this newly mixed population (inhabitants and immigrants), whereas many of these immigrant nationals have dissimilar educational backgrounds, varied eating habits, different religious beliefs and cultural practices [ ] . little is known about the true extent of intestinal parasitic infection, particularly cryptosporidiosis, among the inhabitants of the gcc countries. several studies have reported intestinal parasites infection in immigrant food handlers, labourers, and hospitalized children from this region [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] . economic migrants seeking employment in the gcc countries (e.g., servants, food handlers, housekeepers, childcare assistant, and labourers) may arrive carrying their parasitic infections with them. therefore, the risk of parasitic infection has been estimated to be higher in some sectors of the communities, especially asymptomatic carriers who are employed in the food industry [ ] . the food industry has been suspected to be the greatest threat in the spread of diarrhoeal aetiologies. the gcc countries import large amounts of food in order to bridge the gap between food production and food consumption. imported food mainly comes from high-risk countries with a known epidemiology of diarrhoeal diseases [ ] . imported leafy greens and other fresh produce are highly suspected to be a vehicle for the transmission of the cryptosporidium infection [ , , ] . the potential for food contamination on and off farms is high since it could be produced or washed with contaminated water. infected food handlers are another common source of cryptosporidium contamination in the food chain imported by the gcc countries [ , ] . studies from countries with low, intermediate, and high resources have identified cryptosporidium as one of the major causes of diarrhoea and childhood malnutrition [ ] . the magnitude and nature of environmental threats might be the link with the incidence of cryptosporidiosis burden and might explain the differences between the previous three categories. in this context, immigrant geographic origin, globalization of food supply to meet the demand of the increased labour force, food and water contamination, climate change, as well as poor hygiene after direct animal contact have all contributed to the annual flux in cryptosporidium transmission and infection rates within the gcc countries [ , ] . in the present review, we aim to discuss the size of the burden of cryptosporidium infection in the gcc countries based on the existing information, and to discuss the risk factors that contribute to the cryptosporidium infection in such a wealthy region. the pubmed, science direct, and scopus databases were searched with no restriction to language or year of publication. to evaluate the burden of cryptosporidium in the gcc population, a clear description of the questions raised with regard to participants, interventions, conditions, outcomes, and study design (picos) was performed. the literature search strategy was limited to title/abstract/keyword using the following mesh terms/key words: (cryptosporidium or cryptosporidiosis or parasite) and (infection or prevalence or incidence or occurrence or burden) and (human or animal or water or food) and (bahrain or kuwait or qatar or saudi arabia or oman or united arab emirates). the screened articles were published between and . some relevant articles that were published in arabic local journals have been retrieved from library genesis scientific articles and egyptian knowledge bank, google scholar, iraqi scientific academic journals, and researchgate. retrieved articles with titles that suggested the topic of cryptosporidium in humans were screened and selected as part of the eligibility for inclusion in the literature review. abstracts from the selected reference titles were reviewed to determine if the selected studies have met the inclusion criteria. review of an entire article was performed based on the selected abstracts that previously met the inclusion criteria. the exclusion criteria consisted of studies on animal cryptosporidiosis or studies that related to foodborne/waterborne cryptosporidiosis as they will later be detailed in the risk factors chapter. the articles that have been published in english or arabic were the only selected languages included in the review. articles in the form of case reports or reviews or conference proceedings were excluded. for each article, the following information was extracted: location of the study, type of residents, cryptosporidium detection method, participants classification, most affected age of participants, symptoms associated with the disease (when available), number of cases, and prevalence of the disease-as reported by the authors or calculated from data presented in the paper (when available). the combined search retrieved studies. a total of studies were retained based on screening of the titles. an additional six studies were added by the screening reference lists from other sources. therefore, studies were subjected to abstract screening. in total, articles were retained for full text analysis and subsequently articles were selected for the analysis of human cryptosporidiosis, from which only of the articles were selected for final analytical inclusion ( figure ). due to incompatibility with the inclusion criteria, articles were excluded. specifically, the exclusion criteria were based on articles that had indistinct data, absence of full text, poor quality citation, reviews, case reports, or reports that included the same results as another paper published by the same author. out of the six gcc countries, five countries have reported human infection from cryptosporidium spp. saudi arabia leads other gcc countries in the reporting of cryptosporidium infection. bahrain has not issued any reports concerning cryptosporidium infection (table , figure ). the allocation of cryptosporidium reports in the gcc countries is presented in figure . the burden of cryptosporidium in the gcc countries is presented in table . molecular genotyping and sub-typing data of cryptosporidium in gulf reports are presented in table . the situation of cryptosporidium in water resources of the gcc countries is summarized in table . information on out of the six gcc countries, five countries have reported human infection from cryptosporidium spp. saudi arabia leads other gcc countries in the reporting of cryptosporidium infection. bahrain has not issued any reports concerning cryptosporidium infection (table , figure ). the cryptosporidium occurrence in animals within the gcc countries is tabulated in table . the results that are indicated in the figure and tables are described below. the six gcc countries are classified as high-income developing countries that share an infection prevention and control program [ ] . other public health programs have been declared successful by the world health organization (who) [ ] . only reports of cryptosporidiosis have been published from of the gcc countries. considering that many of these wealthy countries have the necessary research equipment and facilities, the number of reported articles is considerably low for their capability. this situation indicates an underestimation and underreporting of cryptosporidium infection in the gulf region. saudi arabia has the highest number of reported cryptosporidium infections in humans with a significant p-value < . in comparison to the rest of the gcc countries. saudi arabian reports of cryptosporidium infection have formed half of the total reports number ( / ) cited in the literature that reached an incidental rate of % ( figure , table ). the kingdom of sa is considered to be the largest of the gcc countries with a population of . million people [ ] . it has a well-established public health system and public safety measures that are applied before mass gatherings that attempt to protect pilgrims during the hajj season. gastrointestinal infections during mass gatherings are a major health hazard. therefore, sa authorities routinely provide continuous surveillance for several protozoal, viral, and bacterial pathogens as a part of its measures to protect public health [ ] . the proactive safety measures and awareness of infectious disease has placed saudi arabian authorities higher in the reporting scheme within the gcc countries. even though the saudi government has key planning considerations for emerging diseases alerts based on the who's recommendations, cryptosporidium infections has been reported within the population of makkah before and during the umrah season. it has been observed that the incidental rate of various intestinal parasites has increased by . % among people around the holy masjid during umrah [ ] . overcrowding has been frequently cited as a significant risk factor associated with cryptosporidium infection in other low-and middle-income countries [ ] . the allocation of cryptosporidium reports in the gcc countries is presented in figure . the burden of cryptosporidium in the gcc countries is presented in table . molecular genotyping and sub-typing data of cryptosporidium in gulf reports are presented in table . the situation of cryptosporidium in water resources of the gcc countries is summarized in table . information on the cryptosporidium occurrence in animals within the gcc countries is tabulated in table . the results that are indicated in the figure and tables are described below. the six gcc countries are classified as high-income developing countries that share an infection prevention and control program [ ] . other public health programs have been declared successful by the world health organization (who) [ ] . only reports of cryptosporidiosis have been published from of the gcc countries. considering that many of these wealthy countries have the necessary research equipment and facilities, the number of reported articles is considerably low for their capability. this situation indicates an underestimation and underreporting of cryptosporidium infection in the gulf region. saudi arabia has the highest number of reported cryptosporidium infections in humans with a significant p-value < . in comparison to the rest of the gcc countries. saudi arabian reports of cryptosporidium infection have formed half of the total reports number ( / ) cited in the literature that reached an incidental rate of % ( figure , table ). the kingdom of sa is considered to be the largest of the gcc countries with a population of . million people [ ] . it has a well-established public health system and public safety measures that are applied before mass gatherings that attempt to protect pilgrims during the hajj season. gastrointestinal infections during mass gatherings are a major health hazard. therefore, sa authorities routinely provide continuous surveillance for several protozoal, viral, and bacterial pathogens as a part of its measures to protect public health [ ] . the proactive safety measures and awareness of infectious disease has placed saudi arabian authorities higher in the reporting scheme within the gcc countries. even though the saudi government has key planning considerations for emerging diseases alerts based on the who's recommendations, cryptosporidium infections has been reported within the population of makkah before and during the umrah season. it has been observed that the incidental rate of various intestinal parasites has increased by . % among people around the holy masjid during umrah [ ] . overcrowding has been frequently cited as a significant risk factor associated with cryptosporidium infection in other low-and middle-income countries [ ] . the number of cryptosporidium reports from the other gcc countries (kuwait, uae, qatar, and oman) varied between and reports in the literature search ( figure , table ). kuwait is ranked second after sa for reporting cryptosporidium infections ( reports). in a kuwaiti study that estimated the infectious and parasitic diseases mortality, there has been a steady decline in the number of deaths from infectious and parasitic diseases in kuwait since . this decrease in deaths has dropped from in to in . however, when the researcher compared the death rate from infectious and parasitic diseases between kuwait and selected developed countries, the study showed that, despite considerable improvement, the real rate of infectious and parasitic mortality in kuwait remains very high compared to that in developed countries [ ] . in qatar and uae, the reporting system for cryptosporidium infection can be considered marginal, although they have rich economies indicated by per capita gross national income (gni) [ ] . the few reports that have been published from the gcc countries, with regard to parasitic infections, appear to give a false sense of security that these diarrhoeal parasitic pathogens may not be a serious problem in the region. gcc countries that neglect to screen or report the occurrence of cryptosporidiosis cases could be misinterpreted as having an absence or low prevalence of cryptosporidium in those countries. recent published data have highlighted the importance of monitoring and investigating intestinal parasites after several worldwide cryptosporidium outbreaks. bahrain is the only country in the gcc region that does not have a published record for cryptosporidium infections. in spite of reporting helminths and other protozoa in humans since [ ] , cryptosporidium has not been considered or included in routine investigations of diarrhoeal infections. bahrain has a relatively smaller economy than its oil-rich neighbours in the arab gulf. over the years, bahrain's oil production has deteriorated dramatically, resulting in a high unemployment rate and poverty ( % of citizens), which may explain in part its neglected focus and research implementation of neglected diseases [ , ] . in about % of the reported studies in the gcc countries, cryptosporidium has been linked to gastrointestinal symptoms, particularly diarrhoea in children under years old (table ). in the middle east, % ( volunteers) of military soldiers have reported at least one diarrhoeal episode [ ] . in % of the cases, diarrhoea resulted in a median of days of lost work productivity and a median of days confinement to bed. adverse effects of diarrhoea have caused % of the affected subjects to seek medical attention and subsequent intravenous rehydration from diarrhoeal complications [ ] . in the gcc countries, other categories of adult patients (immunocompromised, umrah people, and expatriates/immigrants) have also reported diarrhoea that had been caused by cryptosporidium infection [ , , , , , , ] . if this is indeed the situation with adult diarrhoeal cases, it would be expected that children under years are more vulnerable to the adverse effects of diarrhoea from cryptosporidium infection. two paediatric case reports as early as have linked cryptosporidium infection to symptoms of severe diarrhoea, vomiting, and low-grade fever in children from kuwait [ ] . over one third of the country's infectious and parasitic deaths were reported as diarrhoeal deaths of infants and young children [ ] . in jeddah, the largest commercial city of saudi arabia, it was identified that . % of school children have reported diarrhoea during the previous month in a study focusing on boys' public schools ( schools) that serve children aged - years. the main risk factor indicated in the analysis of the study was the number of children under the age of five living in the same household. other risk factors associated with an increased risk of diarrhoea that was noted in the study are sewage spillage near the home, no drying for hands after washing, use of reusable cloths to dry dishes, and eating out after school hours [ ] . in uae, a survey of parents with children under years of age have reported that % of parents sought medical care for their children for the treatment of acute gastroenteritis within a three-month period, where % of those children required hospitalization with an average length of stay of . days due to complications of severe diarrhoea [ ] . asymptomatic children with cryptosporidiosis are considered to be carriers and act as important reservoirs for cryptosporidium oocysts in the community [ ] . in the global burden of diseases (gbd), injuries, and risk factors study, cryptosporidium infection was the fifth leading cause of diarrhoeal mortality in children younger than years, causing , deaths in . according to the study, for every episode of cryptosporidial diarrhoea, there was an associated decrease in height-for-age, weight-for-height, and weight-for-age z scores, which translated into an additional . million dalys [ ] . in north africa and the middle east, researchers have distributed the dalys source in children under due to cryptosporidium infection into % wasting, % acute diarrhoea, % underweight, % stunting, and % protein energy malnutrition [ ] . paediatric diarrhoea has significant consequences on productivity and the financial impact on the livelihood of the affected families [ ] . in the gcc countries, there has been a notable economic burden due to diarrhoea in children. for example, the total cost of hospitalization in oman due to paediatric diarrhoea was estimated to be $ /child/ days stay in hospital. for all outpatient and hospital settings in oman, the total cost reached $ . million per year [ ] . in the uae, the average cost for medical care per paediatric diarrhoeal episode has been estimated to be $ [ ] . the lack of comprehensive studies on cryptosporidium infection in paediatric diarrhoeal cases need to be strengthened in the gcc countries to reduce the economic burden associated with diarrhoeal diseases, to provide healthy children without long lasting adverse effects, and to reduce the transmission circle between family members and between families where the child is always the focus of cryptosporidium infection. diagnosis and identification of cryptosporidium infections in the gcc countries varies among the reports. the majority of them are based on the use of staining methods; however, occasionally confirmation of staining is combined with other sensitive methods like immune tests and pcr to make diagnosis ( table ). the diagnostic method of choice for the detection and identification of cryptosporidium usually varies according to the investigator's goal as well as the available facilities and resources to make the diagnosis [ ] . the prevalence of cryptosporidium infection also varies among the gcc countries, with a prevalence ranging between . and . %. the studies that have depended on combined stains and immune tests authors noted a wide range of prevalence between . and . %, while studies that have used pcr methods to confirm cryptosporidium prevalence ranged between . and . %. only one study has reported a high prevalence of % by the authors, who used pcr to analyse previously confirmed positive samples via staining [ ] (table ) . only eight out of studies ( . %) from gcc countries have further processed their isolates by molecular analysis to verify the geno-/subtyping of cryptosporidium spp.. the molecular methods used in these studies varied between arbitrarily primed pcr, qpcr, sequencing, and pcr-rflp, where pcr-rflp was the most commonly used technique to the identify the cryptosporidium spp. and subtype ( table ) . pcr methods are well established techniques that are used to detect cryptosporidium dna in samples with accuracy, sensitivity, and specificity over traditional staining methods. quantitative pcr (qpcr) is known to be the most accurate amongst the pcr methods due to a decreased risk of sample contamination; early reporting of results, particularly during outbreak investigations; and with the detection and quantitation of the target nucleotide sequences down to one or a few copies per samples [ ] . the majority of the gcc studies used pcr-rflp to detect cryptosporidium spp., probably due to the lower costs associated with this highly accurate technique. we have concluded that the studies that used pcr methods had the most realistic prevalence and burden numbers of cryptosporidiosis in the gcc countries ( . - . %). other factors must be considered that can affect the prevalence of cryptosporidium in these studies. for example, differences in method, number and type of diagnostic method used, number of selected samples for the study, target population, aim of the study, state of the population's health, symptomatology, and expertise of investigators. c. parvum, c. hominis, c. meleagridis, and c. muris have been the identified species that infect humans in the gcc countries [ , , , , , , ] . distribution of different cryptosporidium genotypes in human populations can be considered an indication of the differences in infection sources [ ] . c. parvum has been reported to be the dominant species in isolates from the gcc countries. in kuwait, c. parvum has been identified as the predominant causative species of cryptosporidiosis in children [ , ] . in qatar, it was the principal species as well in the qatari children and expatriates [ , ] . saudi arabian children from gizan and maddina were also dominantly infected with c. parvum [ ] . c. parvum is a species that infects a broad range of mammals and is considered one of the major zoonotic disease problems [ ] . its dominance in the gcc countries indicates that there is an animal-to-human transmission, particularly when subtyping outcomes are considered. from subtyping data of cryptosporidium infections in the gcc countries, c. parvum iid has been shown to be the predominant subtype family in most of the gcc countries ( table ). the iid subtype has been referred to as the major zoonotic subtype family in europe, asia, egypt, and australia [ ] [ ] [ ] [ ] [ ] [ ] . its distribution has been associated with the domestication of goats, sheep, calves, horses, donkeys, and takins [ ] . according to qatari and kuwaiti paediatric diarrhoeal studies that have investigated the risk factors associated with cryptosporidium infection, there has been limited, if indeed any, contact with farm animals when investigators were considering the source of initial infection [ , ] . on the other hand, the frequent reporting of the iid subtype family in the gcc countries suggests the potential occurrence of zoonotic transmission of c. parvum. the qatari studies have indicated that there is a predominance of the iid subtype family in its hospitalized children and immigrants, and suggested that cryptosporidium contamination from foodborne transmission or person-to-person contact, but there is no indication that the source of infection could also be from contaminated water or contact to animals [ , ] . none of the qatari studies reported prevalence or occurrence of cryptosporidium spp. in local animals or drinking water. one study from kuwait has indicated that nine of the paediatric cryptosporidiosis cases had direct contact with animals but did not demonstrate any significant association between the risks of infection from those animals [ ] . another study in kuwait has investigated sheep and goat farms and found a predominance of the c. parvum iid subtype family in two-thirds of the infected animals [ ] . in saudi arabia, cryptosporidium has been detected in camels, sheep, and goats, but there has been no further molecular identification of these species and subtypes [ ] . more research is needed in the gulf region to confirm if animal contact is a major source of infection. the prevalence of the cryptosporidium needs to be investigated in the animal population. in addition, the authors of this review have speculated that if the elderly populations were included in the gulf research studies, there may be a significant correlation between the cryptosporidium positive cases and contact with animals, particularly in arab falconers and those who enjoy breeding and riding camels (see details in the next chapter). c. hominis is a species mainly restricted to humans (anthroponotic transmission) despite it has been recently reported in young calves [ ] . it has been reported to be the predominant species in children from makkah, saudi arabia [ ] . other studies have noted its occurrence in a few number of cases from qatari immigrants ( ) and hospitalized children ( ) [ , ] , kuwaiti symptomatic children ( ) [ , ] , and saudi arabian children ( ) [ ] (table ) . person-to-person contact is also a plausible way to contract cryptosporidiosis in the gcc countries; however, it appears to only represent a very small percentage of cases in the available literature. c. meleagridis and c. muris have been the least reported species in the gcc countries. qatar and sa are the only countries that reported these species from their isolates. c. meleagridis has been described within mixed infections of c. parvum in two qatari reports (children and immigrants) [ , ] and as a single species infection in asymptomatic saudi children [ ] , whereas its transmission has not been clarified in any of those studies. c. meleagridis primarily infects birds and mammals and is considered the third most common cause of cryptosporidiosis in humans [ ] , despite it frequently being reported in particular populations of thailand, peru, and japan [ , ] . the qatari cases with c. meleagridis infection seem to be linked to travel to endemic areas or countries, or were infected from people coming from endemic areas or contact with birds, e.g., falcons. a single c. muris case has been reported in one saudi child; however, the conclusions are marginal since the authors reported pcr technical difficulties with processing the c. muris dna. further, this particular isolate was the only species that was withheld from the gel electrophoresis during their pcr-rflp analysis [ ] . zoonotic and anthroponotic transmissions of oocysts are known pathways for cryptosporidium infection in the gulf population. it is essential that gulf governments, public health authorities, and investigators consider publishing more investigations on cryptosporidiosis in animals and symptomatic individuals who have had direct contact with those animals. it would be worthy to combine human and animal investigations in one study for the detection of cryptosporidium that uses molecular analysis to verify the genotype/subtype prevalence in human and animal populations. poor water quality, animal contact, overcrowded living conditions, household diarrhoea, and open defaecation have been identified as significant risk factors for cryptosporidium infection in lowand middle-income countries [ ] . countries that have been identified as "poor income countries" can suffer additional risk factors that double the predisposition for cryptosporidiosis. these risk factors include inadequate water supply, water crises, unclean water, poverty, illiteracy, social unrest, climate change, political conflict, and underdevelopment, which can create dramatic consequences in the poorest members of this population [ ] [ ] [ ] . due to the high-income status of the gcc countries, the risk factors for cryptosporidium infection and other infectious diseases are notably lower than those in the "poor income" category. collectively, the gulf reports have only addressed one major risk factor (expatriates) but neglected to specify other epidemiological factors that may contribute to cryptosporidium infection in the region. the most putative important risk factors for cryptosporidiosis in the gcc countries will be presented in the following sections. the gcc countries are considered the poorest region in the world in its water resources. this is due to their geological location and climate. they are characterized by their arid environment (hot and dry) with irregular and infrequent rainfall, high evaporation rate, and scarcity of renewable water resources [ , ] . arid regions have a higher correlation between available water resources and public health problems [ ] , which can consequently have a negative impact on the social and economic development in the region. the gcc countries depend mainly on water desalination, which is an expensive process that removes salts and minerals from seawater and brackish water [ ] . there is almost no surface water either in the gcc countries [ , ] . due to the rapid expansion of the population, lifestyle changes have occurred with the urbanization and reclamation of agricultural areas, where valuable groundwater is extracted to satisfy the demand for water [ , ] . fortunately, the desalinated seawater can provide an unlimited supply of drinking water, although it does come with a risk when it is inadequately produced and contaminated or if the water treatment systems fails [ ] . prior to pumping desalinated water into the distribution network, the water is chemically treated. in jeddah, saudi arabia, the drinking water is only distributed to properties once or twice per week. the processed water is then stored in private underground tanks for two days. afterwards, the stored water reaches the distribution facilities, where it is pumped to roof tanks on homes and businesses to be available when needed [ ] . in many areas of jeddah, the domestic wastewater system uses a cesspool, which runs next to the underground water storage tanks. the long-term use of a cesspool system has caused a rapid rise in the underground water table. this has led to contamination of potable water stored in the underground tanks [ , ] . in the western provinces of sa, the use of conventional on-site sewage systems is the exclusive pathway to dispose sewage. under ideal conditions, the waste effluent is assimilated and treated within the topsoil that is directly adjacent to the cesspool, without regulation or implementation, to ensure there is enough separation between the bottom of the cesspool and the water table [ ] . it has been confirmed that the fate and movement of the chemical constituents (nitrates) and bacterial contamination from this septic/cesspool effluent mixes into the shallow groundwater, private shallow and deep wells, and dump stations [ ] [ ] [ ] . it is recognized that the on-site sewage disposal systems have contaminated the drinking water sources and subsequently caused health problems in the gulf region. if chemical and bacterial contamination is present in the drinking water, it is expected to have parasitic contamination as well; however, this parameter is under recognized in the gcc countries. although cryptosporidium has been frequently detected in faecal samples of local inhabitants in the gcc countries (sa [ , , ] , kuwait [ ] , uae [ ] , qatar [ ] , and oman [ ] ), they have little published data regarding the occurrence of cryptosporidium in the gulf water supply. however, six studies in sa, uae, and kuwait have investigated cryptosporidium in selected water resources in the gcc (table ) , with interesting outcomes. it is remarkable that cryptosporidium was present in almost all water resources from the gcc countries, which included desalinated water, underground water, bottled water, swimming pools, irrigation water, and chlorinated water from sewage treatment plants [ , , [ ] [ ] [ ] [ ] . in the sa city of al-taif, cryptosporidium has been identified in % of desalinated water samples [ ] . in makkah, another sa city located next to al-taif, the presence of cryptosporidium infection among its inhabitants has been suspected to originate from contamination from the local desalinated water system. due to the similarity and construction of the two desalination water systems, this has led investigators to suspect the desalination water system as the most plausible source of cryptosporidium infection in makkah [ , ] . the high prevalence of cryptosporidium in kuwait has been linked to the winter desert camping areas, where large numbers of overhead water storage tanks are used to store potable water. water tanker trucks transport this desalinated water to these camping places. it is very interesting that the cryptosporidium subtyping result from the contaminated tank water has been identified as c. parvum subtype iia, and that five members of the same family using this water source at the camp were also infected with the same subtype [ ] . this has provided a direct link to contaminated desalinated water as a potential source of cryptosporidium infection. moreover, the contamination of water with oocysts has probably occurred at the end of the water treatment process during distribution [ ] . it has been reported that about . % of underground waters (wells) are contaminated with cryptosporidium in al-taif [ ] . the protected wells were previously found to be contaminated with faecal matter [ ] . it is not be surprising if unprotected wells are contaminated from a variety of sources, such as wastewater effluent, overland flow from manure piles, as well as domestic or wild animal grazing. fossil groundwater covers about two-thirds of the arabian peninsula, and it is the main source of water in the gcc countries [ ] . ground water pollution in the gcc countries has been caused mainly due to over-pumping from wells. however, there are other factors that have contributed to ground water pollution, such as irrigation returns, seawater intrusions, liquid effluents from septic tanks, and agricultural chemicals. these factors have led to the abandonment of many water wells in the gcc countries [ ] . water well pollution highlights the necessity of higher water-protection legislation and conservation to ensure the protection of water supply for all inhabitants [ ] . bottled water in tabuk, jeddah, and mekkah in sa has been reported to be contaminated with cryptosporidium using modified ziehl neelsen (mzn) as a diagnostic method [ , ] . in these two studies, the authors have not given clear details regarding the water samples used in their investigations and they published ambiguous results concerning the bottled water contamination. in comparison, another study from al-taif, using nested pcr and five brands of bottled water (domestic and imported), has reported all samples to be free from cryptosporidium oocysts [ ] . the microbiological quality of bottled water has been the focus in uae since . although authors have mentioned that the presence of bacteria in bottled water can act as an indicator for the possible presence of cryptosporidium, there has been no established method yet to screen the bottled water for this protozoan parasite in the gcc region [ ] . as mentioned from some of the literature, the quality of bottled water can vary between brands. researchers have speculated that it might not be any safer than tap water, unless it is distilled or pasteurized to ensure complete disinfection. the source of the bottled water is also very important, especially if it is collected from a surface water source (e.g., a stream) and it may be more likely to contain cryptosporidium and other microorganisms than bottled water derived from a ground water source (e.g., a well). therefore, it is important for companies that sell bottled water to also list the water source on the product label [ , ] . in one study, indoor and outdoor swimming pools from five emirati schools were found to be contaminated with an average concentration of cryptosporidium between and oocysts/l. the ages of the swimmers were between and years old, who attended - swimming classes per week [ ] . due to the hot weather in the gcc countries, many swimming pools are available at schools, hotels, parks, and residential areas that are frequently used by many individuals from various age groups. formed faecal incidents (poop) pose a risk for the spread of infectious disease, including parasitic protozoa [ ] . the cdc's healthy swimming program has indicated that escherichia coli, a faecal indicator, has been detected in ( %) of the swimming pools samples, and further explains the necessity of regular monitoring for chlorine-resistant cryptosporidium oocysts [ ] . detection can signify that swimmers have introduced contaminated faecal material into swimming pools either when it washes off a swimmer's body or by release of a formed (or diarrhoeal) faecal incident into the water. the overuse of swimming pools can significantly compromise the effectiveness of proper cleaning and decontamination efforts. the risk of contamination for cryptosporidium in swimming pools is therefore estimated to be very high in spite of use of filtration and chlorination as a cleaning and sanitization method [ ] . the usage of chlorine as a water disinfectant is known to be effective against many microorganisms; however, cryptosporidium oocysts are resistant to the effects of chlorine [ ] and various environmental stresses, such as extreme temperature variations [ ] . the oocysts are small ( µm) and have a low infectious dose ( - oocysts), and reportedly has the ability to maintain viability in water longer than - months or longer with the capability to cause epidemics, even after the consumption of purified drinking water [ , , ] . in the gcc countries, bacterial and fungal indices are routinely tested in different water resources [ , , ] ; however, only scientific institutions care to identify the absence or presence of cryptosporidium oocysts in water samples. the dubai municipality environmental safety inspectors, who send samples to the central laboratories, do not consider the presence of cryptosporidium oocysts in swimming pool water as an indicator of its quality, while instead mainly focusing on monitoring for bacterial indicators [ ] . the national, the leading english news service of the uae, has warned against the failure to keep uae pools clean due to insufficient disinfection and expressed concerns for infectious disease in swimming pools, including parasites that are known to cause severe diarrhoea amongst children. they have reported that when humans become infected with cryptosporidium, they can act as carriers and release its chlorine-tolerant-oocysts into the swimming pools, and suggested that uv irradiation be applied instead of ineffective chlorine for the disinfection of swimming pools [ ] . it remains uncertain, however, whether and in what extent uv treatment has a real impact on cryptosporidium during the water treatment process. only public and private action on such warnings in all gcc countries can help protect the most vulnerable populations (e.g., children and immunocompromised individuals) from becoming infected with cryptosporidium. cryptosporidium oocysts have been detected in . % of the irrigation water used in public parks in uae [ ] . cryptosporidium oocysts have also been found in chlorinated water samples, as well as effluent samples collected from sewage treatment plants [ ] -an indication that the water treatment systems (wastewater disinfection) have failed to eradicate the transmissible stages of cryptosporidium in the water treatment process. in the uae, it is not routine to test for the presence of cryptosporidium oocysts in recreational water and reclaimed wastewater, while bacteriological (total and faecal coliforms) indices are the only biological parameters used to assess their water quality [ , ] . the gcc countries produce a large amount of wastewater with an average of . bm /year [ ] . this wastewater has been reported to contain a wide range of pathogens, including parasites, viruses, and bacteria [ ] [ ] [ ] , and represents a real challenge when designing conventional treatment plants that can meet the health guidelines of the environmental protection agency [ ] . status of average renewable water resources per capita in the gcc countries has already shown a warning sign, and due to the water crisis conditions they often use improperly disinfected wastewater for irrigation [ ] . water contamination with cryptosporidium is an under-recognised and under-investigated problem in the gcc countries, and probably one of the main sources of diarrhoeal diseases in the region. political and social support is required to include cryptosporidium and other protozoan parasites in the testing framework for water quality and reuse of treated water. a lack of water surveillance systems has been noted in the gcc countries. water research that includes analyses of the cryptosporidium genotypes and subtypes will help strengthen the available information about the extent of this pathogenic parasite and its main sources. it would be also effective if the gulf governments consider funding infrastructural projects to efficiently treat water using good installation facilities and proper pre-treatment of chemicals in the process design. in the gcc countries, only a small number of studies have been performed on the presence of cryptosporidium in different animals. however, nine of the published studies have emphasized the concept that animals can be a significant source of cryptosporidium infection in the gulf human population. whether they are used domestically or ridden during sporting events or leisure activities, various animals and birds (sheep, goats, calves, camels, lambs, arabian oryx, falcons, and stone curlews) have tested positive for cryptosporidium infection in the gcc region (table ). on a well-managed omani farm that maintains closed herds of goats, sheep, cows, and buffalo, with regular vaccinations, a severe cryptosporidiosis outbreak has been reported in goats [ ] . massive catarrhal enteritis with markedly enlarged mesenteric lymph nodes have been observed in post-mortem goats due to an invasion of large numbers of cryptosporidium oocysts. another diarrhoeal outbreak in the uae that has occurred was in juvenile stone curlews [ ] . although the owner maintained a good breeding system for the stone curlews, they all became infected with cryptosporidium. numerous endogenous cryptosporidial stages were confirmed in their histopathological sections. despite intense supportive care, both outbreaks have resulted in a high mortality in animals ( kid goats and adult animals died) and birds ( stone curlews died). c. parvum has been determined to be the main species that caused both outbreaks; however, both studies failed to recognize the main source of infection [ , ] . domestic livestock, especially goats and sheep, are widely raised for meat production in the gcc countries [ ] . in sa, . % of sheep and . % of goats have been reported to be infected with cryptosporidium on three farms located in riyadh [ ] . in kuwait, likewise a wide range of domestic animals (goats, sheep, lambs, and newborn calves) have been screened for the presence of cryptosporidium infection [ , , ] , where sheep and goats constitute the majority of its livestock. these animals have the ability to adapt to the arid climatic conditions (hot/dry season and wet/cool season). cryptosporidium has been reported to be prevalent in . % and . % of sheep and goats, respectively. c. parvum has been noted to be the dominant species responsible for the high frequency of caprine and ovine cryptosporidiosis, and infection is usually associated with a large-size herd (overcrowding in a closed housing system), poor hygiene, and poor management practices on the kuwaiti farms [ ] . many animals were imported into kuwait, particularly cattle, to re-establish the animal industry after the end of the iraqi invasion. during the first three weeks of life, calves from eight dairy farms in sulaibyia have suffered from severe diarrhoea, being unresponsive to antibiotics, which ended with a calf mortality of % and morbidity of - %. the authors have reported that cryptosporidium was the main attributor to the diarrhoeal aetiology in the neonate calf deaths [ ] . housing pens with dirt floors, accumulated manure with no regular removal, early separation from dams, and an intensive system (large number of animals raised on limited space of land) have all been cited factors in studies that might help ease the transmission of cryptosporidium oocysts in calves [ , ] . infected calves are known to excrete large numbers of cryptosporidium oocysts that might reach millions [ ] and therefore likely able to rapidly transmit the infection among herds. it deserves mentioning that the sequence analysis of the c. parvum spp. in ruminants isolates (iida g and iiaa g r ) from kuwait [ ] have been previously documented as dominant subtypes in the infected kuwaiti children [ ] , suggesting that domestic animals can be potential zoonotic reservoirs for cryptosporidiosis and a source of cross contamination in the environment. similar to the situation in kuwait above for cattle imports, cattle were flown into qatar to raise supplies of milk in the midst of a country blockade led by saudi arabia. according to the bbc news, the dairy cows (holstein) came from germany-the first of about cattle to be imported was first imported into qatar. air, sea, and land restrictions have created turmoil in qatar, which is dependent on imports to meet the basic needs of its . million inhabitants. several thousand cattle were later imported from other countries. it remains unknown what epidemiological significance such animals will have for the distribution of cryptosporidial oocysts in the country. animals, whether enjoyed during sporting events or for riding for pleasure, such as camels and captive birds (falcons and stone curlews), have become the focus of cryptosporidium research in sa and uae countries. in the sa city of riyadh, cryptosporidium has been ranked first among the microorganisms (escherichia coli, corona, and rota virus) that can cause diarrhoea in % of the symptomatic camel calves from that area [ ] . samples of camel faeces in the same city have been noted to be highly infected with cryptosporidium oocysts ( . %) compared to goats and sheep that were screened using mzn and elisa methods in another study [ ] . camels are the principal domestic animal in sa and are used as a source of meat and milk. they are likewise used for racing sports and transportation [ ] . in kuwait, camels are often utilized for pleasure rides beside families who are camping in the desert. although they are reported to be infected with cryptosporidium since [ ] , they were excluded as a possible source of cryptosporidium infection in kuwaiti residents who had been infected during a camping incident [ ] . in uae, researchers have tested for the presence of antibodies against many infectious diseases, including protozoa, and these have been reported in their racing camels [ ] . camel racing in the gulf region has returned to the height of its cultural revival [ ] due to its adaptation to life in the hot and arid regions [ ] . although gulf camels have been known as carriers for many zoonotic parasites [ ] , since , screening for cryptosporidium and other protozoa has been probably ignored in camels and the people in close contact with them. zoonotic pathogens carried by camels are a current future risk to public health [ ] . the role of camels in the transmission, distribution, and maintenance of cryptosporidium in the gcc countries should be investigated by governmental authorities and researchers alike, especially in light of the increased use as an increasing source of protein and a sporting gain. captive bred birds (e.g., falcons and stone curlews) are a popular hobby for arab falconers. in uae, two falcons have been identified with cryptosporidiosis during a routine health check. their faecal samples and lung tissues tested positive for c. parvum. in that study, the two falcons were totally asymptomatic for any intestinal or respiratory signs [ ] . conversely, it was reported that c. parvum caused severe symptomatic manifestations (catarrhal enteritis) with a high mortality rate in captive stone curlews in dubai [ ] . the uae has no routine testing for the presence of cryptosporidium spp. in birds, owing to the lack of regional specialized laboratories. even though both falcons were bred in the uae, unfortunately the authors of the study were unable to identify the source of the c. parvum infection and failed to check their owner, "the first suspect", for the possibility of having cryptosporidiosis [ ] . a greater risk for cryptosporidium infection has been linked to a low socioeconomic status [ , ] and travel to developing countries, where poor water treatment and lack of food sanitation are prevalent [ ] . gulf researchers often use terms like expatriates, immigrants, or guests for people who come to gcc countries seeking a better financial situation. sustained economic stability and rapid socioeconomic developments have attracted expatriate workers with mass influx into the gcc countries. these multinational guest workers are mainly from developing countries with a low socioeconomic status [ ] . a factor that has long been associated with the transmission of parasitic diseases and is one of the main focuses of research in the gcc countries. during the pre-employment stage (at the country of origin), expatriate workers are screened for the presence of ova and intestinal worms via stool analysis and culture. although the expatriates must be free of contagious and infectious diseases (hiv, hcv, and hbv) to be allowed entrance into the gcc countries, cryptosporidium, a known pathogenic protozoan, is generally not included on the medical examination list of investigations [ ] . various studies in different gcc countries (sa, qatar, uae, kuwait, and oman) have monitored for intestinal parasites among expatriates. it has been reported that the majority of these workers, including food handlers, housemaids, domestic helpers, babysitters, drivers, and private cooks, have tested positive for parasitic infections in the arabian gulf [ , , , [ ] [ ] [ ] [ ] [ ] [ ] . the prevalence of cryptosporidium has been investigated among expatriates (adults and children categories) from oman, qatar, sa, and uae (table ) , who have mainly originated from developing countries (afghanistan, bangladesh, ethiopia, india, indonesia, nepal, pakistan, philippine, sri lanka, turkey, egypt, and jordan). these countries are known to be endemic with many infectious diseases, including parasitic diseases. moreover, many risk factors have been reported to be associated with expatriate workers that predispose themselves to cryptosporidiosis [ , , , ] . in the uae, expatriate workers mainly originate from asian, african, and arabic countries, where the majority of them are from asia. these migrant workers from asia have the highest prevalence rate of cryptosporidium infection among the guest worker population. in their home countries, they live in rural settings under crowded conditions and have poor sanitation, predisposing them to infectious diseases. migrant workers are often required to stay in similar living conditions in their cgg work destinations, where they may have to live in labour accommodations and share the same bedroom (with ≥ persons) and toilet (with > persons) with many people [ , ] . during the umrah season in makkah, sa, there is crowding of a hundred thousand muslims from different nationalities with close contact and congestions between the pilgrims and local inhabitants. the overcrowding and overcapacity of available accommodations has been noted as an important risk factors for cryptosporidium infection during the umrah season [ ] . in qatar, expatriates from western and eastern asia as well as north and sub-saharan africa have been examined for risk factors and the prevalence of cryptosporidiosis. in the gcc countries, many asian individuals (indian and filipinos) who hold jobs, such as housemaids, builders, mechanics, cleaners, masons, and carpenters (blue collars), have tested positive for cryptosporidium infection. at the country of origin, expatriates who have been infected with cryptosporidium had many of the risk factors associated with parasitic infection, including a low education level (elementary school only), low home index, low monthly income, and those who were accustomed to using pit latrines [ ] . children of expatriates from the middle east, asia, africa, and the local qatari population have been examined for intestinal parasites, whereas c. parvum was the most common incidental parasite affecting . % of cases. surprisingly, qatari nationals had the highest number of parasitic infections from any other group tested in spite of fewer reported cases in the local qatari population when compared to the expatriate groups ( versus ) [ ] . in oman, it has been reported that many of expatriate indian food handlers were infected with multiple intestinal parasites, including cryptosporidium. the authors have stressed in their report that it is necessary to screen food handlers for parasitic infection using different diagnostic methods, especially before these individuals are allowed to work in restaurants, hotels, factories, and private homes [ ] . poor personal hygiene among expatriate food handlers has been emphasized in the literature to be a significant contributor to foodborne outbreaks [ ] . in the context of good hygiene and safety in food handling, multiple risk factors linked to expatriates in the gcc region are noted to promote cryptosporidiosis, which is a threat to public health. social marginalization in the form of low socioeconomic status, low living standards, low education, overcrowding, and unhygienic practices (lack of personal hygiene and/or non-practicing of proper hand washing before eating or handling food) are high risk factors for cryptosporidium infection. symptomatic expatriates (mainly food handlers and housemaids) have a greater potential to inadvertently introduce contaminated faecal material into the food industry when working with food and food processing facilitates and equipment (indirect pathway) or by infecting another person in the household or business of their employer (direct pathway). if this happens, cryptosporidium oocysts will circulate in the community (locals and expatriates) until this outbreak cycle can be halted. cryptosporidium oocysts are well known to be environmentally stable, allowing them to be highly infective within vulnerable groups (e.g., children and immunocompromised individuals). accordingly, it is crucial to increase the health awareness among expatriates (particularly food handlers, housemaids, and babysitters) about different transmission routes of cryptosporidium and the important requirement for its prevention and control. it is interesting to note that the prevalence of cryptosporidium and other intestinal parasites in expatriates has been reported to be lower in gulf studies when compared to the population of their home countries [ , , ] . there has not been a single study that compares the prevalence of cryptosporidium infection between expatriates who have recently entered a gcc country and those who spent a long period of time there. the discussion table comes with a significant point about the source of infection. either expatriates come from their home country with the infection, or they have been infected in the country of their employment. further studies on the health status of gulf natives are therefore urgently required to get a true estimate of the source of cryptosporidium prevalence and finally answer the following questions: who is infecting whom? do foreigners import cryptosporidium oocysts and other infections to the gulf, or are the gulf locals actually infecting the foreigners? more research is needed to clarify cryptosporidium transmission cycle in the gcc countries. the high economic position of the ggc countries has established itself among the more food-secure and high-income countries in the world. this situation has created significant pressure on the available natural resources and food production capability in the region. the six gcc states have limited control over their food sources and production capabilities with limited sustainability due environmental challenges [ ] . additionally, the population of the gcc countries has significantly expanded due to the invitation of large numbers of expatriate guest workers who are needed to help industrialize and urbanize these affluent oil producing countries. in the gcc region, many efforts have been made to transform the arid deserts into more habitable areas by using progressive desalinization and desertification processes. moreover, many challenges must still be overcome to tackle this difficult environment (high temperature and scarce water), where its soils are sandy, fragile, and poorly enriched with organic matter [ , ] . agricultural land in the gcc countries accounts for . % of total land area available, whereas only - % is actually arable (cropland regularly ploughed or tilled) [ ] . therefore, the gcc countries are forced to rely on imported food to meet their high demands [ , ] . approximately % of the gcc's food and drinks are imported. annually they import around million tons of foods with expectations to increase in the future to satisfy their expanding economies [ ] . therefore, great emphasis is placed on food safety and security for all imported foods into the gcc countries, including legislation and guidelines to safeguard the quality of the imported food [ , ] . however, their traditional food safety systems have not properly developed to identify potential problems (e.g., infectious disease and parasites) in the food supply before they occur, but rather they are organized to respond to foodborne outbreaks [ ] . contaminated food and drinks with cryptosporidium oocysts and other pathogenic microorganisms are important routes for foodborne outbreaks of cryptosporidiosis far and wide. the catering and food service industries use many high-risk food materials (vegetables, fruits, shellfish, and meat) that are potentially contaminated with cryptosporidium and have been responsible for occasional outbreaks in the past [ ] . the gcc countries, along with other middle east countries, have been classified to have the third-highest estimated burden of foodborne diseases per population, directly behind the african and south-east asian regions. foodborne pathogens in these regions have caused illnesses in million people per year, and million of those affected are children under five years [ ] . gastrointestinal infections that are frequently seen in the gulf region are primarily caused by salmonella spp., followed by shigella spp. and other pathogens like hepatitis a virus and parasites [ , ] . consumption of unpasteurized dairy products and commercial meat products have been implicated in foodborne diseases in kuwait, oman, and sa [ , ] . in jeddah, sa, there has been a rapid increase in the number of fast food businesses owned by immigrants from developing countries who have not had adequate training in food hygiene. fast food dishes have a great potential for food contamination due to undercooked meat that does not reach the criterial temperatures to kill microorganisms [ , ] . there are scattered reports about the role of bacteria and viruses as causative agents of foodborne diseases throughout the gcc region. often, parasites, including cryptosporidium, are the causative agents in foodborne diarrhoea; however, the actual available reports on diarrhoeal cases in the arabian gulf are scarce or non-existent. only one study in qassim, sa, has investigated the different types of leafy vegetables (green onion, red radish, garden rocket, lettuce, and parsley) for the presence of parasites. the authors reported that all vegetables tested in the study had been contaminated with a variety of parasites, such as giardia, balantidium coli, entamoeba, cryptosporidium, trichuris, enterobius, and taenia [ ] . other foodborne outbreaks have been documented in sa [ ] . however, microbiological surveillance has been performed in the reported foodborne outbreaks, while only salmonella spp. and staphylococcus aureus were the identified pathogens from outbreaks. moreover, the authors declared that many foodborne outbreaks occur every year in the kingdom of sa [ ] ; however, cryptosporidium and other foodborne parasites have been nevertheless excluded from such investigations. the gcc ministerial committee for food safety has established joint legislation and regulations on food safety based upon the certainty that imported foods may represent human health and environmental safety challenges. the food safety guidelines represent health certificates forums, technical regulations, and standards that list food categories and their certification requirements. the technical regulations emphasize the microbiological criteria and the general safety standards for contaminants and toxins [ ] . regrettably, the guidelines do not specify any regulations or laws concerning food safety from parasitic contamination, which have caused foodborne outbreaks such as cryptosporidiosis. it is important to note that imported food could be contaminated with cryptosporidium oocysts (a) from the country of origin due to contamination from animal or human faeces in the water or soil sources used to produce the food, or infected individuals that grow and store the food; (b) from infected individuals transporting the food on the way to the designated country; or (c) from within the destination country via infected food handlers or businesses that store the imported food in improper conditions or washing and preparing food with contaminated water. gcc countries must apply well-developed strategies for prevention and control of foodborne cryptosporidiosis. the food security strategies must include surveillance systems in the health care system and food industry that monitor for the presence of cryptosporidium oocysts. in addition, they must establish an epidemiological information system with local governmental authorities that also partners with applied researchers towards the advancement of technologies that can effectively detect and disinfect oocysts in food and water supply. there are needs to be a modification of current regulatory standards that specifically includes parasitic contamination in imported food and educational programs made available to food handlers in order to further reduce the risk and the incidence of foodborne illnesses, such as cryptosporidium infection. the miniscule size of cryptosporidium oocysts has the capability to disseminate across the air, where they could be inhaled and cause infection in humans and animals [ ] . inhalation of oocysts from contaminated air can infect the respiratory tract and manifest respiratory symptoms [ ] [ ] [ ] . cryptosporidium oocysts have been observed in % of the investigated air samples in mexico [ ] . direct contamination with faecal material because of the lack of sanitary infrastructure results in a greater dispersion of soil via airborne dust during dry season, particularly in those places where people are exposed to large amounts of outdoor dust [ ] . the gcc countries are characterized by arid climatic conditions (long, dry, hot summers and short, relatively warm winters) [ , , ] . weather conditions, such as heat, wind, and a lack of rainfall, have significantly contributed to dust and the formation of the gcc countries' regional climate [ ] . therefore, the gulf population has a higher exposure to large amounts of outdoor dust, which puts them at risk for cryptosporidium infection from contaminated air particles; more so if they have close contact with infected livestock. it has been reported in the epidemiology of cryptosporidiosis that respiratory aerosol droplets from infected individuals can be one of the crucial factors in the transmission, rapid spread, and continuous circulation of cryptosporidium oocysts. evidence has suggested that oocysts can be transmitted via respiratory secretions as well as through the more common faecal-oral route [ ] . it has been documented that wind can increase the spread of viruses in the saliva and respiratory droplets when someone coughs or sneezes. studies have demonstrated that airborne particles from sneezes can travel up to m in . s with an accelerated dispersion rate [ ] . the same scenario also could occur with respiratory droplets from individuals infected with cryptosporidium oocysts. it has been shown that cryptosporidium oocysts are able to infect epithelial organoids derived from human lungs and are successfully able to complete their lifecycle [ ] . the risk of illness for cryptosporidium oocyst air inhalation has been found to be very high and has shown to reach above the safety guidelines of its presence in water ( × − ) [ ] . with or without symptoms, cryptosporidium oocysts are involved in the respiratory tracts of avian and some mammals, which includes a small number of human cases [ ] . all of the published research studies from the gcc countries have not included or excluded questions regarding respiratory symptoms in the diagnosis. however, respiratory cryptosporidium infections have been reported to occur in immunocompetent children with enteric cryptosporidiosis, individuals with an unexplained cough, and in immunocompetent adults with tuberculosis from uganda [ , ] . it is worthy to stress that % of children with intestinal cryptosporidiosis and cough had cryptosporidium dna in their respiratory secretions [ ] , which validates the potential for cryptosporidium to be transmitted by cough, sneeze, and expectoration from those who have cryptosporidial infections and diarrhoea. in the uae, two asymptomatic captive falcons were identified to have cryptosporidiosis and tested positive for c. parvum in their lung tissues by molecular analysis. in addition, the main endoscopic findings from the cases indicated an infectious process in the ostia, caudal lung field, and caudal thoracic air sacs with an accumulation of inflammatory cells. acid-fast positive cryptosporidial oocysts was identified as the cause of the infections in the report [ ] . although, the cryptosporidium infection in the falcon's lungs could have come from the spread of infection from its intestines, the airborne transmission should also be taken into consideration as the initial source of infection, which further illustrates the potential for airborne cryptosporidium transmission in humans. there are a limited number of respiratory cryptosporidiosis cases reported in the gulf countries; however, the extent of this type of lung infection has yet to be established in the region. more research is needed to verify the actual risk from cryptosporidial respiratory tract infections in the gulf human and animal populations. already researchers have shown that breathing has the potential to release aerosols from infective individuals into a room [ ] . recently, investigators have reported the use of computational multiphase fluid dynamics and heat transfer to demonstrate the transport, dispersion, and evaporation of saliva and respiratory particles that can arise from the human cough. they have calculated the effect of wind speed on social distancing safety measures during the covid- pandemic. interesting to note that when they considered all the environmental conditions, they concluded that a safety measure of m between people is insufficient to completely prevent the inhalation of respiratory particles and droplets [ ] . it is advisable that when managing patients infected with enteric cryptosporidiosis, particularly in those who have unexplained respiratory symptoms, they should be isolated or given face masks as a precautionary measure to avoid the spread of cryptosporidium oocysts from their respiratory droplets that can be released when coughing or sneezing. therefore, patients should be advised to always protect their mouths and noses with handkerchiefs when they cough or sneeze. routine diagnostic and surveillance systems are an important part of public health and the treatment of infectious diseases. they have the power to prevent outbreaks and save lives. cryptosporidium and other parasites have not yet been included in the routine diagnostic and surveillance systems of the gulf regions. however, the apparent disease burden of parasitic infections and other infectious disease has been cited in the literature from these gcc countries. the limited number of reports that was found in this review indicate that cryptosporidium has almost infected every element of the gulf region; in addition, the burden of this parasite in humans, animals, and food and water supplies is starting to show up more in the published literature. cryptosporidium has definitely had a negative impact on the economic prosperity and public health in this region, while much of this burden has been underrecognized, underestimated, and underreported in reports. many of the risk factors for contracting cryptosporidium are an everyday reality for the inhabitants of the gcc countries. the most vulnerable groups (e.g., children under years and immunocompromised individuals) are the most susceptible to the adverse effects of cryptosporidiosis and should be protected from this preventable infectious disease. molecular analysis of cryptosporidium from isolates in the gulf population have revealed the presence of zoonotic and anthroponotic transmission according to the published reports. desalinated water and other drinking water sources in the gcc countries have been found to be contaminated with cryptosporidium oocysts. defective waste management systems and water treatment plants have been found to be a source of septic pollutants in the drinking water supplies. camels and other animals often accompany owners to sporting events and leisure activities in the gcc countries, which has been noted to be a significant source of zoonotic cryptosporidiosis in the region. cryptosporidium outbreaks have been recorded in animals by incidental or accidental findings. authors have commented that many of these cryptosporidiosis outbreaks in animals from gulf region continue be undetected or underreported in the literature. expatriates workers have been found to be a source of "imported" cryptosporidium infection via food handling and poor hygiene; however, more detailed investigations are needed to compare this group of the population with the native inhabitants of the area. large quantities of food are imported to feed the expanding work force in the gulf region. food is usually imported from low socioeconomic countries that are associated with a higher risk of contracting cryptosporidiosis due to their social and economic situation. food safety and security legislation has been enacted in the gcc countries to prevent foodborne outbreaks in the region. however, their regulatory standards for imported food still lack many of the parasites known to cause outbreaks, such as cryptosporidium, in their screening protocols. this needs to urgently change so that the prosperity of the local economy and the most vulnerable populations are protected from the burden of foodborne outbreaks in the gulf region. imports of animals, such as cattle, may impact the known epidemiological importance of the release and transmission of cryptosporidium oocysts. a new animal reservoir with its related implications is generated in the gcc countries due to political tensions in the region. further research is required to quantify the influence of transmission parameters such as the infective airborne respiratory droplets of cryptosporidium on disease burden, along with those of other pathogenic microorganisms. more research is needed for the development of highly effective disinfection methods to treat cryptosporidium contamination in swimming pools and the water supplies, e.g., bottled water and ground water. the gcc countries should include cryptosporidium and other parasitic pathogens in their public health protocols for the routine screening of infectious diseases in human and animal faecal samples who have contact with the food and water supply in order to avoid outbreaks. the airborne transmission of cryptosporidium oocysts is highlighted due to the 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human small intestinal and lung organoids infectious virus in exhaled breath of symptomatic seasonal influenza cases from a college community this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we would like to acknowledge chad schou, university of nicosia medical school, , cy- , nicosia, cyprus, for the time and effort devoted to improving the linguistic quality of this review. we write to express our appreciation for his detailed and useful comments, which have much improved the english language level of this review. key: cord- -xhem l authors: tulchinsky, theodore h. title: bismarck and the long road to universal health coverage date: - - journal: case studies in public health doi: . /b - - - - . - sha: doc_id: cord_uid: xhem l the sustainable development goals (sdgs) state that all united nations member states have agreed to try to achieve universal health coverage by . this includes financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. universal health coverage (uhc) means inclusion and empowerment for all people to access medical care, including treatment and prevention services. uhc exists in all the industrial nations except the us, which has a mixed public-private system and struggles with closing the gap between the insured and the uninsured population. middle- and low-income countries face many challenges for uhc achievement, including low levels of funding, lack of personnel, weak health management, and issues of availability of services favoring middle- and upper-class communities. community health services for preventive and curative health services for needs in populations at risk for poor health in low-income countries must be addressed with proactive health promotion initiatives for the double burden of infectious and noncommunicable diseases. each nation will develop its own unique approach to national health systems, but there are models used by a number of countries based on principles of national responsibility for health, social solidarity for providing funding, and for effective ways of providing care with comprehensiveness, efficiency, quality, and cost containment. universal access does not eliminate social inequalities in health by itself, including a wide context of reducing social inequities. understanding national health systems requires examining representative models of different systems. health reform is necessarily a continuing process as all countries must adapt to face challenges of cost constraints, inequalities in access to care, aging populations, emergence of new disease conditions and advancing technology including the growing capacity of medicine, public health and health promotion. the growing stress of increasing obesity, diabetes, and other chronic diseases, requires nations to modify their health care systems. learning from the systems developed in different countries helps to learn from the processes of change in other countries. the world health organization (who) defines a health system as: "the people, institutions and resources, arranged together in accordance with established policies, to improve the health of the population they serve, while responding to people's legitimate expectations and protecting them against the cost of ill-health through a variety of activities whose primary intent is to improve health. it is a set of elements and their relationship in a complex whole, designed to serve the health needs of the population. health systems fulfill three main functions: health care delivery, fair treatment to all, and meeting health expectations of the population." who's world health reports ( , , ) focused on health systems financing and management in the search for universal health coverage. under the globally endorsed sdgs, universal health coverage (uhc) is designated goal (health and wellbeing), target . : "achieve universal health coverage (uhc), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all". box . outlines who building blocks for uhc. universal access is a means of assuring that the economic barrier to health care is mostly if not completely removed for the total population and may lead to increased access to medical and hospital services for those previously excluded. while uhc increases access to medical care and health indices, it does not, of itself, guarantee achievement of many important health targets. allocation of resources is an even more fundamental problem to address the needs of those with the highest risk of early disability or avoidable premature death. a system of national health must be able to allocate resources to meet those needs and must not simply be a payment system for doctors and hospitals. changing demographics, medical advances and epidemiological challenges including social and health inequalities also be addressed with high priority. this case study provides the background and experience of the development of uhc over the past century and a half, with lessons learned for consideration in how-and what-is done to achieve this goal. most industrialized countries have implemented national health programs such as health insurance systems or national health services. each system developed in the political, social, and historical context of the country-and continues to evolve. medium-and lowincome countries are also struggling to achieve universal access to care and health for all by expanding primary health care and social security plans which provide benefits to workers and for certain vulnerable populations-primarily mothers and children. as they move up the scale of economic development, developing countries must also address the problem of how to decrease morbidity and mortality, achieve equity in access to health care, and expand the funding basis for health care through national health insurance. some countries experience rapid economic development, but lag behind in directing increased national wealth towards improving health status. this is often due to a lack of focused political commitment, trained policy analysts, and cultural adaptation to the crucial importance of public health. each national health system has its own characteristics and challenges. systems management requires continuous evaluation based on welldeveloped information systems, trained health management personnel, societal involvement through all levels of government, as well as the private sector, professional organizations and advocacy groups. there is no defined "gold standard" plan for providing universal access to health care that is suitable for all countries. each country develops and modifies a program of national health appropriate to its own political and cultural needs and available resources. however, there are evolving patterns in health care organization, so that networking within and between countries ensures that they can-and do-learn from one another (box . ). barriers to necessary health care can be geographic, ethnic, cultural, social, lack of information and awareness, psychological, financial, and poverty. removing financial barriers to care is necessary and constructive, but not sufficient to address the health problems of individuals and of a society. equity in financial access with universal coverage is vital to population and individual health since anyone can have serious illness at any time. but equally important, long-term preventive care and health promotion are essential to good population and individual health standards. inequities exist in all societies, but many countries have successfully reduced these by poverty alleviation, job creation, education, and other programs that reduce interregional, socioeconomic, and demographic differences in health. special attention to high-risk groups in a population is essential. groups at-risk may be based on age, gender, ethnicity, genetic legacy, occupation, risky lifestyle, location of residence, religion, sexual orientation, economic status, or other factors that increase susceptibility to disease, premature death, or disability. services must be based on need and not only demand, which can escalate costs by over-servicing. health systems planning needs to promote access to patient care, but also those services that reach the entire population, especially people at high risk who are often least able to seek and access appropriate care. a program that provides equal access for all may not achieve the objective of better health for the population unless accompanied by other box . key elements of national health systems . a tradition of government and nongovernmental initiatives to improve health of the population. . public administration and regulation; public-private partnerships. . intersectoral cooperation with education, social services and the private sector. . demographic, economic, and epidemiologic monitoring. . health targets monitored with accessible data systems. . public health programs, including strong elements of health promotion. . universal coverage by public insurance or service system. . access to a broad range of health services. . strategic planning for health and social policies. . monitoring health status indicators. . recognition of special needs of high-risk groups and related issues. . portability and accessibility of benefits when changing employer or residence. . efforts to reduce inequity in regional and socio-demographic accessibility and quality of care. . adequacy of financing. . cost containment. . efficient use of resources for a well-balanced health system. . consumer satisfaction and choice of primary care provider. . provider satisfaction and choice of referral services. . promotion of high-quality service. . promote patient and staff safety. . comprehensive public health and health promotion programs. . comprehensive primary, secondary, and tertiary levels of medical care. . well-developed information and monitoring systems. . continual policy and management review. . promotion of standards and accreditation of services, professional education, training, research. . governmental and private provision of services. . decentralized management and community participation. . assurance of ethical standards of care for all. . conduct epidemiological, basic sciences and health systems research. . preparation for mass casualties from disasters and terrorism. important governmental, community and personal self-care activities. these include enactment and enforcement of environmental and occupational health laws, food safety, nutrition standards, clean water, improved rural care, higher educational levels, and provision of health information to the public. additional national programs are needed to promote health generally and to reduce specific risk factors for morbidity and mortality. responsibility for health lies not only with medical and other health professionals, but also with governmental and voluntary organizations, the community, the family, and the individual. individual access to an essential "basket of services" as a prepaid insured benefit is fundamental to a successful national health program. each country addresses this issue according to its means and traditions, but cost-effective evidence-based methods of meeting a countrys epidemiologic and demographic needs should be prioritized. coverage and payments for heart transplantation, for example, may be beyond the means of a health system, but early and aggressive management of hypertension, smoking, poor diet, physical inactivity, and rapid care for acute myocardial infarction are effective in saving lives at modest cost and containing the need for more intrusive health care interventions. prevention is cost-effective and should be integral to the development of service priorities within the insured benefits with incentives included in the "basket of services". globalization affects health systems around the world not only in the ease of spread of infectious diseases, but in increased access to modern preventive, diagnostic, treatment modalities. access to antiretroviral drugs has dramatically changed the face of hiv/aids globally, including in low-income countries with support of international and bilateral donors. the same is true for vaccines, including the mmr (measles, mumps, rubella, doses), hib (hemophilus influenza b), rotavirus, pneumococcal pneumonia and hpv (human papillomavirus) vaccines, which will save millions of children's lives and foster well being in the coming decade. information technology, migration of medical professionals, and internalization of educational standards are all global health issues affecting national health systems. health systems in all countries are facing common problems in population health, with rising population age, hypertension, obesity and diabetes prevalence, and rising health care costs. health systems research capacity is important in each country as it attempts to cope with rapid changes in population health and individual health needs with limited resources. development of research capacity enables improved capacity of decision-makers for informed, cost-effective decisions. in developing countries, low levels of funding for health in general-including research-impede evidence-based health system development and training of the new health workforce. strengthening reporting systems of data aggregation, as well as economic and epidemiologic analysis, are vital for health policy and management. national health systems from germany, uk, canada, us and russia are presented here as representing major models of organization. these organizational models influence health care system formulation in both developing and developed countries, as well as for countries restructuring their health services. health care systems and financing are under pressure everywhere, not only to assure access to health for all citizens, but also to keep up with advancing medical technology, and contain the cost increase at sustainable levels. because a health system is judged by more than its cost and measure of medical services, indicators of health status of the population, as well as morbidity and mortality are vital and should be available for the public through community organizations and the media. this topic has developed a complex terminology of its own. the world health organization (who) helps development of national health systems as shown in box . . universal health coverage is defined as ensuring that all people have access to needed health promotion, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services. g good health is essential to sustained economic and social development and poverty reduction. g access to needed health services is crucial for maintaining and improving health. g at the same time, people need to be protected from being forced into poverty because of the cost of health care. g a well-functioning health system working in harmony is built on having: trained and motivated health workers; a well-maintained infrastructure; a reliable supply of medicine and technologies; backed by adequate funding; strong health plans; evidence-based policies. who assists in creating resilient health systems by supporting countries to: g "develop, implement, and monitor solid national health policies, strategies and plans. g assure the availability of equitable integrated people-centered health services at an affordable price. g facilitate access to affordable, safe, and effective medicine and health technologies. g strengthen their health information systems and evidence-based policy-making, and to provide information and evidence on health-related matters." source: world health organization. health systems. available at: http://www.who.int/ healthsystems/about/en/ (accessed may ). health systems are meant to improve health and quality of life, as measured by quantitative and qualitative methods. the human development index (hdi) provides a standard method of comparison which combines many health and social indices into a summary figure for social development of countries. these include life expectancy at birth, gross domestic product (gdp) per capita, child mortality, education and others. table . shows life expectancy, still a valued health status indicator, for some industrialized, mid-level, and developing countries. comparisons between countries health indicators are useful to portray relative international health status among nations. the foundations of public responsibility for health care systems go back to ancient greece and rome where city states employed municipal doctors to service the poor and slaves. in the medieval and renaissance periods, monasteries and nunneries provided charitable care to the poor while professional guilds provided prepaid medical care and other social benefits to members and their families. these later evolved into the friendly (benevolent) societies, as mutual benefit programs that provided for burials, pensions, and payment for health services for members. in the twentieth century, these developed through collective bargaining into health insurance plans through private or professionally sponsored insurers, and labor unionÀsponsored health plans. governmental responsibility for health systems evolved in public health and health protection systems in the nineteenth and twentieth centuries and continues to evolve to face new challenges as well as preventive and treatment capacities. the health systems described highlight the unique and common features of national health systems in the search for "health for all", and policies for making health a priority in resource allocation, policy priority for human rights, and for socioeconomic development. figure . indicates the À trends in total health expenditures as percent of gross domestic products of selected countries in the european region of who. german and swedish expenditures rose to between % and %, in the united kingdom to over % while israel is relatively stable under % and the russian federation expenditures rose to % of gdp. germany's health care system today is characterized by participation as well as sharing of decision-making powers between the states (la¨nder), the federal government and civil society organizations. since , statutory health insurance (shi) has been mandatory for all citizens and permanent residents pay a uniform contribution of . percent of their income (gesetzliche krankenversicherung) with sickness funds (krankenkassen, january ). shi covers percent of the population, who have the right to choose their preferred sickness fund for a comprehensive range of services. the sickness funds are linked to associations of physicians accredited to treat patients covered by shi. private health insurance (phi) covers percent of the population for designated groups such as civil servants. others ( %) such as the military are included in other specific governmental programs. since the s financial incentives are being introduced to improve quality and efficiency of care along with beneficiaries right to choose between sickness funds increasing competition and a market orientation. hospitals are paid by diagnosis related groups (drgs)-i.e., payment by diagnostic category rather than hospital length of stay, adopted from us experience. physicians are paid by a capitation system-i.e., a fixed payment for each person registered for care with a doctor for a fixed period of time (as opposed to fee-for-service) in the doctor's medical associations. longterm care is covered by a federal mandatory program. germany expends . percent of gdp ( ) on health, one of the highest levels among eu members, with percent from public sources and percent privately sourced. in , germany had . acute care beds per , beds per population, nearly percent above the rate for the original eu countries ( . per , ). of these, percent of beds were in publicly owned, percent in private nonprofit, and percent in private for-profit hospitals. busse et al. ( ) describes reforms since its founding in gradually achieving universal coverage. the system is also seeking greater cost effectiveness as compared to neighboring countries. in europe, many countries developed taxation or social security models based on the bismarckian approach, with compulsory contributions by workers and their employers to a national social security system. this then financed approved services usually paid through private medical practice with fee-for-service payment. many european countries and japan gradually developed similar forms of compulsory health insurance for workers and their families following world war i, or later after world war ii, expanding to universal coverage health insurance systems. this model is used in france, belgium, the netherlands, japan, switzerland, and latin america as well as post-soviet health reforms and countries of eastern europe (cee). the israeli system, adopted in , based on the bismarckian model is mandatory national health insurance in which everyone must choose one of four long-standing sick funds now called health organizations. they compete for members, and are paid a per capita sum for which they are obliged to provide comprehensive services including hospital, primary care, and preventive services. the services improved vastly under national health insurance, with services kept up to date with annual additions to the statutory "basket of services." health statistics show israel as among the top countries for life expectancy, with rapidly falling mortality from strokes, coronary heart diseases, and cancers. consumer satisfaction is high, maternal and child health are stressed, a low hospital bed to population ratio, while health expenditures are relatively modest and a stable per capita health expenditure just under eight percent of gdp (lancet ). william beveridge was born in in bengal, india, where his father was a judge in the indian civil service. he trained as a lawyer coming to prominence in the british liberal government of À when he advised david lloyd george (chancellor of the exchequer from to , prime minister from to ) on old age pensions and national insurance. in , initiated by lloyd-george, influenced by the german compulsory health insurance scheme, the liberal government of great britain introduced the national health insurance act. it was compulsory for all wage earners between and years of age. this was a two-part plan based on a worker and employer contributory system for both unemployment insurance and for medical care for workers and their families. administration was through approved mutual benefit societies (the friendly societies), some based on insurance companies, and others by professional associations and trade unions. general practitioner services were paid on a capitation basis rather than a salary, preserving their status as self-employed professionals. initially this plan covered one-third of the population increasing to half by , however there was disruption due to mass unemployment during the great depression starting in and continuing to the late s. in the early days of world war ii, the british government established a national emergency medical service for hospitals in preparation for the anticipated large-scale civilian casualties that were expected during the blitz bombing by nazi germany. this established national health planning and rescued many hospitals from near bankruptcy due to the effects of the great depression in the united kingdom (uk). during world war ii, at the behest of prime minister winston churchill, beveridge developed a postwar social reconstruction program. the beveridge report of , social insurance and health services, outlined the concept of a future welfare state including a national health service, placing medical care in the context of general social policy for the total population. the wartime government coalition approved the principle of a national health service, which had wide public support, despite opposition from the medical association. in , the newly elected labour government of clement attlee took up the recommendations of beveridge to introduce the national insurance act ( ) as a comprehensive system of unemployment, sickness, maternity, and pension benefits funded by employers, employees and the government. the national health service (nhs) act was instituted in under the leadership of aneurin bevan, against continued opposition from medical organizations, as a universal state health service in britain. the nhs provides a nationally tax-based financed, universal coverage system providing free care by general practitioners, specialists, hospitals, and public health services. this includes diagnosis and treatment of illnesses at home or in hospital, including dental and optometric care. the original nhs structure was divided into three separate services: hospital, general practitioner, and community health services. the hospital and specialist services were under the authority of regional boards. general practitioners worked under national contracts, and community health services, such as public health, home nursing and health visitors, midwives, maternal-and child care, came under the control of the county and city local authorities. all units reported to the minister of health and his staff. the hospital bed supply in the uk in was just under half the rate in france and one third of the rate of beds in germany per , population. hospital based specialists are salaried but highly independent; general practitioners ran their own practices and provided the foundation of the nhs system. over time, this tripartite structure evolved to some degree of integration of gp and community health services, along with hospitals under hospital trusts reporting to regional health authorities. the nhs, with periodic reforms, is still in place in the uk and well accepted by the population and-over time-even by conservative governments and by the medical profession. there are differences between the nhs systems of the uk: england, scotland, wales and northern ireland each operate their own nhs, albeit with funding and structure of the central nhs. regional disparities in health indicators still exist despite changes in funding giving greater resources within regions (north-south divide) of england; each of the four has their own, policy directions. social class and geographic inequities in health within the nhs have been recognized since the s with a series of reports and analyses showing large gaps in life expectancy, avoidable (i.e., preventable) mortality between the south and north of england and even more so with scotland and significantly poorer health indicators. the marmot report on inequalities from indicated the scope of the problem: "people living in the most deprived neighborhoods will on average die seven years earlier than people living in the richest neighborhoods. even more disturbing, people living in poorer areas not only die sooner, but spend more of their lives with disability-an average total difference of years. the review has estimated the cost of health inequalities in england: productivity losses of d À billion every year; lost taxes and higher welfare payments in the range of d À billion per year; and additional nhs healthcare costs well in excess of d . billion per year." the "beveridge model" is a term used for the national health service model, which has since been adopted by many european countries and should be regarded as a strong model for countries reforming their universal health care systems, such as spain and italy. the scottish nhs diverges from the central english nhs in addressing inequalities by a focus on the health sector as the sole responsibility for reduction of inequalities. the english nhs and other government agencies see the problem more broadly and adopted poverty-fighting measures with some success in improving mortality and morbidity social and health disparities since . the nhs system remains generally popular in providing health security for all, and reaching good outcome measures despite regional inequities. no change of governing political party has led to dismantling the nhs for a privatized health system over the seven decades since its inception. canada: national health insurance tc (tommy) douglas was born in falkirk, scotland and immigrated at the age of with his working class family to winnipeg, manitoba, canada. he developed osteoarthritis and the doctors were going to amputate his leg as the family lacked funds for long-term medical care. his leg was saved by a senior surgeon who refused the amputation. this made tommy a lifelong advocate and fighter for publicly administered, universal health care for all. he became a baptist minister and entered politics winning the saskatchewan general election of for the ccf party in a massive victory. it was the first democratic socialist government elected in north america. he held the office for years, during which time he pioneered many major social and economic reforms. canada (population . million) is a federal state and a constitutional monarchy with parliamentary systems at national and provincial/territorial levels. health is primarily a provincial responsibility, but federal funding and standards play an important role in the canadian health system. local authorities also carry out many primary public health services including sanitation, water safety, and supervision of food safety, among other responsibilities. the provinces/territories are responsible for the funding of hospital, community, home and long-term care, as well as mental and public health services. starting in the s, federal grants-in-aid were given to the provinces/ territories for categorical health programs, such as cancer and public health services programs. since the sars (severe acute respiratory syndrome) epidemic in , the canadian federal government has increased its capacity in public health with a new federal department of public health, regional laboratories and encouragement of many schools of public health across the country. canada's national health program evolved as a system of provincial health insurance with federal government financial support and standards. initiatives for national health insurance in canada go back to the s, but definitive action occurred only after world war ii. the federal government regulates drug and medical device safety, funds research and provides services to the native indigenous population groups, the military, rcmp (royal canadian mounted police) and federal prison inmates. services for veterans were later transferred to provincial medicare programs. the development of national health insurance was largely due to the bitter experience of the great depression of the s, a strong agrarian cooperative movement, and the collective wish for a better society following world war ii. in , the social democratic cooperative commonwealth federation (ccf) party under the leadership of tommy douglas formed the government of saskatchewan, a large wheat-growing province of one million people on the western prairies. the national universal health insurance program evolved from the provincial initiatives led by tommy douglas, now considered "the father of canada's universal medicare plan." douglas established the saskatchewan hospital insurance and diagnostic services act in under provincial public administration. in a federal cost-sharing formula began providing approximately percent cost-sharing with greater levels of funding going to the poorer provinces. by , all provinces and two territories had implemented hospital insurance plans, in a twotiered national health insurance plan-i.e., universal provincial/territorial health plans with federal standards and cost-sharing. in , again in saskatchewan, the medical care insurance plan (medicare) was implemented after a bitter doctors' strike. in , the federal government appointed a royal commission on health services (the hall commission) which in recommended adoption of the saskatchewan model across the country with federal support and standards. the saskatchewan plan was rapidly followed by similar plans in other provinces encouraged by generous federal costsharing. the federal government cost-shares provincial and territorial programs. provinces/territories must adhere to the standards of the canada health act ( ), which defines services to be covered for hospital, diagnostic, and physician services. there is federal funding support for provincial/territorial public health, long-term care, home care and community mental health services. this federal legislation was expanded to provide co-funding for provincial/territorial medicare plans, which over a short period brought all canadians into provincially administered systems of publicly financed health care, while retaining the private practice model of medical care. hospital care is provided mostly through non-profit, non-governmental hospitals. developed over the period À , the provincial/territorial health insurance plans were promoted by federal governmental cost-sharing, political support, and national standards. the plans were initially financed by taxation and premiums, but later solely by general tax revenues with federal support under the canada health act of . federal standards required the provincial plans to be: publicly administered; comprehensive in coverage of health services; universal; portable across provinces; and, accessible without user fees. federal reimbursement to the provinces/territories initially covered percent of national average medical care expenditures per capita and percent of the actual expenditures by each individual province. this provided higher-than-national-average rates of support to poorer provinces as well as portability between provinces/territories. by , all provinces had implemented such plans, and a high degree of health services equity was achieved across the country. care is provided by private medical practitioners on a fee-for-service basis under negotiated medical fee schedules with no extra billing allowed. hospitals are operated by nonprofit voluntary, religious organizations or municipal authorities, with payment by block budgets. per capita spending on health in canada is relatively modest in comparison with that of the us, but above oecd averages. public spending as a percent of total health expenditures is close to the oecd average (see box . ). this medicaretype plan was later adopted in a number of other countries including australia. medicare is still popular in canada, with support from all political parties and by most medical professionals. medicare and federal cost-sharing weighed in favor of the poorer provinces, allowing these to catch up in health care services and standards with the richer provinces. the canadian health program differs substantively from those of the united kingdom and the united states. health systems are important in the political and cultural life of a country. each within its own tradition is attempting to ensure population health through public or private means, to constrain the rate of cost increases. comparisons using various health indicators can be controversial, but the canadian universal health service or insurance coverage seems to have improved the health status of the population more rapidly than similar indicators for the total us population, but not necessarily for all segments of the population. after decades of focus on developing national health insurance, canada became a leading innovator in health promotion prevention (see chapter ) . the canadian health program established universal coverage for a comprehensive set of health benefits without changing the basic practice of medicine from individual medical practice on a fee-for-service basis. poorer provinces were able to use the federal cost-sharing mechanism to raise standards of health services, and a high degree of health services equity was achieved across the country. rapid increases in health care costs led to a review of health policies in (the federalÀprovincial committee on the costs of health services). the resulting report stressed the need to reduce hospital beds and develop lower-cost alternatives to hospital care, such as home-based care and long-term care. federally-led initiatives during this period extended coverage to include home-based care and long-term nursing home care, while restricting federal participation in cost-sharing to the rate of increases in the gross national product (gnp). since then, many provincial and federal reports have examined the issues in health care and recommended changes in financing, cost-sharing, hospital services, development of primary care, and other community services. in , a new approach to health was outlined by the federal minister of health, marc lalonde, in a landmark public policy document, a new perspective on the health of canadians. this report described the health field theory in which health was seen as a result of genetic, lifestyle, and environmental issues, as well as medical care itself. as a result, health promotion became a feature of canadian public policy, with the objective of changing personal lifestyle habits to decrease cross-cutting risky behaviors such as smoking, obesity, and physical inactivity. the pioneering work in nutrition from the national nutrition survey published in led to the adoption of federal mandatory enrichment regulations for basic foods with essential vitamins and minerals. this and other initiatives in the s led to the ottawa charter on health promotion (see chapter ) , which has had a global impact with the foundation of health promotion as a crucial new aspect of public health and health system policy. the canadian health system being primarily the responsibility of the provinces/territories had a down side. during the sars pandemic of , the provinces dealt with it and were found to be lacking strong public health institutions adequate to the task. following high level reviews of the sars episode the federal government established a cdc-like institution, regional laboratories capable of infectious disease challenges and eight schools of public health across the country to ensure continuing development of a competent public health workforce. universal health care needed to be supplemented by introduction of lalonde-initiated health promotion and equally so a strong microbiologic public health component to ensure rapid and competent responses to new emerging health challenges. how does the canadian public view the universal public single payer medicare run by the provinces with federal guidelines and cost-sharing program? despite complaints, mostly from us sources, the canadian public appreciates their health protection very much. in , the canadian broadcasting corporation (cbc) television conducted a program over many months called "the greatest canadian," with candidates and advocates. this included a call to all people in canada to nominate their greatest canadian. canadians from coast to coast were asked to vote and chose tommy douglas, known as the "father of medicare" and selected by national polling as "the greatest canadian of all time." the canadian public is proud of their medicare plan, and appreciates the security and social protection as a great achievement for everyone in the country. australia, taiwan, and south korea have adopted national health insurance systems similar to the canadian model. the us (population million, gdp per capita usd $ , in ) has a system of government based on the federal constitution, with states each having its own elected government. the constitution gives primary responsibility for health and welfare to the states, while direct federal services are provided to armed forces, veterans, and indigenous (native) americans. the federal government has established a major leadership role in national health by the development of national standards, national regulatory powers, funding, and information systems. the federal level has many governmental structures for regulation of food, drugs, and environment, as well as for research, public health services, training programs and health insurance systems for the elderly and the poor. the us has the world's costliest health care system with over percent health insurance coverage, but universal access remains elusive, and population health indicators are well below many less-wealthy countries. however, the us has through trial and error experimentation made major contributions to the content and organization of public health systems, which are important for strengthening health systems in medium-and low-income countries as well as influencing countries with universal health systems (see chapter ) . clearly, the us can learn from other countries as well (see box . ) . in , the federal government established the us marine hospital service to provide hospitals for sick and disabled merchant seamen. this later became the uniformed us public health service commissioned corps (usphs) headed by the surgeon general ( ). services were added for native americans, military personnel and their families (through the veterans affairs department), the food and drug administration (fda), the national institutes of health (nih), the centers for disease control (cdc) and many other world class federal programs of research, service and teaching. other departments and legislation were added to promote nutrition and hygiene, establish state, municipal, and county health departments, and regulate drugs and health hazards. in , the sheppard-towner act established the federal children's bureau that administered grants to assist states to operate maternal and child health programs. from the s, labor unions won health insurance benefits through collective bargaining, which became the main basis for prepayment for health care in the united states until today. in , the committee on the costs of medical care recommended a universal national health program. this initiative was set aside during the great depression of À . the us social security act (ssa) of was introduced by president franklin d. roosevelt as part of the "new deal" to alleviate the mass suffering of the people during this very traumatic period in the us (and europe). the ssa was intended to include national health insurance, but this part of the ssa was set aside largely due to strong opposition of the insurance industry and the organized medical profession. the ssa provides financial benefits for widows, orphans, and the disabled, as well as pensions for the elderly, and provided a base for future reform including health insurance. with the outbreak of world war ii, a significant percentage of eligible military recruits were found unfit for compulsory service due to preventable health conditions. this, and the wish to maintain population health, led president roosevelt to initiate regulations in for fortification of "enriched" foods reaching a majority of the population including salt with iodine, flour with iron and vitamin b complex, and milk with vitamin d. during world war ii ( À ), governmental health insurance was provided to many millions of americans serving in the armed forces, along with their families. at the same time, health benefits through voluntary insurance for workers were vastly expanded in place of wage increases and this became the major method of prepayment for health care for a majority of the population. at the end of the war, millions of veterans were eligible for health care through the veterans administration (va), which established a national network of federal hospitals and primary care services. in , president truman attempted to bring in national health insurance, but the legislation (the wagner-murray-dingell bill) failed in the us congress. one section of the bill was approved, enabling the federal government to initiate a program to upgrade country-wide hospital facilities, while limiting the beds to population ratio, under the hill-burton act (see chapter ) . legislation also provided massive federal funding for the newly established national institutes of health (nih) to fund and promote research to strengthen public and private medical schools, teaching hospitals, and research facilities. in , president truman established the federally-assisted school lunch program through the department of agriculture bringing nutritious meals to many (millions increasing from million in to million in ) of school children throughout the us. in the s, the federal government also established the centers for disease control and prevention (cdc) and increased assistance for state and local public health activities and encouraged expansion of schools of public health across the country. in the us during the s through to the s, rapid health cost increases were attributed to many factors including the lack of a national health insurance mechanism. the plethora of health insurance systems fostered high costs and restrictions on access due to pre-existing conditions. other factors for rapid cost increases included an increasing elderly population, high levels of morbidity in the poor population, the spread of aids, rapid innovation and costly medical technology, specialization, high laboratory and diagnostic imaging costs, and large-scale public investment in medical education, research and health facility construction. the us system includes a mix of public health insurance and service programs (medicare, medicaid, veterans administration, indian health services, and military health coverage) which provide for a significant part- . percent in -of the us population. however, the majority ( %) is covered by the private insurance industry through employer-employee contracts which developed rapidly as the dominant health insurance sector with minimal government regulation. the cost of private health insurance to employers included in labor contracts of their employees and pensioners has become very high. in , general motors reported to a senate hearing that the cost of health insurance per car produced was double the direct cost of labor and more than the cost of steel per car. this impinged on competitiveness in price with for example with japan which has a successful universal governmental health insurance plan with public-private mix of services. the affordable care act (aca) introduced by president barack obama in brought some million previously uninsured persons into public and private insurance, increased governmental regulation to ensure fair pricing and payment and, especially, to abolish the past abuses of the "pre-existing condition" exclusions from insurance. other equally important factors were high levels of preventable hospitalization, institutional orientation of the health system, high administrative costs due to multiple private billing agencies in the private insurance industry, high incomes especially for specialist physicians, and high medical malpractice insurance costs. the pressure for cost constraint came from government, industry, and the private insurance industry. (see chapter ). private medical practice, with payment by fee-for-service, was the major form of medical care in the us until the s. most hospitals were operated through a mix of nonprofit agencies, including federal, state, and local governments, and voluntary and religious organizations, but a growing percentage are privately owned, for-profit (from . % of beds in to . % in ). in an effort to contain costs, the diversity of insurance systems promoted experimentation with organizational systems. health maintenance organizations (hmos) and other forms of managed care systems grew rapidly to become the predominant method of organizing health care in the united states. prepaid group practice (pgp) originated from private companies contracting to provide medical care, especially in remote mining camps and construction sites. in the s, new york city sponsored the health insurance plan of greater new york to provide prepaid medical care for residents of urban renewal and low-income housing areas. this was later extended to include organized union groups such as municipal employees and garment industry workers. pgp became best known in the kaiser permanente network developed for workers of henry j. kaiser industries, at the boulder dam and grand coulee dam construction sites in the s. kaiser permanente health plans now provide care for millions of americans in many other states. initially opposed by the organized medical profession and the private insurance industry, pgp gained acceptance by providing high-quality, less-costly health care. this became attractive to employers and unions alike, and later to governments seeking ways to constrain increases in health costs. since the s, the generic term health maintenance organization (hmo) was promoted by the federal government in the hmo act by president richard nixon in . hmos, which operate their own clinics and staff (i.e., the staff model), or through contracts with medical groups as preferred provider organizations (ppos), have become an accepted, if criticized, part of medical care in the united states and an important alternative to fee-for-service, private practice medicine. in , . million americans were registered in hmo plans or . percent of the total us population. in recent years, the terms accountable care organizations (aco), patient-centered medical home (pcmh) and population health management system (phms) have come into wide use to denote organizations that take responsibility for comprehensive care for enrolled patients, with payment based on a form of capitation rather than fee-for-service. acos are present in all states, washington, dc, and puerto rico, with the population covered increasing from . million in to . million in . the aco comes in different models, but many include a hospital base and may be linked to independent practice associations (ipas), and specialty groups, or hospital medical staff organizations, or in a network of hospitals linked with other providers as an organized delivery system. these are not-for-profit group practices led by doctors who are salaried and subject to rigorous annual professional review. this model may be adaptable on a wider scale to improve quality and cost effective care to improve health of americans. in , a prospective payment system, called diagnosis-related groups (drgs), was adopted for medicare, to encourage more efficient use of hospital care, with payment by categories of diagnosis. the drg is a classification system, for inpatient stays, categorizing possible diagnoses into more than major body systems and subdivides them into almost groups for the purpose of medicare reimbursement. this replaced the previous system of paying by the number of hospital days, or per diem or by itemized billing which encouraged longer hospital stays. drgs provided incentives for hospitals to diagnose and treat patients expeditiously and effectively. payment for medicare and medicaid patients shifted to this method placed the public insurance plans in a stronger position for payments to hospitals. in many states this has also become standard for patients with private health insurance as well. during the late s, the term managed care was introduced, expanding from hmos of the kaiser permanente type to include both non-profit and for-profit systems. these include independent practice associations (ipas), which operate with physicians in private practice, and preferred provider organizations (ppos), which provide insured care by doctors and other providers associated with the plan to the enrolled members or beneficiaries at negotiated prices. the drg payment system and hmos or managed care systems reduced hospital utilization. while total costs of health care increased in this period, without reduction of hospital utilization the increase would have been considerably higher. in , president clinton tried to introduce a health plan based on federally administered compulsory universal health insurance through the place of employment. a state could opt to form its own health insurance program including through its own department of health. physicians could contract with health insurance plans to provide care on a fixed-fee schedule, or in hmos, whether based on group or individual practice. the clinton health plan failed in congress mainly due to well financed opposition by the insurance industry and the organized medical community. in addition, opposition was also widespread among the majority of the population who already had good insurance benefits under their employment-based health insurance plans or medicare. their interest was in keeping the status quo so that the bill was defeated. following the failure of the clinton national health insurance proposal, managed care experienced tremendous growth. managed care systems have been able to cut costs in health care in ways that the us government could not. in the us as a whole, in addition to the nearly million persons enrolled in hmos, another million persons are enrolled in ppos, with percent of medicaid and percent of medicare beneficiaries in various "managed care plans". the search for cost containment led to the development of a series of important innovations in health care delivery, payment, and information systems. hmos demonstrated that good care provision can be operated efficiently with lower hospital admission rates than care provided on a fee-for-service basis. the managed care systems brought about profound changes in health care organization in the united states. in , president barack obama established the patient protection and affordable care act/health care and education reconciliation act of , widely known as the affordable care act (aca or obamacare) bringing health insurance to millions of previously uninsured americans when it went into effect in (see box . ). the aca requires most companies to cover their workers, and mandates that everyone has coverage or pay a fine. aca also requires insurance companies to accept all newcomers, regardless of any preexisting conditions, and assists people unable to afford insurance. this legislation covers young people under their parents' health insurance plans until the age of , covering . million young americans. it eliminated other limits on coverage, allowing those who had already reached a lifetime limit to be eligible for coverage. the affordable care act introduced discounts as large as percent for pharmaceuticals for seniors. health care reform is currently a contentious issue with the donald trump government planning to repeal the obama health care reforms to be replaced with a plan still under development. us health care spending increased from . percent of gdp in to . percent in , threatening the ultimate insolvency of medicare and cutbacks in medicaid in the near future. lack of universal access and the empowerment it potentially brings encourages an alienation or non-engagement with early health care for the socially disadvantaged sector of the population. this promotes inappropriate reliance on emergency department care and hospitalization in response to under-treated health needs. with large numbers of uninsured persons and many others lacking adequate health insurance, access and utilization of preventive care are below the levels needed to achieve social equity in health in the us. this is especially true for maternal-and child-health and for chronic diseases such as diabetes, hypertension, cancer, and heart disease. infant mortality rates in the united states vary greatly by race and ethnicity. as measured by the infant mortality rate, the rate among non-hispanic black mothers was . times higher than the rate for white non-hispanic mothers. a significantly higher rate of infant mortality exists among puerto rican and american indian populations compared with the national average. cdc reports that maternal mortality rates have increased in the united states between and from . to . per , live births possibly due to changes in reporting and increase in chronic illnesses and influenza during pregnancy particularly in the african american population. in , the department of health and human services (dhhs) released healthy people with two main goals: "increase the quality and years of healthy life" and "eliminate health disparities." these goals focus on specific areas developed by over national membership organizations and state health, mental health, substance abuse, and environmental agencies. many states have adopted use of these targets as their own measures of health status and performance. the us public health service, in cooperation with the national center for health statistics, regularly make available a wide set of data for updating health status and process measures relating to these national health goals. various preventive health initiatives are in place to try to alleviate health disparities, which successfully improved immunization coverage of us infants to meet national health targets, as well as for lead and other efforts directed toward poor population groups. in , a program called racial and ethnic adult disparities in immunization initiative was introduced in order to improve influenza and pneumococcal vaccinations among minorities aged and over. the us department of agriculture's women, infants and children (wic) program enables millions of poor americans to have good nutritional security. the wic program covers pregnant women, breastfeeding women (up to infant's first birthday), non-breastfeeding postpartum women (up to months after the birth of an infant or after pregnancy ends) and infants and children (up to their fifth birthday). wic serves percent of all infants born in the united states. the benefits include: supplemental nutritious foods, nutrition education and counseling at wic clinics, screening, and referrals to other health, welfare and social services such as completion of immunization and special needs counseling. school lunch programs are widespread under a federally assisted meal program operating in over , public and non-profit private schools and residential child care institutions, providing nutritionally balanced, low-cost or free lunches to more than million children each school day in . nutrition support for pregnant women and children in need, alleviates some of the ill effects of poverty in the united states, but lack of health insurance affects these groups severely especially in chronic disease, trauma, and other diseases of poverty. health disparities are a complex problem that goes beyond the issue of uninsured americans. low-income and illegal immigrants face challenges to access medical insurance. new immigrants must wait five years before they are eligible for medicaid. the structure of the medical system plays an important role in an individual's ability to obtain medical care. this includes convenience of making an appointment, office hours, waiting times, and transportation. a lack of health literacy also plays a role in an individual's ability to seek medical attention. individuals not fluent in english experience communication gaps. in , it was estimated that an excess of usd $ billion a year is spent on health care in the united states as a result of low health literacy. in certain areas of the country, medical facilities are scarce. minorities are under-represented in medical professions. black, latino, and native american populations make up approximately six percent of the physician workforce, although these populations represent over percent of the population in the united states. health disparities remain an important social and political issue in the united states. the office of minority health (omh) of the department of health and human services was established in to address issues of health disparities among racial and ethnic minorities. important health disparities exist in america in relation to region of residence, with the southern states having high rates of obesity, stroke, and coronary heart disease mortality, which are thought to be due to customary diets rich in fatty and salty foods. state health departments will need to address these issues in order to reduce gaps in life expectancy due to lifestyle factors which are grounded in tradition and poverty as well as lack of health insurance. one of the main goals of healthy people is to eliminate health disparities. the us has developed extensive information systems of domestic and international importance. the cdc publishes the mmwr (morbidity and mortality weekly report), which sets high standards in disease reporting and policy analysis. the us national center for health statistics (nchs), the health care financing administration (hcfa), the us public health service (usphs), the food and drug administration (usfda), the national institutes of health (nih), and many nongovernmental organizations (ngos) carry out data collection, publication, and health services research activities important for health status monitoring. national nutrition surveillance and other systems of health status monitoring are reported in the professional literature and in publications of the cdc. national monitoring of hospital discharge information facilitates the understanding of patterns of utilization and morbidity. these information systems are vital for epidemiologic surveillance and managing the health care system. us surgeon general reports have an important influence on health systems not only in the united states, but also internationally. the cdc created the national center for public health informatics (ncphi) in to provide leadership and coordination of shared systems and services, to build and support a national network of integrated, standards-based, and interoperable public health information systems. this is meant to strengthen capabilities to monitor, detect, register, confirm, report, and analyze data, as well as provide feedback and alerts on important health events. this will enable partners to communicate evidence that supports decisions that impact health. electronic medical and personal health records are now widely used. these protect patient privacy and confidentiality, and serve legitimate clinical and public health needs. media coverage of health-related topics is extensive, and is important to promote health consciousness in the public. however, the sheer volume of information may make it difficult to discern which information is most relevant, and due to misinformation on internet sites, can also create opposition to public health initiatives such as the refusal to vaccinate children. public levels of health knowledge grow steadily, but vary widely by social class and educational levels. in , the us surgeon general's report healthy people set a series of national health targets for a wide variety of public health issues. the program defined objectives in program areas within the three categories of prevention, protection, and promotion. these goals and objectives were formulated based on research and consultation by experts in different fields who participated in a conference by the us public health service. consensus is based on position papers, studies, and conferences involving the national governmental health agencies, the national academy of science institute of medicine, and professional organizations such as the american academy of pediatrics (aap), the us preventive health services task force, and the american college of obstetrics and gynecology (acog). many private individuals and organizations contribute to this effort, including state and local health agencies, representatives of consumer and provider groups, academic centers, and voluntary health associations. these targets are periodically assessed as performance indicators of the us health system and then updated. progress made during the s included major reductions in death rates for three of the leading causes of death: heart disease, stroke, and unintentional injuries. infant mortality decreased, as did the incidence of vaccine-preventable infectious diseases. the latest iteration, healthy people , identifies national health priorities. it strives to increase public awareness and understanding of the determinants of health, disease, disability, and opportunities for progress. it defines measurable objectives and goals for federal, state, and local authorities in the areas of health promotion, health protection, preventive services, surveillance and data systems, and age-related and special population groups. the final reviews of healthy people showed significant decreases in mortality from coronary heart disease and cancer. healthy people renews this effort to establish national targets which are adopted by state level governments and strongly influence policy in health insurance systems. the us has managed to achieve many of the targets set by the surgeon general's healthy people report. at the same time, the average annual increases in health care expenditures in the united states slowed markedly from the À period with average annual increases of . percent, falling to under percent annually between and . this is partly due to lower general inflation rates (, %), but also cost-containment measures being adopted by government insurance (medicare and medicaid) programs, the health insurance industry, the growth of managed care, and rationalizing the hospital sector by downsizing and promoting lower-cost alternative forms of care. national health insurance was delayed by congressional rejection of the clinton health plan. president barack obama's affordable care act (aca) provided millions of previously uninsured americans health insurance within better regulated private insurance or in state-run medicaid plans, but in is facing "repeal and replace" efforts by the president trump administration and republican congress. a number of possibilities exist to extend health insurance coverage: state health insurance initiatives with federal waivers and cost-sharing; a federal single payer universal coverage plan based on the federal medicare model or a federal-state medicaid model. the us health system is often called a costly and inefficient nonsystem. there are many stakeholders and providers, high costs, and poorer population health results than those achieved in other industrialized countries such as britain, germany, and canada. the health system is diffused with high levels of coverage for diverse insurance plans through employment-based insurance along with publicly financed and administered health insurance (e.g., medicare, medicaid, aca). inequalities are a significant health challenge in the us along with the uninsured, poverty, aging of the population, rising levels of obesity and diabetes. the principle of universal access through public insurance for all is still a highly politicized issue in the united states, although public acceptance seems to be gradually growing. the us has a reputation for good to outstanding quality of medical care, but for those without insurance, services are limited to hospital emergency care only. important ethnic, social, and regional inequities in health status are still present, but not necessarily greater than in countries with universal access health care plans such as the uk nhs. further, there are many parallel programs in the united states that have important positive public health content, such as universal school lunch programs, nutrition support for poor women, infants, and children (the wic program); food stamps for the working poor; fortification of basic foods, free care for the uninsured in emergency departments, medicare for the elderly, medicaid for the poor, and aca coverage for the near-poor. box . shows the challenges of the us health system. despite rapid increases in health care expenditures during the s and s, despite improved health promotion activities and rapidly developing medical technology, the health status of the american population g preventive programs strong tradition; screening for cancer; smoking reduction; food fortification, school lunch programs; nutrition support for poor pregnant women and children (wic); g hospitals obliged to provide emergency care to all regardless of insurance status, citizenship, legal status or ability to pay has improved less rapidly than that in other western countries and universal coverage has not been achieved. us performance measures are lower than many middle-and high-income countries with much lower per capita health expenditures, including measures such as infant mortality rates and life expectancy. infant mortality in the us remains high in comparison to oecd countries and ranks th among all countries in (estimated). even the rate of infant mortality of the white population of the united states was higher than that of countries that spent much less per person and a lesser percentage of gnp per capita on health care. life expectancy at birth in the united states in was below that of countries, just behind costa rica, portugal and slovenia. in , the us life expectancy at birth was . years, well below the oecd average of . years. social inequities in these health status indicators are further evidence of failures of the united states health system to reach its full potential, despite its being the costliest system in the world and its high quality for those with access (commonwealth fund, ) . the advent of the aca (obamacare) introduced in brought health insurance to millions of americans, but is challenged as unaffordable. the us still lacks a universal single payer health plan of canadian or european tradition, but the aca is a huge step forward in america where the working poor are in large measure excluded from access to health care except for emergencies. the struggle for universal access and cost containment are still formidable political and societal challenges for the united states. in , following the russian revolution, the soviet union (ussr) introduced its national health plan for universal coverage within a state-run system of health protection. the soviet model, designed and implemented by nikolai semashko, provided free health care for all as a governmentfinanced and -organized service. it brought free health services to the population, with a system of primary-and secondary-care based on the principles of universal and equitable access to care through district organization of services. it achieved control of epidemic and endemic infectious diseases and expanded services into the most remote areas of the vast under-developed country. this model was also applicable in countries included in the ussr following world war ii until the collapse of the ussr. the model developed in the former soviet union in by semashko brought free health care with governmental management by republic and regional authorities according to national norms set out by the ministry of finance. since the s health care became available for all with mostly underdeveloped basic infrastructure for health care including human resources. the semashko plan provided universal access to preventive and curative care, and control of infectious disease in a uniform plan, with many republics previously having only primitive care available, achieving national standards of services and improved health indicators. since the s, an "epidemiologic transition" was occurring characterized by declining mortality from infectious diseases and rising death rates from non-infectious diseases. life expectancy increased since , still remains far below levels in many medium-income developed countries. the transition in health systems following the collapse of the soviet union in took different paths for the socialist central and eastern european countries (cee) as compared to the core countries of the soviet union, called the commonwealth of independent states (cis). the cee countries moved rapidly to dismantle their soviet, centrally managed sanitary-epidemiological system (sanepid) system with decentralization while retaining universal coverage with central funding, but with local authority participation in some cases. most cee and cis countries have introduced health insurance systems, with more out-of-pocket payments (both formal and informal), and efforts to strengthen primary health care, with family medicine delivered by general practitioners. in most cases central authorities also maintained responsibility for epidemiological surveillance and environmental monitoring with some transferring responsibilities for environmental health in other ministries. the cee and cis countries maintained similar levels of health expenditures as percent of gdp between six and seven percent over the past decade, while the original european union (eu) countries reached an average of percent of gdp. the cis acute care hospital bed capacity ratio declined to six per population in far higher than cee countries (declined to . per ), which were higher than the western countries, although all country groups were declining (see chapter ) . the importance of these differences lies in the fact that total resources allocated for health in the soviet system was relatively low while the allocation allowed hospital care to consume some percent of total expenditures compared with less than percent in western countries. the outcome of this allocation of resources was weakness in development of primary care, prevention and community care in favor of an over-developed hospital bed supply. the russian federation adopted a mandatory health insurance (mhi) plan in to open up additional funding for health care in the face of severe governmental funding constraints. it remains a highly centralized system and is struggling to provide universal access to basic care. despite this, death rates from avoidable causes such as stroke and coronary heart disease have declined in the past decade and life expectancy has risen modestly, but remaining far below western as well as former socialist countries of central and eastern europe. developing national health systems with universal access has been a long process in high-income countries and is an important goal for all countries including medium-and low-income countries to promote improving access to health for the total population. the commonwealth fund published an outstanding international profile of selected health care systems in highincome countries ( ) including: australia, canada, china, denmark, england, france, germany, india, israel, italy, japan, the netherlands, new zealand, norway, singapore, sweden, switzerland, and the united states. global spending on health is expected to increase from us$ . trillion in to $ . (uncertainty interval . À . ) trillion in (in purchasing power parity-adjusted dollars). we expect per-capita health spending to increase annually by . % ( . À . ) in high-income countries, . % ( . À . ) in upper middle-income countries, . % ( . À . ) in lower middle-income countries, and . % ( . À . ) in low-income countries. low-and medium-income countries face major difficulties in developing universal health coverage, especially in terms of financial and professional resources. a study of global health care financing (dielman et al lancet ) reported on health expenditures from countries, including public, donor, and private ("out of pocket") payments between and . high-income countries spent more, and mostly from public sources, increasing expenditures by an estimated three percent per year. medium income countries increased their health spending more than three-four percent per year and low-income countries by two percent. economic development was positively associated with total health spending and a gradual shift away from a reliance on development assistance and out-of-pocket spending towards government spending. in , . percent of all health spending was financed by the government, although in low-income and lower-middleincome countries, percent and percent of spending was out-of-pocket, . percent and three percent respectively was with development assistance. recent growth in development assistance for health has been tepid. between and , it grew annually at . percent, and reached usd $ Á billion in . nonetheless, there is a great deal of variation revolving around these averages. in countries spending less than five percent of gdp on health, included many in asia, the middle east and sub-saharan africa (institute of health metrics and evaluation, ). while there is wide variation in health spending in low-and lowermiddle-income countries and there is overall increased spending in absolute terms, there is still a heavy reliance on out-of-pocket spending and development assistance, which itself is growing very slowly. this indicates that medium-and low-income countries are not providing the financial means to develop universal health access insurance plans. economic growth also does not translate into adequate funding for universal health care without dramatic changes in policy and decreased dependency on donor aid. international agencies-such as who-are promoting the search for ways to provide universal and equitable care, while controlling costs and improving efficiency in low-and middle-income countries. the universal declaration of human rights, article states: "( ) everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. ( ) motherhood and childhood are entitled to special care and assistance. all children, whether born in or out of wedlock, shall enjoy the same social protection." the universal declaration of human rights specific inclusion of access to medical care for all should be seen as a priority in planning universal health insurance (uhi) for promotion of access to health needs for remote rural populations as well as urban poor, and displaced persons. this also applies to conditions of warfare, civil strife, natural disasters as well as incitement to and actual genocide. as said previously, the global consensus of the mdgs ( À ) and the sdgs ( À ) have undertaken to implement key elements of this important declaration. it is easier to be pessimistic than optimistic in the potential for success, but the significant achievements of the mdgs in poverty reduction, educational equity between the genders and in reduction of child and maternal mortality as well as in control of hiv, malaria and tuberculosis are signs of important progress and future possibilities. national governments must take up the financial burdens and management of expanding health systems as well as contributory advances in education, environment and other government sectors toward achieving these goals. bilateral aid and international donors are vital, but they cannot achieve or sustain all this without national commitments and resources. national health systems are essential to provide universal access to health care, but must be developed recognizing that restraint in increasing costs, equity in access and quality, as well as efficiency and effectiveness in use of resources are vital to achieve health targets and equity in population health. in the united states, a study of ethnic differences in utilization of services among medicare beneficiaries who have the same entitlements show significant differences indicating lesser use of preventive services such as mammography and higher rates of lower limb amputation for diabetes indicating poorer management of diabetes. studies in the united kingdom also show sharp differences in mortality rates by region of residence that correlate with socioeconomic gradations. universal access alone does not guarantee equality so that the design of service systems needs to take into account differing needs of groups or regions at higher risk and greater need. universal access by itself is important, but not sufficient to reduce inequalities, which have more complex needs than medical care alone. universal coverage health insurance must be developed with great care to avoid mistakes made in many countries in previous decades of promoting rapid increase in health expenditures to the benefit of the middle class while rural and poor urban populations linger in relatively poor health. a universal health insurance plan without strong incentives for prevention and community health will find itself in a trap of punishing the poor for the benefit of the rich. population health experience of the past century has shown the power of public health, in all its aspects, to raise life expectancy and quality, yet inequalities still plague all health systems. this provides an ethical challenge in planning, resource allocation and political support. beyond financing and resource allocation, there are many "nontariff" barriers to health. even in highly developed national health systems, social class, place of residence, education level, and ethnicity play significant roles in morbidity and mortality rates. addressing important health risk factors other than medical or hospital care is vital. the disease-risk factors of diet, smoking, physical fitness, nutrition status including obesity, and untreated hypertension. such conditions are not necessarily managed even where all residents of a country are insured for health care. social class, ethnic and regional differences in morbidity and mortality exist due to povertyassociated factors, such as insecurity, lack of control over one's life, lack of financial means or knowledge to purchase healthy foods, as well as fear, loneliness and depression. these are issues that are important and must be addressed in public health policy to reduce inequalities in health and the achievement of national health goals and equity. models of financing of universal health insurance include a variety of methods: general taxation; social security by employee-employer payments through payroll deductions; private insurance under contracts between employee and employer; and private out-of-pocket payments. taxation financing can be mainly through progressive income tax, resource taxes, surcharges or "sin taxes" (e.g., on cigarettes, alcohol, gasoline) and excise taxes along with local property and business licensing taxation where local authorities have a management role. funding by general tax revenues at national or state levels or shared between the two levels provides for more local administration while sharing in costs may be the most equitable way of raising funds. many countries use social security systems based on employerÀ employee contributions to pay for health services. the who, the world bank and oecd promote universal health insurance (uhi) for middle-income countries. the advantage will be to reduce the heavy burden of out-of-pocket payments, which are percent of health expenditures in many emerging countries. universal health insurance provides security for individuals and families against catastrophic health events, for regular medical and hospital care, and for ageing populations with increasing health needs. oecd recommends increasing health expenditures, which improves life expectancy, and to allow uhi implementation. even a percent increase in national health spending has been shown to reduce child mortality across many countries. universal health insurance must include promotion of greater efficiency in health care, such as shifting of services from hospital care to outpatient and primary care along with community and home-based care (see chapter ) . the process requires developing new health care provider roles with emphasis on outreach to groups with greater than average need, promoting public health and preventive care such as for underserved rural or urban communities or groups at special risk for disease such as cardiovascular disease (cvd) and diabetes, making use of epidemiologic and sociologic health data and information systems. universal health insurance undoubtedly contributes to improving health indicators such as life expectancy by coverage of the total population, systematizing financing of the health system and providing access to the population. however, without good management of resource allocation, universal health insurance cannot guarantee achievement of important health targets. allocation of resources is a fundamental problematic aspect of universal health insurance. national health policy governing universal health insurance must invest adequately in health promotion and disease prevention in order to reduce excessive allocation and utilization of hospital care. continuous monitoring and evaluation are essential to a health system, but not only for traditional outcome indicators, such as infant, child and maternal mortality rates, and disease-specific mortality rates. these are all valuable indicators of population health, but not sufficient. input, process and outcome indicators are important and necessary to include, such as supply and distribution of resources e.g., primary care, maternity centers, hospital beds; process measures e.g., immunization rates, incidence of vaccine-preventable diseases, growth patterns and anemia rates in infancy and childhood, food fortification, micronutrient supplements to risk group, prenatal delivery and neonatal care. outcome measures include prevalence of disabling conditions morbidity and mortality rates. disability adjusted life years (dalys) and quality adjusted life years (qalys) help change the emphasis from mortality to quality of life measures as part of the evaluation. national health systems require data systems that generate information needed for this continuous process of monitoring. monitoring of hospitalizations, length of stay, health-care facility acquired (nosocomial) infection, readmission rate by diagnosis and many more indicators, compliance with standards of care such as in infection control, surgical and maternal mortality, including infection and error rates, and other qualitative measures are now part of monitoring and payment systems. high-quality academic centers are needed for training epidemiologic, sociologic, and economic analyses professionals as well as health system managers and to carry out the studies and research vital for health progress. health systems are large-scale employers and among the largest economic sectors in their respective countries, with À percent of gdp in middle-and high-income countries and, therefore, a major factor in the total national economy. but the gap between countries is very high. many countries have per capita spending of less than usd $ per year, so that inadequate resources prevent people from receiving quality health care, without unaffordable out of pocket expenditures. in contrast, in many high-income countries annual health expenditures are above usd $ , per capita. donor aid to low-income countries from bilateral or international agencies or other donors rose rapidly from with an estimated $ billion usd to a peak of usd $ billion in , with only a modest change up to . low-income nations, many of which are undergoing important economic development, are under-spending in national allocations to the health sector and remain highly reliant on international aid. a goal of five to six percent of gdp spent on health is widely regarded as a minimum to provide the health care needed in any country. a study published in lancet by the institute for health metrics and evaluation, indicates that only one of low-income countries, and out of of middle-income countries, are expected to meet the target of five percent. low rates of national health expenditures in countries will be a serious limiting factor in improved health and universal access, especially if preventive care is unable to compete for resources as compared to clinical and hospital services. all countries face problems of financing, cost constraint, overcoming structural inefficiencies, and funding incentives for high quality and efficiency in health services. national health systems are necessarily complex, but go well beyond medical and hospital care. the quality of the community infrastructure-sewage, water, roads, communication, urban planning-social support such as pensions and welfare for the disabled, widows, orphans and others in need are essential for population health. attention to the quantity and quality of food (i.e., food and nutritional security), levels of education, and professional organization are all parts of this continuum. national health systems are not only a matter of adequacy and methods of financing and assuring access to services; they must also address health promotion, national health targets, and adapt to the changing needs of the population, the environment, and with a broad intersectoral approach to health of the population and the individual. the structure, content, and quality of a health system plays a vital role in the social and economic development of a society and its quality of life. universal access is increasingly widely accepted as essential to reduce the social inequalities in health. even when income gaps are high. however, vulnerable populations with higher levels of risk than those of the general population are still relatively deprived even under classical universal insurance systems. the key common factors of elevated vulnerability are poverty, isolation by geographic location, physical access by reasons of residency location, ethnicity, education and institutional barriers which reduce access. these inequality factors are the achilles heel of classical universal health insurance and service systems most of which have sought health promotion measures. there can be little doubt that universal access to health insurance or service systems reduces inequalities, but they require imaginative and outreach-oriented approaches to reach those urban and rural poor, people of aboriginal descent, those with an income lower than the poverty threshold, the unemployed, the homeless, and those who have not completed secondary education. societal programs to increase family disposable income for the poor are effective in reducing the health inequities. the two are complementary and equally important in social policy. in the united states more than ten percentages of the population are without any, or have inadequate, health insurance. loss of health coverage with change of place of employment and the rapidly increasing cost of private health insurance generated widespread pressure for a national health program. the business community, too, loses confidence in voluntary health insurance as costs of health insurance mounted rapidly and as a cost of employment in an increasingly harms the competitive international business climate. narrow planning for health systems ignores this message at the risk of missing their targets of improved health indicators, such as those adopted by the united nations-i.e., the millennium development goals and sustainable development goals. the mdgs and sdgs represent a growing movement of globalization of health with economic and political dimensions and greater stress on human rights to health policy. they are particularly relevant to lmics (low-and middle-income countries), but high-income countries have health inequalities that require new approaches based on outreach poverty abatement, and health promotion concepts. mdgs and sdgs presented a challenge to establish common data systems for performance measures to monitor effectiveness of policies and programs. this helps to build capacity for target-oriented health planning in low-and middle-income countries (lmics). a holistic view of health for all must take into account the many reasons for health disparities and disadvantage to the poor in health status. insurance to pay for doctors, hospitals, laboratories and imaging centers is necessary, but not sufficient, to raise population health standards for all. the "nontariff barriers"-i.e., issues beyond payment for services which may be addressed with incentives in payment systems, not only to reduce hospital length-of-stay, but to reduce health-care acquired infections, reaching out to chronically ill people with health promotion measures such as nutritional support, pneumonia and influenza immunization, hypertension control, cancer screening, and many other features of public health promotion. since the s, when bismarck introduced national health insurance in germany as part of social security with funding though sick funds, many countries have grappled in unique ways with developing health care systems. national health insurance systems developed through social security and social welfare systems, by national health insurance, or options to provide access to health services. in canada national health insurance provides universal coverage through national support for provincial health plans, paid for by general taxation, with national criteria. in the united states, president lyndon johnson established social security-based health insurance for the elderly and the poor through amendments to the social security act of , and president barack obama extended health insurance through the affordable care act of . the uk national health service-with the northern ireland, scottish and welsh nhs run semi-independently-was established in , providing a state-run system of medical, hospital, preventive, and community health care. though not discussed here, nordic and other european health systems provide universal coverage with involvement from all three levels of government, but over percent of expenditures are funded through public sources. in denmark, norway and sweden county councils are central to funding and management; in finland, the municipalities provide most of the health care. the former socialist countries have gone through painful periods of transition. many of these countries have developed free-market systems with dynamic growth in national economies along with health system reform. health systems in transition have adapted with great gains in longevity and reduced mortality from preventable diseases in many former socialist countries in central and eastern europe. others have had difficulties addressing the "missed epidemiologic transition" from infectious disease to control of noncommunicable disease but have begun to make progress in the st century. globally, public and private donor partnerships have emerged to help the poorest countries cope with overwhelming health problems of raising immunization coverage levels, reducing child and maternal mortality, managing hiv, tuberculosis, malaria, diarrheal and respiratory diseases and vaccinepreventable diseases in keeping with the mdgs based on a consensus of all member nations of the un. the objectives and specific targets included: reducing poverty, improving equal access of boys and girls to primary education, reducing child and maternal mortality, managing significant diseases such as hiv, tuberculosis, and malaria, along with improving the environment. reaching the targets for achieving these goals depends on developing infrastructures of health systems that provide access for all and distribution to meet geographic and social inequities in health. each country needs to develop its own system, but can learn from the experience of others. the purpose of this case study is to highlight the unique and common features, including positive and negative lessons learned from national health systems. observing and learning can help in defining needs for countries lacking but aspiring to achieve universal health systems, including positive and negative challenges. universal access is an important means of assuring that the economic barrier is removed for the total population, leading to increased access to medical and hospital services for those previously lacking the means to reach these services. universal access systems have been achieved in most industrialized countries. however, the us has not achieved this goal even with, by far, the highest health expenditures of oecd countries. this is due mainly to political gridlock despite success with its single payer system for medicare for the elderly. for low-income countries, the rates of health expenditures at present and forecast for the coming decades will be insufficient to achieve universal access systems. there must be a fundamental political change in national policies with health as a higher priority for funding and leadership. universal healthcare access is still a work in progress. the goal of universal access is a worthy one: to make health care accessible to all. the advent of universal access, however, is not assured given low levels of funding in many countries most in need of improved access but strengthening health systems: the role and promise of policy and systems research. geneva: global forum for health research alliance for health systems policy and research. world health organization. what is health policy and systems research (hpsr)? . geneva: world health organization achieving a high-performance health care system with universal access: what the united states can learn from other countries health spending in the united states and the rest of the industrialized world the publicÀprivate pendulum-patient choice and equity in sweden uk health dividesÀwhere you live can kill you disease and disadvantage in the united states and in england lessons from the east-china's rapidly evolving health care system the affordable care act at five years gatekeeping in health care the organization of personal health services. milbank quart noncommunicable diseases: stepping up the fight: how the russian federation is collaborating with other commonwealth of independent states' countries comparing health systems in four countries: lessons for the united states germany: health system review germany and health : statutory health insurance in germany: a health system shaped by years of solidarity, self-governance, and competition how canada compares: results from the commonwealth fund international health policy survey of primary care physicians healthy people : topic areas at a glance. national center for health statistics, last reviewed national health expenditure fact sheet, last modified health and health care in israel: an introduction. lancet. . special series international health care system profiles international profiles of health care systems united kingdom: health system review reforming the russian health care system the fragmentary federation: experiences with the decentralized health system in russia health care reform: lessons from canada ata international conference on primary health care the development of social security in america. social security administration national spending on health by source for countries between regional health inequalities in england. uk office for national statistics, department of health health care systems in the eu: a comparative study. directorate general for research systems science for universal health coverage health systems special edition. health systems: more evidence, more debate evolution and patterns of global health financing À : development assistance for health, and government, prepaid private, and out-of-pocket health spending in countries reforming sanitaryepidemiological service in central and eastern europe and the former soviet union: an exploratory study effects of race and income on mortality and use of services among medicare beneficiaries global health: a pivotal moment of opportunity and peril a systematic review of studies comparing health outcomes in canada and the united states how does the quality of care compare in five countries? financing global health : development assistance, public and private health spending for the pursuit of universal health coverage disease control priorities in developing countries kaiser family foundation. us global health policy strengthening health systems to provide rehabilitation services a new perspective on the health of canadians. ottawa, on: department of national health and welfare, a new perspective on the health of canadians. ottawa, on: department of national health and welfare access to care, health status, and health disparities in the united states and canada: results of a cross-national population-based survey social medicine vs professional dominance: the german experience universal health care: lessons from the british experience a system in name only-access, variation, and reform in canada's provinces the unequal health of europeans: successes and failures of policies a comparative analysis of health policy performance in european countries nordic health systems: recent reforms and health policy challenges. copenhagen: who regional office for europe on behalf of the european observatory on health systems and policies the history of health care in canada the marmot review final report: fair society, healthy lives a precious jewel-the role of general practice in the english nhs canada health system review reinventing public health: a new perspective on the health of canadians and its international impact international health care systems international profiles of health care systems the global campaign for the health mdgs: challenges, opportunities, and the imperative of shared learning red medicine: 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ambulatory specialist care-germany's new health care sector ethics of resource allocation and rationing medical care in a time of fiscal restraint-us and europe addressing the epidemiologic transition in the former soviet union: strategies for health system and public health reform in russia the new public health brave new world: the welfare state united nations human development report transforming our world., agenda items and sustainable development goals. goals to transform our world healthy development. the world bank strategy for health, nutrition, and population results spotlight on nutrition: unlocking human potential and economic growth world bank life expectancy at birth, total (years) world health organization. global health observatory. world health statistics : monitoring health for the sdgs everybody's business: strengthening health systems to improve outcomes: who's framework for action. geneva: world health organization world health report : working together for health. geneva: world health organization health systems: improving performance european health report : charting the way to well-being. copenhagen: world health organization research for universal health coverage world health organization. european health for all database (hfadb) world health organization. health systems: health system financing universal health coverage: sustainable development goal , health relying heavily on donors and out-of-pocket payments. the devil is in the details. . universal health insurance (uhi) or national health service systems are essential for advancing population health and should be give high priority in policy and funding by national governments and international aid agencies in middle-and low-income countries in the coming decades. . universal health insurance or service systems cannot be expected to succeed without continuing development of public health and health promotion as equal needs for population health and to achieve sdgs. . all countries seeking health development will need to raise public support for financing health systems by raising health expenditures to more than five -six percent of gdp. . all countries addressing these issues should endeavor to expand training to include bachelor and master degree training in public health and health systems management in order to raise the professional leadership and management levels to lead in the complexities of health systems in the challenges ahead. health promotion to hospice care on par with acute and rehabilitation care hospitals as essential, but managed so as to avoid unnecessary economic domination of the health system and potentially damaging health-care infections and trauma. . reaching out to populations-at-risk and in need of preventive care and health promotion by multi-professional and paraprofessional teamse.g., community health workers, is vital to address chronic care needs and prevent their complications, for remote villages or urban poverty areas, or to groups of people with chronic disease conditions. . health information systems including development and implementation of epidemiology and information technology for monitoring of disease and quality of care require emphasis. . immunization and nutritional support for prevention of infectious diseases, chronic diseases and micronutrient deficiency conditions are crucial for population health and should be given high priority in health system development. . health policy management is vital to achieving universal health coverage to advance population health, but it must be seen as part of health in all strategies and the sdgs to be effective within financial limitations and cost restraint. . health promotion must be developed in all its aspects to raise population and professional awareness with educational and legal means to reduce risk factors in population health. health systems to promote efficient use of resources and achievement of specified health targets? . what methods may be incorporated into national health systems to promote quality of care? . how can developing countries achieve universal health care, and at the same time work toward national health targets such as upgrading maternal and child heath, control of infectious diseases and preventing chronic diseases? . how can low-income countries address the low public expenditure on health to reduce dependence on global financial aid for sustainable development goals (sdgs)? key: cord- -rozpps v authors: faye, c.; wade, c.; dione, i. d. title: a dissymmetry in the figures related to the covid- pandemic in the world: what factors explain the difference between africa and the rest of the world? date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: rozpps v humanity has experienced outbreaks for millennia, from epidemics limited to pandemics that have claimed many victims and changed the course of civilizations. the advent of vaccines has eradicated some of the serious pathogens and reduced many others. however, pandemics are still part of our modern world, as we continue to have pandemics as devastating as hiv and as alarming as severe acute respiratory syndrome, ebola and the middle east respiratory syndrome. the covid- epidemic with -exponential contamination curves reaching million confirmed cases should not have come as a surprise, nor should it have been the last pandemic in the world. in this article, we try to summarize the lost opportunities as well as the lessons learned, hoping that we can do better in the future. the objective of this study is to relate the situation of covid- in african countries with those of the countries most affected by the pandemic. it also allows us to verify how, according to the observed situation, the african ecosystem seems to be much more resilient compared to that of other continents where the number of deaths is in the thousands. to verify this, the diagnosed morbidity and mortality reported for different states of the world are compared to the ages of life and the average annual temperature of these states. the results show that the less dramatic balance of the african continent compared to other continents is partly linked to the relatively high temperatures on the continent but also to the relatively young character of its population. humanity has experienced outbreaks for millennia, from epidemics limited to universal pandemics that have claimed many victims and changed the course of civilizations. the advent of vaccines has eradicated some of the serious human pathogens and mitigated many others. however, pandemics are still part of our modern world, as we continue to have pandemics as devastating as hiv and as alarming as severe acute respiratory syndrome, ebola and middle east respiratory syndrome (saqr and wasson, ) . the covid- epidemic with exponential curves reaching million confirmed cases should not have come as a surprise. however, we seemed to ignore the past. (peeri et al., ; morse, ) . unfortunately, covid- is not the last pandemic in the world and we need to learn what we missed and how to avoid failures. today. while border closures and travel restrictions within countries may be helpful, this is much less effective than in the past. pandemics require a stronger who with sufficient resources (morse, ) . failure to manage a pandemic in one country can have repercussions for the entire planet; therefore, pandemics require more solidarity and coordination so that fragile countries can find the resources to treat, isolate and combat severe epidemics. there are good signs that such efforts are being implemented (for example, the european union has announced eur billion to combat the current pandemic in developing countries) and, hopefully, these efforts are being consolidated to become systemic, proactive and organized. in other words, pandemics require global efforts with a strong and resourceful world health organisation. having appeared in china in the city of wuhan, covid- , initially a zoonosis, has spread throughout most of the world to become a pandemic affecting all social strata and relatively all ages of life. today, more than million people are affected and the spread of covid- continues to grow beyond the world's best performing health systems. however, it is clear that the geography of covid- disease shows significant disparities between countries and age groups in terms of the level of disease and the extent of mortality. this differentiated prevalence prompts reflection on possible explanations by taking into account a set of endogenous and exogenous factors (geographical, environmental, biological, socio-cultural, political contexts, etc.) . new epidemiological trends on transmission and mortality in africa and the most affected regions of the world suggest that better studies of this infection in sub-saharan africa than in other regions of the world are needed. the covid- pandemic has lower rates of local transmission and mortality in africa, the region where the virus was the last to arrive (imaralu, ) . the daily statistics emanating from the high infectious property of the new strain of coronavirus covid- , particularly its rapid worldwide transmission and the nature of the resulting deaths sweeping across countries, call for concerted efforts to limit local transmission in already colonized territories. there is currently no known consensual cure for covid- infection and there is currently no evidence to recommend specific anti-covid- treatment for patients confirmed to have this disease (who, a). the news of very high mortality rates in industrialized countries with stronger health systems and sophisticated infrastructure is cause for concern (who, b). facilities and equipment in industrialized countries that have so far provided assistance to developing countries are overwhelmed and not even sufficient to meet the current challenges facing these countries. as of april , , , confirmed cases of covid- -positive persons and , deaths worldwide had been reported to who (who, c) . there was concern about the impact of this virus on african nations, given the weakness of prevailing health systems with suboptimal infrastructural support (who, c). the recent mass exodus of health workers to europe and the americas and the continuing security threats of terrorism and violent crime make this new deadly viral threat a source of concern for governments in this subregion (imaralu, ) . on the basis of the above, the social and health implications of intervention measures to limit the spread of covid- virus should be considered and interventions carefully planned . this study thus proposes a diachronic reading of the evolution of covid- with as inputs the diagnosed morbidity and mortality reported in different states of the world on the one hand, and on the other hand the life expectancy and the average annual temperature of these states for a comparative study in order to draw all the specificities generated. this contribution focuses on the factors explaining this disparity in a statistical, sociodemographic and geographical analysis. it is based on a statistical treatment of aggregated data with a plural input taking into account the specificities of the prevalence of covid- at the level of the countries of the world. the covid- statistics used in this study are from the world health organization database and are as of monday, april , (https://www.weather-atlas.com or http://data.un.org/data.aspx?d=clino=elementcode% a figure ). for this study, countries were selected, countries in africa (these are indeed the african countries that have counted the most cases of covid- as of monday april ) and countries generally located in other continents ( countries in europe, in america, in asia, in oceania). indeed, these are the countries in the world that have counted the most cases of covid- as of monday april . the objective of this study is to relate the situation of covid- in african countries with those of the countries most affected by the pandemic. it also allows us to verify in what way the african ecosystem seems, according to the observed situation, much more resistant compared to that of other continents where the number of deaths is counted in thousands. to verify this state of affairs, two key hypotheses are raised: one natural (this is the average annual temperature of the country) and the other anthropogenic (this is the structure of the population). according to several scientists, the less dramatic balance of the african continent compared to other continents would be linked to the relatively high temperatures on the continent but also to the relatively young character of its population. to carry out this correlation study, the data used are shown in the following table. this article is a us government work. it is not subject to copyright under usc and is also made available (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / this article is a us government work. it is not subject to copyright under usc and is also made available (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. . it reduces the number of variables to those that are the most significant among a set of variables and is used to find a link between variables and individuals in order to group them into homogeneous regions. one of the objectives of pca is to obtain useful information from a data matrix, and to provide a graphical representation of the data to facilitate analysis. the mathematical procedure of principal component analysis is actually a multivariate statistical method of data processing. this article is a us government work. it is not subject to copyright under usc and is also made available (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint we subjected all the variables studied for the different countries under study to a principal components analysis, in order to determine the affinities between these countries and to deduce the most characteristic parameters. to do this, a correlation matrix was used and the components were determined according to the type of rotation of the orthogonal axes. the first factorial axis (f ) of this representation is such that it determines the maximum inertia of the cloud and thus the variance. the second axis (f ) perpendicular to the first expresses the maximum remaining variance. the third axis, always perpendicular to the other two, is defined by the maximum remaining inertia; etc. principal component analysis, or pca, is a method of reducing the number of variables allowing the geometric representation of observations and variables. this reduction is only possible if the initial variables are not independent and have non-zero correlation coefficients (bouroche and saporta, ) . the method was applied to countries ( in africa and in other continents) and variables which are: the covid- situation on monday april (confirmed cases and reported deaths), the mean annual temperature and the structure of the proportion ( to years, to years and over years). the final reconstitution of the distribution of the countries allowed us to define the factor axes or factors responsible for this distribution and consequently, to highlight the affinities between the different countries and to deduce the variables linked to the covid- pandemic that best characterize them. analysis of tables and and the eigenvalue curve ( figure. ), shows that the first three factors represent the maximum amount of information. thus the first three factor axes express . % of the total variance, with . % for the first factor, . % for the second and . % for the third factor (table and figure ). this article is a us government work. it is not subject to copyright under usc and is also made available (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint there is an inverse relationship between the covid- pandemic (confirmed cases and reported deaths) and temperature, suggesting that generally the warmer a country is, the less likely it is to be affected by the coronavirus pandemic, and vice versa. the opposing relationship between the covid- pandemic (confirmed cases and reported deaths) and the proportion of elderly (and/or young) is apparent, suggesting that generally the younger a country's population is (and therefore the fewer vulnerable people), the less likely it is to be affected by the coronavirus pandemic, and vice versa. the number of confirmed cases is well correlated with the number of deaths, weakly correlated with the ageing character of the population and negatively correlated with the average temperature of the country and the youthful character of the countries' population. the axes , and thus selected highlight their relations with the parameters studied (table ) . the correlation matrix of the covid- pandemic variables and variance weight factors (table ) and figure. show that axis (main axis of inertia) which represents more than . % variance is very well positively correlated with the mean annual temperature of the country and the proportion of young people in the total population of the country. it is also weakly but this article is a us government work. it is not subject to copyright under usc and is also made available (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / negatively correlated with the number of confirmed covid- cases, the number of reported deaths and the proportion of elderly in the total population. axis , with . % variance, is positively related, strongly with the number of confirmed covid- cases, the number of reported deaths and the proportion of elderly in the total population, weakly with the average annual temperature of the country and the proportion of young people in the total population of the country. it is negatively correlated, albeit weakly, with the proportion of the elderly in the total population. as for axis , which represents almost . % of the variance, it shows only a positive but weak correlation with the number of confirmed covid- cases and the mean annual temperature of the country. its correlation with the number of reported deaths and the proportion of young and old in the total population remains negative. the correlation of the covid- pandemic variables studied with this axis, whether positive or negative, is weak. these different characteristics of the covid- pandemic-related variables and of the countries studied are represented in circles and planes, respectively (figures and ) , which illustrate the projection of the variables and the variables on factorial planes and . each variable related to the covid- pandemic is associated with a point whose coordinate on a factorial axis is a measure of the correlation between that variable and the factor (axis or axis or axis ). projected on a factorial plane, the variables studied fit into a side plane ( figure ). they are all the closer to the side of the plane the more the variable is well represented by the factorial plane, i.e. the variable is well correlated with the two factors making up this plane. .. this article is a us government work. it is not subject to copyright under usc and is also made available (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. in plans i-ii and i-iii ( . % of cumulative inertia), axis i is determined by variables related to the covid- pandemic such as the mean annual temperature of the country and the proportion of young people in the total population, which are opposed to the number of confirmed covid- cases, the number of reported deaths and the proportion of elderly people in the total population. the purpose of this representation is to provide approximate planar images of the cloud of the countries located in the plane. thus, the x-axis represents the thermal component (mean annual temperature of the country) and the anthropogenic component (proportion of young people in the total population) of the countries, while the y-axis represents their profile (in terms of number of confirmed covid- cases and number of reported deaths). indeed, a country represented on the positive part of axis generally has a high temperature and a young character of its population; this is the case, for example, of african countries. in the u.s. plan, plan i-ii highlights three groups. the first group is made up of the countries that have recorded the greatest number of cases of contamination and deaths (e.g. united states, spain, italy, germany, france, etc.). these are the countries with the highest form values (a, p, kg , l and l). in this group, the united states stands out clearly from the others due to its higher number of contamination and deaths. the second group is made up of european countries (belgium, netherlands, switzerland...), american countries (canada, brazil, peru...), asian countries (israel, south korea, japan...) and oceania (australia) which have recorded a lower number of cases of contamination and deaths than those in the first group, despite certain common characteristics (such as temperature and the ageing of the population). the last group is made up of african countries with the lowest number of cases and deaths related to covid- . these countries also benefit from a high temperature and a young population. for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. what analysis can be made of this cpa figure , which distinguishes three categories of countries? • the first category (usually - ) and the second category (usually - ) are made up of the european, american and asian countries most affected by the covid- pandemic. these countries are generally located in the temperate zone (where temperatures are relatively mild and conducive to the easy spread of the pandemic). in addition, they are countries with an aging population, and therefore a high number of vulnerable people), hence the high number of deaths related to the pandemic. however, there are some exceptions because among these countries there are a few that are located in the tropical zone, such as brazil, and are in this group. some african countries, such as mauritius, are also located in the group, due to its low average annual temperature, which brings it closer to countries in the temperate zone. • the third category (generally - ) consists strictly of african countries selected for this study (those most affected by the covid- pandemic). these countries are generally located in the tropical zone (whose temperatures are relatively high and unfavourable to the spread of the pandemic). in the early stages of the epidemic, the speed of contagion decreases with the temperature of the country or region and high temperatures reduce the initial rates of contagion (demongeot et al. , ) . containment policies and other rules of expulsion should take into account climatic heterogeneities in order to adapt public health decisions to possible geographical or seasonal gradients. in addition, these are for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / countries with young populations (i.e., with very few vulnerable people), hence the low number of pandemic-related deaths. ultimately, the principal component analysis (pca) synthesized the information contained in table by crossing countries (individuals) and variables (quantitative). it produced a summary of information (figures , , and ) by establishing similarity between the selected countries, searching for homogeneous groups of countries, identifying a typology of countries and variables related to the covid- pandemic studied, and also identifying linkage budgets between variables related to the covid- pandemic, using synthetic parameters or variables. the cpa has generally established the linkages between these two typologies (kouani et al., ) . in conclusion, we note that the cpa has the advantage, on the one hand, of summarizing the set of correlated initial parameters into a reduced number of uncorrelated factors. on the other hand, it has enabled us to highlight similarities or oppositions between parameters and subbasins (faye, ; baba-hamed and bouanan, ) what analysis can be made of this cpa figure , which distinguishes three categories of countries? • the first category (usually - ) and the second category (usually - ) are made up of the european, american and asian countries most affected by the covid- pandemic. these countries are generally located in the temperate zone (where temperatures are relatively mild and conducive to the easy spread of the pandemic). in addition, they are countries with an aging population, and therefore a high number of vulnerable people), hence the high number of deaths related to the pandemic. however, there are some exceptions because among these countries there are a few that are located in the tropical zone, such as brazil, and are in this group. some african countries, such as mauritius, are also located in the group, due to its low average annual temperature, which brings it closer to countries in the temperate zone. • the third category (generally - ) consists strictly of african countries selected for this study (those most affected by the covid- pandemic). these countries are generally located in the tropical zone (whose temperatures are relatively high and unfavourable to the spread of the pandemic). in the early stages of the epidemic, the speed of contagion decreases with the temperature of the country or region and high temperatures reduce the initial rates of contagion (demongeot et al. , ) . containment policies and other rules of expulsion should take into account climatic heterogeneities in order to adapt public health decisions to possible geographical or seasonal gradients. in addition, these are countries with young populations (i.e., with very few vulnerable people), hence the low number of pandemic-related deaths. ultimately, the principal component analysis (pca) synthesized the information contained in table by crossing countries (individuals) and variables (quantitative). it produced a summary of information (figures , , and ) by establishing similarity between the selected countries, searching for homogeneous groups of countries, identifying a typology of countries and variables related to the covid- pandemic studied, and also identifying linkage budgets between variables related to the covid- pandemic, using synthetic parameters or variables. the cpa has generally established the linkages between these two typologies (kouani et al., ) . in conclusion, we note that the cpa has the advantage, on the one hand, of summarizing the set of correlated initial parameters into a reduced number of uncorrelated factors. on the other hand, it has enabled us to highlight similarities or oppositions between parameters and subbasins (faye, ; baba-hamed and bouanan, ). for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / two months after the first cases of covid- appeared in africa, the spread of the disease appears to be progressing more slowly than elsewhere. since the first cases of covid- infection detected in africa in mid-february, as of may , there have been just over , reported cases (including those already cured) and deaths in africa, compared with over , , cases of illness and , deaths worldwide (who, d) . statistically, many experts still point to the african anomaly and link it to climate, geography and, in the most extreme cases, even to a kind of biological resilience (savana, ) . africa, with per cent of the world's population, is home to only . per cent of the world's sick and . per cent of its dead. better still, with already more than , recoveries, it seems to be much more resistant than others to covid- . for the time being, in any case, no one denies that the spread of the virus seems to be singularly slow on the continent, and many reasons are cited to try to explain this (marbot, ) . climate: like influenza, coronavirus is believed to be a disease that thrives in the cold season and does not tolerate heat, drought, or even heavy sun exposure. the hypothesis seems to be supported by the fact that the countries most affected by the pandemic have a rather temperate climate and that most cases are concentrated either in the extreme north of the continent or in the extreme south, where heat and drought are less overwhelming. on the research side, a british study confirms that, on average, fewer respiratory illnesses are found in hot and dry countries, and an american report of april states that the half-life of the virus, i.e., the period required for its infectious power to be halved, may increase from to hours if heat and humidity increase (marbot, ) . researchers nevertheless remain very cautious, like the director of international affairs at the pasteur institute, pierre-marie girard, who stresses that during in vitro experiments it was found that the coronavirus "multiplied very well in heat". sun, heat and humidity could weaken the covid- virus. according to a study of the american government, presented thursday april in washington, the virus responsible for the pandemic of covid- weakens in a hot and humid atmosphere as well as under the rays of the sun. "our most striking observation to date is the powerful effect that sunlight seems to have in killing the virus, both on surfaces and in the air," said a senior department of homeland security official bill bryan ( ). despite this, health minister olivier véran was sceptical and the who believes that high temperatures do not prevent the virus from being contracted. the youth of the population: this is the other major explanation put forward. in englishspeaking countries, it has even become a slogan: "the virus isold and cold and africa is young and hot". doctors confirm that the majority of severe cases of covid- involve people over years of age, which would be fortunate for the continent, where the median age is . years and % of the population is under years of age. it is also pointed out that one of the hardest hit countries, italy, has . per cent of its population aged and over, compared to per cent in africa. there is almost unanimous agreement on this hypothesis, but scientists qualify it by pointing out that although the african population is young, it is unfortunately more affected than others by diseases such as hiv or malnutrition, which can make it vulnerable. finally, some researchers note that in europe and the united states the elderly often live among themselves in old people's homes, which encourages the spread, whereas in africa they more frequently live with their families. this could protect them. average, and that cities such as lagos or abuja have record population densities. today, this position must be put into perspective because in some countries, it can be observed that most cases of infection concern localities with dense populations, including cities. another rational explanation that is difficult to circumvent is that the african population moves less, on average, than that of many advanced countries, and the risks of contamination are therefore necessarily lower. as a reminder, there is only one african airport in the list of the world's sites with the highest concentration of air traffic: johannesburg. the experience of epidemics: as many point out, this is not the first epidemic in africa, and there have been far more deadly ones, including the recent ebola crises. healthcare workers and populations alike are therefore used to dealing with health crises, lessons have been learned and "good practices" have been put in place. certain methods of detection, isolation of patients, and precautions during care developed previously are duplicable in the face of the coronavirus. the authorities also took the measure of the danger more quickly than others and put in place very early on the control or closure of borders, distancing or containment. this led dr moumouni kinda, who has faced several crises with the non-governmental organization alima, to say, "epidemics like ebola have given us experience on communication and awareness, which are key points in breaking the chains of transmission of the virus. for some african scientists, the continent also has the advantage of practicing true solidarity. when one country lacks masks or test kits, neighbouring countries that are less affected are likely to provide them. lesotho, which does not yet have an operational laboratory, has its samples tested in south africa, and a network for detecting seasonal influenza, used against covid- , already brings together some countries on the continent. without being overly optimistic, it must be said that solidarity sometimes seems to work better in africa than in certain richer regions, where we see the major laboratories jealously watching over their discoveries in the hope of being able to market a treatment or a vaccine. not to mention a donald trump trying to get his hands on the patents of drugs under development for the sole (financial) benefit of the united states...on a much more local scale, it is also pointed out that the community-based functioning of many african populations makes it possible to better convey prevention messages, but also to detect patients more quickly, since few people are likely to be left to their own devices. this hypothesis is the subject of much controversy, and the who, in particular, is very cautious. however, some doctors have noted some disturbing coincidences: there are reportedly fewer coronavirus contaminations in the countries most affected by malaria" or tuberculosis. or in those that massively vaccinate their population with bcg. would contracting certain diseases be a barrier to covid- ? it will take time to prove it, but many doctors believe that antimalarial treatments such as chloroquine have some effectiveness. that's partly why french professor didier raoult and teams like the drug discovery and development centre (h d) at the university of cape town are giving priority to testing antimalarial drugs. the who is critical, noting that some countries such as burkina faso, nigeria and senegal, where malaria is devastating, are not spared by the virus. more recently ( april), the malagasy president announced that his country was in possession of a "vita malagasy" remedy (made in madagascar) with preventive and curative virtues against the coronavirus. covid-organics, the name given to this treatment, is an herbal tea made from dried artemisia leaves, produced by the malagasy institute for applied research (imra). despite who warnings, member countries of the economic community of west african states (ecowas) will now be able to treat their for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / coronavirus patients with covid-organics, and test the effectiveness of this improved traditional remedy proposed by imra. faced with the fight against the covid- pandemic, africans have chosen to put forward the unity and solidarity of africa. madagascar was able to demonstrate to the world that we africans can cooperate and help each other not only in an economic situation but above all in a health and humanitarian situation. a "genetic" immunity: what if africans were protected by their dna, which, for some reason yet to be determined, would be more robust against the coronavirus? the hypothesis is far from unanimous -at the pasteur institute, pierre-marie girard "doesn't really see why" such a specificity would exist -and will take time to be explored. the cameroonian professor christian happi, specialist in genomics, who divides his time between harvard university and nigeria, does not completely rule out this possibility: "africans are exposed to many diseases, so it is possible that their bodies react better. you'll have to look for antibodies to find out, but it's possible. after ebola, we saw that many people in nigeria had been exposed to the disease but had not developed it. » another version of the virus: an idea that is similar to the previous one: since it now seems that several different strains of covid- are present on the planet (up to eight distinct forms), perhaps the one present in africa is less aggressive? this could also explain the fact that there seem to be more asymptomatic cases there than elsewhere. the hypothesis remains audacious insofar as the virus arrived through patients who contracted it elsewhere. could it have mutated afterwards? the who does not rule out the idea, but stresses that in order to validate it it will be necessary to sequence the genome of covid- , which is currently underway. better masks: when asked about the specificities that could work in favour of africa, matshidisomoeti, who africa director, points out that the continent "has a very active and competent textile industry", especially in brazzaville, where the organization's offices are located. this particularity perhaps allows the population to benefit from more and better quality cloth masks than in some rich countries, where scarcity is the rule. in conclusion, the scientists point out that what probably explains the low number of cases observed on the continent is, above all, the fact that most countries took drastic protection measures very early on. and perhaps also the fact that because the disease initially affected people who were travelling, rather better informed than average and living mostly in cities, it was easier to identify the first cases than in other epidemics. but the modesty of the figures continues to amaze, as congolese biologist francine ntoumi notes: "in some countries on the continent, people eat bats, people live on top of each other... in fact, everything is done to make it explode, but it doesn't. "it's up to african scientists to find out why. however, caution should be exercised in the face of the figures because even if africa is not the continent most affected by covid- , the damage could be considerable, according to virologist denis chopera. in addition, the contamination rate would be underestimated due to the lack of medical facilities. in the context of this sars-cov- virus, transmission can take place during the last days of viral incubation, before symptoms appear or at least are significant. this is a viral strategy that has certainly allowed the virus to spread so impressively. another risk of under-evaluating cases is the lack of diagnostic tests or one of the reagents that make them up. given the international demand, the whole world is struggling to obtain everything necessary to fight the pandemic and africa is not always in an ideal position to be able to negotiate prices compared to other regions of the world. at the moment, patient management is going relatively well in the hospitals that have been identified to play this role and the system is not overwhelmed, although some tools, such as respirators, are sorely lacking. at present (as of may , ), just under ( ) deaths for approximately times the number of identified confirmed cases, which would correspond to for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint a lethality of . %. although the global case-fatality rate is generally higher ( %), severe cases are more easily identified than non-symptomatic or minimally symptomatic cases, and it is possible that several foci of the infection have not been identified. if this is the case and the virus is insidiously transmitted in the population, it is likely that hospital infrastructures will be rapidly overwhelmed when the weakest are affected. globally, deaths due to covid- are lower among young people, including women and children, but higher among the elderly and people with chronic diseases. the pandemic appears to have lower local transmission and mortality rates in africa, the region with the youngest median age of the population and where the virus arrived last. while special efforts should be made to protect the elderly and infirm from infection, preventive measures among women (especially pregnant women) must provide access to emergency care to prevent the maternal mortality caused by covid- . similar to the crisis of the late s, the current crisis will have an impact on international relations. the structural changes already seen in the globalisation process can be expected to accelerate. in general, the world needs serious investment in research and development to understand current epidemics and to prepare for possible future ones. we need to prepare our health care infrastructure, develop new diagnostic and therapeutic solutions, invest in broadspectrum vaccines and antivirals, and fund research infrastructure and pandemic predictability. we need more social science research to help understand the social aspects of the pandemic, to foster engagement and trust in our communities, to improve our education to be more adaptive and to target misinformation. we need each other more than ever with greater compassion, solidarity and collaboration. a global pandemic requires global efforts. there will be future severe pandemics. who, d : coronavirus disease (covid- ) situation report - data as received by who from national authorities by : cest, may this report has been reformatted to improve accessibility for persons with visual impairment. p. https://www.who.int/emergencies/diseases/novel-coronavirus- /situation-reports for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / for use under a cc license. this article is a us government work. it is not subject to copyright under usc and is also made available (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / : caractérisation d'un bassin versant par l'analyse statistique des paramètres morphométriques : cas du bassin versant de la tafna temperature decreases spread parameters of the new covid- case dynamics a principal component regression method for estimating low flow index méthode d'analyse statistique de données morphométriques : corrélation de paramètres morphométriques et influence sur l'écoulement des sous-bassins du fleuve sénégal temporal evolution of groundwater composition in an alluvial aquifer (pisuerga river, spain) by principal component analysis clinical features of patients infected with novel coronavirus in wuhan : emerging statistics on the epidemiology of covid- : making prevention in pregnancy less grievous than the disease analyse en composantes principales une méthode factorielle pour traiter les données didactiques. radisma : coronavirus : décryptage des hypothèses qui expliqueraient la faible contamination en afrique du mai à h pandemic influenza: studying the lessons of history covid- ) epidemics, the newest and biggest global health threats: what lessons have we learned? application of principal components analyse to the study of co -rich thermaineral waters in the aqufère system of alto guadalentin (spain) covid- : lost opportunities and lessons for the future covid- : l'exception africaine à l'épreuve des statistiques exploration des séries chronologiques d'analyse de la qualité des eaux de surface dans le bassin de la tafna en algérie. revue des sciences de l'eau who, a : world health organization. clinical management of severe acute respiratory infection (sari) when covid- disease is suspected: interim guidance who, b : world health organization. health systems in africa: community perceptions and perspectives. the report of a multi-country study. who. geneva; situation report- . who. geneva; key: cord- -o d yure authors: abdelsalam, omneya; chantziaras, antonios; omoteso, kamil; ibrahim, masud title: the impact of religiosity on earnings quality: international evidence from the banking sector date: - - journal: nan doi: . /j.bar. . sha: doc_id: cord_uid: o d yure we examine the impact of religiosity on earnings quality, utilising a global sample of , listed banks headquartered in countries and covering the period – . using instrumental variables two-stage least squares regressions, we demonstrate that religiosity has a significant positive impact on banks’ earnings quality. we further show that the impact of religiosity becomes more pronounced among banks headquartered in countries where religion is an important element of national identity and in countries with weak legal protection. we show that the effects of religiosity are more intense during the global financial crisis period. overall, these findings support the notion that high religiosity tends to reduce unethical activities by managers and can function as an alternative control mechanism for minimising agency costs. our empirical investigation is robust to alternative model sample specification. in the last decades, the recurrent corporate collapses have given rise to a wave of criticism with regard to the role and effectiveness of formal institutions, such as conventional governance and regulatory structures (tonoyan, strohmeyer, habib, & perlitz, ) . at the same time, academic interest has been directed toward exploring the roles of informal institutions, especially religiosity, in influencing management behaviour and the quality of financial reporting (see callen, morel, & richardson, ; kanagaretnam, lobo, & wang, ) . previous researchers have shown that high levels of religiosity affect managers and the organisations they control (leventis, dedoulis, & abdelsalam, ; longenecker, mckinney, & moore, ; mccullough & willoughby, ; mcguire, omer, & sharp, ; vitell, ; abdelsalam, duygun, matallín-sáez & tortosa-ausina, ) since religious norms convert emotions of guilt and shame into a sense of accountability among actors, directing them towards choosing ethical decision making. however, a few questions remain unexplored: (a) does earnings quality differ between countries where religion is part of the national identity and therefore adherence is more pronounced? (b) does the impact of religiosity on earnings quality differ between countries in accordance with the strength of formal institutions? (c) does the impact of religiosity on earnings quality differ during a crisis period? our paper aims to fill these gaps. we argue that although the influence of these religious social norms may function in a similar manner across different countries (see gallego-alvarez, rodríguez-domínguez, & martín vallejo, ; horak & yang, ; leventis et al., ) , the magnitude of their influence in shaping economic decisions differs between countries. this is due to the varying levels of adherence to religious norms and the different qualities of institutional governance between nations (halikiopoulou & vasilopoulou, ; north, ) . the classic sociological literature from the s to early s (e.g., blake & davis, ; lapiere, ; parsons, ) suggests that certain behaviour is normative when it is socially requested or is considered appropriate. we also show that the impact of religious norms varies depending on its perceived importance and its significance in groups' and nations' identity. when religion becomes an integral part of a community's or a nation's identity, it is institutionalised and generates influential collective values (llobera, ) . in addition, north ( ) notes that informal institutions act as a complement to conventional formal institutions, especially when the latter become less effective. empirical investigations are supportive of this notion and demonstrate that informal institutions play an important role in countries with weak formal institutions, such as legal protection and law enforcement (see for example, ang, cheng, & wu, ; guiso, sapienza, & zingales, ; qian, cao, & cao, ) . for instance, empirical evidence from italy (guiso et al., ) and china (ang et al., ) indicates that religion impacts on decision-making frameworks, although the level of such an impact varies depending on the strength of the countries' formal institutions. surveys show that nearly per cent of the global population is associated with faith or religious beliefs (sherwood, ) . it is also argued that a large number of people become more spiritual during crises (orman, ) due to the fear of socio-economic consequences, such as job losses, poverty, depression, slow growth for firms and other associated uncertainties. under such circumstances, religion plays a key role in strengthening social solidarity and deploying strategies to deal with adversities (norenzayan & hansen, ; pargament, tarakeshwar, ellison, & wulff, ) . it also brings a sense of spiritual belonging and tranquillity (bentzen & gokmen, ) . as religion promotes the importance of ethical behaviour and renounces manipulation, we argue that its role in reducing unethical practices (and subsequently increasing earnings quality) becomes more pronounced during crisis periods. our study extends previous studies, such as callen et al. ( ) and kanagaretnam et al. ( ) by examining the association between religious social norms and earnings quality in the context of the banking sector. we use a sample of , bank-year observations of , listed banks headquartered in countries, covering the period - , for our tests. we consider the size of our sample with a view to enhancing the generalisability of the religiosity effects on earnings quality. although the previous literature has documented that religiosity affects firm behaviour, it does not show how the impact differs from one country to another. indeed, cross-national surveys, such as the ones from the pew research center and the international social survey programme, reinforce this notion. we utilize religiosity at the country of corporate headquarters, since headquarters constitute the place where business decisions and policies are made (pirinsky & wang, ; rubin, ) . using instrumental variables two-stage least squares (iv- sls) regressions, we demonstrate that religiosity has a significant positive impact on banks' earnings quality. we further demonstrate that the impact of religiosity is more pronounced among banks headquartered in countries where religion is an important element of national identity. furthermore, the impact is more pronounced for banks headquartered in countries with weak legal protection, as well as during the global financial crisis. our findings are consistent with the earlier predictions about the rationality of religion as a control instrument for unethical corporate decisions as well as the interaction of religion with institutional settings to influence corporate behaviours. we offer new insights into the influence of religiosity on earnings quality and how the magnitude of the relationship differs between countries according to their level of adherence to religious social norms. we document evidence on the varying degree of adherence to religious norms across countries on how religiosity serves as a monitoring mechanism in reducing the agency costs associated with the levels of banks' earnings quality. our sensitivity analyses support the notion that increased religious norms can restrain unethical activities by the managers as agents of the shareholders, thereby minimising the risk of failure. our study responds to prior calls for further research on the ways social norms influence bank behaviour (fungáčová, nuutilainen, & weill, ; stulz & williamson, ) . it our focus on banks is motivated by the following factors. first, banks are important institutions through which the financial system of every country is built, and the integrity of financial markets is at stake when banks' investors cast doubts on the quality of their financial information (barro & mccleary, ; callen & fang, ) . second, banks are opaque and more complex than non-financial firms, given their unique role in mobilising and allocating funds, thereby boosting capital formation and stimulating productivity (levine, ) . third, banks are subjected to heavy regulation and supervisory actions (beatty & liao, ; cornett, mcnutt, & tehranian, ) . fourth, the existence of deposit insurance schemes increases the risk of fraud and selfdealing in the banking industry by reducing incentives for the thorough scrutiny of banks' operations (macey & o'hara, ) . finally, banks have been widely accused of many unethical activities, e.g. money laundering, fake bids, insider trading, and excessive manipulation of earnings (herzog, ). j o u r n a l p r e -p r o o f thereby contributes to the existing literature in several ways. first, we provide empirical evidence on the institutional role of social norms in shaping corporate decisions towards earnings quality within the banking sector across countries, thus extending knowledge on corporate behaviours (chircop, johan, & tarsalewska, ; chourou, he, & zhong, ) . second, our study contributes to prior work by showing that the geographical location, the strength of formal institutions, and the importance of religion to national identity influence banks' earnings quality. we are, therefore, able to extend the current literature on the supplementary role of informal institutions (north, ; pevzner, xie, & xin, ) . this contribution is particularly important to policymakers when designing and implementing systems of regulatory measures for soundness and stability of the banks across countries (adhikari & agrawal, ) . third, we contribute to the important debate on the nexus between religiosity and corporate accountability, focusing particularly on earnings quality during a crisis period. this contribution is useful to both policymakers and shareholders in understanding areas of priorities concerning corporate behaviours during a crisis period. the rest of the paper is organised as follows: section reviews the prior literature, describes the theoretical underpinning, and develops our hypotheses. section discusses the data selection and methodology used. section presents the empirical findings; section presents the sensitivity testing and robustness of our results, and section concludes the paper. social norms are rules or expectations of behaviour that encompass a group's consensus on the ontological interpretation of appropriate behaviours. they are widely viewed by sociologists as a mechanism for explaining social order (durkheim, ; parsons, ) and certain social behaviours (weber, ) . the expectations can be descriptive about what individuals or organisations are likely to do or normative in terms of what they ought to do, which collectively dictates actors' cognitions, behaviours, actions and emotions (eriksson, ) . initially introduced by perkins and berkowitz ( ) , social norms theory provides a useful framework for understanding patterns of behaviour based on the sanctioning and rewarding systems embedded in the norms for noncompliance as well as compliance with such norms, respectively (leventis et al., ; weaver & agle, ) . in a conceptualised form, religiosity is a prime example of social norms and refers to the extent of adhering to prevailing religious beliefs, codes, values, practices and promulgations. although ethical behaviour is not exclusively attributable to religious adherence, recent research evidence within social sciences suggests a strong positive association between the two (vitell, ) . religion provides a mechanism through which social norms, such as honesty and risk aversion, are promoted to influence behaviours (dyreng, mayew, & williams, ) . with the promulgation of a joint set of principles and beliefs by influential religions, this can be presumed to be a set of code of actions and virtues for good ethical behaviour (melé & fontrodona, ) . as such, religious norms interact with individuals as well as corporate decision-making in promoting an anti-manipulative ethos that covers earnings management practices (callen & fang, ; iannaccone, ; mcguire et al., ) . prior research suggests that highly religious individuals are less likely to view accounting manipulation as an acceptable practice (conroy & emerson, ; longenecker et al., ) . therefore, it is widely argued that firms located in religious countries are less likely to be associated with unstable financial performance because of lower degrees of risk exposure (hilary & hui, ) and less likely to have irregularities in their financial reporting owing to an aversion to litigation risk (mcguire et al., ) . corporations within countries with high religiosity are influenced by the prevailing religious norms (callen & fang, ; dyreng et al., ) , which subsequently affect corporate decisions (adhikari & agrawal, ; chircop et al., ) . for example, us firms located in highly religious areas are associated with lower variances in equity returns and return on assets (hilary & hui, ) and stock price volatility (blau, ) . leventis et al. ( ) provide a useful summary of the mechanisms through which religious location can influence corporate behaviour around role expectations. the first mechanism is associated with the intensity of religiosity. this mechanism proposes that the presence of a high concentration of religious individuals within a given territory could translate into a high proportion of religious individuals at different stages of an organisation. this, in turn, translates into a general alignment of corporate attributes and decisions to reflect the prevailing social norms of the local community (hilary & hui, ). the second mechanism entails the role that religiously adherent staff can play in whistleblowing on irregular and unethical practices perpetrated by the firm. firms are highly likely to refrain from such unwarranted and unethical practices for fear of being exposed by religiously adherent individuals within the firm because such exposure could be costly (callen & fang, j o u r n a l p r e -p r o o f ; javers, ). the final mechanism relates to the location effect, wherein a large proportion of religiously adherent individuals are able to influence the behaviours, actions and decisions of managers of an organisation that may not have any religious inclination (dyreng et al., ) . the influence is achieved through the social interactions that guide behaviours within the boundaries of the endorsed religious norms practised in the location in order to avoid societal sanctions and negative reactions (callen & fang, ; dyreng et al., ; mcguire et al., ) . the recent literature (such as gallego-alvarez et al., ) supports the notion that the values advocated by major religions are similar across a sample of countries. it indicates a consistent pattern of higher levels of adherence to norms and are associated with the implementation of better corporate ethical behaviours. within the context of the social norms literature, normative beliefs and peer influences are instrumental in changing behaviours within corporate settings. religious norms shape peer behaviour and promote appropriate corporate ethical decisions and practices (dyreng et al., ; leventis et al., ; weaver & agle, ) . however, despite the popular conception of the positive impact of geographical religiosity on the behaviours of individuals and corporations, another strand of the literature argue that religiosity has little or no impact on corporations' ethical decisions (i.e., callen et al., ; walker, smither, & debode, ; weaver & agle, ) . an individual proclaiming religiosity may possess an extrinsic motivation that is linked to 'positive self-perception' rather than the actual group's needs and this leads to moral hypocrisy (batson & thompson, ; batson, thompson, seuferling, whitney, & strongman, ; graafland, ) . this is usually a result of the misperception of common norms caused by underestimating the consequences of deviation from the group's acceptable norms, thus leading to a lack of engagement with the desired behaviour (helmke & levitsky, ) . evidence of earnings management in banks has been well documented in the literature (beatty & liao, ; bushman & williams, ; cornett et al., ). in the context of banks, kanagaretnam et al. ( ) observe a lower probability of reporting asset deterioration in countries with higher adherence to religious norms. moreover, corporations in these countries have a lower propensity to backdate options, practice aggressive earnings management, and be involved in securities lawsuits (grullon, kanatas, & weston, ) . both the theoretical and empirical perspectives indicate a positive relationship between religious social norms and a firm's earnings quality. consequently, we propose our main hypothesis (h ) as follows: j o u r n a l p r e -p r o o f h : there is a positive association between religiosity and earnings quality. it is widely argued that national identity is formed based on the collective narratives of the majority, as culture and politics continue to interact (triandafyllidou & wodak, ) . there has long been a theoretical debate on how religion interacts with identity (brubaker, ; santiago, ) . however, the nature and outcome of the interactions differ from one country/region to another, depending on the historical evolution of their identity. for example, until the fall of the iron curtain and collapse of the soviet union between and , central and eastern europe were dominated by atheist regimes. today, however, many of the governments in the region have a state official religion or an unofficial preferred faith (fox & sandler, ; harry, ) . hence, the importance of religion to national identity can be viewed as being varied across europe. this is often attributed to the varied historical struggle and quest to create a distinct identity, potentially impacting on their policies (see mccleary & barro, ) . within the context of the nation-state, religion is established as an important determinant of economic beliefs (guiso et al., ) . as such, a country where religion is important to national identity is highly likely to produce a set of economic attitudes consistent with its dominant religious beliefs. thus, a mimic isomorphism pattern will be followed by both individuals and firms via circumventing any form of behaviour not listed within societal norms just to avoid societal punishment. consistent with north's theory of institutional change, formal institutions are viewed as the crystallisation of informal ones (north, ) and both co-evolve through the functioning of different organisations. this provides a strong rationale for the notion that informal institutions (e.g., religion) can complement formal institutions in dictating how individuals, firms, and governments behave in attaining their economic objectives. employees with a membership of either religious or union groups with distinct values are found to adhere to the groups' norms and rules (tajfel, ; turner, brown, & tajfel, ) , which induces them to make ethically sound decisions in accordance with religious norms for recognition and legitimacy. the importance of religion as part of national identity influences the social norms by upholding negative sanctions with a view to enforcing normative behaviour. religion, as an informal institution, becomes more influential when recognised as part of national identity, thus forming a strong connection and interaction between the state and religious institutions. this is because the latter dominate the political landscape (horak & yang, ) . against this background, we extend our hypothesis as: j o u r n a l p r e -p r o o f h a : the association between religiosity and earnings quality is more pronounced in countries where religion is an important element of national identity. formal institutions involve documented and accepted sets of rules and regulations introduced to structure the economic and legal set-up of a given country to protect the rights of investors and prevent unethical behaviour. the strength of the governance infrastructure (e.g., legal framework) may be weak, depending on the institutional settings (north, ; powell & dimaggio, ) . therefore, the role of informal institutions in mitigating earnings manipulations becomes vital in understanding interactions with formal institutions. informal institutions are perceived as a consensus around unconsciously designed societal traditions, norms, customs, cultures, ideologies, templates as well as undocumented codes of conduct (denzau & north, ; north, ) . where the above elements are enshrined in religious beliefs and accepted by societies as norms, personal and institutional behaviours are guided by consensus, which can be transmitted through generations by observation/imitation or teaching (tonoyan et al., ) . therefore, individuals' decisions are influenced by institutions and eventually signal which of the choices is (un)acceptable in addition to establishing the socialisation of norms and behaviours into a given society (bruton, fried, & manigart, ; peng & heath, ) . this form of boundary, or the set of beliefs that collectively shape behaviours for ethical judgement in the overall interest of an organisation, is voluntary and therefore informally institutionalised (pearce, ) . arguably, formal institutions can influence both individuals and organisations to behave in strict compliance with a pre-defined framework, created and enforced by recognised authorities (mallor, barnes, bowers, & langvardt, ) . it is expected that when formal institutions are strong, high compliance will be in force and firms will comply to avoid punishment. however, where formal institutions are weak, the success of firms in upholding ethical judgement can be determined by the informal institutions. therefore, investors have the choice to entrench either or both ethical values and legal protection in the business context (pearce & doh, ; smith, wokutch, harrington, & dennis, ) . the decision by a firm to embark on earnings manipulation will be highly discouraged and perceived as unethical because of the religious social norms if the formal institutional framework is less effective in detecting such manipulations (dyreng et al., ) . this notion supports the typology of informal institutions (helmke & levitsky, ) in that the relationship between j o u r n a l p r e -p r o o f formal and informal institutions depends on the effectiveness of, and compatibility with, the actors' goals in the institutions. in this regard, religiosity becomes more influential and complements the weak formal institutions (horak & yang, ) . in the light of potential cross-country variations in formal institutions' effectiveness, we extend our hypothesis and expect that: the association between religiosity and earnings quality is more pronounced in countries with weak formal institutions. the crisis placed financial institutions -most particularly banks -at the hit-hard centre, which resulted in stock crashes, job losses, huge liabilities, and failed and rescued this view is consistent with agency theory, which purports that the selfish interests of the managers, coupled with information asymmetry, generally result in exploitation at the expense of the owners (healy, ; kothari, ; schipper, ) . empirical evidence suggests high earnings manipulations, especially in the early stages of the financial crisis when earnings were on the rise (türegün, ) . various reasons are identified in the literature as drivers of earnings management practices during financial crises. for example, management may react to different phases of the business cycle (i.e., expansionary vs. contractionary phases) in order to maintain consistent earnings, including during the period of crisis (johnson, ; kumar & vij, ) . more particularly, for financial institutions such as banks, studies indicate that rating agencies play a crucial role in deterring earnings management practices by downgrading the credit scores of securities found to be evasive (gode & sunder, ) . in view of the effect of the additional cost of capital/borrowing following downgrading, banks may be motivated to circumvent this by embarking on offbalance-sheet adjustments in order reallocate risky assets to special purpose vehicles from their statement on their financial position (henderson, ) . in contrast, it is well documented in another strand in the literature that religiosity plays a role in shaping individuals' behaviour and resilience to cope with major life events/changes j o u r n a l p r e -p r o o f (e.g., koenig, king, & carson ; mcdougle, konrath, walk, & handy, ) . the psychology of religion indicates that people are likely to be more religious as a way of maintaining their tranquillity during a financial crisis than in a non-crisis period (díez-esteban, farinha, & garcía-gómez, ). a crisis period is a time when individuals' adherence to religion increases as a result of rising uncertainties, such as a fear of losing jobs. the period is associated with uncertainties and financial difficulty. as such, people attain well-being and psychological and spiritual stability during this period by becoming more religious (halikiopoulou & vasilopoulou, ) and by benefiting from strong religious community support and social belonging (orman, ) . therefore, the prominent yet universal role religiosity plays in providing a moral framework and deterring unethical decisions can equally apply in the functioning of both financial and non-financial institutions, particularly during financial crises (marshall, ) . this is because a crisis period involves strengthening social capital to enable the members of religious groups or societies to cope with the crisis (steenekamp, du toit, & kotzé, ) . despite the increasing relevance of this strand of the literature, little evidence is documented about how religious individuals may behave when making decisions about firms during a period of crisis. studies on the impact of religiosity on banks during financial crises are quite limited (adhikari & agrawal, ) . furthermore, the conclusion is mixed on the impact of the financial crisis on firms' earnings management behaviour across the world (kumar & vij, ) . evidence from europe suggests that the overall level of earnings manipulation for countries in the continent dropped significantly during the crisis (filip & raffournier, ) . we argue that religious norms help individuals within groups to build social capital prior to the crisis period, which eventually results in the calmness, stability and resilience needed to cope with a crisis through communitarian mechanisms (woolcock & narayan, ) . the mechanisms enable the community-oriented activities that religion helps with by bringing religious people together and providing a sense of belonging. this develops into working at cross-purposes as a community and placing the society's collective interests above those of individuals in the hope of reward, either from the supreme being or through societal recognition of an exemplary pattern of behaviours encouraged by religious social norms (halikiopoulou & vasilopoulou, ) . this evidence is further strengthened by a recent survey which showed that over per cent of american citizens sought help from god with prayers during the crisis instigated by the covid- pandemic (pew research center, ). the prospect of religiosity in providing a positive pathway characterised by self-sacrifice and moral judgement could lead to improved earnings quality because individuals build more resilience with increased spirituality during crisis periods (orman, ) . thus, with bank managers acting as agents of socialisation, the effect of adherence to religious norms on earnings quality is more emphasised during a crisis than a non-crisis period. thus, our hypothesis is extended as follows: the association between religiosity and earnings quality is more pronounced during crisis periods. to measure banks' earnings quality, we rely on data provided by the starmine database. we choose the starmine earnings quality score (earnqual) as our dependent variable for various reasons. first, recent studies highlight that the explanatory power of accrual-based measures has dramatically declined (bushman, lerman, & zhang, ) . second, highest rank. fourth, the composition of the multi-factor earnings quality model is designed to provide higher ranks for stocks whose earnings are backed by cash flows and other sustainable sources, while it penalises firms that are driven by accruals and other less sustainable sources. in particular, low earnqual values are indicative of potentially low earnings sustainability over the subsequent twelve months. we follow kanagaretnam et al. ( ) , mcguire et al. ( ) , and parboteeah, hoegl, and cullen ( ) and define adherence to religious norms by capturing three distinct dimensions of religiosity, namely: (a) the cognitive, (b) the affective, and (c) the behavioural. we use data from the world values survey (wvs), specifically responses to questions about religious importance, religious affiliation, and religious services attendance that collectively determine adherence to religious norms as part of social norms. in particular, we create a measure of religiosity (relig), definable as the principal component of the proportion of respondents who indicate that (a) religion is important to them (rel_imp), (b) they are affiliated with a religion (rel_memb), and (c) they attend religious services (rel_serv). these three important components can define identity from the religious norms perspective. we build our model specification by considering previous studies (e.g., abdelsalam, dimitropoulos, elnahass, & leventis, ; kanagaretnam et al., ) and state our model as follows: earnqual = β + β relig + β inst_own + β gov_own + β ebt + β size + β leverage + β growth + β big + β ! cfo + β gdpgr + β corrup + β pop + β male + ∑ year + ε ( ) all the variables of our empirical model are estimated in terms of the us dollar. earnqual denotes the earnings quality metric (as presented in section . ). relig represents the principal components of the three religion variables rel_imp, rel_memb, and rel_serv (see section . for a description). we include several firm-level variables to control for cross-sectional differences in bank characteristics that may influence the relationship between religiosity and earnings quality. we include the percentage of stocks owned by institutional (inst_own) and governmental investors (gov_own). we anticipate a negative coefficient with banks' earnings quality as institutional investors can j o u r n a l p r e -p r o o f encourage short-term managerial behaviour among firm managers and increase earnings management (bhide, ) , while state-owned firms are associated with higher earnings management (megginson, nash, & van randenborgh, ; shleifer, ) . in eq. ( ), ebt denotes earnings before taxes deflated by lagged total assets (abdelsalam et al., ) . it represents a measure of a bank's capacity to use its assets to generate earnings in advance of its contractual relations and loan loss provisions (leventis, dimitropoulos, & anandarajan, ) . a positive coefficient is expected. we measure bank size as the natural logarithm of total assets (size). considering that larger banks are more visible to the public (leventis & dimitropoulos, ) and, thus, are less likely to engage in aggressive earnings management (cornett et al., ), we anticipate a positive coefficient for size. leverage represents the ratio of total debt to common equity and we expect a negative coefficient with earnings quality as levered banks are more likely to manage accounting earnings upward for capital adequacy requirements and regulatory scrutiny reasons (cornett et al., ; leventis & dimitropoulos, ) . growth captures the change in total assets and enters in our model as a measure of growth opportunities (kanagaretnam et al., ) . on the one hand, firms with increased growth opportunities were found to be associated with less discretionary accruals (lai, ) , especially when they experience increased monitoring. on the other hand, chen, elder, and hung ( ) demonstrate that high investment opportunities increase the likelihood of earnings management as controls in high-growth firms are less likely to be effective (anderson, francis, & stokes, ) . thus, we cannot infer any predictions about the sign of this coefficient. big is an indicator variable that equals one if the bank is audited by a big four audit firm (deloitte, pricewaterhousecoopers, ernst & young, and kpmg), and zero otherwise. banks audited by big firms are expected to report financial statements of enhanced quality and, consequently, are less likely to practice earnings management (gul, tsui, & dhaliwal, ) . we also control for net cash flow from operating activities deflated by average total assets (cfo) as a proxy for bank financial performance. we expect that highly performing banks are less likely to manipulate their accounting numbers (abdelsalam et al., ) . in eq. ( ), we also control for demographic characteristics bounded with religiosity. following prior studies, we augment our model for the natural logarithm of the country's population (pop) and the percentage of male residents (male) (hilary & hui, ), both retrieved on an annual basis through the world bank. we conclude our model for country-j o u r n a l p r e -p r o o f level macro-economic conditions by including the annual growth in gdp (gdpgr) (kanagaretnam et al., ) and the level of control for corruption in the country (abdelsalam et al., ) , derived through world bank's world governance indicators, as leuz, nanda, and wysocki ( ) document that corruption is a significant determinant of corporate accounting quality. corrup takes values between zero and , with the highest value indicating the highest level of perception of corruption, meaning more corruption in terms of the government and officials. throughout our analysis, we standardise corrup to be between zero and one. the standard errors of all the regression estimates are adjusted using heteroskedasticity corrected and clustered robust standard errors, clustered on banks. * denotes the error term. finally, we control for year dummies and winsorise all continuous variables at the top and bottom per cent to mitigate the effect of outliers; we present the variable definitions in appendix i. the literature advocates the existence of an interrelationship between religiosity and the quality of institutions, indicating a bidirectional version of causality (berggren & bjørnskov, ) . additionally, previous studies raise concerns about the potential endogeneity between religion and corporate behaviour (callen & fang, ; hilary & hui, ; jiang, john, li, & qian, ) with respect to potential omitted unobservable factors affecting people's faith in religion and earnings quality. to control for potential endogeneity, we adopt an instrumental variable two-stage least squares (iv- sls) and use the fox ( ) level of state regulation of religion (scx) as an instrumental variable. we differentiate from previous studies (i.e., barro & mccleary, ; mccleary & barro, ) in the way we measure the state regulation of religion, and instead of using a binary measure, we include a scale indicating the level to which each state is willing to restrict some or all religions. scx takes values from zero to five and captures the exact level of official restrictions on religion. we expect a negative relation between scx and relig since the higher the restrictions imposed, the higher the decrease in the efficiency of religion providers and, therefore, the lower the rates of religious services attendance (barro & mccleary, ; mccleary & barro, ) . although state regulation of religion is likely to be related to religiosity, there is no obvious reason why it should affect a bank's earnings quality. to test our predictions, we construct a global sample of all listed banks with common support across the orbis bank focus and starmine databases. we consider the period from to . we omit banks as the country of their corporate headquarters is not covered by the world values survey. our data requirements on the control variables in eq. ( ) drop a further banks due to missing financial information and due to missing ownership structure data. following beck, demirgüç-kunt, and merrouche ( ), our sample selection criteria require at least two bank-year observations for each bank within one country and at least two banks in one country, and thus we eliminate banks. our final sample comprises , banks (translated into , bank-year observations) scattered across countries (see table ). the right side of table shows the composite measure of religiosity (relig) and its constituents, as per country. the table shows that china, japan, and sweden are among the bottom three, while ghana, morocco, and the philippines are among the top three in terms of the importance of religion, affiliation with religion, and attendance of religious services. [insert table about here] empirical results we provide the descriptive statistics of the variables included in the analysis in table . the mean value of the dependent variable suggests that the average bank is ranked approximately th as compared to all other securities trading in the same region (earnqual = . ). the mean level of earnings before taxes is . per cent of total assets, similar to the values reported by abdelsalam et al. ( ) . the average bank has a leverage ratio of . and exhibits a positive growth ( . per cent) in its total assets, which is lower compared to the values reported in kanagaretnam et al. ( ) . finally, big audit firms audit . per cent of our sample banks. [insert table about here] j o u r n a l p r e -p r o o f table presents the pearson correlation coefficients among the sample variables. the largest correlation coefficients observed are those between cfo and ebt ( . ), and cfo and leverage (- . ), and thus suggest no serious problem of multicollinearity. this is also verified by the low values of the mean-variance inflation factors (vifs), which do not exceed . across all models and are even lower than the cut-off value of (studenmund, ) . finally, we observe that the main variable of interest, relig, exhibits a positive and statistically significant coefficient (at %) with earnqual. [insert table about here] column of table presents the impact of religiosity on the earnings quality of the bank compared to all other securities trading in the same region (earnqual) using an iv- sls approach. hence, we suppress the first-stage results for the sake of brevity, while we report the coefficient of the instrument for religiosity, namely scx. we observe that relig has a significant positive impact on earnings quality (p-value ≤ . ) after controlling for numerous bank-level and country-level control variables, and thus we accept h . the hausman statistic is significant (p-value ≤ . ). this indicates that iv- sls is the preferred estimation relative to the ols. the partial r-squares and the f-statistics indicate that the instrument is highly correlated with the endogenous variable. the high f-statistic of . is above the threshold of (staiger & stock, ) and suggests a strong instrument. referring to the control variables in column of table , most of the coefficients have the predicted sign. the negative coefficients of inst_own and gov_own corroborate the findings of previous studies (bhide, ; megginson et al., ; shleifer, ) . ebt and size have positive coefficients, supporting the notion that more profitable and larger banks, respectively, have higher earnings quality (cornett et al., ) . leverage is positive and significant at the per cent level. the positive sign contrasts the findings of previous studies (cornett et al., ; leventis & dimitropoulos, ) . the negative and statistically significant coefficient for growth is consistent with the findings of chen et al. ( ) . big is positive and significant (p-value ≤ . ) and indicates that big clients have better quality earnings (gul et al., ) . finally, the magnitude of corrup corroborates with leuz et al. ( ) as earnings quality increases with higher control for corruption. next, we test our sub-hypotheses regarding the variations in the effect of religiosity. in particular, we expect the effect of religiosity to vary due to cross-country differences. in order to assess the validity of our sub-hypotheses, we empirically test the effect of religiosity on banks' earnings quality in the several forms: (a) across banks located in countries where religion is important to national identity (h a in subsection . . ), (b) across banks located in countries with poor legal protection (h b in subsection . . ), and (c) during the global financial crisis period (h c in subsection . . ). we present these results in the sub-sections below. prior studies (halikiopoulou & vasilopoulou, ) to test this prediction, we collect data for the importance of religion on national identity from two sources. first, we consider the cross-national survey of the pew research center of across countries. second, we collect data from the international social survey programme (issp), which conducted three cross-national surveys during , and for countries. both organisations asked participants how important the "dominant denomination" is for being a truly "survey country nationality". using data from both sources, we create an aggregate measure, defined as the sum of the percentage of respondents indicating that religion is very important or somewhat important to their national identity. to overcome the issue of missing data because of the discontinued participation of certain for more information on the "global attitudes and trends" survey, conducted by the pew research center, please visit http://www.pewglobal.org/dataset/spring- -survey-data/ (accessed june, ). for more information on the issp's cross-national surveys, please visit https://www.gesis.org/issp/modules/issp-modules-by-topic/national-identity/ (accessed june, ). countries in the surveys, we use linear interpolation/extrapolation to fill any missing observations. in column of table , we test h a and incorporate the interaction term between relig and an indicator that equals one if more than per cent of respondents of the aforementioned sources indicated that religion is very important or somewhat important to their national identity (rel_import_nat_id), and zero otherwise. the coefficient of relig×rel_import_nat_id is positive and statistically significant (p-value ≤ . ). comparing the coefficient of the interaction term with that of relig in our baseline model (column ), religiosity has a stronger effect on a bank's earnings quality when it is an important element of a nation's identity. despite the observed negative coefficient of rel_import_nat_id (p-value ≤ . ), the relative impact of the interaction term has a higher magnitude, suggesting that the effect of religiosity strengthens in countries where religion is an important element of national identity, and thus we accept h a . in this section, we assess whether the effect of religiosity strengthens with weak country formal institutions (h b ). we use the legal rights index from the doing business project for economies, similar to qian et al. ( ) , to capture the strength of a country's legal protection. using the sample median of legal protection, we create an indicator variable (low_legal_prot) that equals one if the country's legal protection index is lower than the sample median, and zero otherwise. column in table indicates that the coefficient of the interaction term relig×low_legal_prot is positive and significant (p-value ≤ . ), suggesting that the impact of religiosity on banks' earnings quality is more prominent in countries with lax legal protection. therefore, our evidence confirms the notion that informal institutions have larger effects in regions where formal institutions are less effective (guiso et al., ; north, ; qian et al., ) , and thus we accept h b . we also examine whether the effect of religiosity on banks' earnings quality varies over time, and in particular during the global financial crisis period. we create an indicator linear interpolation/extrapolation is a common practice in the prior literature (see for example dyreng et al., ; kumar, page, & spalt, ) . the index ranges from to , and higher values indicate better legal protection. details of the index can be found at http://www.doingbusiness.org/ (accessed june, ). (crisis) that equals one for the crisis period (i.e., - ) , and zero otherwise. the coefficient of relig×crisis is positive and significant (p-value ≤ . , column of table ), while the crisis coefficient is statistically insignificant. comparing the coefficient of the interaction term with that of relig alone, the impact of religiosity is more than doubled during the financial crisis. such evidence is supportive of our last sub-hypothesis (h c ) and also consistent with the notion that the effect of religiosity is stronger during recessions and periods of turbulence in the market (adhikari & agrawal, ; jiang et al., ) . given that there are various ways to measure religiosity, we conduct additional tests to probe the robustness of our inferences for a significant association between religiosity and bank earnings quality. in this regard, we use the components of our measure of religiosity (relig), namely rel_imp, rel_memb, and rel_serv, as alternative measures of religiosity. panel a of table reports these additional tests, in which the coefficients of all three measures are positive and statistically significant (p-value ≤ . ). for this and all subsequent tests reported in table , we suppress the coefficient estimates for the remaining control variables of eq. ( ), which can be found in the online appendix. [insert table about here] in line with the prior literature (i.e., pevzner et al., ) , we examine whether our results are robust when using the logarithmic transformation (ln(earnqual)) of the earnings quality measure -this is to address the concern that the original measure has a skewed distribution. we also employ two alternative specifications of the earnqual proxy. first, we use the quality of the accruals component (eq_accr), which captures the changes in operating assets (both current and non-current) and liabilities during the last four quarters. second, we follow kanagaretnam et al. ( ) and capture earnings management through discretionary loan loss provisions (allp). we report the results in panel b of table . the coefficient of relig remains positive and statistically significant (p-value ≤ . ) when the dependent variable is ln(earnqual) or eq_accr (columns and of panel b, respectively). when the dependent variable is allp (column of panel b), the coefficient of relig becomes negative and statistically significant (p-value ≤ . ), which affirms the findings of the previous literature regarding the negative relation between religiosity and earnings management (kanagaretnam et al., ) . in this sub-section, we probe the robustness of our results using alternative sample constructs. first, we mitigate concerns related to the high representation of certain countries in our sample by excluding banks headquartered in the us, in japan, or in both countries. second, we exclude banks with total assets less than $ million and or $ trillion to accommodate concerns related to the positive association between bank size and earnings manipulation propensity (beatty, bin, & petroni, ) . repeating our analyses using the aforementioned sample constructs (see panel c of table ) does not alter our inferences as the coefficient of relig remains positive and statistically significant (p-value ≤ . ). beyond the aforementioned tests, we also examine the robustness of our inferences when augmenting eq. ( ) with additional control variables. we begin with the incorporation of alternative specifications of the control variables used in eq. ( ), namely size, leverage and growth opportunities. specifically, we control for (a) the natural logarithm of market capitalisation (lnmcap), (b) the ratio of total debt to total assets (lev), and (c) the market to book ratio (mb). panel d of table (columns to ) reveals that our inferences are not sensitive to alternative constructs of the control variables as the coefficient of relig is positive and significant (p-value ≤ . ). next, we replace the ownership structure variables with the percentage of shares held by the ultimate shareholder (ult_own). we intend to capture controlling shareholders' ability to control the firm by determining strategic corporate business decisions and how management is monitored and compensated (jensen & meckling, ; zou & adams, ) . column of panel d informs that the coefficient of relig remains positive and significant (p-value ≤ . ), while ult_own has a negative and significant coefficient (pvalue ≤ . ). the relative impact of ult_own is stronger, as compared to relig, and j o u r n a l p r e -p r o o f supports the findings by chen et al. ( ) for controlling shareholders being associated with higher earnings management. in addition to these tests, we include a battery of country-level controls to mitigate the omitted variables concerns regarding the multinational nature of our study and to isolate the potential effects arising from country cultural and demographic factors. hence, for the sake of brevity, we do not tabulate the following tests but present them in the online appendix. lopez-de-silanes, & shleifer, ) , (c) investor protection (pevzner et al., ) , (d) the quality of the audit function and the degree of accounting enforcement in each country (brown, preiato, & tarca, ) , and (e) income inequalities. finally, we control for demographic characteristics bounded with religiosity using the natural logarithm of the per capita income and the percentage of female residents, since iannaccone ( ) considers gender and income as influential determinants of religious participation at the individual level. incorporating all the aforementioned variables does not alter our inferences as the coefficient of relig remains positive and statistically significant at % or better. our study explores how the degree of religiosity in the country of corporate headquarters impacts the earnings quality of banks. the empirical analyses are consistent with the earlier predictions about the importance of religion as an informal control instrument for checking unethical corporate decisions. we demonstrate that religiosity has a significant positive impact on earnings quality after controlling for various bank-level and country-level variables. we also show that the effect of religiosity on banks' earnings quality becomes more pronounced among banks headquartered in countries where religion is an important element of national identity and in countries with weak legal protection. additionally, we provide evidence that the effects of religiosity are more than doubled during the global financial crisis period. a range of sensitivity tests lends support to the notion that religiosity can restrain the unethical activities of managers acting as agents of their shareholders, thereby minimising the risk of bank failure. in light of the above findings, our paper contributes to prior studies in the earnings quality literature by highlighting the positive influence of religiosity on the earnings quality of banks. furthermore, our study contributes to the understanding of the institutional effect of religious social norms (by focusing particularly on its informal characteristics) on the degree of earnings quality, particularly in jurisdictions with weak formal institutions. this contribution has a strong implication for the development of an effective regulatory framework by the policymakers, which could lead to a less costly but more efficient regulatory policy. the positive influence of religiosity on earnings quality is equally useful to investors, because it provides a comprehensive framework for considering investments, particularly in less developed countries that may have weak formal institutions but strong religiosity. moreover, we provide distinctive evidence through the lens of social norms theory on how the level of religious social norms collectively influences banks' earnings quality for certain countries where religion is part of their national identity compared to other countries where religion is not part of their national identity. the implication of this contribution for political office holders is important. for example, politicians can benefit by building a considerable national image and reputation that can enhance investors' confidence and attract better foreign direct investment into their countries. finally, this study contributes to the important debate on the nexus between religiosity and the earnings quality of banks during crisis periods. this contribution has implications for both regulators and societies. although our study considers the financial crisis, its findings offer some lessons for banks regarding their response to the covid- crisis, thereby potentially supporting the fact that people tend to be more spiritual and socially supportive during crises. this demonstrates the strength of religion in providing some sort of emotional succour and consistency in corporate decision making during a crisis. the foregoing contributions, we note the following limitations in our research design that could potentially impact our results. first, the religiosity variable is taken as a country-level average measure, although it may be different across decision-makers within banks. second, we assume that decision-making responsibility lies with the management and is influenced by the degree of religiosity of the large controlling shareholders. however, our data for the individual banks do not capture the religiosity of the shareholders; rather, we assume that they behave within the scope of the country average. these are potential avenues for future research. j o u r n a l p r e -p r o o f bank distribution and the mean values of our religiosity measure and its constituents as per country. rel_imp is the percentage of respondents that indicates religion is important to them (based on the wvs). rel_memb is the percentage of respondents says that they are a religious person (based on the wvs). rel_serv is the percentage of respondents says that they attend religious services (based on the wvs). relig is the first principal component of rel_imp, rel_memb, and rel_serv. the dependent variable across all models is earnqual, and represents the rank of earnings quality of the firm in the country of corporate headquarters, derived through starmine database, with higher values indicating higher rated firms. column indicates the effect of religiosity on earnings quality of global banks. the next three columns present the joint effect of religiosity and: (a) an indicator interaction variable signalling that is located in a country where religion is important to national identity (column ); (b) an indicator interaction variable signalling that is located in a country with weak legal protection (column ); and (c) an indicator for the global financial crisis (years and ) . the z-statistics in parentheses are based on heteroskedasticity corrected and clustered robust standard errors, clustered on banks. the continuous variables are winsorized at the st and th percentiles. for the sake of brevity, we suppress all other control variables included in the first-stage and indicate only the coefficient of the instrument (scx). we further present the fstatistic and partial r for the instrumental variables used for relig and its interaction separately (i.e., the first statistics correspond to scx, while the f-statistic and partial r at the bottom of the table refer to the interacted variables). all variables are defined in appendix i. * p < . , ** p < . , *** p < . in panel b we consider alternative measures of the dependent variable. panel c presents robustness using alternative sample constructs. panel d provides the analyses when considering for alternative constructs of the control variables and for ultimate ownership. the z-statistics in parentheses are based on heteroskedasticity corrected and clustered robust standard errors, clustered on banks. the continuous variables are winsorized at the st and th percentiles. for the sake of brevity, we suppress all other control variables and maintain only the variables of interest. we further present the f-statistic and partial r for the instrumental variables used for relig. all variables are defined in appendix i. * p < . , ** p < . , *** p < . earnings management behaviors under different monitoring mechanisms: the case of islamic and conventional banks is ethical money sensitive to past returns? the case of portfolio constraints and persistence in islamic funds does local religiosity matter for bank risk-taking? earnings management in malaysian 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( ) . discourses on religion and identity in norway: right-wing radicalism and anti-immigration parties. in e. earnqual is the rank of earnings quality of the firm in the country of corporate headquarters, derived through starmine database, with higher values indicating higher rated firms. relig is the first principal component of: (a) the percentage of respondents that indicates religion is important to them (rel_imp), (b) the percentage of respondents say that they are a religious person (rel_memb), and (c) the percentage of respondents say that they attend religious services (rel_serv). inst_own is the percentage of stocks owned by institutional investors. gov_own is the percentage of stocks owned by the government or governmental agencies. ebt is earnings before taxes deflated by lagged total assets. size is the natural logarithm of year-end total assets. leverage is the ratio of total debt to total common equity. growth is the annual growth rate of total assets. cfo is cash flow from operating activities deflated by average total assets. gdpgr is the annual growth rate of gdp. corrup is the control of corruption, which captures perceptions of the extent to which public power is exercised for private gain, including both petty and grand forms of corruption, as well as "capture" of the state by elites and private interests. percentile rank indicates the country's rank among all countries covered by the aggregate indicator, with corresponding to the lowest rank, and to the highest rank. we standardise corrup to be between zero and one. pop is the natural logarithm of the country's population. male is the percentage of male residents in the country of corporate headquarters. the observations use to capture the variables from the accounting measures are in thousands of us dollars. all variables are defined in appendix i. key: cord- -xu h ac authors: berlinguer, giovanni title: bioethics, health, and inequality date: - - journal: lancet doi: . /s - ( ) - sha: doc_id: cord_uid: xu h ac nan first, the technique of preimplantation genetic diagnosis (pgd), which was introduced after in-vitro fertilisation (ivf), allows recognition and elimination of an embryo with a genetic disorder or malformation and permits selection of sex. the international bioethics committee (ibc) of unesco (united nations educational, scientific, and cultural organization) recommended that "pgd be limited to medical indications. therefore sex selection for non-medical reasons is considered to be unethical." nevertheless pgd is also practised, and sometimes morally and legally justified, in developed countries. the debate in frontier bioethics concerns mainly the right of parents to decide the characteristics of their children. sex selection, however, is widely put into practice not only through elaborate technologies but also in daily life through infanticide, discrimination in nutrition and health care, and other barbarous methods. in , amartya sen showed the existence-on the basis of changes in the ratio of women to men in the total population of asia and africa-of hundreds of millions of missing women caused by similar actions. worldwide indignation and appropriate cultural and legal measures have been taken in several countries to reduce this situation. did anything change? sen revisited the data in , and reported that the reduction in female overmortality has been counterbalanced by the spread of sexselective abortion against the female fetus, and as a result the number of missing women is now greater. embryos, fetuses, or babies can be selected by many methods from different cultures, which manifest a unique and crude tendency-this selection is a sharp and visible aspect of gender inequality. in developed countries, acceptance of sex selection through biotechnological methods can hinder any effort to reduce any kind of sex selection in any part of the world. second, the question of whether the human body be bought and sold has a history as long as the existence of slavery, and has been a very embarrassing problem for philosophers, from aristotle to locke, and for theologians. the antislavery movements finally imposed its abolitionone of the most impressive cases of a turn in history by effect of moral principles. it led to the geneva convention (sept , ) , which called on all nations to pursue the suppression of slavery in all its forms, as soon as possible. but in many places, old and new forms of slavery still exist, including bonded labour, in which a worker or labourer is bound to a company or a landlord for life by inextinguishable debts. a type of such bonded slavery existed in the villages of sultanpur mela, kot momin, and mateela in pakistan. in this case, peasants-almost one in every family-sold one of their kidneys for less than us$ . specialised hospitals transplanted their organs into rich patients coming from different cities and other countries. the peasants were obliged to become rewarded donors for the hope or the illusion to free themselves from debts. in this way, slavery met the biotechnological market of spare parts of human bodies. such rewarded donation is the dark side of the enormous advantages coming from the possibility to transfer, from a person to another, organs, corneas, tissues, cells, gametes, stem cells, and other commodities. the moral question "is there a freedom to sell his own body?" was answered, to a certain extent, long ago by immanuel kant (man cannot be at the same time a person and an object; therefore we cannot sell any part of our body) and by john stuart mill (man has all the liberties, except that of choosing to be a slave). now the debate has been reopened. the june, , edition of the journal of medical ethics was dedicated to supply of organs for transplantation, and particularly to the moral legitimisation of the biotechnological market. in my opinion, the question would be most clear if raised the other way round: has a person the right to buy (or to rent) parts of the body of another human being? robert evans, a uk labour member of the european parliament, answered no, and proposed to declare illegal and punishable such practice, according to which wealthy people "are able to exploit desperate people with no fear of penalties". if the answer to this question is yes, the risk is to legitimise a society in which everything could be bought; ourselves, too, who would be regarded as the final commodity. third, prevailing opinion on human cloning is mainly in favour of the cloning of cells and tissues for therapeutic reasons but is against reproductive cloning because this technique denies the casual combination of genes, restricts individual freedom, and implies genetic predetermination. the few people who are in favour of reproductive cloning affirm that human beings are almost always largely predetermined insofar that they are born in a particular country, time, class, and family. if a person's destiny is to become social, cultural, and moral clones, why should genetic cloning not be permitted? perhaps human liberty and self-determination should prevail over all limits and obstacles, either due to social and gender injustice or manipulation of minds; use of science in favour of genetic arrogance would deny or discourage the daily efforts of any person to build autonomously his or her own future. can we develop universal principles in bioethics? these and similar cases could stimulate the debate and (i hope) growth, by consensus, of common universal values in bioethics and of moral norms, accompanied (sometimes) by legal international regulations. this action becomes necessary for two additional reasons. first, many scientific practices have extended beyond national borders, such as the legal (and sometimes illegal) importation and exportation of stem cells, tissue collections, organs, dna samples, and genetic data. moreover, human experiments are done in several countries, and we should avoid putting unnecessary burdens on poor people and communities or creating new forms of exploitation. the bioethical issues that are generated need fair solutions, in accordance with the plurality of values and with the common interests of the world community. second, positive actions for health are essential on a world and local scale. the idea that the combination of scientific progress and free market would spontaneously extend its benefits worldwide, which was dominant in the past two decades, has failed, and a paradoxical situation about science has arisen. new, impressive advances in biomedical knowledge, which at some times in the past were largely accessible-eg, in the s and s, use of antibiotics against microbial diseases and vaccines against smallpox and poliomyelitis-are now becoming more and more selective. many individuals affected by aids or other serious infectious diseases can benefit from new drugs and survive; however, most people cannot afford to pay for the drugs and could die. in africa and other areas of the world, aids could lead to catastrophic effects similar to those the black death caused in europe in - . according to roy porter, "plague killed a quarter of europe's population-and far more in some towns; the largest number of fatalities caused by a single epidemic disaster in the history of europe. this provoked a lasting demographic crisis." the differences are in the progress of the aids pandemic, which is slower than that of the black death but equally cruel, and in the fact that now we know the causes and possible remedies for aids, malaria, tuberculosis, and other scourges. the eradication of smallpox, the substantial reduction of childhood diarrhoeal deaths, and the elimination of poliomyelitis in countries show that www.thelancet.com vol september , wellcome library, london rights were not granted to include this image in electronic media. please refer to the printed journal. many goals have already been achieved through knowledge and common action. unfortunately, the undesired but foreseeable result of medical progress tends to increase inequalities, because it is oriented by vested interests and directed towards the rich instead of general goals. annette flanagin and margaret a winker wrote: "the contemporary era of globalization, which was anticipated to capitalize on advances in technology, science, communication, and cross-national interdependence, has been accompanied by gaps . . . and wide disparities in societal resources . . . moreover, only a small fraction of funds for biomedical research is dedicated to research that affects most the poor or supports research conducted by resource-poor scientists and for the benefit of resource-poor populations." the / gap refers to the fact that only % of the us$ billion spent on health research and development by the private and public sector is used for research into % of the world's health problems. a similar (or greater) imbalance exists for expenditures on prevention and health care. benefit-sharing and equal access to advances in biomedical science are now urgent and universal issues. this moral change in values and priorities should guide public policies on health at all levels. if we think of universal principles in bioethics, the fundamental ones should probably be equal dignity of every individual and equity of life, disease, and death. a step towards universal principles-on a european level-is the convention for the protection of human rights and dignity of the human being with regard to the application of biology and medicine, adopted by the council of europe in oviedo on april , , and opened to the signature of other nations. two fundamental articles state that the convention "shall protect the dignity and identity of all human beings and guarantee everyone, without discrimination, respect for their integrity and other rights and fundamental freedom" (article ), and that "the interests and welfare of human beings shall prevail over the sole interest of society or science" (article ). the convention includes articles on the rights of the patient, on equitable access to health care, on respect for private life, on non-discrimination on genetic grounds, on transplants, and on prohibition of financial gains "from the human body and his parts as such" (article ). at its st session in , the general council of unesco-after an explicit invitation of the round table of ministers of science-invited its director general to submit the technical and legal studies undertaken regarding the possibility of elaborating universal norms on bioethics. during and , the ibc of unesco worked on a feasibility study, and concluded in june, , with a report on the possibility of elaborating a universal instrument on bioethics, a declaration that is less binding than a convention. the nd session of unesco in october, , judged setting of universal standards in this area to be imperative and desirable, and invited the director general "to continue preparatory work on a declaration, and to submit a draft declaration at its rd session in , involving from the very beginning states, the united nations and the other specialized agencies of the un system, other inter-governmental and non-governmental organizations and appropriate national bodies and specialists". i know by personal experience in the ibc (in which i was a rapporteur) that to proceed from a feasibility study to a universal declaration on bioethics is almost impossible, but trying is worthwhile. the process of elaboration can be itself a contribution to the ethics debate, to knowledge and participation, as long as the existence of many different ethics, and bioethics in particular, is considered-not as an obstacle-but as an expression of richness and freedom. since the text of the preliminary report of the ibc is now publicly accessible, i will not discuss it in detail. i would only underline that, after the preliminary remarks, its first substantial section deals with health and health care (points , , and ) . it begins with this paragraph: "health has a dual moral value: it is essential for the quality of life and life itself, and is instrumental as a precondition for freedom. when disease prevails, the destiny of a person (and even of a nation) is left to external www.thelancet.com vol september , during the summer of , more than elderly people died in france ap rights were not granted to include this image in electronic media. please refer to the printed journal. factors and powers and may enter into an irreversible vicious circle of regression. the inequality between the rich and the poor-at the level of individuals, communities and nations-is becoming increasingly deeply felt in the area of health and healthcare, thereby contributing to the desperation and injustice that prevail and continue to increase in other health-related fields such as food, income and education." the main difficulty in practising moral principles concerning human dignity and equity in health is that in the past years a singular ethics (and a singular policy) prevailed in the world, which resulted in overturning the health paradigms that had successfully guided public health and health services for one century. the principle that health is a value and an objective of economic development has been replaced by the opposite idea: that systems of universal care represent one of the main obstacles to economic growth. the leadership of national health policies has been transferred from health ministers to economics ministers, and internationally (particularly in developing and under-developed countries) was influenced more by the international monetary fund (imf), the world bank, and the world trade organization (wto) than by who. even when the negative results of their policies in relation to equity became clear, and the action of who (whose president at the time was gro harlem brundtland) succeeded in bringing health back on the world political agenda, the model of the commission appointed by who on macroeconomic and health continues to be that of the influential report of the world bank, investing in health. the model does not include any critical analysis "of currently dominant macroeconomic policies or of the structure and mechanisms that entrench developing countries disadvantage, ill health, and deteriorating services". in this framework, the debate refers mainly to healthcare systems, putting aside the concepts of healthy societies and systems. the idea of the priority of primary health care and of the prevention accessible to everybody has been supplanted by high technologies, even in countries where the resources are minimal. discussions on resources for health have been restricted to monetary aspects, ignoring the many possibilities of human resources, of changes in environment and workplace, and of improvements in nutrition and education. the need to identify priorities and to distribute fairly the resources for health care is replaced by the idea of rationing them: not through priorities and universal inclusion, but through selective exclusion. the analysis of diseases' causes has been concentrated mainly on individual factors, such as genes and behaviours, whereas the role of social factors, so important for disadvantaged people, has been neglected. the role of social factors is sometimes even concealed. one example is in the world health report ( ). another example comes from the death, during the summer of , of more than elderly men and women in france, many of them poor or socially marginalised; of more than in germany and italy; and of others in many other european countries. it is true that in august the temperature in these countries was unusually high, but this risk had been widely described in epidemiological research, and preventive measures for elderly people in such conditions are available in almost all gerontology textbooks. the almost unanimous comment of the media was that they were killed by the heat. commentators forgot the isolation, loneliness, lack of attention by many family doctors and local health services, absence of any warning or information being broadcast on television (which is often the only communication between non-self-sufficient elderly individuals and the rest of the community), and insufficient funding for active assistance and care at home. the ministers of health were surprised by the events, and local health authorities tried to underestimate and even to conceal numbers (almost like the epidemic of severe acute respiratory syndrome in china). very few raised two general questions: what else can we expect for world health from potential climate change, and what should we do about present and future risks? at the end of the s, new political and moral trends began to emerge in the world, and new emphasis was given to health and equity in health. these trends became very influential culturally, although they were politically contradicted by the orientations of the dominant powers. health was reintroduced to the international political agenda. in many countries, researchers have shown a growing interest in health equity, inspired either by their moral and scientific sensitivity, or by evidence. the main efforts were inspired by the attempt to integrate altruism and self-interest, to reconsider health as an indivisible good, and by the refusal of simple charitable transfers of benefits among countries or groups. this is an old idea, now defined as compassionate conservatism, which may include the virtue of ethics but has two faults: ( ) those who are helped are placed in a compromising, dependent position, treated as victims not agents; and ( ) societal rules and structures that generate such social consequences are not addressed. public opinion, nevertheless, became more critical towards inequities in health, probably for two reasons. one is that the inequity in health, which often means life or death, raises higher indignation than other inequities concerning income or material goods. the other is an increased knowledge of reality through public inquiries, books, medical journals, and campaigns. a few years ago, amartya sen, closing in dhaka the bangladesh session of the global equity in health initiative in , said: "information concerning discrimination, torture, poverty, illness, and abandonment helps coalesce the forces opposing these events by extending the opposition to the general public. this is because the people have the capacity and willingness of reacting to other people's difficulties." evidence confirms the willingness of people to help others. millions, mainly young people, are working in voluntary services at home or abroad. often, they combine in their activities two aspects that in the past have been separated and even conflicting: to struggle for collective interests, and at the same time to work daily to help individuals. on the political and cultural scene, the role of civil society and of community organisations has increased almost everywhere. a new generation has emerged that criticises the effects of one-sided globalisation on environment, health, justice, and relations between science and society, which underlines that a better world is possible and demands peace. there are some analogies with the youth movements of the late s, but also three differences that can make this new movement more lasting and more effective: their extension beyond schools and far beyond the usa and western europe; their will to integrate criticism with proposals; and their growing influence on national policies and on international agencies, as we can see from two examples. one example is the victory obtained against the bill of indictment, requested by the multinational pharmaceutical industries to the south african court against nelson mandela and his government, for the crime of producing and importing antiretrovirals by ignoring or violating patents. mandela made the decision to ignore the patent to make therapies accessible for the poor population, in a country where one in nine people is hivpositive. after global criticism from governments, nongovernmental organisations, hiv/aids specialists, and a globalised movement mainly organised through the internet, the pharmaceutical companies decided not to pursue the case. after a bitter struggle between the companies and who, new rules were adopted. it is now possible to suspend or limit the royalties for "intellectual property" in case of widespread epidemics: a partial victory in what could be called, perhaps improperly, conflict between patents and patients. later, in october, , the south african competition commission concluded that the companies "had overcharged for the drugs and had limited their licensing to competitors to try to suppress competition"; and finally, in december of that year, glaxosmithkline and boehringer ingelheim, while still rejecting the accusation, agreed to reduce the price for therapy by as much as %. a door has been opened for new international rules on everyday bioethics. the second example is the wto meeting in cancun, mexico, sept - , , where no agreement was reached on trade in agricultural and industrial products, and the attempt to push decisions on fundamental issues, such as the privatisation of water resources and of health and educational services, completely failed. the consequences of this failure may be contradictory, but surely a new factor emerged: the formation of an alliance between more than developing countries who represent more than half of the world's population, and antiglobalisation movements. developing countries have been deeply divided in the past - years, and have had almost no voice in the international arena. cultural and political antiglobalisation groups had already gained publicity in seattle years ago, and now had common goals with many governments. so far, the main result is the defeat of the proposal to extend rules governing the trade of commodities to the services for persons, such as health and education, and to natural resources. the argument has been that such services affect human rights, are essential for human life and growth, and that nations should decide how to guarantee them to all citizens. the two cases show how far other international agencies such as the wto, the imf, and the world bank, are involved in decisions about people's health, which often is not considered as a value but a variable and uncomfortable element of the economic system. as far as ethics is concerned, the difference is that who does have a moral obligation towards people's health, whereas the wto, the imf, and the world bank do not. during and after the recent change in the who leadership, there was much discussion about its future, such as the stimulating debate in the lancet. at the same time, the connections between health and human security became more evident. the un appointed an ad hoc commission that stated: "in addition to the persistent problems and vulnerabilities with which the world has long been familiar, there is a new wave of dramatic crises at the turn of the millennium related to terrorist attacks, ethnic violence, epidemics and sudden economic downturns. there is also a fear that existing institutions and policies are not able to cope with weakening multilateralism, failing respect for human rights, eroding commitments to eradicate poverty and deprivation, outdated sectarian perspectives in educations systems and the tendency to neglect global responsibilities in an increasingly interrelated world. at the same time, the opportunities for working towards removing insecurity across the world are also larger than ever before." two deep contradictions are now arising. one is the move back to the idea of security, which was historically intended (with mixed intentions and results) to counter the threat of aggression across borders or violence against people. in the th century this concept was deepened and expanded through the experience of the welfare state and through the emergence of new personal and collective rights. the questions are now: what security, and for whom? not only against the threat of attacks and crimes against nations and persons, but also for individuals and their dignity; for human welfare, health, and nutrition; for water and clean air; for the biosphere; and for the interests of future generations. the other contradiction is the policy of governments like the usa that, in the struggle against the threat ofinternational terrorism, choose to use their military and repressive power, without addressing the social, cultural, and political causes that cannot ever justify but might explain the growth of terrorism. from a practical point of view, the results of this policy are dubious at the very least. from an ethical point of view, it restricts the range of individuals who could contribute to society; it might demobilise popular, intellectual, and political energies; it introduces a rigid separation between those who are considered good and those who are branded evil; and it weakens the duties of public authorities and international institutions to face other individual and collective needs. the future of health, health policies, and health equity is strictly connected to the resolution of these contradictions. everyday bioethics: reflections on bioethical choices in daily life letters from prison report of the ibc on preimplantation genetic diagnosis and germ-line intervention: shs-est/ /cib- / . geneva: united nations educational, scientific, and cultural organization missing women missing women: revisited il villaggio dei disperati: qui tutti si vendono i reni (the village of the desperates: here all sell their kidneys) il corriere della sera oct la merce finale: saggio sulla compravendita di parti del corpo umano (the final commodity: an essay on the sale and purchase of parts of the human body). milan: baldini and castoldi attack on organ trade begins with transplant tourists. the times the greatest benefit to mankind: a medical history of mankind global health: targeting problems and achieving solutions convention for the protection of human rights and dignity of the human being with regard to the application of biology and medicine (convention on human rights and biomedicine) report of the ibc on the possiblility of elaborating a universal statement on bioethics investing in health: world development indicators the report of the commission on macroeconomics and health: a summary critical appraisal: geneva: who the world health report : reducing risks, promoting healthy life. geneva: world health organization morti da canicola: epidemiologia per non dimenticare challenging inequities in health: from equity to action agreement expands generic drugs in south africa to fight aids who director-general elections-join the lancet debate united commission on human security (ogata s, sen a, co-chairs) what is security? key: cord- -b rxh bd authors: nouhjah, sedigheh; jahanfar, shayesteh title: challenges of diabetes care management in developing countries with a high incidence of covid- : a brief report date: - - journal: diabetes metab syndr doi: . /j.dsx. . . sha: doc_id: cord_uid: b rxh bd background and aims: diabetes mellitus (dm) is one of the most critical risk factors for complications and death in covid- patients. the present study aims to highlight challenges in the management of diabetic patients during the covid- outbreak in developing countries. methods: we reviewed the literature to obtain information about diabetic care during the covid- crisis. we also seek opinions of clinicians working in undeveloped countries. results: current challenges faced by clinicians in the management of diabetic patients in developing countries are as follows: lack of preventive measures, inadequate number of visits, loss of the traditional method of communication with the patient, shortage of medications, impaired routine diabetic care, and absence of telehealth services. conclusions: developing countries are faced with many challenges in diabetes management due to a lack of resources. challenges of diabetes care management in developing countries with a high incidence of covid- : a brief report highlights • covid- pandemic may be a potentially diabetogenic situation and may worsen hyperglycemia and possibly diabetes-related complications • challenges faced by developing countries in managing diabetes during covid- outbreak is different from those in developed countries. • strategies for better management of diabetes care during current crisis should be based on available resources. background and aims: diabetes mellitus (dm) is one of the most critical risk factors for complications and death in covid- patients. the present study aims to highlight challenges in the management of diabetic patients during the covid- outbreak in developing countries. methods: we reviewed the literature to obtain information about diabetic care during the covid- crisis. we also seek opinions of clinicians working in undeveloped countries. results: current challenges faced by clinicians in the management of diabetic patients in developing countries are as follows: lack of preventive measures, inadequate number of visits, loss of the traditional method of communication with the patient, shortage of medications, impaired routine diabetic care, and absence of telehealth services. conclusions: developing countries are faced with many challenges in diabetes management due to a lack of resources. the covid- crisis is a severe public health concern in the world. it is now well recognized that older age, diabetes mellitus, severe obesity (bmi≥ kg/m ), and hypertension increase the risk of complications and death in covid- patients [ ] [ ] [ ] . diabetes affects coronavirus mortality, and the process of its recovery and covid- will impact management, self-care, and prevention strategies. we need proper guidelines specifically designed to reduce diabetes complications, during, and following the pandemic. stress and physical inactivity at home also increase the risk of obesity, worsening of hyperglycemia (increase in hba c), and increase in diabetes-related complications [ ] . at the end of this tragic story, we might learn that the covid- outbreak was potentially diabetogenic, increasing the burden of disease on the community. of all patients with diabetes mellitus, % live in developing countries. now, more than ever, these countries are faced with many challenges in the management of diabetes. some problems are common between all countries, but some are unique to developing countries with low-income. these countries are faced with many pressing health issues due to practical, political, cultural, and social dilemmas [ ] . the most significant challenges are as follows: . with the absence of sick pay or social security, low-income nations have less tolerance to most of the recommended preventive measures such as preservation of social distancing, use of protective gear, and avoiding the utilization of emergency health services. . access to drugs, especially insulin, is restricted and needs a physician's prescription. disparities in health care delivery and drug access make the situation worse. . infectious diseases such as the covid- outbreak over-utilize governmental hospitals and non-communicable disease units in health care centers, hence access to care is diminished for diabetic patients. admission to hospitals for diabetic patients who need care is proven difficult. admissions to hospitals are restricted to a specific number of hospitals. moreover, the hospital requires documentation from the patient to prove a negative covid-test before allowing admission. this adds to the cost of care, which might further complicate receiving care for diabetic patients. . routine diabetic care is significantly impaired during the current epidemic. many outpatient clinics and training units have been closed. many private clinics of endocrinologists are also temporarily shut down. this leaves the private sector to provide emergency services to non-covid patients, only. many patients can't use such private services due to a lack of insurance or facility to pay for services. . due to the fear of illness, patients do not visit a few opened laboratories to monitor their blood sugar status, and many do not have a glucometer for self -monitoring. . the basis of education and treatment of diabetes in low-income countries is limited to a faceto-face visit of the endocrinologist or primary care provider. there are no telemedicine practices, so in this epidemic, preventive measures which traditionally were communicated with patients have been disrupted. . experience of video call and online non-face-to-face communication exists for a limited number of cases. the use of text messages and social networks are more likely to be merely available for those patients participating in research activities. . many patients are elderly and illiterate or have little literacy. they can't afford to use new smartphones. even if the cellphone was provided, they would have difficulty utilizing it and require training to do so. . providers do not engage with digital health tools, so telehealth services don't work in this situation. . there is no integrated national registration system for diabetes to provide a connection with limited digital health services. . in some areas, the scientific societies are still in shock, having lost their usual communication tools (meetings, etc.) and are, therefore, inactive. the majority of members of such societies are health care providers themselves and are engaged in delivering necessary health care themselves. few strategies for better management of diabetes in the covid- crisis were suggested for low-income countries. the available guidelines are mostly adopted for developed countries and do not foresee critical problems faced by diabetic patients in undeveloped countries. the most essential suggestions of such guidelines were using telehealth, remote patient monitoring, wearable technologies, implementation of online services for glucose management, popularization of internet and smartphones, utilization of free educational videos, e-books on diabetes self-management, and covid- prevention advice for the public via wechat mobile app. to improve such wireless communications emerging fifth-generation networks were also suggested [ ] [ ] [ ] . none of these are potentially possible for undeveloped nations due to poverty, lack of education, and poor health care planning. is there a way for us to localize such experiences? due to the noted barriers, we need innovative strategies to deliver care to patients with dm in resource-poor settings. some potential suggestions are as follows: *replace active follow-up with passive care, recall patients with diabetes mellitus *establish vibrant centers for visit and training outside of hospitals in local mosques, churches, community centers *activate more outpatients clinics and primary health care centers *recommend self-monitoring of blood glucose by providing the monitors to patients free of charge *utilize text message education and interventions for those who have access to smart cell phones *provide guidelines for physicians on how to manage clinical cases during the period given the conditions dictated to low-income countries *allocate individual telephone numbers for people with diabetics to receive a consultation from endocrinologists via landlines which potentially is more available compared to cell phones *send an educational video by the smartphone of other family members and finally *conduct needs assessment surveys by trained investigators these strategies might partially alleviate the burden on diabetic patients under current emergency circumstances and may play a small role in reducing complications imposed by the lack of care on a diabetic patient. reducing morbidity and mortality of diabetic patients in the future depends on our sound action in these difficult times. case-fatality rate and characteristics of patients dying in relation to covid- in italy national diabetes statistics report clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study. the lancet estimation of effects of nationwide lockdown for containing coronavirus infection on worsening of glycosylated haemoglobin and increase in diabetes-related complications: a simulation model using multivariate regression analysis. diabetes & metabolic syndrome management of diabetes in resource-poor settings timely blood glucose management for the outbreak of novel coronavirus disease (covid- ) is urgently needed. diabetes research and clinical practice covid- infection in italian people with diabetes: lessons learned for our future (an experience to be used) kamlesh khunt, managing diabetes during the covid- pandemic the authors declare that there is no conflict of interest. n.s and j.s conceived the idea, prepared, and wrote this report. • covid- pandemic may be a potentially diabetogenic situation and may worsen hyperglycemia and possibly diabetes-related complications • challenges faced by developing countries in managing diabetes during covid- outbreak is different from those in developed countries.• strategies for better management of diabetes care during current crisis should be based on available resources. key: cord- - v grqa authors: kasilingam, dharun; prabhakaran, s.p sathiya; dinesh kumar, r; rajagopal, varthini; santhosh kumar, t; soundararaj, ajitha title: exploring the growth of covid‐ cases using exponential modelling across countries and predicting signs of early containment using machine learning date: - - journal: transbound emerg dis doi: . /tbed. sha: doc_id: cord_uid: v grqa covid‐ pandemic disease spread by the sars‐cov‐ single‐strand structure rna virus, belongs to the (th) generation of the coronavirus family. following an unusual replication mechanism, it’s extreme ease of transmissivity has put many counties under lockdown. with uncertainty of developing a cure/vaccine for the infection in the near future, the onus currently lies on healthcare infrastructure, policies, government activities, and behaviour of the people to contain the virus. this research uses exponential growth modelling studies to understand the spreading patterns of the covid‐ virus and identifies countries that have shown early signs of containment until (th) march . predictive supervised machine learning models are built using infrastructure, environment, policies, and infection‐related independent variables to predict early containment. covid‐ infection data across countries are used. logistic regression results show a positive significant relationship between healthcare infrastructure and lockdown policies, and signs of early containment. machine learning models based on logistic regression, decision tree, random forest, and support vector machines are developed and show accuracies between . % to . % to predict early signs of infection containment. other policies and the decisions taken by countries to contain the infection are also discussed. coronaviruses, though uncommon, are serious pathogens responsible for infections that posit flu-like symptoms in infected individuals. these symptoms sometimes resemble the cold and cough symptoms caused by the rhinovirus. recently, the family has added its seventh generation coronavirus -sars-cov- (chengxin et al., ) . the virus shares % identity to severe acute respiratory syndrome (sars) and % identity to middle east respiratory syndrome (mers) epidemic outbreak in and (salute, ) . sarc-cov- that causes covid- mutated to transmit from animal to human. this virus is believed to have transferred to humans through bats from a meat market in wuhan, china (rajendran et al., ; shereen et al., ) . in march , who declared the covid- to be a pandemic; a pandemic being described as an infection that has spread across countries and international borders rather than within a local region or neighbouring countries. the sarc-cov- is a deadly corona virus that is transmitted readily between humans and already infected more than , people all over the world in countries as on th march which led global shutdowns (who, ) . the fatality rate has varied among countries and age groups. until june , the fatality rate averaged . % with italy recording the highest of . %. the fatality rate of us, germany, and india were . %, . %, and . % respectively until june (our world in data, ) . of the total deaths, less than % belonged to the age group of less than years thereby indicating that the younger population is much more resilient to the covid- (worldmeters, ) . while these fatality rates are significantly less than those of mers ( . %) and sars ( . %) (petrosillo et al., ) , covid- has severe transmissivity because of the possibility of asymptomatic people being carriers and spreaders of the virus (daw et al., ) . the reproduction number r for sarc-cov- has been found to be between . to . (sheng et al., ) . a value of r greater than indicates that the disease can invade the human population and higher the value, the easier is it's spread. sarc-cov- is the largest single-strand rna virus known to the humankind; while other viruses have a single protein spike for attachment to the human cell, this coronavirus family has to spike proteins, which makes it easier for the virus to attach itself to the ace- protein in humans (paraskevis et al., ) . the virus follows an unusual double step replication mechanism, which leads to high rates of proliferation (luan et al., ) . the this article is protected by copyright. all rights reserved incubation period is typically to days, and the infected person often does not have serious symptoms, rather showing common symptoms associated with flu and pneumonia (rodeny, ) . general symptoms of pneumonia include fever, cough, chest pain, shortness of pain, fatigue, headache, myalgia, and arthralgia (sattar sba, ) . in addition to symptoms of pneumonia, covid- infected individuals may experience a loss of taste or smell, nausea, congestion, and diarrhoea (cdc, ) . there are a few drugs that are being recommended and used to manage the symptoms of covid- , but there has, as yet, been no vaccines that are proven to be effective against the coronavirus family, including covid- (sexton et al., ; gautret et al., ) . in the absence of vaccines, it is imperative to check transmission of the virus by alternative ways (dey et al., ) . policy changes in pandemic and epidemic situations involve social distancing, lockdowns, travel restrictions, awareness campaigns etc. it has been speculated in past research that environmental conditions of countries like temperature and humidity also sometimes play a significant role in controlling pandemics (lin et al., ) . quantitative covid- impact analyses are scarce in literature, given the recency of the pandemic and more studies in this area are necessary, given the seriousness of the infection. epidemics are assumed to have an exponential growth at an early stage and the number of infections reduces over time, due to interventions like lockdowns, travel restrictions, awareness programs, etc. mathematical modelling studies using exponential growth analysis coupled with machine learning could provide a better prediction model for covid- transmission (keeling and danon, ; siettos and russo, ; victor, ) . such models must incorporate the various precautionary measures taken during the viral outbreak. the objective of the research is to develop a mathematical model using exponential growth analysis coupled with machine learning, to predict worldwide covid- early containment signs. models have been developed based on data collected from countries. the objectives of this work are twofold. first, it seeks to identify countries that were successful in early containment of the covid- virus. secondly, the research aims at building supervised machine learning models with high accuracies for predicting signs of early containment with infrastructure availability, environmental factors, infection severity factors, and government policies of countries as independent variables. in the process of modelling, the significance of the above variables in containing the infection at early stages is this article is protected by copyright. all rights reserved also studied. this report also includes a discussion on other activities undertaken by the governments of various nations to flatten the infections curve and their corresponding effectiveness. covid- is believed to have originated in an animal meat market in wuhan, china and it is thought to have been transmitted from bats (shereen et al., ) . within few months, the virus has rapidly spread across the world, through transmissions of fluids and aerosol particles between humans. initially, all diagnosed cases outside china had a travel history to the wuhan market. soon, community transfer caused exponential increases in infections in countries like italy, us, uk, korea, japan, etc. the ability of the sars-cov- virus to double replicate with the spike protein, has posed significant challenges to the development of vaccines (shereen et al., ) . while hydroxychloroquine and azithromycin have been recommended by some researchers, to treat covid- -infected people, there haven't been too many clinical trials to validate the claim (gautret et al., ) . thus, until a scientifically validate cure or vaccine is developed, countries have to rely on preventive measures to contain the spread. this, in turn, depends on epidemiological studies that can predict spreading patterns so that policymakers can take appropriate protective measures. several viruses including sars have been reported to be vulnerable to hot temperatures, which results in differences in spreading patterns across geographic locations (zhang et al., ) . however, such geographic variations have not yet been analysed for covid- . other factors like government policies and interventions, infrastructure availability, and the severity of the infection itself can affect the ability of a country to contain epidemics and pandemics. this research seeks to explore all the above factors. the climatic conditions such as temperature and humidity play an important role in both airborne and aerosol virus transmissions. the -year human relationship with the influenza virus has proven that the mortality rate is directly related to temperature and humidity (lowen and steel, ) . hence, in order to minimize transmission of diseases, isolation wards in hospitals generally tend to have optimized pressure, temperature, and humidity (who, ) . research on the virus in the diamond cruise ship off the coast of japan showed that a one-degree rise in temperature and a one percent increase in pressure this article is protected by copyright. all rights reserved could reduce the reproduction number r down by . - . . it must be mentioned that the generalizability of the study is questionable because the ship was a contained environment and the results may not apply to the real world (sheng et al., ) . certain studies in china and indonesia have investigated the relationship between the temperature and the spread of infection and resultant deaths and have reported a low to medium level of correlation (tosepu et al., ; yueling ma et al., ) . relative humidity was found to have low to no correlation with infection spread or deaths. global warming has also been a reason for recent temperature increases and certain studies indicate that this can reduce flu based viral infections (national research council, ; actuaries, ; dincer et al., ) . however, these statements need to be further validated. while the spread of virus may be affected by climatic conditions, once the virus enters the human body, it is independent of the outside environment. however, since the virus lives outside the human body for a period of at least hours under normal conditions (richard, ) , it is necessary to study the effects of the environmental on the spreading patterns itself. social distancing, although a new terminology for the st century, is not a new approach to epidemic control. it was used by the united kingdom in to control the influenza virus outbreak that caused about million deaths. social distancing involves the avoidance of mass gatherings and distancing of at least six feet between people. such measures are combined with enhanced personal hygiene through regular hand wash, and wearing a protective mask for flu-like outbreaks (yu et al., ; leung et al., ) . this is done primarily because flu causing viruses are spread through aerosols generated from saliva and nasal fluid, which can be transmitted across distances as much as three feet. the average lifetime of covid- viruses in the outer environment is believed to be about hours, which increases transmissivity because aerosols from infected people can settle on doorknobs, lifts, transports, hotels, malls etc. and stay active for a long time, thus increasing the window of transmission. direct physical contacts, such as hand-shaking, are also avenues of transmission of the virus. the reduction of social contact has been proven to significantly reduce flu-like diseases (maharaj and kleczkowski, ) . the closure of schools and malls flattened the this article is protected by copyright. all rights reserved spread curve during the influenza pandemic in (rashid et al., n.d.; moh, ) . thus, governments worldwide have stressed on social distancing and quarantining measures for at least daysthe typical incubation period of covid- virus -to contain its spread (prem et al., ) . lockdown is a preventive strategy taken by local, central or global administration during the spread of epidemic or pandemic diseases and involves stopping transportation between cities, provinces or counties. the world has so far seen four major pandemics, viz., plague in the th century, influenza in , sars in , and the current covid- in as reported by who (porta, ; east et al., ; pi, ) . in all these cases, lockdowns were implemented by various countries to control the outbreaks. china announced lockdown as early as january , to flatten the curve of the covid- infections over time. in march, most countries around the globe announced lockdowns of local transport, office, industries, city and national borders to contain the virus (callaway et al., ) . although quarantine centres for the infected are available in hospitals, large-scale infections necessitate self-quarantines and lockdown measures, in addition to the hospital-based quarantines (wuhan, ) . during epidemic and pandemic viral outbreaks, the availability of and access to health care infrastructure such as hospitals, beds, healthcare workers, clinical equipment, first aid kits, ventilators, and protective equipment are vital to pandemic management (bambas and drayton, ; persoff et al., ) . during the massive influenza outbreak of , even developed countries had inadequate health care infrastructure, which further expanded the outbreak (george, ). the ebola outbreak in west africa became uncontrollable due to lack of infrastructure facilities (paweska et al., ) . after the outbreak, who in south africa had asked the hospitals to report their available facilities to plan for future infections optimally (murrin, ) . innovative measures have been recommended, to create necessary healthcare infrastructure during pandemic and epidemic situations by converting schools, colleges, theatres, and stadiums into hospitals and quarantine centres (wimberly, ; nuzzo et al., ) . health care workers supported by ngos, youth, and volunteers also play a significant role in containing outbreaks (itzwerth, ) . hence studying health care this article is protected by copyright. all rights reserved infrastructure availability across countries can predict covid- containment at an early stage. predictive modelling using machine learning and growth models can provide actionable insights to policy makers and governments to contain epidemic and pandemic infections (thompson et al., ) . during the onset of an epidemic, it is crucial to use exponential growth models to understand the infection rates and with proper policy implementations and behavioural changes among the susceptible group of the population, the slope reduces and the curve flattens over time (keeling and danon, ). for other outbreaks like smallpox, ebola, sars, and influenza, various studies have used mathematical and statistical modelling to understand the growth of infections (dietz, ; nishiura, ; kerkhove and ferguson, ) . in fact, the centres for disease control and prevention has an exclusive book with established procedures for analysing disease outbreaks, stressing on the importance of the such modelling studies. (dicker, ) in outbreaks, epidemiologists generally use the exponential growth model at the onset of an outbreak and proceed with prediction and classification techniques like regression, decision trees, neural networks deep learning, etc. to forecast outbreaks. (sameni, ; victor, ) . there are few studies on modelling and predicting containment of covid- so far (lin et al., ; prem et al., ) . the research work reported in this paper, sought to integrate crucial variables concerning infrastructure, environment, policies, and severity of the disease to predict initial signs of containment. the study used a machine learning and exponential growth model. the variables used as part of the predictive mode were, doctors per population, beds per population, average temperature, average humidity, days since official lockdown, percentage of lockdown days, total cases per million population, deaths per million population, days since the first contact, and percentage of serious cases of infected. data associated with the variables were collected from different official sources for a total of counties with respect to covid- infections as on th march . this accounts for , covid- cases comprising of . % of the total infections this article is protected by copyright. all rights reserved worldwide. the daily number of infections, recovery, and deaths were collected from the website of the who. the data for infrastructure-centred variables like the number of hospitals and the number of doctors were taken form (world bank, ) . environmentbased variables like average temperature and humidity since the onset of covid- was taken from (weather underground, ). day-wise covid- case distributions extracted from who were used to identify countries that showed sign of containment of the virus based on a novel exponential growth modelling approach. raw data from the sources were also consolidated and the variables physicians per thousand individuals, hospitals per thousand individuals, percentage of lockdown days since the first contact, cases per million population, deaths per million population, days since the first case, serious cases per thousand infections, average temperature since the first infection, and average humidity since the first infection were calculated to train the machine learning models. most epidemic and pandemic diseases grow exponentially in the initial stages of the outset in a country (ma, ) . a popular modelling technique that demonstrates this is the susceptible-infectious-recovered (sir) model (kermack et al., ) . if s denotes the fraction of susceptible individuals to a pandemic, i indicates the fraction of infectious people, r is the fraction of recovered patients, β indicates the transmission rate per infectious individual, and the recovery rate is denoted by γ, the infectious period is exponentially distributed with a mean of / γ as shown below. linearizing this about the disease-free equilibrium, we get the following. hence from the above expression, if − > , then the infection function i(t) grows exponentially about the disease-free equilibrium point. in addition to this, at the onset of the infection, ≈ and hence the incidence rate = also grows exponentially. hence, modelling the initial stages on a pandemic like covid- is both relevant and crucial in understanding the growth of the infection. although sub-exponential and polynomial modelling have worked in cases of outbreaks like ebola, hiv, and foot and mouth diseases (chowell et al., ) , they generally work well with proceeding generations. for pandemics like covid- , the exponential growth model is relevant and the use of least-squares at the initial stages can afford precise insights. figure shows the analysis plan to achieve the objectives of the research. this article is protected by copyright. all rights reserved the exponential growth model assumes that the onset of any outbreak follows an exponential distribution. however, due to government interventions, medical innovations, behavioural changes etc, at a later stage, the growth curve flattens and rate of infections gradually reduces (kermack et al., ) . to identify such signs, we looked at the infections in the last seven-day period and the deviation of the data points from the modelled exponential curve was captured using the mean absolute percentage error metric. based on the errors and the direction in which the actual data points were to the modelled growth curve, the countries were classified according to whether they showed initial sign of containment or not. in line with the objectives of the study, classifiers were built based on a set of independent variables to predict if a country that has covid- infections showed early signs of infection containment as a reflection of policy implementations and behaviour changes. logistic regression was used to understand the list of independent variables significantly affecting the infection containment and their corresponding importance in the model. then, to predict signs of early containment, machine learning algorithms like logistic regression, decision trees, random forest and support vector machines were used and their corresponding accuracies are compared. for all models, cross-validation was done in folds to address overfitting. logistic regression by le cessie and van houwelingen, ( ) is a generalized linear model (glm) and is one of the most widely used classifiers. according to (kondofersky and theis, ) , when there is binary response, as in this research, by using logistic regression one typically aims at estimating the conditional probability . as with simple linear regression, bearing equation = + , estimating the dependent variable y directly, the logistic regression estimates p( = ) using the following equation. this article is protected by copyright. all rights reserved as with multiple linear regression, logistic regression can also handle multiple independent variables and its probability estimate can be represented as follows. = + −( + + ……+ the conditional probability ( = | = ) can be calculated using the odds ratio /( − ). the significance of the beta coefficient values ( , , , … , ) in the above equation can be tested to see if their corresponding independent variables ( , , , … , ) are influencers of the dependent variable. a wald test is generally conducted to evaluate the statistical significance of the coefficients in the model. since logistic regression falls under the category of glm, the significance of each independent variable in predicting the outcome of the dependent variable, sign of early containment, can be studied. a decision tree is a decision support model that illustrates the consequences, chance, and event outcomes of certain decisions. decision trees are used as a predictive model to make statistical conclusions about an item's target value, based on observations. in this tree structure, leaves represent class labels and branches represent conjunctions of features that lead to those class labels. there are both classification trees where the response variable takes on a set of categorical values and regression trees where the response variable takes on a set of continuous values. the collective name for such trees is classification and regression trees (cart), first introduced and developed by (breiman et al., ) in classification and regression trees. decision trees use two metrics namely entropy and information gain to arrive at the final tree. entropy is the measure of the total amount of uncertainity in the dataset and is given as follows: s -the data set for which entropy is to be calculated cset of classes in the data set s p(c)ratio of number of elements in class c to the number of elements in set s this article is protected by copyright. all rights reserved when the entropy value is equal to zero, the dataset s is perfectly classified. the information gain metric is defined as the measure of the difference in the entropy from before to after the dataset s is split based on an atribute a and is given as follows. step : compute entropy for the dataset step : for every feature in the dataset, compute the following i. calculate the entropy for all the categorical values ii. find the average information entropy for current attributes iii. calculate the gain for curret attributes step : select the attribute with the highest gain step : repeat from step till the desired tree is achieved introduced by (breiman, ) , random forest is a statistical supervised machine learning technique that we used for both regression and classification. this is an ensemble learning technique that uses an averaged combination of many decision trees for the final prediction. the technique of averaging a statistical machine learning model is called bagging and it improves stability and avoids overfitting (hastie et al., ) . normally, decision trees are not competitive to the best-supervised learning approaches in terms of prediction accuracy since they tend to have high variance and low bias. this is because building two different decision trees can yield in two different trees. bagging is therefore well suited for this article is protected by copyright. all rights reserved decision tress since it reduces the variance. the idea behind random forests is to draw bootstrap samples from the training data set and then build several different decision trees on the different training samples. this method is called random forest because it chooses random input variables before every split when building each tree. by doing this, each tree would have reduced covariance, which, in turn, would lower the overall variance even further (hastie et al., ) . the random forest algorithm has two stagesrandom forest creation followed by random forest prediction. the steps involved in the stages are as follows. step : randomly select 'k' features from the total 'm' features available in the dataset where k << m step : using the best split point, calculate the node 'd', among the selected 'k' step : split the node into daughter nodes using the best split step : repeat steps to until 'l' nodes are reached step : repeat steps to for 'n' number times to create a forest of 'n' number of trees stage ii: random forest prediction step : using the features and applying the rules of randomly selected decision tree, predict the outcome and store it as a predicted target step : calculate the votes for each predicted target step : the highest voted predicted target will be the prediction of the random forest algorithm the objective of support vector machine (svm) is to find a line that best separates the data into multiple groups. this is achieved by an optimization process supported by the data in the training set. these instances are called support vectors and they form a crucial role in the classification process (flake and lawrence, ) . finally, few datasets can be separated with just a straight line. sometimes a line with curves or even polygonal regions must be marked. this is achieved with svm by projecting the data into a higher-dimensional space to draw the lines and make predictions. svms calculate a maximum margin around the boundary that ultimately results in a homogenous partition. the ultimate goal is to establish a this article is protected by copyright. all rights reserved margin as wide as possible. in order to so, a lagrange multiplier has to be constructed as follows and maximized. ( , ) = + table shows the result for logistic regression with early containment as the dependent variable. of all the independent variables, the availability of beds in hospitals and the percentage of lockdown days significantly and positively affected the signs of early this article is protected by copyright. all rights reserved containment. other variables did not significantly influence the dependent variables. the model had an accuracy of . % in the classification. the true positive and false negative rates were found to be . % and . % respectively. precision and recall values were . and . . the f score and roc values were found to be . and . respectively. a j decision tree was constructed for predicting early infection containment with the independent variables listed in figure . the batch size was set to and a confidence factor was selected as . . the minimum number of objects on the tree was set as . the accuracy of the tree was found to be . %. the variables in the decision tree were percentage lockdown days, days since official lockdown, and death rate per million population. the decision tree is shown in figure . the true positive and false negative rates were found to be % and . % respectively. precision and recall values were . and . . the f score and roc values were found to be . and . respectively. a random forest ensemble algorithm was created with combined trees. the batch size was selected as and the depth of the trees was set to unlimited. other metrics for the random forest algorithm are given in table . this model reported a high accuracy figure of . % in correctly classifying countries that showed signs of early containment. the true positive and false negative rates were found to be . % and . % respectively. precision and recall values were . and . . the f score and roc values were found to be . and . respectively. in order to make predictions for signs of early containment, an svm was modelled this article is protected by copyright. all rights reserved on -fold cross-validation with the data for all the algorithms and models, it can be inferred that the random forest design produces the minimum error and maximum accuracy as reported in table . it outshines all the other machine learning algorithms constructed in the study. j decision tree, logistic regression and svm produce almost similar levels of accuracy in predicting the sign of containment of covid- . this research is one of the first of its kind to integrate exponential growth modelling with machine learning techniques for predicting the spread of covid- . the research presents machine learning models based on variables such as infrastructure, environment, policies, and the infection itself, to predict early signs of containment in the country. for the purpose, disease data from leading countries in covid- infections were taken and exponential growth modelling was used to see if the countries showed signs of containment. then with the sign of the early containment of the infection as a dependent variable, supervised machine learning predictive models including logistic regression, decision tree, random forest, and support vector machine were developed. this research can directly be of use to countries and policymakers to understand if their proposed interventions are effective in containing infections even during early stages. (tosepu et al., ; yueling ma et al., ) . however, the long-term effect of environmental factors on the infection rates may prove to be significant. decision tree analysis also shows that early signs of containment are possible if the number of lockdown days is at least . % of the days since the first contact to contain the infection. if that is not the case, countries show recovery signs if the lockdown is at least days or more. for countries with a lockdown period less than days, variable depicting the number of deaths per million population plays a significant role in containing the infection. this variable is indirectly related to the health care infrastructure of countries like beds, physician, ventilators, icus etc. hence in any pandemic situation, governments must be proactive and frame policies even at the onset, thereby reducing the risk of spread, which would ultimately lead to early containment. this also emphasises on the need for resilient health care infrastructure to contain infections at an early stage. the machine learning models random forest and support vector machines were able to classify the countries with respect to their signs of early containment with an accuracy of . and . percentages, respectively, proving random forest to be the best machine learning algorithm for the problem studied. although this research applies data from only countries, the proposed models with their corresponding hyper parameters can be extended to predict early containment for the other countries as well. similarly, although these models were built only for the covid- pandemic, they can serve as a base for other future pandemics that have similar characteristics and reproduction numbers thereby giving governments the necessary information to take timely actions to protect both people and the economy. this article is protected by copyright. all rights reserved act called covid- act which has proven to be effective to contain the infection (library of congress, ). the number of hospital beds per population of austria was also high, which facilitated early recovery. chile has implemented sanitary barriers and intense screening mechanisms to track and quarantine the infected (us embassy, ). in addition to tough quarantine measures, denmark closed down schools and also announced lockdown in march. employers were also instructed to not cut salaries of the employees on quarantine thereby encouraging social distancing and hence containing the infection (carstensen, a) . japan, south korea, and singapore did not announce any lockdowns. south korea used processes that led to early detection of the covid- and quarantining the infected, thus stopping spread. they also predicted the movement of viruses and tactical interventions were taken to minimize spread (npr, ). singapore had a ready infrastructure with isolation wards in place during the sars outbreak and was readily equipped, which led to early containment of covid- . strong community engagement messages and communications from the government also led to better pandemic management in singapore (fisher, a) . most other countries that showed early signs of recovery rigorously followed lockdowns, social distancing, travel restrictions, and testing to contain infections. another reason for the countries like japan, korea and austria to contain the infection was the presence of availability of strong health care infrastructures in these countries to address the infections. the various actions taken by the government to control the transmission of covid- are shown in table . countries like italy, brazil, india, malaysia, pakistan, united kingdom etc. do not have the necessary health care infrastructure to support mass admission of covid- patients and hence need to rely on intense lockdowns to contain the infections. the increase in the number of covid- cases in the us and the inability to contain it is also due to late lockdown decision of the government post-outbreak. the percentage of lockdown days since the first infection continues to be low for these countries to be on a recovery path against the infection. with time, there is a high probability that the infection will be contained. however, in the long run, these countries must invest in improving health care facilities to reduce causalities during pandemics. countries must be prepared for epidemics and pandemics and proactive policies and infrastructure as in the case of singapore can save more lives than reactive measures. it is evident that covid- , unlike sars, will not be controlled by environmental factors and any future outbreaks will still rely on healthcare infrastructures, timely lockdowns, and social distancing for containment. this article is protected by copyright. all rights reserved there is no conflict of interest with the authors. no funding received. the data is openly available in world health organisation report. the research confined to the highest level of ethics. this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved gesley, ) brazil employees at the airport were asked to wear a mask. borders were closed for flights from affected countries (cdcp, ) canada all travellers were forced to self-isolate for days upon entry to control the outbreak (gc, ) chile screening in the airport was enhanced and people with symptoms were iran followed strict social distancing and lockdown (duddu, ) ireland invested in massive testing facilities. treated all patients equally irrespective of their income strata. all hospitals operated on a not for profit basis (bbc, this article is protected by copyright. all rights reserved ) used technology to track the movement of infected individuals with their mobiles and quarantined the people who came in contact with the individual (lomas, ) italy though italy closed borders during the onset, lack of proper testing facilities caused a massive outbreak. this was followed by a strict lockdown (gary, ) japan managed the outbreak with rules and excellent medical infrastructure. (japan, ) luxembourg quarantined people over years to reduce casualties (piscitelli, ) malaysia the banned entry of people from infected countries followed with additional screening measures in the airport. promoted personal hygiene and eventually ended with a lockdown. (world, a) netherlands travellers returning from affected countries were advised to visit doctors and medical facilities if symptoms were felt. post outbreak, the country went under lockdown. (world, b) norway travel bans and closure of schools, public services like gums, malls, theatres etc. (norway panorama, ) formed a team to monitor situations and take necessary actions on a daily basis. (pakistan, ) portugal employed strict lockdown (ivo oliveira, ) qatar proper tracking, and strict screening and testing of travellers (health, ) republic of korea proactively built a centralized testing and quarantine facility before an outbreak in the country. china's reports triggered this action (beaubien, ) romania lockdown and border closing (gherasim, ) singapore with previous experience from sars pandemic, the country had a proper infrastructure facility with negative pressure room for pandemic control. the testing was done rigorously and the infected were not let back into society. migrants from other countries were not allowed to work until the pandemic is controlled. (fisher, b) slovenia used innovative ways to spread covid- control messages before going into lockdown. (slovenija, ) south africa immediately implemented entry and exit to affected countries. declared as a this article is protected by copyright. all rights reserved national disaster and went for the lockdown to prevent a major outbreak (fihlani, ) spain local movement controlled by social distancing. travel to an affected country completely banned. enhanced medical attention at arrival to control the spread. (kate mayberry, ) after closing school, colleges and non-essential business, the country used their military and civilian support to enhance infrastructure and healthcare needs to contain the infection (keystone, ) the united kingdom people with symptoms were asked to self-quarantine. cancelled overseas travels and only tested people who were admitted. followed social distancing, lookdown, isolation and house quarantined. the country did not force people for testing. (yong, ) united states of america enforce travel restriction and implemented mandatory quarantine in new york. a level of screening and lockdown was implemented. 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protected by copyright. all rights reserved emergency management, epidemics, government, infectious and parasitic diseases, public health test every suspected case" of covid- -live updates mathematical modelling of infectious diseases : cnn, why is covid- death rate so low in germany epidemic and intervention modelling -a of the royal society of london. s.a. mckendrick containing papers of a mathematical, and physical character, : a contribution to the mathematical theory of epidemics : swissinfo, coronavirus: the situation in switzerland statistical learning with sparsity: the lasso and generalizations : iceland review, steps taken to prevent spread of covid- in iceland ridge estimators in logistic regression individual preventive social distancing during an epidemic may have negative population-level outcomes austria: government tightens rules to contain spread of coronavirus : international journal of infectious diseases a conceptual model for the coronavirus disease ( covid- ) 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model : a case study of pandemic influenza : the nordic page, norway government takes radical decisions against spread of coronavirus: first time since ww how south korea reined in the outbreak without shutting everything down what makes health systems resilient against infectious disease outbreaks and natural hazards ? results from a scoping review channel news asia, covid- self-isolation is punishing the poor in indonesia gulf news, steps pakistan is taking to contain coronavirus : full-genome evolutionary analysis of the novel corona virus ( -ncov ) rejects the hypothesis of emergence as a result of a recent recombination event a modular high biosafety field laboratory the role of hospital medicine in emergency preparedness: a framework for hospitalist leadership in disaster preparedness, response, and recovery elsevier has created a covid- resource centre with free information in english and mandarin on the novel coronavirus covid- . the covid- resource centre is hosted on elsevier 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report of the who-china joint mission on coronavirus disease : digitalcommons @ unmc pandemic planning : estimating disease burden of pandemic influenza to guide preparedness planning decisions for nebraska medicine physicians (per , people) [online] available at accepted article this article is protected by copyright a: garda world, malaysia: new travel restrictions introduced february /update b: garda world, netherlands: government confirms first case of covid- nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study : locked down wuhan and why we always overplay the threat of the new kenan malik china ' s reaction to the coronavirus outbreak may have the opposite effect to what ' s needed : tthe atlantic, the u.k.'s coronavirus 'herd immunity' debacle effects of reactive social distancing on the influenza pandemic effects of temperature variation and humidity on the death of covid- in sars-cov- turned positive in a discharged patient with covid- arouses concern regarding the present standard for discharge : estimating the effective reproduction number of the -ncov in china this article is protected by copyright. all rights reserved key: cord- -ng ydl authors: marques, antónio cardoso; caetano, rafaela title: the impact of foreign direct investment on emission reduction targets: evidence from high- and middle-income countries date: - - journal: nan doi: . /j.strueco. . . sha: doc_id: cord_uid: ng ydl besides bringing countries closer, the effects of globalization can help increase the production of goods and services, and foster economic growth. foreign direct investment (fdi) is one of the processes of globalization. one aspect of globalization that has piqued the interest of economists, is the transfer of polluting industries between countries. a principal factor in this are discrepancies of environmental regulations, and these have also been instrumental in a failure to control pollution worldwide. with this impasse in mind, a panel autoregressive distributed lag was applied to evaluate the impacts of fdi on the carbon dioxide emissions of countries divided by income level, for a period from to . this methodology allowed the analysis of the resulting dynamics of pollution into the short-run and long-run. the characteristics of efficiency, innovation, and regulation are crucial to better understand the consequences of flows in fdi. regulation seems to increase pollution in high-income countries, which merits further discussion. fdi decreases emissions in high-income countries, while increasing them in the short-run in middle-income countries, which supports the pollution haven hypothesis. nonetheless, the capacity of middle-income countries to absorb technology is crucial for them to benefit in the long-run. trade openness is also highly influenced by environmental regulation in middle-income countries. since our aim is to understand the transfer of polluting industries, an analysis of emissions from the industrial sector provided a robustness check. it also revealed that policymakers do not seem to be paying sufficient attention to innovation and controlling the environmental degradation that this sector causes. a country that wants to transfer green technologies and knowledge through fdi will evaluate the capabilities of prospective recipient countries, such as their capacity for innovation and efficiency. conversely, a country that wants to relocate its polluting industries to another country to circumvent environmental taxes, will search for a country with lower environmental regulations. this paper contributes by expanding knowledge in this area, by providing empirical evidence that reveals that regulatory measures seem to be less effective in reducing emissions in high-income countries. this surprising finding strongly suggests that further discussion of the regulatory structure of these countries is needed, and should be further investigated. the study also found that trade openness is highly influenced by regulation in middle-income countries. apparently, these countries are almost entirely focused on developing new patents with the aim of increasing their income, and not to improve environmental performance. furthermore, the dichotomy found between short-and long-run impacts, is further indication of the need to use the ardl model, as a failure to use this type of dynamic analysis could well result in misleading results. indeed, fdi was shown to decrease overall pollution and from the pollution from the industry sector in high-income countries, while increasing it in middle-income countries in the short-run. this suggests that the transfer of polluting industries from high to middle-income countries confirms the phh. however, middle-income countries could also be receiving clean fdi but, as will be discussed in this paper, their capacity to absorb technology also influences the impact of fdi on the environment. the ardl model also provides better evidence on this technology-absorptive-capacity of countries, as it analyses the impacts over time. the rest of the paper is organized as follows: section presents a theoretical background; section discloses the data and methodology; section reveals the results and discussion about overall co emissions and those from industry, with a brief comparison between models; and section concludes. the industrial structure of countries has been continually evolving since the industrial revolution. as industrial output has increased, so have co emissions, and with that, environmental degradation has emerged. fdi has an important role in economic growth (omri et al., ) . however, besides the effect on economic growth, fdi also impacts the environment of host countries. the relationship between fdi and the environment was initially analysed by academics through the impact of international trade on the environment, and subsequently, by considering the effect of fdi on the environmental quality of host countries (shahbaz et al., ) . international trade (reflected in trade openness) is still of great value and its effects are commonly evaluated in this field (e.g., essandoh et al., ; sbia et al., ) . in addition to its high correlation and granger causality with fdi, trade openness also has an effect on pollution. essandoh et al., ( ) find that trade openness is environmentally favourable for developed countries, with no evidence of impact in developing countries. however, as noted by ren et al., ( ) , trade openness could harm the environment if countries have a comparative advantage in dirty production due to weak environmental regulations. the irresponsible behaviour of certain countries in order to increase their income, increases pollution, impacting the global environment, and ultimately leads to climate change. however, unlike the economic recessions the world encounter, climate changes may be irreversible (doytch & uctum, ) . the characteristics of a country matter when evaluating the impact of fdi on the environment, because fdi, per se, does not have an impact. there is contrasting empirical evidence in the literature about the effect of fdi on the environment. for some countries, fdi has a positive and significant role in reducing emissions due to the transfer and adoption of greener technology. this technology boosts efficiency (pao & tsai, ) and improves environmental quality. however, in other countries, fdi increases co emissions (ren et al., ) contributing to environmental degradation. in addition to the different characteristics of the countries, the adoption of different empirical methodologies or different periods may also impact the resulting conclusions (zhang & zhou, ) . in several studies, the effect of fdi on the environment is divided into three categories: technique, structural, and scale effects (see liang, ; he, ; cole & elliott, ) . the technique effect is based on the diffusion of new and more efficient machines, for example, though fdi (pazienza, ) , which decreases the emissions per unit of a good produced. this effect also suggests that the introduction of environmental regulations can improve the environment by decreasing emissions (shahbaz et al., ) . the structural effect is related to the characteristics of an economy. for instance, an economy whose production of goods is energy-intensive, consumes more energy than an economy specializing in the services sector (pazienza, ) . succinctly, the effect of fdi depends on the comparative advantage and specialization of the sectors of an economy (shahbaz et al., ) . lastly, the scale effect states that as fdi increases the industrial output of the host country, it also increases energy consumption and co emissions (pao & tsai, ) . a country's characteristics may amplify the impacts of fdi. it can harm the environment in countries with lower environmental awareness (xing & kolstad, ) , or improve environmental quality in countries more conscious of its importance as referred by demena & afesorgbor ( ) . these characteristics are more exploited in the three main hypotheses associated with the fdi-environment nexus: the porter, pollution halo, and pollution haven hypotheses. the porter hypothesis states that fdi can improve the environmental quality of host countries by introducing new technologies that consume less energy; the so-called eco-friendly technologies (c. zhang & zhou, ; mielnik & goldemberg, ) . the main impetus for this are environmental regulations that encourage firms to invest in green innovation (shen et al., ) to improve their efficiency. however, both regulation and the development of new technologies lead to an increase in costs. thus, it is important to bear in mind the cost-benefit analysis, because regulations can only promote innovation when their benefits exceed their costs. in other words, to benefit the environment, regulation should offset the cost of environmental compliance by improving the competitiveness of firms (shen et al., ) . the pollution halo hypothesis is based on the positive effect that fdi has on the environment. the transfer of new technologies that can decrease energy consumption (mielnik & goldemberg, ) , and the transfer of business knowledge-so-called "know-how"- (shahbaz et al., ) are some examples of benefits that fdi can bring to countries if multinationals are less pollution-intensive (cole et al., ) . the countries' characteristics are relevant to determining this impact, because countries with higher levels of environmental awareness are unlikely to accept polluting fdi. finally, the phh states that fdi harms the environment in host countries (e.g., baek, ; al-mulali, ) . countries with strict environmental regulations transfer their polluting industries to countries with more relaxed environmental laws, to avoid additional costs and taxes (shahbaz et al., ) . however, the phh only occurs when it is relatively easy and inexpensive to transfer the industries. this divides industries into two groups as dou & han, ( ) state: strongly-, and weakly-mobile pollution industries. strongly-mobile industries will be relocated when environmental regulations become more stringent, whereas weakly-mobile industries will invest in r&d to improve efficiency; and effect known as "innovation compensation" (dou & han, ). thus, environmental regulation is the main focus of these two hypotheses, which state that the effect of fdi on pollution depends on the level of environmental regulation of host countries. some literature links the environmental regulation and environmental performance of the countries, mainly reflected in their levels of pollution. on the one hand, environmental regulation may improve environmental quality, by increasing the productivity and efficiency of the country's firms, mainly through saving energy (n. zhang & choi, ) , which means that regulation can decrease pollution (hashmi & alam, ) . on the other hand, environmental regulation could produce an inhibitory effect on green innovation for some firms and industries, by imposing additional costs (gray & shadbegian, ) . this negative effect could result in the transfer of industries to countries with lower environmental standards (z. dong et al., ) , as suggested by the phh. energy-efficiency and innovation emerge as important factors in the debate about the effects of environmental regulation on pollution. the extensive literature about energy consumption states that it is detrimental to the environment, which means that advances in energy-efficiency could help reduce pollution (balsalobre-lorente et al., ) . inflows of clean fdi, and investment in r&d targeting innovation, could both improve energy-efficiency. therefore, policies on energy innovation are required, since economic growth cannot improve pollution by itself, and the continued promotion of energy innovation can reduce emissions (balsalobre-lorente et al., ) . furthermore, innovation can help countries improve their environmental performance by reducing the cost of environmental compliance, and could also help countries boost their sustainable economic growth (balsalobre-lorente et al., ) . to analyse the full impact of fdi on the environment, it is crucial to consider variables that represent the specific characteristics of the host countries, complemented with a transversal consideration of their impacts over time. in this paper, the ardl is used to distinguish between short-and long-run impacts. to better understand the effect of inward fdi on host countries, this study empirically considers their levels of innovation, efficiency, and regulation, thus filling an important gap in the literature. source countries evaluate specific features of a country before providing investment there, and these features are considered in this paper. countries that want to transfer polluting industries will check if environmental restrictions are more relaxed in the potential host country. however, countries that want to increase global access to technology, by transferring their green technologies to another country, will check the efficiency, and innovation capabilities of host countries. as polluting industries are generally transferred between countries with different levels of development and income, the countries in the study were divided by income level to better investigate this transfer. analysis of the industry sector was found to produce stronger evidence of the phh and could serve as a robustness check. the results suggest that policymakers should realize that policies directly related to fdi should be carefully considered, because they not only affect fdi, but also the environment. in this paper, a panel of countries was studied, namely: argentina, austria, bulgaria, croatia, the czech republic, france, germany, greece, hungary, ireland, japan, the netherlands, norway, peru, philippines, portugal, romania, south africa, spain, turkey, and the united kingdom. the period studied was from to . the sample was selected according to the availability of data to create as larger a panel as possible. data on the environmentally-related tax revenue variable is less available for low-middle and upper-middle countries, as is that for industrial production. the lack of data on these variables reduced the number of countries under scrutiny, particularly middle-income countries. the countries were divided into high-or middleincome countries, according to the world bank's classification (see more in table appendix (a )). given the limited availability of data on the variables for lower-middle-income and upper-middle-income countries, both the upper-and lower-middle countries were combined in the same group. as mentioned above, the efficiency level of the countries is important for evaluating the impacts of fdi. in this study, the energy efficiency index represents the industrial efficiency of the countries and was calculated using equation ( ). this concept was developed by patterson ( ) and reveals how many units of input are necessary to produce an output unit (marques et al., ) . ( ) industrial production was used as a proxy of the industrial production index (ipi) to represent the output. energy consumption from industry in kwh was also used. recent studies indicate that the incorporation of energy consumption in co emissions regressions could produce biased results (jaforullah & king, ) , and for this reason, energy efficiency was considered more suitable. in the literature, co emissions are commonly used as a proxy of environmental pollution. co emissions from the industrial sector represent the environmental pollution derived from the industry. gross fixed capital formation (gfcf) was used as a proxy of a country's economic performance. gfcf could be related to capital intensive industries, as increasing the capital invested in a production process generally results in higher energy consumption that may, in turn, increase pollution (sapkota & bastola, ) . trade as a share of gdp (to) represents trade openness, as is usual in the literature (e.g., essandoh et al., ; sbia et al., ) , and has a higher correlation with fdi, and also granger causality, meaning that trade is, most probably, related to fdi. environmentally-related tax revenue (reg) is used as a proxy for environmental regulation (hashmi & alam, ) . environmental regulations may stimulate innovation as suggested by the literature (kneller & manderson, ; lee et al., ; johnstone et al., ) , which could mean that countries with a high level of innovation do not admit polluting or inefficient industries. to evaluate this, patents (pat) were used to measure the innovation level of the countries (burhan et al., ). all numerical variables are converted into per capita, and then into natural logarithms. as they represented a share of gdp, the variables to and reg are directly converted into natural logarithms. the descriptive statistics of the variables are shown in table a . preliminary tests were carried out to assess the presence of multicollinearity, collinearity, and the cross-sectional dependence of variables. to do this, correlation matrices, vif, and cross-sectional dependence tests were used. cross-sectional dependence (cd) must be checked in panel data studies since, if it is present, this means that the observations on individual countries are no longer independent, but affect each other's outcomes. this must be corrected as it can produce misleading results (de hoyos & sarafidis, ) . the null hypothesis of the crosssectional dependence test proposed by pesaran ( ) is cross-sectional independence. tables a and a reveal that none of these phenomena are a concern. first-generation unit root tests may not be effective for assessing the order of integration of the variables in the presence of individual cd, as stated by pesaran ( ) . therefore, both first-generation unit roots tests (levin et al., ; maddala & wu, ) and a second-generation unit roots test, crosssectional augmented ips (cips) (pesaran, ) , were carried out, following shahbaz et al., ( ) . these tests suggested that all variables are stationary in their levelsi.e. i( ) -and on their first differences -i( ) -, which further vindicates the use of the ardl model. the ardl model was proposed by pesaran et al., ( ) . the main motivation for using this methodology is that it allows an analysis of the dynamic effects of the variables, by analysing effects in the short-and long-run. the specification of the ardl model is the following: ( ) to capture the dynamic relationships between variables, the parameters of equation ( ) were reparametrized to the following equation: ( ) the prefix "d" represents the first differences of variables, and "l" the natural logarithm. is an intercept. are the short-run coefficients of the explanatory variables, are the long-run outputs, t refers to the period analysed in years, i represents the cross (countries), and is the error term. lco it- represents the error correction mechanism (ecm), that is, the long-run coefficient of the lagged dependent variable. to avoid biased results, the robust hausman test was carried out (see, e.g., neves et al., ) with bootstrap repetitions to check for the presence of the individual effects by countries. this test was carried out instead of a traditional hausman test, because it more appropriated in the presence of heteroskedasticity and/or serial correlation (neves et al., ) . the results showed that the fixed effects estimator was suitable to use, and it also highlighted the existence of individual effects. moreover, in this section, three other diagnostic tests were carried out on the residuals, to further analyse the data's characteristics, namely: (i) the modified wald test to verify the existence heteroskedasticity with the null hypothesis of homoskedasticity; (ii) the breusch pagan lm test to analyse the cross-sectional correlation with the null hypothesis of cross-sectional independence; and (iii) the wooldridge to test existence of first-order serial autocorrelation with the null hypothesis of no first-order serial autocorrelation. the existence of cross-section dependence, first-order serial correlation, and heteroskedasticity in the high-income countries model, allowed the use of the driscoll & kraay ( ) estimator (dk), as this estimator produces robust standard errors with these characteristics and allows the utilization of fixed effects (neves et al., ) . the dk was also used in the middle-income countries model. this section consists of three subsections. the first two reveal the results and discussion for both overall co emissions and co emissions from the industry. the majority of the results from the analyses of co emissions from the industry sector corroborated the results from overall co emissions, thereby providing a robustness check. furthermore, the analysis of the industry sector provides useful additional information about the impact on pollution of the sector's levels of innovation and regulation, which merits considerable attention; this issue is further explored in the final subsection in a comparison between the models. the long-run elasticities were derived from the ratio between the coefficient of the respective variable and the ecm; both lagged once, and this ratio was subsequently multiplied by - . the socio-economic context of the countries was considered and controlled through the inclusion of impulse dummies. failing to consider socio-economic events could produce misleading results. consequently, the zivot & andrews ( ) (za) unit root test was performed to verify the existence of any structural breaks, and the results are presented in table a , in the appendix. jointly considering the results of the za test, an analysis of each country's socio-economic context, and an analysis of the residuals, the milestones were identified and evaluated. in addition, a test of overall significance was carried out, with the null hypothesis that the coefficients of dummies are equal to (see table a ). following the united nations framework convention on climate change (unfccc), norway registered an increase in its co emissions of % in , compared to . in , portugal installed % more renewable energy capacity, and its emissions reduced by . %. according to statistics portugal (ine) , portugal registered green patents that year. these improvements are allied to the first commitment period of the kyoto protocol. bulgaria increased its energy consumption in and was considered the economy with the highest level of energy intensity in , according to the european commission . as stated in the unfccc inventory , more than half of the emissions from bulgaria are related to energy supply. from , emissions in bulgaria started to rise, and in reached levels of pollution. spain dealt with an economic crisis in , which could explain the slowdown in its emissions. https://www.ine.pt/xportal/xmain?xpid=ine&xpgid=ine_publicacoes&publicacoestipo=ea&publicacoescoleccao= &seltab=tab &xlang=pt https://ec.europa.eu/clima/sites/clima/files/strategies/progress/reporting/docs/bg_ _en.pdf https://unfccc.int/sites/default/files/resource/bulgaria% bg_br .pdf gross fixed capital formation was found to increase pollution in both the short-and long-run, which was not unexpected. as stated by sapkota & bastola ( ) , an increase in the level of capital of a production process will consume more energy, which could also be related to the scale effect: an increase in investment will increase production and energy consumption. if an increase in energy consumption leads to an upsurge in pollution, this rekindles the argument about energy sources, suggesting that these countries are not using enough renewable energy sources (res), which can help in reduce emissions (e.g., ben jebli & ben youssef, ; apergis & payne, ). trade openness has been found to contribute to environmental degradation, which could be linked to increased energy consumption (sbia et al., ) , for example, due to the exports of energy-intensive goods that consequently increases pollution (sun et al., ) . once again these are related to the question of energy sources. energy-efficiency contributes to reducing emissions in high-income countries, but it is only effective in reducing pollution in the long-run in middle-income countries. as a proxy of environmental regulation, environmentally-related tax revenue produced an unanticipated result, as it was expected to reduce co emissions. on the contrary, it appeared to increase pollution in the short-run in high-income countries. this outcome could mean that these environmental taxes are not a good instrument for reducing emissions. for middle-income countries, environmental regulations seemed to decrease emissions as they were supposed to do. this effect does not necessarily mean that environmental regulation is more effective in middle-income countries. even though regulation decreases pollution in the long-run, the implementation of new environmental laws does not have much effect in the short-run. with respect to patents, they were not shown to be statistically significant for highincome countries model, which was also unforeseen, given the higher levels expenditure on research and development (r&d) and human capital, which are a feature in these countries. for instance, countries develop new technologies (and register their intellectual property) with the specific aim of decreasing pollution. this unexpected effect could be connected to an eventual decrease in the number of patents, as explained by su & moaniba ( ) . this does not mean that these countries have become less environmentally aware, but rather that they develop new technologies to decrease emissions to a certain level, and then suspend further research in new technologies. in contrast, middle-income countries seem to develop new patents in direct proportion to their economic growth, with the aim of growing as quickly and inexpensively as possible. the significant current obstacles to the transfer of the carbon mitigation technologies usually developed by high-income countries (cheng et al., ), could also explain this negative effect. high-income countries were found to benefit from fdi, as it reduced co emissions, both in the short-and long-run, thereby supporting the pollution halo hypothesis. this effect has a strong linkage with the level of a country's environmental protection and efficiency, policies that tend to preclude the admission of dirty fdi. one can observe that, in middleincome countries, fdi caused an increase in pollution in the short-run, while decreasing it in the long-run. the short-run effect supports the phh. however, in the long-run, fdi decreased emissions. initially, the effect of fdi on the environment depends on a country's environmental awareness, economic development, and above all, its capacity to absorb technology. this capacity reflects the country's ability to learn quickly, as noted by adom et al., ( ). even if high-income countries want to transfer their eco-friendly technologies through fdi, if the capacity of the host countries do absorb them is low, their effect will only be gradual, and the costs of adjustment will be greater (adom et al., ). in brief, middle-income countries could be receiving both dirty and clean fdi. in the short-run, clean fdi does not improve the environment due to the lower capacity of middle-income countries to absorb technology. however, in the long-run, these countries seem to incorporate the new technologies and techniques, applying imported knowledge in their domestic firms, and, consequently, decreasing pollution. the impact that fdi has on co emissions could be due to the impact on energy consumption of the resulting increased industrial activity, such as stated by salim et al., ( ) . furthermore, as previously stated, the main objective of this paper is the analysis of the transfer of polluting industries between countries through fdi, as this transfer does not embody environmental improvements, only a reallocation of emissions sources. to address this, an analysis was made of the impact on emissions of the industry sector, involving all the previously-described tests (see tables a to a ). the socio-economic context was also considered, paying particular attention to the industrial sector. a more detailed analysis of the idiosyncrasies of certain countries showed that in , for example, the price of oil caused a favourable shock in demand in norway, which increased oil investment and fiscal receipts. this shock could also have been responsible for a % growth in emissions in , compared to . in , bulgaria faced a difficult year. in addition to the global economic crisis, gas supplies were cut during the russia-ukraine gas dispute. moreover, the production of industrial minerals, such as cement, for example, registered a significant decrease, accompanied by a significant reduction in refined lead exports according to international business publications . these changes were reflected in a decrease in industrial production and emissions from the industrial sector. the hungarian central statistical office stated that, in , a substantial increase in the external trade of transport equipment arose. in this year, the gross fixed capital formation rose by . %, and industrial performance achieved an increase in volume of . %, which explains the substantial emissions. both gross fixed capital formation, and trade openness increase pollution. energy efficiency enhances environmental quality and defines the environmental performance of the industrial. neither patents nor environmental regulations were shown to be statistically significant in explaining emissions from industry in either high-and middle-income countries. this absence of statistical significance could mean that governments are not paying enough attention to increasing innovation in the industry sector or considering the pollution emitted by this sector. one observes that fdi presents different degrees of statistical significances in the shortand long-run. as detailed by baek ( ), fdi could be considered as a long-run phenomenon, but in the short-run, the environmental benefits of introduction new technologies may be insufficient to mitigate the negative impact that fdi has on pollution (shahbaz et al., ) . thus, fdi causes a decrease in co emissions from the industry in high-income countries, and it increases them in middle-income countries. these results also support the phh for middleincome countries. the findings of this paper shed light on the impact of fdi on the environment and addresses two aspects of this relationship: overall co emissions and co emissions from the industry sector. overall, the results were high consistent, not only in relation to the literature but also between each other. they suggest that gross fixed capital formation and trade openness should be treated as the main drivers of pollution, probably due to them causing an increase in energy consumption. these countries affected should improve their res capacity. given that energy-efficiency helps in reducing emissions, these countries should rethink their environmental regulations related to energy production sources to move away from fossil fuels. at the same time, policymakers should encourage investment in r&d to increase industrial efficiency in countries where the sector is a major source of pollution. where it is more costeffective, some firms prefer to pay extra taxes to keep pollute, rather than invest in innovation, as it is more countervailing, which explains why pollution may increase despite regulation in high-income countries. one observes that fdi can be seen to improve environmental quality in high-income countries, but harms in middle-income countries in the short-run. however, in the long-run, fdi could also help middle-income countries reduce their emissions. these contrasting effects reveal these countries' lower capacity to absorb technology. regarding the contrasting effects on highincome and middle-income countries, there is no doubt about the effect of transferring of polluting industries in the short-term; however, the positive effect in the long-run could provoke some doubts. broadly speaking, if middle-income countries receive new technology, it must be absorbed and applied in their industries to increase the influence of the technique effect. the results suggest that this absorption is happening, but only very slowly. however, regarding the industry, the fdi only impacts their emissions in the short-run, which means that they are not applying or absorbing enough green technology to benefit from the phenomenon as much as high-income countries. in summary, the pollution halo hypothesis is supported for highincome countries, and the phh is sustained for middle-income countries. although high-income countries increase their external dependency by importing finished goods, they are still more profitable, because they circumvent stricter environmental regulation. nonetheless, this only happens because middle-income countries have lower levels of environmental regulation. the shift of fdi away from the industrial sector should not be an option, since it could lead to deindustrialization (doytch & uctum, ) . this means that environmental policies encouraging clean fdi are required to achieve sustainable development (essandoh et al., ) . if this is the case, these countries must rethink their regulatory structure, and encourage investment in r&d and the development of human capital, as this can improve their capacity to absorb technology, which would help them benefit more from fdi. without sufficient capability to absorb technology, firms cannot apply imported knowledge quickly, and its benefits will be delayed. policymakers must pay more attention to the industrial sector to encourage the development of green patents linked to industries, to increase their efficiency. furthermore, policymakers should also tighten their environmental laws, especially concerning the admission of new industries, to avoid dirty fdi. moreover, increasing the stringency of these countries' environmental regulation will help them improve their environmental performance. different countries need different policy frameworks to reduce environmental emissions (soytas & sari, a , b . it is extremely important to establish a logical linkage between outcomes. trade openness was once considered a main driver of pollution in middle-income countries, but does not appear to be statistical significance in the long-run. middle-income countries may not have enough trade openness to have an impact on pollution in the long-run, but a more probable explanation has emerged. in the short-run, in an attempt to increase income, these countries increase their trade openness without major environmental concerns. this is reflected in the statistical non-significance of regulation in the short-run. then, both fdi and trade openness increase pollution, reflecting the arrival of new polluting industries and the production of energy-intensive goods. however, perhaps due to the pressure of international agreements, in the long-run, these countries improve their environmental awareness and regulations to control polluting emissions. to begin with, these countries have a comparative advantage in polluting industries, but as they raise their environmental standards, foreign investments decrease. this brings a corresponding decrease in the significance of trade openness in determining the emissions of these countries. the foreign investments that middle-income countries receive in the short-run are mainly due to their more relaxed environmental laws. but, in the long-run, they increase their environmental standards, and efficiency becomes more important for attract more fdi inflows and reducing emissions. finally, what if suddenly and unexpectedly, countries, irrespective of their income level, were all confronted by a symmetrical crisis? for example, a crisis resulting from a pandemic, like that of covid- . generally, during an economic crisis, automatic stabilizers are triggered without additional efforts by governments to diminish its impacts, in an attempt to harmony the government budget balance. but this does not act in a symmetric crisis. international trade suffers, and globalization reduces substantially, as reflected in areas such as tourism and the flows of fdi. a major question concern is whether the current pandemic will have a lasting impact on globalization; something that cannot be answered yet. an optimistic post-crisis scenario would anticipate the speedy return of international trade to pre-crisis levels, presenting a v-shaped recovery, but this may not happen. the same is true for fdi flows. this crisis, although symmetrical among countries, has greater consequences for less-developed countries. for some countries, fdi is one of the major sources of income, productivity, and development. the consumption and the exportations highly reduced, the production stalled, and consequently, a sharp downward trajectory for these countries. this symmetrical crisis exposes the fragilities of the dominant strategy of exploiting the comparative advantages of countries, particularly in production. besides the peak effect of pollution in countries with a comparative advantage in polluting industries, this exploitation also exposes the debilities, external exposure, and dependency of the countries. at a time of economic uncertainty, multinational enterprises rethink their priorities, and limit capital expenditure related to foreign investments, delaying the flow of fdi flows, or even cancelling it. more developed countries are major sources of outbound fdi, which means that profits in their foreign subsidiaries will be substantially reduced. according to the unctad ( b), fdi flows will be hitting their lowest level for the past two decades (unctad, a) . this means that the effect of the phh will be "weakened", not because of stricter or more relaxed environmental regulations, but as a consequence of the reduction in fdi. although less frequent, industry transferrals will probably still continue, source countries will probably switch their investment to closer countries. this will lead to changes in those countries most commonly targeted as recipients of fdi, which are generally less developed, and extremely dependent on fdi inflows. consequently, countries must invest more than ever in r&d to increase innovation and efficiency. this can reduce the costs (of both the firms, and the public health response). fdi is crucial to help middle-income countries soften the impact of the pandemic crisis. middle-income countries should not reduce their environmental standards to attract fdi, but should increase the attractiveness of their workforce, through human development (investing more in r&d and reducing the uncertainty of corruption, ill health, and terrorism, for example). furthermore, source countries of fdi should make a greater effort to transfer improved technologies and techniques to these countries. this bidirectional benefit could lead to: cheaper labor, reduced costs, and improved environmental quality worldwide. this is obviously a major issue needing urgent and extensive investigation in further research. this paper focuses on the analysis of the impact that fdi has on pollution. in this study, countries were divided by income levels, because polluting industries are mainly transferred between countries with different levels of development and income. the ardl model provided a useful disaggregation of the impacts, making it possible to better understand the impacts extended over time. this paper contributes by expanding the literature on the fdi-environment nexus with empirical evidence of a linkage between variables whose may vary over time. another, innovative aspect of this paper is its consideration of factors such as the levels of regulation, innovation, and efficiency in the countries under scrutiny. furthermore, the discussion about overall emissions and those from the industrial sector provides robust support for the phh in middle-income countries, whereas high-income countries benefit from fdi phenomena. the capacity of middle-income countries to absorb technology plays a critical role in analysing the impacts of fdi, although the positive effect of fdi on overall emissions takes time to develop. the countries in this study face a trade-off between fdi and meeting pollution reduction targets. the findings of this paper can provide policymakers with useful guidance to help understand how they can increase the income of a country through an inflow of fdi while, at the same time, preserving the environment. with this in mind, is it crucial to establish a stable legal structure, as regulation plays an important role in this theme. regulation can shift attitudes, encourage investment in r&d, and increase the use of res. given the unexpected findings on the impact of regulation in high-income countries, these countries must combine different policy tools to obtain the goal of decreased emissions. for instance, it is available to not only regulate in the form of fees and taxes, but also to provide subsidies. for example, the awarding of subsidies to efficient firms with a high level of innovation and highly qualified workers could encourage investment in r&d. these subsidies must reward the investment that companies are obliged to carry out. the creation of direct subsidies for researchers and the foundation of research centres is strongly recommended. increasing the level of human capital in countries will increase their environmental awareness. an increase in the use of res is also required. however, given that renewable energy involves higher costs than fossil fuels, policymakers should introduce policies to increase the competitiveness of res, by decreasing investment costs. the environmental laws of the middle-income countries under analysis must be tightened. if the quality of their human capital increases, this will be reflected in greater innovation and efficiency. furthermore, these countries must improve their evaluation criteria for fdi quality, and make them more attractive for the entry of new multinational enterprises, enterprises that could bring with them advanced and eco-friendly technologies, and efficient management skills. recipient countries must absorb these technologies to change their industrial structure. co-operation between countries is also essential to guarantee the transfer of knowledge and efficiency, and it is important to remember that corruption is a serious concern and is difficult to control. policymakers from high-income countries must impose stricter controls on outflow fdi, applicable to the foreign subsidiaries of their parent companies, and ensure that these companies are investing in 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comments that greatly contributed to improving the quality of the paper. key: cord- -k x rjdi authors: hashim, muhammad jawad; alsuwaidi, ahmed r.; khan, gulfaraz title: population risk factors for covid- mortality in countries date: - - journal: j epidemiol glob health doi: . /jegh.k. . sha: doc_id: cord_uid: k x rjdi death rates due to covid- pandemic vary considerably across regions and countries. case mortality rates (cmr) per , population are more reliable than case-fatality rates per test-positive cases, which are heavily dependent on the extent of viral case testing carried out in a country. we aimed to study the variations in cmr against population risk factors such as aging, underlying chronic diseases and social determinants such as poverty and overcrowding. data on covid- cmr in countries was analyzed for associations with preexisting prevalence rates of eight diseases [asthma, lung cancer, chronic obstructive pulmonary disease (copd), alzheimer’s disease (ad), hypertension, ischemic heart disease, depression and diabetes], and six socio-demographic factors [gross domestic product (gdp) per capita, unemployment, age over years, urbanization, population density, and socio-demographic index]. these data were analyzed in three steps: correlation analysis, bivariate comparison of countries, and multivariate modelling. bivariate analysis revealed that covid- cmr were higher in countries that had high prevalence of population risk factors such as ad, lung cancer, asthma and copd. on multivariate modeling however, ad, copd, depression and higher gdp predicted increased death rates. comorbid illnesses such as ad and lung diseases may be more influential than aging alone. the covid- outbreak was first reported at the end of december from the city of wuhan in china [ ] . within a short period of just months, sars-cov- , the coronavirus causing covid- , had spread to virtually all countries and territories worldwide [ ] . in spite of implementing stringent measures such as travel restrictions, social distancing, lockdowns, and increased testing, many countries have struggled to control the spread and minimize the death toll [ ] . at individual country level, the number of deaths and case fatality rates (cfr) of confirmed cases vary enormously. this can be due to numerous reasons, including the extent of testing, the measures taken to mitigate the spread, healthcare access, underlying population demographics, socio-economic development and prevalence of comorbidities [ ] . moreover, different countries are at different stages of the covid- pandemic and cfr can change depending on how each country responds to the epidemic. for example, uk, as of th june, had over , confirmed cases with over , deaths (cfr: . %). by contrast, germany had , cases with just over death (cfr: . %). a recent study has indicated that sars-cov- has mutated into several different types which could have different virulence [ ] . however, the order of magnitude difference in cfr noted between some countries cannot simply be explained by the variation in the virulence of the virus strains, since some of these countries have the same strain circulating [ ] . although the extent of testing is another obvious factor for these difference, it too does not explain all the differences. the most common reported predictors of severe covid- include age above years and comorbidities such as cancer, asthma, hypertension and heart disease [ , ] . thus, countries with larger older population and/or with higher burden of chronic diseases are expected to have the highest mortality rates. however, it is unclear how mortality rates interact with these reported predictors when examined at country population level by age and prevalence of comorbidities. we chose to analyze case mortality rates (cmr) by country population, rather than by the number of test-positive cases (cfr), since the latter is dependent on the number of tests performed in each country and this varies enormously from country to country [ ] [ ] [ ] . in this study, we aimed to examine cmr for countries against eight diseases and six socio-demographic factors. we analyzed covid- pandemic data for variations in mortality rates across different countries. data from johns hopkins university coronavirus resource center (https://coronavirus.jhu.edu/data) were obtained on covid- death rates per , population. these rates were used to classify countries into an elevated risk category. prevalence data for selected diseases was retrieved from the global burden of disease (gbd) dataset (http://ghdx.healthdata.org/gbd-results-tool). while this expansive dataset includes a wide range of health-related conditions including trauma and congenital birth defects, we limited our analysis to potential risk factors for covid- mortality. these included asthma, chronic obstructive pulmonary disease (copd), lung cancer, diabetes, depression, hypertension, ischemic heart disease (ihd) and alzheimer's disease (ad). socio-economic indicators were obtained from the world bank data (https://databank.worldbank. org/home). selected indicators were chosen to assess social risk factors for susceptibility. these included gross domestic product (gdp) per capita in us dollars, unemployment rates (percent of workforce), urban population as a percent of total population, population density per square kilometer and population over age years. an additional measure of social development, the sociodemographic index (sdi), from gbd was also analyzed. expressed on a scale of to , sdi is the mean ranking of the national income per capita, educational attainment, and fertility rates. data were merged with multiple error checking steps and redundancies. data were analyzed for countries (primarily limited by availability of covid- data). world bank data from was used as it had a lower proportion of missing values compared with . missing values ranged from none (in the gbd data), to three countries (gdp) to (unemployment rates) in the world bank data. no data transformations were applied. the primary dependent (outcome) variable was covid- death rates (cmr) per , population. we believe this metric is a more accurate measure than covid- deaths per confirmed cases (cfr) which is heavily dependent on the extent of viral case testing carried out in a country and the reliability of testing [ ] [ ] [ ] . the data was analyzed in three steps: correlation analysis, bivariate comparison of countries, and finally, multivariate modelling. statistical data analysis was conducted using jamovi version . . (the jamovi project, , https://www.jamovi.org, sydney, australia). generalized linear model (gamlj module) was used to evaluate predictors for the dependent variable, cmr. poisson regression was applied using the log link function. log likelihood ratio tests were used to evaluate the predictive performance of each covariate, while r was maximized for overall model error reduction. backward stepwise process was used to remove covariates with the greatest p-value at each iteration. covariates were centered but not standardized. a fixed intercept was used. two-way interaction terms were reviewed; however, none of them were statistically significant. collinearity among predictor variables was assessed using a correlation matrix and tolerance in linear regression. oneway anova was used to compare the risk factors in elevated risk versus other countries. mean differences in rates (including % confidence intervals) were obtained as a measure of effect size. a correlation coefficient (cut-off) of < . was considered as indicating lack of statistical association. globally, cmr was . covid- deaths per , population, with highest rates in belgium ( . ), andorra ( . country-wise correlations showed an association between total confirmed cases and total covid- deaths (r = . ) and between confirmed cases and cmr (r = . ). sdi of the countries did not correlate with any of their covid indicators such as confirmed cases and cmr (r < . ). greater gdp per capita correlated with cmr (r = . ) but not with other covid- variables such as number of cases. having a relatively older population structure with a higher number of over year old persons was associated with more confirmed cases (r = . ) and deaths (r = . ) but not with cmr. social overcrowding as measured by population density and urbanization did not correlate with cmr (r < . ). from amongst the clinical risk factors, positive correlations with cmr included alzheimer's disease (r = . ), lung cancer (r = . ), and weakly with asthma (r = . ) and copd (r = . ). these correlations should be interpreted as preliminary exploratory analysis as confounding variables can mediate these findings. countries were divided into two groups: those with cmr greater than or more covid-related deaths per , population, versus those with fewer deaths. the mean values of predictor variables were compared in these two groups using one-way anova ( table ). the results were consistent with correlation analysis, reaffirming greater prevalence of ad and respiratory illnesses in countries with high covid- cmr. however, more conclusive inferences were derived using multivariate modeling. with covid- cmr per , population as the primary outcome (dependent) variable, multivariate modeling showed that certain risk factors were independent predictors (r = . , log likelihood ratio tests, p < . ). these risk factors included alzheimer's disease, copd, depression and gdp per capita (figure ). key findings from our analysis highlight certain population risk factors that were associated with covid- mortality. these included chronic respiratory diseases such as lung cancer, asthma and copd and age-related illnesses like ad. a surprise finding from this study was the strong correlation between ad and covid- death rates. of the risk factors assessed, ad was a dominant and statistically significant risk factor, even on multivariate analysis (which controls for other risk factors including aging) [ , ] . our findings support several recent studies that also point to a positive correlation between covid- severity and neurological disorders, including ad [ ] [ ] [ ] . the details of this association however, remain unknown. it has been reported that the virus has neurotropic characteristics, exploiting the angiotensin-converting enzyme receptor to gain entry into cells of the central nervous system [ ] [ ] [ ] . another notable finding from this analysis was that countries with lower socio-economic development and social overcrowding were not associated with higher death rates. one of the major concerns has been the impact this pandemic will have on developing countries with poor infrastructure and healthcare systems. our analysis appears to give some hope that low socio-economic status does not necessarily mean a guarantee of poor outcome for covid- . we must stress however, that our study focused on mortality and not on the risk of transmission. interestingly, a previous study assessing infectious disease vulnerability scores also indicated that low income status does not necessarily correlate with high vulnerability to infections [ ] . studies have identified certain comorbidities such as age above and hypertension as important risk factors for increased mortality [ , ] . although this may be true when looking at crude figures, analyzing the risk of mortality in multivariate modeling shows only weak correlation. thus, countries with a higher percentage of older people may witness a higher burden of deaths [ , ] but this is not because older people are specifically at higher risk of developing severe disease compared with younger individuals in the population. other clinical risk factors such as co-morbid illnesses, alzheimer's dementia and chronic lung diseases (copd) may be more influential. in a recent systematic review, hypertension and diabetes were reported as leading risk factors for covid- severity [ ] . these were followed by cardiovascular diseases and respiratory conditions. it is pertinent to note that data from hospital-based series should not be used to make public health decisions elsewhere as these associations are context dependent. each medical center receives a unique set of patients depending on referral patterns, pre-hospital care and clinical expertise. limitations of our study include the use of secondary data, estimation techniques used by the data sources, accuracy of data estimates and the potential of ecological bias due to confounding by countrylevel analysis. we sought to minimize bias and systematic errors by removing outliers and not relying on case-fatality rates. it is worth mentioning that observational studies on clinical cases suffer from similar confounding effects that are difficult to remove even by adjustment or stratification. definitive proof via randomized exposure to the causative virus would be unethical. hence, observational data provide the best available source for public health and clinical decision making. the current covid- pandemic has exposed some of the weaknesses in the public healthcare systems and lack of preparedness for dealing with infectious disease outbreaks [ ] . emerging and re-emerging infections, particularly due to viruses are not new and covid- is certainly not going to be the last. previous pandemics such as the influenza pandemic, famously known as the 'spanish flu' and the two subsequent influenza pandemics of and resulted in millions of deaths [ , ] . to limit the devastating impact such pandemics can have on human health and healthcare systems, our only options are to be better prepared for such events. one essential component for this preparedness is to have established policies for future pandemics. early identification, testing, contact tracing, and isolation are fundamental principles of public health that have to be implemented. determining which groups in a population are at increased risk of severe disease can help to better manage the limited resources and stretched healthcare systems in such situations. moreover, any planning for lifting the existing lockdown measures should take into consideration these vulnerable groups. this is also true for prioritizing recipients for candidate vaccines against covid- . the authors declare they have no conflicts of interest. mjh design of the protocol, acquisition of data, data analysis/ interpretation, preparing first draft and critically reviewing the paper, giving approval for the final version to be published. ara critically reviewing the paper, giving approval for the final version to be published. gk principal investigator and corresponding author, conception/design of the protocol, data analysis/interpretation, preparing first draft and critically reviewing the paper, giving approval for the final version to be published. this research received no external funding. a novel coronavirus from patients with pneumonia in china duration of sars-cov- viral shedding during covid- infection early dynamics of transmission and control of covid- : a mathematical modelling study phylogenetic network analysis of sars-cov- genomes nextstrain: real-time tracking of pathogen evolution epidemiology working group for ncip epidemic response, chinese center for disease control and prevention. [the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) report of the who-china joint mission on coronavirus disease (covid- ) world health organization case-fatality rate and characteristics of patients dying in relation to covid- in italy positive rt-pcr test results after consecutively negative results in patients with covid- a case of imported covid- diagnosed by pcr-positive lower respiratory specimen but with pcr-negative throat swabs clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study apoe e genotype predicts severe covid- in the uk bio bank community cohort neurologic manifestations of hospitalized patients with coronavirus disease features of uk patients in hospital with covid- using the isaric who clinical characterisation protocol: prospective observational cohort study genomic characterisation and epidemiology of novel coronavirus: implications for virus origins and receptor binding the neuroinvasive potential of sars-cov may play a role in the respiratory failure of covid- patients evidence of the covid- virus targeting the cns: tissue distribution, host-virus interaction, and proposed neurotropic mechanisms identifying future disease hot spots: infectious disease vulnerability index prediction models for diagnosis and prognosis of covid- : systematic review and critical appraisal covid- : risk factors for severe disease and death prevalence of comorbidities and its effects in patients infected with sars-cov- : a systematic review and meta-analysis covid- exposes weaknesses in european response to outbreaks global mortality impact of the - influenza pandemic influenza: the mother of all pandemics we would like to thank the sources of original data including johns hopkins university, institute of health metrics (university of washington, seattle) and the world bank. supplementary data related to this article can be found at https:// doi.org/ . /jegh.k. . . key: cord- -cli mpev authors: schaller, karl title: neurosurgeons in the corona crisis: striving for remedy and redemption. a message from the president of the eans date: - - journal: acta neurochir (wien) doi: . /s - - - sha: doc_id: cord_uid: cli mpev nan it is difficult these days to keep a clear and unbiased mind: real experts, self-declared experts, and politicians are issuing apodictic statements and restrictive orders with a big impact on our daily lives. many of those statements are contradictory, and the various countries are reacting in equally different ways. even within the same country many different public directives may be put in place by the regional governments, due to their federal political organization (i.e. germany). as a result, i happen to know that in some neurosurgical departments not a single or had been shut down, and not a single covid- -positiv patient had been admitted to their icu, whereas in my own, for example, we are not allowed to do elective surgeries anymore, and more than icu beds are taken by intubated and ventilated corona-patients already (as of march , ). in other countries with more centralized health care, specialists proposed some sort of a herd immunization of the whole population (i.e. netherlands). but, with increasing pressure through one or another interest group and/ or so-called public opinion, such major decisions may be revised from one day to the other (also netherlands). inagain other countries (for example the usa), the danger related to that virus has been denied to a large extent ("hoax by the democrats"). now, from one day to the other, and a °-turn later, entire us states are preparing for lockdown, and large navy-ship-based mobile hospital units are being moved around and prepared to anchor along their coastlines. from other mainly eastern countries (russia, kazakhstan etc.,) we don't hear anything through our usual news channels. furthermore, it seems that the profound and special european spirit of a common departure, which reigned in the beginning of the s is being jeopardized by specific political interests, and by the lack of solidarity across european borders: supply chains for surgical masks are interrupted for the reason of national egoisms. tools, and mechanical or electronic components, which are desperately needed to build for example ventilators are no longer delivered straight from one country to the other. all together that will be put on a very big bill, once all will be over, and it will take a long time to reinstall confidence in our political leadership, in our idea of a europe without limits in humanity, as a model for the world, and as the place to be. there is a ghostly feeling when looking outside. it is as if somehow we have become figures inside real-world edward hopper paintings. all that leaves the strange feeling behind that something big may be going on. but there is no clear and consistent answer, neither from the experts, nor from political leadership, as to how to address this exceptional situation. important decisions may become triggered by public opinion, and thus the overall situation may entirely spin out of evidence-based control. it seems that the hour of countless experts, of epidemiologists and lab-scientists has arrived. the hour of those who were hidden behind large screens and next to super-computers for big data management and pcr analysis, in remote corners and basements of our hospitals and faculty buildings, and that these people seem to have been prepared for their moment to arrive. that's what is happening now: we, who are used to treating patients on an individual basis have become subordinates of crisis units and eminent telegenic virologists. that may the right thing for the time being, if there was coherent advice. but i wish these experts would be more consistent in their analysis of the situation and in their recommendations, because even for us as doctors it is difficult to understand what's right and what's wrong. how should we expect the public to understand such a situation and to behave accordingly, if we don't know ourselves what's going on based on facts? having tried to drink a beer with one of my colleagues at the lakeside this week, we were driven away by patrolling police. that made me recall dystopic scenarios from stories and movies of the past, depicting totalitarian states, where entirely new professions were generated, such as stalkers, who used to guide people and take them around to forbidden zones [ ] (https://www. youtube.com/watch?v=xb jvtut -g). the current situation is also unmasking in a painful way that there is also an important economic inequality across all european countries. there is a significant lack of doctors and of nursing staff, and in terms of access to icu-beds with ventilators in some countries, whereas in others, the situation seems to be less precarious. for example, how is it that in the uk, home to some of the finest educational and research institutions and to a good proportion of the richest people in the world, only approximately icu beds exist -for a population of approximately million people? other countries on the other hand, were deprived of their medical staff due to more precarious general economic situations, with doctors and nurses following the westward stream toward politically more transparent and wealthier countries. medical education is expensive, and there is global competition for well-trained and mobile doctors and nurses. poor political planning and cultural differences from an all-inclusive state responsibility to more social darwinist principles may be the reason, and reflect the different approaches across european countries. in times of crisis, nobody wants to be left behind however, and that's why we are hearing so many outcries from various corners for more social fairness at this time. undoubtedly, there is a clear need for guidance and clarity. it is clear, that a day will come when we will understand what happened. that may become redemption day for some, and it may become pay day for others; beyond the giant socioeconomic impact of this crisis, there will be an accounting of medical and surgical collateral damage, which has been caused by the currently imposed restrictions and postponing of otherwise indicated medical and neuro/surgical care. in our field alone thousands of patients, with degenerative spinal disease, low grade gliomas, cavernomas, epilepsy and other pathologies are put on ever-increasing waiting lists. meanwhile, mild paresis may become moderate, tumors may grow to more complexity, cavernomas may bleed, and repeated seizures may have deleterious consequences. all that will happen, and it will have to be accounted for, when there will come a time to do so, and after the whole mountain of delayed surgeries will be worked up. truth will come, and it won't be comfortable for those, who may be riding on hightide right now. this unclarity, radiating from the highest levels of political leadership and from contradictory expert panels, this lack of consistent leadership continues to induce a feeling of insecurity among people. seeing photos of old people, who were overrun by hysterical crowds during the opening of supermarket doors, or of overworked and tired nurses, who find themselves in front of emptied grocery shelves, and of strong men defending the towers of toilet paper, which they had just bought; all these images, that materialized prove that the taint of civilization is so thin that it's being blown away after only a couple of complicated weeks, appalls me and it renders it difficult not to lose faith in our species. and it confirms my long-standing notion that sometimes the seemingly biggest and strongest among us seem to have the least compassion in those moments, when one should stay calm and cool and caring. then, i have to focus my mind on the enlightening idea that not all people are like that, that the majority isn't in fact. and that's why we have to continue to strive to deliver the best possible service to our patients and to have confidence in our species. but how will things develop if the situation is not resolved in a few weeks' time? the current image of humanity leaves a stale feeling. and to relaunch a system with such inertia after weeks and months of deprivation, if many companies no longer exist, will take tremendous effort? doctors will just go back to work, as usual. but to reboot whole economies and have a labour force with less pragmatic backgrounds returning to their jobs may be less evident. all of us are somewhat trapped in our own inertial systems. we have to adapt to the current state-of-mind and to our regional rules and play the game. it is up to us to stay calm and to transmit an anti-hysterical mindset to our peers, be them professional, nurses, secretaries, cleaners, it specialists, and all kind of intermediate hospital staff, or patients and the general public. we have to live up to the current situation, whether the whole hype is justified or not. we have to provide an example to show how to stand together, across all national borders, and with the optimism of pragmatic and generous people, who we should always strive to be. that's why most of us became neurosurgeons in first place. that spirit was generated by european neurosurgical leaders many years ago, not long after the european carnage of world war ii. that spirit has formed the foundations of the eans. even during the iciest times of the cold war, european neurosurgeons were connected without boundaries. the first european training courses started in the s, and the course sites are illustrative for the visionary european thinking of our predecessors. i refer you to our website to see that list and encourage you to upload your own material related to these events, should you happen to have something of interest. otherwise, be referred to the photography books of john garfield, who documented that particular spirit from the beginning with his camera. eans wants to provide a trans-national and inspiring base for us neurosurgeons. we would like to improve our common platforms for the exchange of thoughts, and we shall stand in for each other. let's stay in contact more intensively via social media, telephone calls or video conferences, respectively. i would like to see more networking and information passed on through our own, eans-based communication channels. we have installed an easy-to-use format to upload your comments, your thoughts, data, and scientific material related to the corona crisis now. all that may serve us some day to understand better what's happening currently, and to analyze potential collateral damage associated with it, and to be prepared better should such a situation recur in the future. here, the links to our website: https://www.eans.org/default.aspx https://www.eans.org/news/ /eans-presidents-message-on-corona-virus-feedback.htm please feel encouraged to contact the eans team at any time. in every crisis lies the seed of opportunity. i am sure we will grow from that, and we shall meet and celebrate under liberating circumstances in the near future. and, should it turn out that chloroquine may contribute to ameliorate the course of corona-disease indeed, then be referred to john garfield again [ , ] . neurosurgeons have always been frontrunners, when it came to visionary treatments. take good care of yourself, of those next to you, and of your patients. we will retake the drivers' seats in our natural habitat, in hospitals and in neurosciences, and we shall meet soon again, hopefully in belgrade in october ! with my warmest regards, karl schaller. but a neurosurgeon: after the third gin and tonic roadside picnic. . sf masterworks publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- - b swi l authors: grima, simon; kizilkaya, murat; rupeika-apoga, ramona; romānova, inna; dalli gonzi, rebecca; jakovljevic, mihajlo title: a country pandemic risk exposure measurement model date: - - journal: risk manag healthc policy doi: . /rmhp.s sha: doc_id: cord_uid: b swi l purpose: the purpose of this study is to develop a pandemic risk exposure measurement (prem) model to determine the factors that affect a country’s prospective vulnerability to a pandemic risk exposure also considering the current covid- pandemic. methods: to develop the model, drew up an inventory of possible factor variables that might expose a country’s vulnerability to a pandemic such as covid- . this model was based on the analysis of existing literature and consultations with some experts and associations. to support the inventory of selected possible factor variables, we have conducted a survey with participants sampled from people working in a risk management environment carrying out a risk management function. the data were subjected to statistical analysis, specifically exploratory factor analysis and cronbach alpha to determine and group these factor variables and determine their reliability, respectively. this enabled the development of the prem model. to eliminate possible bias, hierarchical regression analysis was carried out to examine the effect of the “level of experienced hazard of the participant (leh)” considering also the “level of expertise and knowledge about risk and risk management (lek)”. results: exploratory factor analysis loaded best on four factors from variables: demographic features, country’s activity features, economic exposure and societal vulnerability (i.e. the prem model). this model explains . % of the variance in the level of experienced hazard (leh). additionally, we determined that lek explains only about % of the variance in leh. conclusion: the developed prem model shows that monitoring of demographic features, country’s activity features, economic exposure and societal vulnerability can help a country to identify the possible impact of pandemic risk exposure and develop policies, strategies, regulations, etc., to help a country strengthen its capacity to meet the economic, social and in turn healthcare demands due to pandemic hazards such as covid- . the coronavirus or, as it is better known, covid- has disrupted life as we knew it. this virus is causing a national disaster of epidemic nature with considerable economic and social impact. the united nations (un) defines disaster as a serious disruption of the functioning of a community or a society at any scale due to hazardous events interacting with conditions of exposure, vulnerability and capacity, leading to one or more of the following: human, material, economic and environmental losses and impacts. the centre for research on the epidemiology of disasters (cred) identifies a disaster if at least one of the following criteria is met: or more people are reported killed; people are reported affected; a state of emergency is declared; a call for international assistance is issued. the pandemic covid- meets all these criteria. a pandemic is defined as "an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people". on the other hand, a pandemic can be defined as a natural event that causes a disruption in the functioning of the economic system that has a significant negative impact on assets, production factors, output, employment or consumption, etc. when a hazard arises, such as that of a pandemic, it leads to the loss of life and damage to infrastructure, emphasizing the reality that society and its assets are vulnerable to such events. according to the sendai framework for disaster risk reduction - , a hazard is a process, phenomenon or human activity that may cause loss of life, injury or other health impacts, property damage, social and economic disruption or environmental degradation. can be characterised as a biological hazard, since biological hazards are of organic origin or conveyed by biological vectors, including pathogenic microorganisms, toxins and bioactive substances. examples are bacteria, viruses or parasites, as well as venomous wildlife and insects, poisonous plants and mosquitoes carrying disease-causing agents. the covid- pandemic outbreak so far, during march to june has substantially influenced the majority of the countries in the world, besides, according to the research note of german deutsche bank, experts already speak about the second wave of the virus, and highlight that during the next ten years the world can face a much more serious pandemic than covid- . therefore, there is a need to understand the objective factors that indicate the experienced level of hazard that a country may be faced with, if or when pandemics such as covid- or similar outbreaks strike. the purpose of this study is to develop a pandemic risk exposure measurement (prem) model to determine the factors that affect a country's prospective vulnerability to a pandemic risk exposure such as covid- . these factors can be indirectly and directly affected by different factors on each other and similarly have a direct and indirect effect on vulnerability. the idea is to answer the following a priori research questions: rq -what are the factors that enable the measurement of a country's vulnerability to a pandemic risk exposure such as covid- ? rq -do the factors vary according to the level of experienced hazard of a country (leh)? rq -do the factors vary according to level of expertise and knowledge of the respondents (lek)? the questions above and the forecasts noted above increase the importance of developing such a model, which can be used as a checklist for determining the status of a country in terms of possible vulnerabilities, which can later develop into hazards. it is useful for risk managers and policymakers to proactively identify the factors that make the country more vulnerable to the pandemic risk and if necessary, manage them and/or set tolerance limits, policies, regulations, rules, standards, etc. prem could also serve as a guide for businesses in developing their business continuity plans and insurance policy documents. insurance underwriters can also utilise this model to set the correct policy wording and premiums when underwriting risks. although there are various studies that have indicated factor variables that are important for addressing and measuring the vulnerability of countries, the covid- pandemic has indicated a serious need to go back to the drawing board. it is important to understand the areas or functions that have been missed and to develop a tool that is flexible enough to help national risk managers and policymakers proactively identify and determine the risk vulnerabilities of their country; and devise a continuity plan that improves the measure of vulnerability of a country. this is important so as to determine when to take action or flag the problem, based on a present tolerance level. to develop this inventory of factor variables we consulted literature on pandemics such as the covid- and identified variables that might not have yet been considered. therefore, the case of the covid- pandemic was used to help add value to current measures, by updating the model with new important factor variables that might not have been seen as important until now. for the purpose of this study, a purposely built semistructured survey was designed by creating an inventory of factor variables that can be used to measure a country's exposure to a pandemic risk such as covid- . to develop such an inventory we participated in various online forums, grima et talks, webinars and sub-groups related to risk management during disruptions of infectious diseases such as that of covid- and asked other participants and colleagues (who worked in a risk management function) to provide us with those aspects that in their opinion safeguarded or hindered a country's preparedness against infectious diseases. this information together with that gathered from the research literature and using a thematic approach resulted in the construction of an initial set of variables and additional data measurements that reflect vulnerability of a country for a pandemic (see table ). there exists a variety of studies on different aspects of country's development. some studies suggest such factor variables as "population density" measured by the number of persons per square kilometre, "night-time light intensity" measured by the night light development index. , , as well as 'the ecological footprint index, "transport network density" , , and "net migration rate". , , various studies suggest using "human development index (hdi)" as a composite index of life expectancy, education, and per capita income indicators and "tourism". recent studies suggest population age structure related indicators as 'population over/below ʹ , , in conjunction with gender. studies on population health measures commonly use "the infant mortality rate (imr)". , healthcare system capacity studies emphasize the "hospital beds available per capita", , , , "out-of-pocket expenditure (oops)" , , and "health care expenditure % to gdp". , [ ] [ ] [ ] , , there is a variety of widely used economic factor variables that influence country's vulnerability as 'gross domestic product' and "gdp per capita"; , "public and private debt to gdp" , and "government expenditure to gdp", , "inflation rate" and "unemployment rate" , as well as "current account balance to gdp". taking into account the specifics of the recent covid- outbreak such indicators as 'socio-cultural disparity' and use of "telecommunication" tools became important. although at the time of writing, studies on the covid- pandemic and its effect on a country's economic, social and health vulnerability measures were still limited, we were still able to uncover studies on covid- and others based on similar infectious diseases and pandemics such as severe acute respiratory syndrome (sars), the human immunodeficiency viruses (hiv), etc., which helped us build the inventory laid out in table . the survey was administered as an online survey via weblink on qualtrics to contacts of the authors on social media, namely linkedin, facebook and twitter, who worked in a risk management function (non-probability purposive sampling). moreover, respondents were also invited using direct emails and were also asked to send this link to others working in the risk management function (non-probability snowballing sampling). responses were collected through qualtrics. the url was set to limit only one response per computer, but respondents had the option of going back to edit or update their answers until they finished. confidentiality of responses was guaranteed. a total of completed surveys were received between may and june of . the survey consisted of three sections. the first section consisted of questions, wherein question we asked the participants to state whether they are working in a risk management function, which was the main filter to allow participants to continue with the survey only in the event of a positive response, and then in question (q ), we asked them to indicate on a likert scale of ' ʹ-being the lowest lek and ' ʹ-being the highest lek of the participant, their lek. this was done to understand whether the level of expertise and knowledge (lek) affected the scores provided by participants (who worked in a risk management function) in the development of the model. in the next section, which consisted of main question (question ), the participants were required to indicate on a -point scale their level of agreement with each of the inventory items (q to q ) developed as described above. these items were individually operationalized via a five-point likert scale ranging from " " for strongly disagree to " " for strongly agree. the final section, question and q in our proposed inventory we asked participants to provide us with an indication of their country of residence to enable us to determine their country's exposure to the hazard/disruption and asked them to add any comments they would like to express about the subject. we then determined "the level of experienced hazard of the participant (leh)", q , through the number of coronavirus (covid- ) cases per million population as of the th june of their country of residence provided by the participant. the data were determined from the worldometer website. we used the following scale: a score of " "-for the lowest risk with under cases; " " -between and cases; " " -between and cases; " " -between and cases; and " " -for the highest risk with over cases per million population. participants with the lowest risk experience, i.e. level - . %, level - %, level - . %, level - . % and level -the highest level of risk exposure . %. we then loaded all the data in a quantitative format onto ibm spss v software package through which we carried out all our statistical analysis. as a next step, to answer research question (rq ) we selected the variables and developed the prem model using exploratory factor analysis. exploratory factor analysis, via principal components extraction with orthogonal rotation (varimax with kaise normalization), was used to assess the construct validity of the country risk exposure index while internal-consistency reliability was assessed by computing cronbach's alpha coefficients. this further supported continuance of factor analysis and so the analysis proceeded. cronbach's alpha reliability coefficient was . , kmo value was . , and bartlett test was found to be . , df p < . . we used varimax rotation because the factor variables are interrelated and we reduced them to grouped factors consisting of -factor variables. hierarchical regression analysis was carried out to see the effect of factors on "level of expertise and knowledge (lek)" and on "the level of experienced hazard of the participant (leh)" to enable us to provide an answer to research question and -(rq ) and (rq ). the hierarchical regression analysis was carried out with the obtained data in two steps. in the hierarchical regression analysis, "leh" was used as the dependent variable. in the first stage of analysis (model ), the obtained factors as a result of factor analysis were used as independent variables. in the second stage (model ), the analysis was repeated by adding the "lek" variable to the four factors in the first stage. thus, the effects of both factors and lek on "leh" were measured. analysing the completed surveys, we conclude, that . % of the participants stated that their lek was ; . % stated that their level was , . % stated that their level was ; . % stated that their level was and . % stated that their level was . using exploratory factor analysis, we determined that -factor variables were eliminated from the model, q -"net immigration", q -"gross domestic product", q -"health care expenditure % to gdp", q -"gender", q -"population of males below years" and q -"population of females below years". this was because these variables explained too little of the variance and this made them unstable and often unreliable because they were defined by other variables. this left us with the -factor variables included in the prem model and exhibited in table . all factors have been carefully interpreted and omitted scientifically. the factor variable q -"public and private debt to gdp," which is highly related to one of two factors (factor and ), but lower to factor , was attached to factor . based on the analysis made, we have identified four factors indicating vulnerability of the country: factor 'country's activity features', factor "demographic features', factor 'societal vulnerability', and factor 'economic exposure'. these factors affect a country's prospective vulnerability to pandemic risk exposure. table shows the factors and reliability values of the four identified factors. cronbach's alpha coefficient of these factors varies between . and . . of the four factors, the total variance in the survey explained . %, while the factor common variances were observed to vary between . and . . the results of the hierarchical regression analysis are shown in table . results show that the factors composing the prem model [factor (country's activity features), factor (demographic features), factor (societal vulnerability), and factor (economic exposure)] explained % of the change in leh with a high level of statistical significance (p< . ). when the lek variable was included in the analysis in the second stage, the rate of the total variance increased from % to approximately %. therefore, we can conclude that the lek variable helped to explain only another % with a high level of statistical significance (p < . ). as noted in table , the exploratory factor analysis loaded best under four factors. factor includes population density (q ), night-time light intensity (q ), ecological footprint (q ) and transport network density (q ). there is a variety of factor variables that can promote the spread of diseases, such as high population density and economic activity, ubiquitous air travel and with fast transportation comes a quick and extensive diffusion of a communicable disease. many studies have shown that light at night and population density can be used as indicators of economic activity. , population density is one of the key parameters for assessing the magnitude of the population exposed to risk. the increase in human population density and the growth in transportation networks of roads, container ships, and airways that has now linked the global population presents more rapid and robust pathways for infectious pathogens. whereas ecological footprint as a measure of human impact on the land by urbanization shows country exposure to the pandemic risk. summing up, we label factor , as country's activity features, as it represents the people's activity features and infrastructure located in hazard-prone areas. factor includes gdp per capita (q ), hdi (q ), tourism (q ), old population male over (q ), old population female over (q ), imr (q ), hospital beds available per capita (q ) and oops (q ). gdp per capita is a commonly used indicator for economic and human development and as poverty measure , .hdi is a statistic composite index of life expectancy, education, and per capita income indicators, ranking countries in human development. cities with robust governance and health infrastructure are in a better position to manage pandemics and have lower case fatality rates and excess mortality than those that do not. meanwhile, the infant mortality rate (imr) is a commonly used measure of population health. imr is associated with other factor variables affecting the health status of an entire population, such as its economic development, general living conditions, social well-being, incidence rate and environmental quality. , also, covid- statistics show that the older population is, the more vulnerable to the virus it is. in many countries, an ageing population is challenging the healthcare system, social security, fiscal system. , , one of the proxies for healthcare system capacity is the number of hospital beds available per capita. this variable has become critical because of covid- , as availability of excess beds means more lives are saved. out-of-pocket payments (oops) signify spending on health directly out of pocket by households in each country. dependence on oops varies widely around the world, but there is a very strong correlation between the level of oops and the incidence of catastrophic and impoverished health expenditures. these two indicators are determined by the extent to which oops absorb a household's financial resources. [ ] [ ] [ ] besides, the current situation with covid- has shown that countries with a high level of tourism, such as italy, are more vulnerable to pandemics due to population flows. in this paper, we label factor as demographic features, because it represents variables that increase a person's and in turn the country's vulnerability to the effects of hazards. factor includes telecommunication (q ), public and private debt to gdp (q ), government expenditure to gdp (q ), and socio-cultural disparity (q ). the modern economy is characterized by the increased use of telecommunication tools. during the recent covid- outbreak, mobile phone data were actively used to tackle the pandemic and internet provided timely informing and warning of population. meanwhile, debt has an important role in ensuring the resilience of the country to macroeconomic and other shocks. , we believe that lower level of public and private debt in case of pandemic enables the country to provide timely financial support of the economy, providing external and internal access to finance. government expenditure to gdp indicates total government consumption, investment and transfer payments as a share of the country's gdp. this indicator is seen as a factor of a country's fiscal behaviour and the determinant of output volatility, whereas increasing government expenditure allows for reducing the negative effects of output volatility. besides, higher government expenditure is increasing disaster mitigation capability of the country. according to alesina et al, the sociocultural disparity has an impact on the behaviour of individuals and the community as a whole especially in the case of a hazard. the contribution of the socio-cultural disparity to the pandemic risk exposure is not unambiguous. factor we label as societal vulnerability due to the variables indicating vulnerability of society to pandemics. factor includes inflation rate (q ), unemployment rate (q ), current account balance to gdp (q ). the inflation rate is one of the fundamental indicators of a country's macroeconomic conditions. however, the contribution of the inflation rate to the country's exposure to pandemic risk is not uniform. moderate inflation stimulates economic growth making the country less vulnerable to the risk, whereas high inflation rate implies rising prices good and services, including healthcare expenditures, increasing out-of -pocket payments and making the country more vulnerable to pandemic risk. the unemployment rate is one of the fundamental macroeconomic indicators showing the number of unemployed people as a share of the labour force. given a higher unemployment rate, the total output is more sensitive to demand shocks, making countries more vulnerable to pandemic risk. the current account balance to gdp is one of the measures of a country's external imbalances. it indicates the level of the international competitiveness of the country. high current account deficit increases the probability of capital flow contraction increasing the country's vulnerability to external shocks and more vulnerable to pandemic risk. factor we label as economic exposure following the economic nature of the included variables. to the knowledge of the authors, it is the first paper, which provides a pandemic exposure measurement risk model to determine the factors that affect a country's prospective vulnerability to a pandemic risk exposure such as covid- . before the covid- pandemic, the global health security index (ghsi) was used as a measure of the country's pandemic preparedness. the more developed and prosperous countries are better equipped to deal with pandemics, according to ghsi. in practice, it is better to benchmark countries during a pandemic in ways that allow information on outcomes and performance to be obtained, analysed, reported, and used in real-time. the recent study of measuring the economic risk of covid- has computed measures for exposure (population, night-time light and transport density), vulnerability (data on economic outcomes, human development, tourism, and health quality) and resilience (internet access, public and private debt, government expenditure, sociocultural disparity) of the local economy to the shock of the epidemic. the study concludes that the highest economic risks are in countries and regions that do not get much global attention in normal times (such as sub-saharan africa) and get even less during pandemic's spread. another study used independent variables, such as hospital, mosque, atm, bank, fuel, attraction, city, footprint, road, and village, to model and map the risk of covid- . based on the analysis of existing literature, including literature on covid- , consultations with experts and associations and survey conducted with risk managers we have identified the unaddressed factor variables for determining the vulnerability of countries to the pandemic. with this study we aimed to develop a pandemic risk exposure measurement (prem) model to determine the this event has revealed the limits of extension of the national hospital and intensive care unit capacities in scenarios of sudden exceptional demand for medical care. the comprehensive burden was exposed to the mature post-industrial societies and emerging markets and other lmics countries alike. due to a variety of distinctively different historical legacies of national health system establishments, they all responded with an array of adaptive strategies. despite the burden, efficient responses came from india, china, russia and few other non-oecd economies. another side of the equation was the unstable response burdened with several core inefficiencies in the traditional western european high-income societies such as italy, spain and few others. thus, covid- has revealed huge mutual interconnectivity among the distant economic hubs of the modern-day world. proper risk assessments and the development of effective coping strategies might be highly valuable for the public health challenges of the future. besides, supranational actions might be needed to build up both public and private capacity to deal with pandemics. the developed prem model consists of factor (country's activity features), factor (demographic features), factor (societal vulnerability), and factor (economic exposure), and explains . % of the variance in "the level of experienced hazard of the participant (leh)". we also found that "the level of experience and knowledge of the participant" (leh) explains only approximately % of leh. our developed prem model is useful for risk managers and policymakers to proactively identify the factors that make the country more vulnerable to the pandemic risk and if necessary, manage them and/or set tolerance limits, policies, regulations, rules, standards, etc. it is not the intention with this study to design a one size fits all model but to provide policymakers and risk managers with a list of factors to enable the identification of country exposure and thereby enable proactive management and the development of a business continuity plan. moreover, as noted in the methodology section the study analysis is based mainly on self-reported responses to an online survey. this was built after consultation of the literature and case studies and deliberation with experts in the area of risk management. despite known weaknesses of this methodology, such as participant bias due to personal experiences; may result in classification error and underestimation or overestimation of measures. the case studies used, deliberation with peers and the literature review was carried out before choosing the measures, to limit this and provide a robust list of measures. moreover, hierarchical regression analysis showed that the difference in the explanation of variances when q -"the level of experience and knowledge of the participant" was added was of only approximately %. therefore, we can conclude that monitoring of these factors can help a country manage the change in their leh and devise policies to ensure that the country strengthens its capacity to meet demands for healthcare brought about by pandemic hazards such as covid- . that is, to flatten the curve of healthcare, social and economic demands below the capacity and thus provide to this demand over some time. this is a flexible model which can be adjusted to the specificities of the relevant countries since the aim is to provide a way to measure vulnerability without considering the tolerance level and the controls put in place, which is dependent on the country itself. therefore, only when the latter two variables are considered can a country give value to the prem measure and prepare an accurate plan to ensure continuity of the norm (the variables to be considered by each country in addition to the prem model are tolerance and the controls in place). we declare that we have abided by the research ethics review procedures of the university of malta, faculty of economics, management and accountancy, malta ethics committee and gdpr directive -research and data protection unique form id: _ , submitted by professor simon grima to the faculty of economics, management and accountancy ethics committee (frec). since there were no ethical issues or personal data collected we were provided with an automated ethical clearance and the clearance was submitted for filing with frec. the survey was administered as an online survey via weblink on qualtrics to contacts of the authors on social media, namely linkedin, facebook and twitter, who worked in a risk management function (non-probability purposive sampling). moreover, respondents were also invited using direct emails and were also asked to send this link to others working in the risk management function (non-probability snowballing sampling). responses were collected through qualtrics, no personal data were collected and/or maintained (anonymous response) and participants participated on a voluntary basis. the only filters, were that participants had to tick a box noting that they worked within a risk management function and that they consent (an informed consent) that we use the information collected for the analysis purposes of our study, before they could continue to answer the survey. an introductory paragraph describing the study was also provided at the beginning of the survey. risk management and healthcare policy is an international, peerreviewed, open access journal focusing on all aspects of public health, policy, and preventative measures to promote good health and improve morbidity and mortality in the population. the journal welcomes submitted papers covering original research, basic science, clinical & epidemiological studies, reviews and evaluations, guidelines, expert opinion and commentary, case reports and extended reports. the manuscript management system is completely online and includes a very quick and fair peer-review system, which is all easy to use. visit http://www.dovepress.com/testimonials.php to read real quotes from published authors. submit your manuscript here: https://www.dovepress.com/risk-management-and-healthcare-policy-journal report of the open-ended intergovernmental expert working group on indicators and terminology relating to disaster risk reduction a dictionary of epidemiology underlying differences in health spending within the world health organisation europe region-comparing eu , eu post- , cis, eu candidate, and carinfonet countries after covid: the next massive tail risk thematic analysis exploring factors affecting the proper use of derivatives: an empirical study with active users and controllers of derivatives. managerial finance fine-scale population density data and its application in risk assessment measuring the economic risk of covid- global metropolis: assessing economic activity in urban centres based on nighttime satellite images night-time light data: a good 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constrained by population aging-an opportunity to learn from japanese experience comparison of historical medical spending patterns among the brics and g the impact of health expenditures on public health in brics nations the people's bank of china's response to the coronavirus pandemic-a quantitative assessment. economic modelling emerging evidence of a silver lining: a ridge walk to avoid an economic catastrophe in italy and spain. safe white paper prevalence and attributable health burden of chronic respiratory diseases, - : a systematic analysis for the global burden of disease study we would like to thank primo -public risk management organisation https://www.primo-europe.eu/ for their help and guidance when preparing the inventory. the authors report no conflicts of interest in this work. key: cord- -sikgk i authors: breevoort, arnar; carosso, giovanni a.; mostajo-radji, mohammed a. title: high-altitude populations need special considerations for covid- date: - - journal: nat commun doi: . /s - - - sha: doc_id: cord_uid: sikgk i the atmospheric pressure that decreases with altitude affects lung physiology. however, these changes in physiology are not usually considered in ventilator design and testing. we argue that high altitude human populations require special attention to access the international supply of ventilators. aside traditional international diplomatic conventions. thus far, countries have placed restrictions on the export of icu ventilators . moreover, on several occasions countries have confiscated other countries' ventilators during transit through their borders, which the press has referred to as "modern-day piracy" . commercial icu ventilators are largely designed and tested near sea level. yet, with altitude there is a progressive reduction in barometric pressure and subsequently in oxygen pressure leading to major physiological adaptations in the lungs , which are not usually considered in ventilator quality tests. limited studies have compared the accuracy in tidal volume delivery of commercial ventilators at varying altitude and were all in the context of aeromedical evacuation , . in these tests, the majority of commercial ventilators failed at high altitude, delivering tidal volumes with up to % error from the set volume . importantly, technical errors and canceled ventilation were frequently reported . long-term care of critically ill patients, including covid- positive patients, at high altitude is therefore unfeasible with the majority of these ventilators and there is a general lack of ventilators specialized for the million people living at higher elevations. history shows that a failure to contain a pandemic locally can lead to increased viral spread, and an increase in the global overall morbidity and mortality of a virus. the h n pandemic and the sars-cov pandemic are similar in which both the h n and sars-cov- virus are antigenically novel, transferred zoonotically to humans, have adapted to the human body and are a cause of severe respiratory illness . after the initial failure to contain the spread of h n in , a second more pathogenic wave swept across the world, accounting for the majority of casualties related to h n . this second wave particularly affected ill-prepared populations which then became new sources of viral spread. adequate containment and treatment of a virus is paramount to prevent its spread and hamper potential increase in pathogenicity. it is therefore in the interest of the international community as a whole that each nation is able to strongly respond to covid- . geographically, several high-altitude countries are located and well connected to other nations with high population density. bolivia, for example, being at the center of south america, neighbors five countries, including brazil, the most populated country in the region. having one of the poorest healthcare systems in the americas, it is common for bolivians to search for medical treatment in neighboring countries . consequently, failure to contain and treat the virus in bolivia would hamper the efforts of other south american countries. similarly, failure to contain the virus in ethiopia, the second most populated country in africa, would negatively affect the treatment efforts of the region. when international collaboration ensures that less-affluent nations are able to respond strongly locally, covid- can be contained internationally. the west-african ebola outbreak in met a strong international response spearheaded by the united states and the world health organization (who) resulting in the end of the internationally concerning public health emergency regarding ebola in early . the further spread of covid- can be halted under international collaboration and the understanding that success is dependent on the containment of covid- in all countries, including economically challenged countries . however, this success relies on two factors. firstly, equipment to adequately treat and test for covid- should be developed and made available that matches the geographical, economic, and educational challenges that are relevant to these countries. this is not limited to the development of icu ventilators that are functional at higher elevation but can also be aimed at improving testing methods for covid- at lower cost and easy scalability to a relatively small population of trained laboratorians. secondly, although it is inherent that each country aims to acquire the necessary amount of equipment required for the treatment and prevention of covid- , lessaffluent countries should receive international support in their efforts to obtain the equipment and tests that are necessary and relevant to their response to covid- . implementation of these two factors will both improve the epidemiological response of economically and geographically challenged countries to covid- in a humanitarian way and reduce the chance that these countries might become centers of new 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ebola situation report - scientists as non-state actors of public diplomacy correspondence and requests for materials should be addressed to m.a.m.-r.reprints and permission information is available at http://www.nature.com/reprintspublisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this license, visit http://creativecommons.org/ licenses/by/ . /. key: cord- -p e authors: tan-torres edejer, tessa; hanssen, odd; mirelman, andrew; verboom, paul; lolong, glenn; watson, oliver john; boulanger, lucy linda; soucat, agnès title: projected health-care resource needs for an effective response to covid- in low-income and middle-income countries: a modelling study date: - - journal: lancet glob health doi: . /s - x( ) - sha: doc_id: cord_uid: p e background: since who declared the covid- pandemic a public health emergency of international concern, more than million cases have been reported, as of aug , . this study aimed to identify what the additional health-care costs of a strategic preparedness and response plan (sprp) would be if current transmission levels are maintained in a status quo scenario, or under scenarios where transmission is increased or decreased by %. methods: the number of covid- cases was projected for low-income and middle-income countries for each of the three scenarios for both -week and -week timeframes, starting from june , . an input-based approach was used to estimate the additional health-care costs associated with human resources, commodities, and capital inputs that would be accrued in implementing the sprp. findings: the total cost estimate for the covid- response in the status quo scenario was us$ · billion over weeks, at $ · per capita. for the decreased or increased transmission scenarios, the totals were $ · billion and $ · billion, respectively. costs would triple under the status quo and increased transmission scenarios at weeks. the costs of the decreased transmission scenario over weeks was equivalent to the cost of the status quo scenario at weeks. by percentage of the overall cost, case management ( %), maintaining essential services ( %), rapid response and case investigation ( %), and infection prevention and control ( %) were the main cost drivers. interpretation: the sizeable costs of a covid- response in the health sector will escalate, particularly if transmission increases. instituting early and comprehensive measures to limit the further spread of the virus will conserve resources and sustain the response. funding: who, and uk foreign commonwealth and development office. on jan , , who declared sars-cov- a public health emergency of international importance, later formally identified as covid- . the declaration advised the member states to prepare for containment and prevention of onward spread of the virus. after a week, cases were reported, % of which were in china and the rest in other countries. in response, who appealed for us$ million to support member states over a -month period, as they began implementing priority public health measures. the priority public health measures were outlined in the eight pillars of the strategic preparedness and response plan (sprp), and ranged from country coordination to clinical case management. as of july , , more than million cases of covid- , including more than deaths, had been reported globally. who explicitly expanded the scope of the sprp to include a ninth pillar on the maintenance of essential health services in acknowledgment that the pandemic was already straining the health system. who also released guidance on public health and social measures (phsm) to slow down the transmission of the virus. countries closed offices, schools, restaurants, places of worship, and banned large gatherings to restrict movement and to avoid further straining of the health system. epidemiological models have predicted that many more deaths and infections would have occurred if these measures were not implemented. however, the social and economic repercussions of the phsm are also beginning to emerge. the world bank has forecast global gdp will contract by · % in , on the assumption that measures will start to be lifted in the second half of the year. if the covid- pandemic persists, and movement restrictions are maintained or intensified, greater losses are predicted. this study aims to project the future costs of the strategic response and preparedness actions in the health sector to counter the covid- outbreak. given the uncertainty in the future course of the disease, estimates are provided in the short term, and separate scenarios are modelled where current measures to restrict movement are maintained, relaxed, or intensified. this study estimates the costs of implementing the nine pillars of the sprp in low-income and middle-income countries (appendix p ), accounting for · % of the total population in that group of countries. the nine pillars of the sprp and the key cost items in each pillar are presented in table . the study includes low-income countries, and the most populous lower-middle-income and upper-middleincome countries, and it excludes countries for which no gdp or epidemiological data were available. the costs were additional to what is currently known to exist, or to have been spent by the countries at the start of the analysis (june , ), and were estimated in the -week and -week periods after this date (ie, until july and sept , ). the costing was therefore synchronised chronologically to show the same time period in countries at different stages of the epidemic. all of the one-time and recurrent inputs that were expected to occur within these two time periods to prevent new cases, and to treat prevalent and incident cases, were costed. during this time, the course of the pandemic might change, depending on decisions taken by national leaders on either relaxing or intensifying phsm. in an attempt to capture this potential uncertainty, for each time period, three scenarios were analysed with the current measures to restrict movement, and facilitate physical and social distancing, being either maintained, relaxed, or intensified. only costs expected to be borne by the health sector were included, and costs related to any social mitigation interventions, such as cash or in-kind transfers, were excluded. an inputs-based approach was taken, where quantities of items related to each activity were multiplied by the unit price for each item. the interim guidance documents issued by who and consultations with experts from relevant technical programmes were the sources of the types and quantities for key items. the estimated number of cases of covid- were secondary data taken from the epidemiological model from imperial college (london, uk). this model was used because it provides publicly available estimates for a evidence before this study since jan , , when who labelled the covid- pandemic a public health emergency of international concern, countries have tried to limit its spread, instituting measures on physical distancing and restrictions on movement. with more than million cases reported, the world bank and other major financing institutions have projected an overall contraction of • % of global gross domestic product due to covid- in , with persisting effects in the years to come. this projection was made on the assumption that the restrictions will be lifted in the second half of ; however, the costs of the actions needed to respond to the pandemic, which could enable the lifting of these restrictions, have not been estimated for low-income and middle-income countries. from a different perspective, some costing work has been done on preparedness. in , after the ebola outbreak, the national academy of medicine launched the commission on a global health risk framework for the future. the commission estimated us$ • billion a year globally for pandemic preparedness versus an annualised expected loss from potential pandemics of more than $ billion. in december , the international working group on financing preparedness issued a report on investing in health security. based on a few country studies costing the multisectoral national action plans for health security, they estimated a cost of $ • - per person per year on preparedness. to our knowledge, this is the first study costing a strategic response to covid- , a public health emergency of international concern. considering the baseline preparedness of low-income and middle-income countries, and the limited resilience of their health systems, major investment will be needed to counter the virus. the result of the status quo scenario, a health-care cost total of us$ • billion or $ • per capita after weeks for low-income and middle-income countries, is not an insignificant cost, but reflects the constrained capacity in the countries facing a virus that has spread and established itself. some hope is offered by the scenario in which the public health and social measures are intensified, resulting in a decrease in transmission by %. however, the costs, when the restrictions are relaxed and transmission increases by %, escalated at weeks and further escalated at weeks. the results show which pillars of the strategic preparedness and response drive the costs. this study should inform governments, as they consider relaxing restrictions to jumpstart their economies. the arguments for investing in preparedness are strong, juxtaposed against the price tag for the response versus covid- , and coupled with the expected shock on the global economy. future work at the country level is needed to strategically identify the gaps in both preparedness and response against not only covid- , but also for other potential future pandemics. see online for appendix large number of low-income and middle-income countries. this susceptible, exposed, infected, and recovered or removed (seir) model was calibrated on confirmed deaths from the start of the covid- outbreak up to june , . imperial college runs the model regularly for all countries, except those where low levels of reported covid- deaths does not permit accurate modelling. for this costing exercise, countries without projected covid- epidemiology from the model were china, iran, tanzania, uganda, and zimbabwe. for these countries, a separate seir model, provided by imperial college as a script in the r programming language, was run by our research team using effective reproduction (rt) values taken from the centre for mathematical modelling and infectious diseases repository associated with the london school of hygiene & tropical medicine (london, uk). rt values are commonly described as the number of contacts that a case infects. the model projected cases for the weeks and weeks following june , , under three scenarios: status quo (maintain current transmission), an increase in transmission by %, and a decrease in transmission by %. the increased and decreased transmission scenarios work through changes in the rt and the level of mobility in the epidemiological model. as the projections are made based on the current state of the pandemic in each country, the results reflect a wide range of response strategies. we also report outputs of the epidemiology modelling at the start and the end of the period according to the oxford stringency index, which measures the level of covid- mitigation measures implemented at the country level. capital costs included within the resource needs for covid- response are intended for upgrading laboratories for diagnostic testing (pillar ), buying field hospitals to expand capacity for treating covid- patients (pillar ), and repurposing health facilities to enable them to cope with non-covid- patients who would otherwise have been treated in hospitals providing care to covid- patients (pillar ) to lift the supply side constraint of hospital and intensive care unit beds, procuring communications equipment (pillar ), and providing motorcycles for contact-tracing teams (pillar ; table ). another capital cost would be the provision of handwashing stations for hygiene (pillar ). in addition to capital costs, a series of one-time costs are included, such as the hiring of consultants to develop or adapt guidance documents, prepare online training courses, document plans, design communications materials, and other related duties. all these components would be scaled depending on the level of the epidemic and according to appropriate administrative scalars (eg, by the number of subnational administrative units or number of health facilities per country). the essential supplies forecasting tool version (esft ) was used to estimate the costs of key commodities and supplies as part of the covid- response. these commodities and supplies included personal protective equipment, single-use masks, diagnostic tests, supportive drugs (including dexamethasone), disposable supplies, and oxygen for hospitalised patients. to estimate the quantities of commodities needed for a country's covid- response, the esft combined the assumptions on the number of items related to each case with the number of cases, split by severity. only % of cases ( % severe and % critical) were assumed to need hospitalisation. the prices of each item, although found in the esft , were updated using international market prices. for diagnostics and testing, the esft assumed that all hospitalised covid- patients were tested, and that there was a targeted testing strategy, where % of all suspected cases were also tested. testing was constrained by a country's diagnostic capacity, as determined by the available diagnostic instruments and the number of laboratory technicians available to focus on covid- diagnostics and do the pcr-based tests. these supply-side constraints were lifted partly by the purchase of automated extraction platforms, expanding the working week for laboratories from days to days, and adding another h shift to laboratory operations. an assumption was made that a supply side constraint existed, and only a maximum of % of the existing health workers could be prioritised for the covid- response. they continued to receive their salaries, and these are not included in the costing. incentives, both financial and non-financial (eg, paid sick leave including time spent in quarantine; occupational risk insurance or life insurance; ensuring treatment for illness; provision of child or elder care support; or accommodation near the health facility, transport, or relocation allowance, or all three), estimated at % of the average monthly salary, were paid to all those working directly in the covid- response in health facilities. hazard pay at % of salary was paid to all those at increased risk, defined as those having close contact with a covid- -positive patient. to maintain essential health services, salaries were paid to new hires to replace half of the number of existing health workers prioritised for covid- response, on the assumption that % replacement was not needed because non-urgent consul tations and elective admissions are being postponed. the new hires were expected to come from the private sector, or from retirees or soon-to-be graduates. salaries were obtained from the who-choice salary database and were updated to us$. to capture the main uncertainty in the cost of the pandemic response that arises from the course of the pandemic itself and the policy responses of the governments, both increase and decrease in transmission of % were modelled. in addition, because providing incentives is a policy response that governments might choose to exercise, the costs are presented with (base case) and without the incentives. more details are available in the full technical documentation (appendix pp [ ] [ ] . resources from who (funding for consultants and salaries of staff) were used to produce the estimates in this paper. the authors (all from who except ow, who is funded by the uk foreign commonwealth and development office) were solely responsible for the design, conduct, analysis, and writing up of the study. the corresponding author had full access to the data and took the decision to submit for publication. at the start of the analysis on june , , seven countries had an rt of less than , two countries had an rt of or more, but most countries had an rt of - (table ) . across the rt categories, the median oxford stringency index, ranged from · to · (with representing the most stringent measures); the mean number of daily contacts, which is the number of personal interactions, ranged from • to · ; and the percentage of the population infected, which is an estimate of cumulative infections, ranged from • % to • %. at the end of weeks, the percentage infected was projected to increase in the status quo, particularly in those with an rt of · or greater, and much larger burdens were projected for the % increase in transmission scenario. under the % decrease in transmission scenario, only a slight increase in the percentage infected was projected. during the -week timeframe, a similar pattern emerged, and many more cases were projected in the status quo and % increased transmission scenarios, whereas in the % decreased transmission scenario, the case burden remained relatively stable, except in countries where the rt was or greater. the costs of the covid- response in low-income, lower-middle-income, and upper-middle-income countries after weeks and weeks under the different scenarios are shown in table . the total cost at this stage of the epidemic, if the status quo is maintained over weeks, is $ • billion with a per-capita cost of $ • . if more measures to facilitate physical and social distancing, and to restrict movement were applied, and countries' transmission was reduced by %, the -week resource requirements would be reduced to $ • billion ($ · per capita). with % increased transmission, under a scenario of relaxed restrictions, costs of $ • billion ($ · per capita) over the same -week period would be generated. in the -week projection, costs would more than tripled under the status quo and % increased transmission scenarios. the costs of the % decreased transmission scenario over weeks is equivalent to the cost of the status quo scenario at weeks. most of the costs would be accrued in the middle-income countries. the top ten countries (appendix p ) would account for % of the costs in the -month status quo scenario, and this pattern is stable across the different timeframes and scenarios. the dominance by a handful of countries is due to a combination of factors: larger populations, higher prices, and a more widespread epidemic. the distribution of the costs over the nine pillars are shown at weeks in table (data for weeks are provided in the technical documentation; appendix p ). under the status quo scenario, case management would account for around % of the costs, % would go to maintaining essential health services, and around % to investigation, surveillance, and rapid response. the building of handwashing stations, and procurement of personal protective equipment and cloth masks within pillar accounts for about % of the cost. these pillars would be the major cost drivers of implementing an effective covid- response. the pattern of the distribution of the costs is generally maintained under the % increased and decreased transmission scenarios, except for a decrease in the proportion of costs in investigation in the % decreased transmission scenario and an increase in the same costs under the % increased transmission scenario, compared with the status quo scenario. the costs by category for human resources, commodities, capital, and other costs at weeks and weeks for the status quo scenario are shown in table . at weeks, capital costs are nearly equivalent to human resources costs; however, at weeks, the costs of human resources becomes higher than all other categories, at % of the total cost. recurrent costs are primarily for human resources, and secondarily for commodities. costs for human resources are high, at $ · billion at weeks, and they are driven by salaries for newly hired staff and incentives. the cost of the status quo scenario would decrease to $ billion and $ billion at weeks and weeks, respectively, if incentives are not included. as of june , , the costs of the full, nine-pillar response to covid- in low-income and middleincome countries after weeks, on july , , were projected to be approximately $ billion, assuming that the rt was unchanged and the status quo continued. costs are estimated to be more than three times that amount after weeks on sept , , under a status quo scenario. the costs were projected to be greater at weeks and weeks if transmission values increased by %. this analysis shows that the cost of responding to a pandemic with % decreased transmission at weeks is coinci dentally equivalent to the cost at weeks under the status quo scenario. the per-capita cost of the response under the status quo scenario for weeks is $ • for low-income countries and $ • to $ • in lower-middle-income and upper-middle-income countries. for weeks, the costs per capita are $ • for low-income countries and about $ for middle-income countries. to put this in context, the health expenditure per capita in , for a whole year, in low-income countries was $ , and from $ to $ in lower-middle-income and upper-middleincome countries. the potentially huge opportunity costs within the health sector in not responding rapidly are clearly evident. the benefits of acting early and comprehensively, like in vietnam, are a clear lesson that can be drawn from this costing exercise. an early and rapid response will not only mitigate future covid- costs, but more importantly, it will be able to mitigate future covid- costs because of a lower number of covid- infections, and a corresponding lower number of deaths and long-term consequences among survivors. a strong pillar response on maintaining essential health services can also potentially decrease the number of deaths indirectly caused by covid- . social and economic disruptions can also be shortened. this analysis also shows the interconnectedness of the nine pillars of the covid- response. as the number of cases increases, the share of costs found in case management (in pillar seven) and in maintaining essential health services (in pillar nine) both increase. increases in the number of cases will also generate increased demand for personal protective equipment, hospitalisation and attendant costs, and contact tracing. however, it is important to note that, for preparedness, all countries must invest in more handwashing stations, and better risk communication and community engagement, even with low numbers of cases. the predicted resource needs for a full response for weeks continue to be onerous burdens for countries with a high expected number of cases. however, some of the resource requirements can be decreased by examining where efficiencies or cost savings can be made. the analysis described in this article has used international market prices that are readily obtainable for many commodities. however, some items can be locally produced, such as personal protective equipment (including gloves and cloth masks), some medicines, and single-use supplies. testing kits might be able to be produced at a lower price in countries with local manufacturing capacity, and good quality assurance and regulatory capacity. for human resources needed to respond to covid- and maintain essential health services, perhaps the current workforce is capable of providing enough surge capacity, and together with approaches such as telemedicine, task shifting, and quick upskilling through intensive training and supervision, there will be no need to replace the health workers directly engaged in the covid- response, and the large resource requirement this implies. however, the assumption of spare capacity within the health workforce in low-income and middleincome countries should be questioned. the health system response to covid- has been shown to have a negative impact on the delivery of other services, from immunisation to non-communicable diseases, with decreased coverage rates, substantiating the need to at least partially replace health workers prioritised to the covid- response. aside from hiring new health workers and paying salaries, hazard pay and incentives should be provided to workers in direct contact with patients diagnosed with covid- . countries might choose whether they will provide incentives, but hazard pay for arduous conditions is consistent with legally binding conventions of the international labor office. a more effective approach to reduce the costs will be to decrease the transmission of the virus and have fewer cases to respond to, from the implementation of interventions such as contact tracing and subsequent effective quarantine or isolation, washing stations. all these individual-level measures have been fully costed within this exercise, but their slowing of the transmission of the virus has not been taken into account, as each country's rt is fixed at the start for the period of analysis. as such, the true costs for countries would probably be lower than those estimated per scenario. this difference highlights the need for more dynamic and more frequent modelling and costing to get a more accurate estimate. the precision of the modelling used and the scope of the study have some limits. the first is that the costing is primarily driven by the epidemiological model used. running an epidemiological model and making projections for many countries is fraught with uncertainty, especially given the assumption that the rt remains fixed over the -week and -week timeframes. in this exercise, to cope with this uncertainty, scenarios with different transmission levels were projected to provide higher and lower bounds to the base case estimate. in terms of scope, this costing exercise did not include the isolation or quarantine costs of people with mild to moderate covid- , and their contacts who are unable to successfully isolate or quarantine themselves in their own homes, and where mass quarantine shelters or facilities would need to be set up. this could potentially be a large cost, but it is usually borne by local governments or ministries of social welfare. the use of international market prices, without freight, insurance, and import tariffs also underestimates the costs. however, countries have been known to allow time-bound, tariff-free entry for supplies and medicines for covid- . in addition, countries would have to bear costs of waste management of the covid- response, primarily for non-durable personal protective equipment, which are not included in our estimates, but could require significant amounts of resources. finally, these costs would change significantly once directly acting medicines or vaccines proven to be effective against covid- are produced and added to standard treatment or prevention protocols. in summary, the results of this study show the need to account for health systems in the context of health security. preparedness for health emergencies and disasters has been highlighted as a key component of the common goods for health that require explicit public investment to overcome market failures. these results emphasise that critical components of health systems essential to the surge capacity, which can deliver an effective response (eg, human resources and laboratories), need to be in place, and mechanisms for mobilisation need to exist for when an outbreak occurs. this study also shows that, when faced with a decision to adjust phsm, epidemiological modelling and costing of different scenarios based on different rt values, often reflecting various policy options, updated frequently and using good local data, can be informative. whatever the estimated costs of the response, it might be the case that this amount is not fully within the financial capacity of low-income and some middle-income countries. this gap in the resources can be partly filled by development partners and the private sector. to facilitate modelling, costing, and priority setting, who will be releasing a country level costing tool based on this exercise. it will be made available through the covid- partners platform, where countries and partners can interact in real time to prepare for and respond to the covid- pandemic. finally, this study highlights that while fully implementing a covid- response will entail significant resource needs, the impact of such an early and comprehensive response in limiting the spread of the virus will markedly reduce the resources needed to respond to a more widespread pandemic just a few weeks later. tt-te, oh, am, gl, llb, and as conceptualised the article. tt-te, oh, am, gl, and ojw reviewed articles, contacted experts, and collected data. tt-te, oh, am, pv, and ojw ran the analysis. tt-te, oh, and am wrote the first draft of the article and revised it based on feedback from co-authors. all authors reviewed and approved the article. we declare no competing interests. covid- as a public health emergency of international concern (pheic) under the ihr us$ million needed for new coronavirus preparedness and response global plan operational planning guidelines to support country preparedness and response director-general's opening remarks at the media briefing on covid- who. covid strategy update. overview of public health and social measures in the context of covid- oxford covid- government response tracker the effect of large-scale anti-contagion policies on the covid- pandemic global economic prospects the impact of covid- and strategies for mitigation and suppression in lowand middle-income countries projections of covid- epidemics in lmic countries covid- essential supplies forecasting tool clinical management of covid- : interim guidance emergency global supply chain system (covid- ) catalogue global health observatory data repository global health worker salary estimates: an econometric analysis of global earnings data global spending on health: a world in transition combating the covid- epidemic: experiences from vietnam excess mortality from the coronavirus pandemic (covid- ) updated estimates of the impact of covid- on global poverty the-use-of-masks-in-the-community-during-home-careand-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-( -ncov)-outbreak new zealand eliminates covid- rapid assessment of service delivery for ncds during the covid- pandemic ilo nursing personnel convention no. effectiveness of isolation, testing, contact tracing, and physical distancing on reducing transmission of sars-cov- in different settings: a mathematical modelling study physical distancing, face masks, and eye protection to prevent person-to-person transmission of sars-cov- and covid- : a systematic review and meta-analysis de-escalation by reversing the escalation with a stronger synergistic package of contact tracing, quarantine, isolation and personal protection: feasibility of preventing a covid- rebound in ontario, canada, as a case study covid- : trade and trade-related measures who. global research on coronavirus disease (covid- ). financing common goods for health: core government functions in health emergency and disaster risk management covid- partners platform we acknowledge the modelling group from the mrc centre for global infectious disease analysis at imperial college london (azra ghani, patrick walker, and charlie whittaker) for providing up to date epidemiological projections. we also acknowledge justin graves, luke baertlein, zachary panos, and owen demke from the clinton health access initiative for their technical support with the use of essential supplies forecasting tool version , and technical inputs on diagnostic testing. finally, we acknowledge expert contributions from staff at various departments at who (juana paola bustamante, hong anh chu, giorgio cometto, bruce gordon, fiona gore, lisa hedman, sara hollis, teena kunjumen, ben lane, margaret montgomery, pryanka relan, teri reynolds, cris scotter, adriana velazquez, and lara vojnov). key: cord- -d d amk authors: edmond, karen; zaidi, anita title: new approaches to preventing, diagnosing, and treating neonatal sepsis date: - - journal: plos med doi: . /journal.pmed. sha: doc_id: cord_uid: d d amk karen edmond and anita zaidi highlight new approaches that could reduce the burden of neonatal sepsis worldwide. neonatal sepsis or septicaemia is a clinical syndrome characterized by systemic signs of circulatory compromise (e.g., poor peripheral perfusion, pallor, hypotonia, poor responsiveness) caused by invasion of the bloodstream by bacteria in the first month of life. in the pre-antibiotic era neonatal sepsis was usually fatal. case fatality rates in antibiotic treated infants now range between % and % with the highest rates reported from the lowestincome countries [ ] . the world health organization (who) estimates that million deaths per year ( % of all under-five mortality) are due to neonatal sepsis and that % of these deaths occur in the first week of life [ ] . there are wide disparities in neonatal care between highand low-income countries. in high-income countries the major concern is the increasing numbers of extremely premature infants with high nosocomial infection rates due to multiresistant organisms in intensive care units. health facility infections are also a major problem in lowincome countries, but the more pressing issues are the high proportion of home deliveries in unclean environments predisposing to sepsis and ensuring that all neonates have access to effective interventions from health care providers in the first days of life . indeed, new strategies that can prevent, diagnose, and treat neonates with sepsis are needed in both low-and high-income settings. distal risk factors for neonatal sepsis include poverty and poor environmental conditions. proximate factors include prolonged rupture of membranes, preterm labour, maternal pyrexia, unhygienic intrapartum and postnatal care, low birth weight, and prelacteal feeding of contaminated foods and fluids [ ] [ ] [ ] . the bacteria that cause neonatal sepsis are acquired shortly before, during, and after delivery (figure ). they can be obtained directly from mother's blood, skin, or vaginal tract before or during delivery or from the environment during and after delivery. streptococcus agalactiae (group b streptococcus, gbs) is the most common cause of neonatal sepsis in many countries, though low rates are reported from many low-income countries, especially those in south asia. [ ] [ ] [ ] ; gramnegative bacilli (escherichia coli, klebsiella spp., pseudomonas spp., acinetobacter spp.) and gram-positive cocci (such as staphylococcus aureus and staphylococcus epidermidis) are other important causes [ ] [ ] [ ] . however, there are many difficulties in interpreting aetiological neonatal sepsis data, because many studies report selected populations of high-risk infants. specimens from infants in the first hours of life are also seriously under-represented, especially those from low birth-weight babies and babies born outside health facilities [ , [ ] [ ] [ ] . intrapartum antibiotic prophylaxis against s. agalactiae has also led to a substantial change in the bacteria responsible for early onset neonatal sepsis; gramnegative bacilli and staphylococcus spp. predominate in countries implementing these programs [ ] . there are also many other important neonatal infectious disease pathogens that are not associated with the sepsis syndrome including: treponema pallidum, rubella virus, herpes simplex virus, cytomegalovirus, toxoplasmosis, clostridium tetani, hiv, hepatitis b virus, and bordetella pertussis ( figure ) [ , , ] . these infectious pathogens cause serious morbidities in young infants and multifaceted disease syndromes including congenital anomalies, developmental disabilities, chronic liver disease, neonatal tetanus, and apnoea. they are also important causes of morbidity and mortality in older age groups. however, only pathogens that cause neonatal sepsis are discussed in this paper. neonates have a functionally immature immune system. they have extremely low immunoglobulin (ig) levels except for igg to specific maternal antigens transferred passively across the placenta during the last trimester of pregnancy [ , ] . t cell function is relatively unimpaired but complement activity is half that of healthy adults. neonates have a low neutrophil storage pool, and their existing neutrophils have impaired capacity to migrate from the blood to sites of infection [ ] . the basal expression of toll-like receptors (tlrs, receptors that detect the presence of microbes) is similar in the neonate and adult [ ] . however, innate immune responses of neonatal mononuclear cells are characterised by markedly reduced release of the proinflammatory th -polarizing cytokines tumour necrosis factor-alpha (tnf-a) and interferon-gamma (ifn-c) with relative preservation of anti-inflammatory th -polarizing cytokines such as interleukin (il ) [ ] . these findings may reflect in utero requirements, including the avoidance of harmful inflammatory immune reactions [ ] . these immunological problems are reflected in the clinical presentation of neonatal sepsis. neonates have a rapid and fulminant progression of septicaemic disease, nonspecific clinical signs of infection, and difficult-to-interpret laboratory results including haematological and immunological biomarkers of infection and inflammation. low birth-weight (preterm and small for gestational age) infants have even poorer functional immunity, and are especially at risk of sepsis [ ] . however, neonates do have well-functioning cationic membrane-active antimicrobial proteins and peptides (apps) which have microbicidal properties [ , ] . these apps can be found in the vernix caseosa covering the skin at birth, and in the neonatal gastrointestinal and respiratory tracts. many older studies have demonstrated that improving maternal health and nutri-tion before delivery is directly associated with improved neonatal health outcomes [ ] . randomised controlled trials (rcts) of maternal protein-calorie and multiple micronutrient and supplementation have demonstrated significant improvements in rates of prematurity and birth weight and variable impact on mortality; but no studies have examined their impact on rates of neonatal sepsis [ , ] . maternal immunisation is an important method of providing neonates with appropriate antibodies as soon as they are born [ ] . this approach is less sensitive to obstacles in accessing the health care system than are other approaches, and examples of successful interventions include maternal tetanus toxoid and influenza immunisations [ , ] . studies of maternal immunisation with s. agalactiae type iii conjugate vaccine have demonstrated excellent placental transfer and persistence of protective levels in month-old infants [ ] . phase i and ii trials of other serotypes in nonpregnant women have also demonstrated safety and immunogenicity. a recent modelling study estimated that vaccination with s. agalactiae vaccine would prevent % of us preterm births and %- % of neonatal s. agalactiae infections [ ] . encouraging results are also emerging from studies of maternal immunisation with pneumococcal polysaccharide and conjugate vaccines [ , ] . the vaccines all have excellent safety profiles. however, barriers to maternal immunisation include: liability issues for vaccine manufacturers in developed countries; education of the public and health care providers regarding the benefits of maternal immunisation; and poor ascertainment of data from lowincome countries [ ] . there is strong evidence that clean delivery practices and handwashing during delivery reduces rates of neonatal sepsis in both home and health facility settings [ ] [ ] [ ] . interventions to improve handwashing rates have been remarkably successful in research settings [ , ] . the reasons for lack of successful scaleup of handwashing interventions into policy, programs, and behaviour change are less clear [ ] . new studies from malawi and nepal indicate that maternal antisepsis interventions such as vaginal chlorhexidine during labour may have a significant impact on rates of neonatal mortality and sepsis in developing countries [ ] . however, other studies from high-income countries have demonstrated little effect on rates of hiv or neonatal infections [ ] . intrapartum antibiotic prophylaxis has been highly effective in reducing both early-onset neonatal bacterial and maternal sepsis in developed countries [ ] . chemoprophylaxis in the us has halved the incidence of early-onset neonatal bacterial sepsis caused by s. agalactiae from . per , live births in to . per , in [ ] . clear protocols are in place in high-income countries for the management of women with risk factors for neonatal sepsis [ ] . risk factors for early-onset neonatal bacterial sepsis in low-income settings are probably similar to resource-rich settings, but have not been evaluated in the context of high rates of maternal undernutrition, anaemia, hiv, and malaria. there is also strong evidence that handwashing by health care providers after delivery can reduce neonatal sepsis and infection rates, especially in hospitals [ , ] . there is less evidence for the importance of rigorous handwashing and use of antiseptics in mothers of their own infants. five key papers on preventing, diagnosing, and treating neonatal sepsis in high-income settings, studies have not shown an advantage of antibiotics or antiseptics over simply keeping the umbilical cord clean [ ] . however, umbilical stump chlorhexidine cleansing has recently been shown to substantially reduce neonatal deaths in nepal [ ] . other studies investigating the effects of chlorhexidine on prevention of omphalitis are currently underway in several countries [ ] . there is emerging evidence that neonatal skin antisepsis preparations such as sunflower seed oil provides cheap, safe, and effective protection against nosocomial infections in hospitalized preterm neonates and infants in studies in south asia. application of chlorhexidine to neonatal skin has also been shown to be effective in reducing neonatal sepsis in studies from south asia [ , ] . neonatal immunisation has long been considered an important method of reducing neonatal infections. however, response varies according to the antigen [ ] . bcg, polio, and hepatitis b vaccines are highly immunogenic when given at birth [ ] . however, maternal antibodies interfere with a neonate's response to measles vaccine when administered under six months. protein antigen vaccines (e.g., pertussis and tetanus toxoid) given at birth have been shown to produce poor responses compared to the same antigen given at two months of age and are associated with later tolerance [ ] . studies also indicate that s. agalactiae and streptococcus pneumoniae vaccines are both likely to be ineffective when given in the neonatal period [ ] . breastmilk contains secretory iga, lysozymes, white blood cells, and lactoferrin and has been shown to encourage the growth of healthy lactobacilli and reduce the growth of e. coli and other gramnegative pathogenic bacteria [ ] . rcts that focused on increasing early initiation and exclusive breastfeeding rates demonstrated significant reductions in diarrhoea and acute respiratory infections in neonates and older infants in india [ ] . other observational studies have demonstrated impact on infection specific mortality rates and all-cause mortality during the neonatal period [ ] [ ] [ ] . neonatal micronutrient supplementation trials have focused on vitamin a supplementation. older studies have shown significant reductions in respiratory disease in low birth-weight infants after the administration of parenteral vitamin a [ ] . more recently, trials of newborn vitamin a supplementation have shown encouraging reductions in neonatal mortality, and more trials are underway [ ] . in high-income countries, clinical trials of immune stimulants such as granulocyte/ monocyte colony stimulating factor (gm-csf) to enhance the quantity and quality of neonatal neutrophils and monocytes appear promising but have not yet shown a significant clinical benefit [ ] . the evaluation of recombinant apps as adjunctive therapy for neonatal infection are still under evaluation. the impact of tlr agonists to improve defences against microorganisms are also being evaluated [ ] . neonatal clinical sepsis syndrome identification is difficult as the clinical signs of neonatal septicaemia can be very similar to those of other life-threatening diseases such as necrotising enterocolitis, hyaline membrane disease, and perinatal asphyxia [ , ] . however, recent studies in middle-and low-income countries have provided seven danger signs which can be used to identify infants with very severe disease including neonatal sepsis (table ) [ ] . these signs provide high sensitivity and moderate specificity for detecting serious illness in newborns in low-resource settings and have now been incorporated into the new neonatal who integrated management of childhood illness (n-imci) guidelines. identification of neonatal sepsis before delivery also remains challenging. a combination of maternal risk factors and clinical signs and symptoms is currently used [ ] . however, peripartum proteomic analysis of the amniotic fluid is now offering the opportunity for early and accurate diagnosis of early-onset neonatal sepsis in the select population of women undergoing amniocentesis in high-risk pregnancies [ , ] . confirmation of pathogenic organisms allows targeted antibiotic therapy. however, identification of pathogenic organisms in neonates with sepsis syndrome is fraught with difficulties. bacterial load may be low due to mothers receiving antepartum or intrapartum antibiotics and because only small amounts of blood can often be taken from newborns [ ] . contamination rates may also be very high due to the technical difficulties of sterile venipuncture in small babies. there may also be misinterpretation of the role of coagulase-negative staphylococci (e.g., s. epidermidis), as these organisms are both normal skin flora and pathogenic organisms in preterms and infants with indwelling blood vessel catheters [ ] . automated blood culture systems have long been considered the gold standard for microbiological diagnosis. however, despite improvements in growth media and instrumentation, results of blood culture can be delayed by up to hours [ , ] . the condition of a neonate with true sepsis can deteriorate quickly, thus the most common approach is to initiate empiric broad-spectrum antibiotic therapy in all young infants with suspected bacterial infection [ ] . a negative blood culture after hours may allow cessation of antibiotic therapy in a well infant. while appropriately cautious, this practice leads to antibiotic exposure in a large number of newborns for whom antibiotic treatment may be unnecessary since blood cultures are positive in only %- % of suspected sepsis cases, even at highly resourced facilities [ ] . antigen detection techniques allow rapid detection and identification of microorganisms without culturing. the most commonly used commercially available test is the latex agglutination assay, which is based on specific agglutination by bacterial cell wall antigens of antibodycoated latex particles. however, these tests can only detect specific organisms such as s. agalactiae and are associated with high false positive and negative rates [ ] . new urinary antigen tests for pneumococcus are more encouraging but are also associated with false positives from pneumococcal carriage [ ] . the polymerase chain reaction (pcr) has been widely used in biomedical research laboratories for pathogen identification in neonatal sepsis and in some clinical hospital laboratories. the high sensitivity of pcr allows detection of bacterial dna even when concentrations are low [ ] . conventional assays are being replaced by a newer ''real-time'' system, which is faster and associated with lower contamination rates because amplification and detection occur simultaneously in a closed system [ ] . the real-time pcr is based on the measurement of a fluorescent signal generated during each amplification cycle. it produces quantitative results within minutes and calculates bacterial load. broad-range real-time pcr uses a single primer to detect the universal bacterial genome ( s rna or s rna) which is a conserved ribosomal genome sequence across all bacterial genera [ ] . broadrange real-time pcr can be used to distinguish bacterial septicaemic disease from other causes of neonatal illness such as asphyxia or complications of prematurity. however, it has been used with varying success in the analysis of whole blood for neonatal sepsis; specificity is generally high but sensitivity can be as low as % [ , ] . in contrast, multiplex pcr involves the parallel amplification of different targets but is focused only on specific pathogens, and false negatives can occur if the aetiologic agent of interest is not included in the database [ ] . real-time pcr is now often used to screen for microbial load, followed by sequence-based targeting and identification of pcr amplicons (pyrosequencing) [ ] . this process can detect very small copy numbers of specific nucleic acid sequences. there is also a new commercially available multiplex pyrosequencing pcr assay which can identify up to different bacterial and fungal pathogens directly from whole blood [ ] . realtime pcr and pyrosequencing of the universal s rrna gene has also recently been used successfully in neonatal blood culture samples [ ] . further tests on neonatal whole blood have been planned by a number of different research groups. the biggest problem with real time pcr testing is that the specimen must be collected with a sterile venipuncture, which may be difficult in young neonates. neonatal capillary heel prick specimens are easier to collect but highly contaminated by skin flora. there is also high potential for contamination of enrichment media, reagents, or the sample during collection and processing [ ] other problems include low sensitivity due to competition from human dna in whole blood, especially if white cell counts are high. also, bacterial organisms require lysis before their dna can be available for analysis, and gram-positive organisms are difficult to lyse because of their resilient cell wall [ ] . real-time pcr technologies are also expensive and currently can be used only by highly trained staff. important haematological tests include microscopic examination of the blood for white cells (total leucocyte count, differential, neutrophil count, and immature neutrophil to total neutrophil ratio). advantages are that these specimens do not require sterility and a heel prick specimen can be used. however many of these indices are falsely low in a septic neonate. biological biomarkers are human blood components that increase in response to infection. the most commonly used acute phase reactant is the c-reactive protein (crp). however, the crp takes - hours to increase to measurable levels; its half life is very long and it takes - days to normalize after eradication of the infectious agent. cytokines such as il , il , tnf-a, and procalcitonin have also been extensively studied [ , ] . cytokines rise quickly after infection even in neonates, and are more sensitive to low concentra- tions of pathogens than crp [ ] . however, cord and postnatal blood cytokine concentrations can be depressed in the presence of pregnancy-induced hypertension and can rise after induced vaginal or urgent cesarean delivery, delivery room intubation, muscular damage, and inflammation from other causes [ ] . simultaneous measurement of multiple biomarkers may improve both sensitivity and specificity [ , ] . however, biomarker assays are likely to be less acceptable to physicians who often place higher value on tests that confirm biological agents and allow targeting of antibiotic therapy [ ] . microtechnologies, especially microfluidics, have provided the greatest recent contribution to the diagnosis of neonatal sepsis. microfluidics is the study of the behaviour, precise control, and manipulation of fluids geometrically constrained to submillimetre (nanolitre or picolitre) channels [ ] . microfluidic technology uses the unique proprieties of continuous flow micro-volume channels: viscosity, surface tension, energy dissipation, and fluidic resistance, and also includes micro pneumatic pump and valve systems. one specific application of microfluidics is bacterial dna protein microarray hybridization [ ] . in this test, dna probes specific to selected targets are spotted on a glass or silicon slide in a known order. target dna fragments are labelled with a reporter molecule, combined into a single hybrid, and measured using fluorescent signals [ , ] . this technique has been used in the identification of the specific sepsis pathogen in bacterial meningitis, acute viral respiratory tract infections, and neonatal sepsis, and also in the detection of their antimicrobial resistance and virulence genes in research settings [ ] . microfluidic technology has also allowed sample preparation and a number of different assays to be combined in small, disposable, single-use diagnostic cartridges or cards that have been called a ''lab on-achip'' or loc (figure ) [ ] . some locs have combined sample preparation, biomarkers, real-time pcr, and dna microarrays to provide information about indices of inflammation, pathogen identification, and antimicrobial susceptibility patterns at the point of care [ , ] . locs have been reported to perform assays at sensitivity, specificity, and reproducibility levels similar to those of central laboratory analysers, but yet require little user input other than the insertion of the sample. single drops of blood, faeces, and saliva have all been tested with encouraging results. locs are currently being evaluated for use in sepsis, endocarditis, hiv, tuberculosis, severe acute respiratory syndrome (sars), and pneumonia [ ] . however, they are not yet in clinical use nor licensed by regulatory authorities. as neonatal sepsis can be rapidly fatal if left untreated, highly effective antibiotic therapy must be used and delays in the provision of care must be minimised. treatment must be effective against the causative pathogen, safe for the newborn, and feasible to deliver reliably in the hospital or community setting. parenteral (intravenous or intramuscular) regimens for neonatal sepsis currently recommended by national paediatric associations are a combination of penicillin/ ampicillin and gentamicin, or third-generation cephalosporins (e.g., ceftriaxone or cefotaxime) for - days. these antibiotics are safe and retain efficacy when administered at extended intervals (e.g., twice daily or daily dosing) [ ] . these regimens are very effective against streptococcus spp., but staphylococcus spp. can be highly resistant [ ] . gram-negative antimicrobial susceptibility to ampicillin and gentamicin can also be poor, especially for klebsiella spp. [ , ] . emerging e. coli resistance to ampicillin, gentamicin, and third-generation cephalosporins in hospital nurseries in both developed and developing countries is also causing increasing concern [ ] . the potential for significant life-threatening toxicity among neonates associated with chloramphenicol makes it the least preferred empiric parenteral therapy [ ] . oral antibiotic therapy must be considered in settings where referral is not possible and there are no health care providers trained to give parenteral antibiotics [ ] . the incremental benefit of injectable over oral antibiotics is not known, and oral antibiotic therapy is better than no antibiotic therapy at all. a series of trials are currently evaluating the impact of home and clinic-based short course ( days) intramuscular and oral antibiotic therapy for neonatal sepsis in low-income countries [ ] . most data are available on the effect of oral cotrimoxazole in community-based treatment of serious neonatal bacterial infections from nepal and india. however, there are concerns about high resistance rates, and side effects such as neonatal jaundice have been reported [ ] . oral amoxicillin is highly efficacious against streptococcus spp. and some gram-negative bacilli and has an excellent safety record. however, it has no anti-staphylococcus coverage and resistance is emerging in gram-negative bacilli such as e. coli. new, better-absorbed oral antibiotics are also being considered. the new second-generation cephalosporins (e.g., cefadroxil and cefuroxime) have an excellent safety profile, a spectrum of activity similar to cotrimoxazole, and may be more effective given the high resistance of neonatal pathogens to cotrimoxazole. ciprofloxacin also is increasingly accepted as safe in neonates and warrants further investigation for treatment of infections in newborns. however, the current cost of these agents and potential for exacerbating antimicrobial resistance may limit widespread use in developing countries [ ] . poor maternal-neonatal health systems, low levels of care-seeking, and lack of access to sick newborns during the first day of life, when mortality risks are highest, are also important concerns [ ] . recent studies have shown that community health workers can deliver antibiotic treatment to neonates with very severe infections at home safely and acceptably when hospitalization is not feasible [ ] . trials are currently evaluating the effectiveness, quality of care, and coverage of these community health worker programmes in asia and africa [ ] . barriers to large-scale implementation include high cost, poor staff training and retention, and difficulties with referral (e.g., lack of ambulances and poor institutional links). newborn sepsis is a major cause of child mortality across the world. industrialized countries have made remarkable progress in reducing newborn sepsis and sepsisrelated mortality by providing access to hygienic skilled delivery for all women, risk-based intrapartum antibiotic prophylaxis, and high-quality intensive care for newborns that need it. although resource constraints preclude whole-scale adoption of these strategies in developing countries, there are a number of low-cost proven interventions and promising approaches that have the potential to significantly reduce the burden of neonatal sepsis worldwide (table ) . however, practicability of implementing these new advances must be considered. skilled attendance at delivery is increasing in low-and middle-income countries. thus, intrapartum approaches such as risk-based antibiotic prophylaxis and improved hand washing during delivery are likely to be both cost-effective and feasible in these countries. more challenges face the implementation of diagnostic technologies. it may take many years for technologies such as the ''lab-on-a-chip'' to be sufficiently robust and affordable for scale-up to low-income countries. homebased antibiotic treatment of neonatal sepsis also faces major obstacles to largescale implementation. concerns such as ''one law for the rich and another for the poor'' have already been raised. a careful assessment of the risks and benefits of new technologies and interventions is clearly needed. in low-income settings there are also difficulties with care-seeking for neonatal illnesses, and home visiting programs are needed to identify sick newborns early in life. neonatal sepsis is also one of the most rapidly fulminating clinical diseases, and many practitioners, including experi-enced neonatologists, administer parenteral antibiotics rather than wait for the results of any diagnostic tests. these practitioners rightly consider that the individual patient's health is more important than the potential risks of emerging antibiotic resistance. thus, front-line health workers and families must be partners in all research and evaluation planning. detailed assessment of end-user attitudes and preferences using formative and qualitative research methods must be included in the development of programs to reduce morbidity and mortality from neonatal sepsis. finally, advocacy for equitable resource allocation across and within 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microfluidic immunoassay for the developing world by integration of on-card dry reagent storage antimicrobial resistance among neonatal pathogens in developing countries oral antibiotics in the management of serious neonatal bacterial infections in developing country communities management of newborn infections in primary care settings: a review of the evidence and implications for policy? effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural india key: cord- - kudfjp authors: sarma, u.; ghosh, b. title: quantitative modeling and analysis show country-specific quarantine measures can circumvent covid infection spread post lockdown date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: kudfjp the outbreak of covid has been declared a global pandemic by who which started in wuhan last november and now has spread to more than countries with . million cases and a death toll of more than thousand. in response, many countries have implemented lock down to ensure social distancing and started rigorously quarantining the infected subjects. here we utilized the infection dynamics available from who and quantitatively calibrated the confirmed, recovered, and dead populations from different countries. the chosen countries chosen are in three stages of infection . where the first wave of infection is significantly diminished . infection peak is reached but daily infection still persists significantly . the infection peak is not yet reached. the model successfully captured the daily trajectories of countries with both early and late phase of infection and determined incubation time, transmission rate, quarantine and recovery rates. our analysis shows, the reduction in the estimated reproduction number with time is significantly correlated to the testing rate and medical facility of a country. further, our model identifies that an increase in quarantine rate through more testing could be the most potent strategy to substantially reduce the undetected infection, accelerate the time to infection peak and facilitate faster recovery of a nation from the first infection wave, which could perhaps have direct social and economic implications. our model also shows, that post lockdown infection spread towards a much larger second wave can be controlled via rigorous increase in the quarantine rates which could be tailored in a country specific manner; for instance, our simulations suggest that usa or spain would require a fold more increase in quarantine rates compared to india to control the second wave post lockdown. our data driven modeling and analysis of the trajectories from multiple countries thus pave a way to understand the infection dynamics during and post lockdown phases in various countries and it can help strategize the testing and quarantine processes and influence the spread of the disease in future. declaration of the coronavirus pandemic by who severely overhauled global economic and social endeavors for last few weeks [ ] . with the first case encountered in wuhan, china, in november and subsequent outbreak in hubei province, the virus now has spread to more than countries globally. western europe and the united states are severely affected with more than . million infected population and global death toll rising over thousands [ ] . many european countries already started imposing strong mitigation measures through nationwide lock-down in order to maintain effective social distancing within the population. even with nationwide lock-down, many countries are struggling to contain growth of the infection [ ] . hospitals are getting overwhelmed with patients and are running out of necessary equipment and medicines [ , ] . the health-care personnel were in severe crisis of medicines, masks, testing kits, ventilators etc. the vaccine preparation is already on it's way at a breakneck pace [ ] but a fully operational vaccine after clinical trial is expected to take at-least a year from now. until then, isolating the infected population by aggressive testing and maintaining strong social distancing measures are adopted as the two most effective ways to deal with the current situation [ ] . from the experience in wuhan, we learned that the outbreak can be effectively contained with strong social distancing measures [ , ] . on the other hand singapore, hong kong and south korea took a different strategy by aggressive testing and isolating the infected population without imposing nationwide lock-down [ ] . however, at this moment both the strategies are argued as equally essential to deal with the situation, especially in europe, us and countries with high population density like india. thus in this global emergency scenario, and in the absence of vaccines, model driven strategies to contain the infection rate could be of immense use. hence, in general, if we can predict the spread of the infection and project possible numbers as well as estimate the social and medical factors influencing the spread of the disease, it would help policy makers in considering multiple strategies to address the state of infection that would also have far reaching socio-economic implications. there indeed is an upsurge in epidemic models to predict possible projections of the current situation in different countries [ ] [ ] [ ] [ ] which aims to help the policy makers and the medical practitioners to prepare for upcoming situations. along with prediction, analysis of the models should also inform us with possible quantitative measures to deal with the current and subsequent waves of the infection. in this paper, we present a dynamic epidemic model for the spread of coronavirus. by quantitatively calibrating the time series data(data from who [ ]) for confirmed, recovered and dead population for different countries with various stages of infection, we made an estimate of different important parameters like incubation time, transmission rate, rate of quarantine, recovery and death rate, that controls the infection dynamics in a given country. we introduced lock-down in our model to observe the effect of social distancing and also estimated the effectiveness of implementation of lock down in individual countries. using the best fit parameter sets, a prediction of the infected numbers for different countries has been projected. variations in the reproduction number as well as variation in reduction of reproduction number with time is also observed . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint to be correlated with different demographics and socioeconomic quantities, including health-care facilities, which we show by building statistical regression models. the key insights from our study are . lock-down start time following infection is the most sensitive parameter determining the final infection status w.r.t the first wave of infection . at any stage of infection, rigorous and country specific tailoring of testing and quarantining can accelerate the time to peak and should eventually contain the infection . lock-down removal would most likely start the second wave irrespective of the time of early lockdown to contain the first wave. this is because even in countries with a minimal number of asymptotic infected people, the susceptible subjects can get exposed and infected eventually . immediate early lock-down and rigorous testing coupled to systematic quarantining could be the most effective way to rapidly contain the second wave of infection and hence reduce the time of lockdown as well as size of infected population in a country. in order to explore the dynamics of the covid infection spread, we took the daily confirmed infection time course data from who and clustered the region-wise data according to their dynamic pattern. a hierarchical clustering algorithm (hierarchical clustering from pheatmap package in r) is used to analyze the dynamics of countries selected (each country with at least infections per day). the provinces in china clearly are clustered together since infection spread happened at the earliest times. then the infection spreads to different parts of western europe and the united states. the number of new cases in western europe and the united states are much higher compared to other parts of the world which can also be seen as close proximity of these countries in the clustering analysis ( figure a , color bar represents log transformed value of the daily confirmed cases). next, we calculated the doubling rate from the time series of the countries. the doubling rate is defined as the inverse of the doubling time, i.e., how much time does the population take to double the number of infections ( figure b ) . the clustering analysis shows similar patterns, although, there are large region to region variations in the doubling rate. using a stochastic nearest neighbor algorithm (tsne), we projected the dimensional time-course data onto two dimensions ( figure c ). tsne is a machine learning technique for dimension reduction of high dimensional data [ ] extensively utilized for visualization of high dimensional data in diverse fields such as computer graphics [ ] , neuroscience [ ] , medicine [ ] to protein structure [ ] or embryonic development [ ] . the analysis provides us with clearer visual information about different countries and their proximities according to their respective infection trajectories. here also, we observed that the provinces in china are very closely placed and countries in europe form a different cluster. similar analysis was conducted for the doubling rate time courses( figure d ). an estimate of reproduction number is calculated from the doubling rate rate using an incubation time of days. we observed a % cv in the reproduction number among countries. these results indicate that there is a substantial country-wise . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint variability in the infection spread. these variations may stem from each region's different demography, health-care facility, general health or factors implicit to a given country. we now extracted the doubling rate at the start of the infection and after days. although, the initial doubling rate does not show any correlation with any of the factors,( figure e ) the doubling rate at days exhibits significant correlation with number of tests per million ( figure f ). this indicates the possibility that countries performing more tests on the population are able to manage the infection rate much more efficiently. the total population size also displays significant correlation. this could be due to the fact that countries with higher population size usually tend to have lower test per million rate. in order to estimate different parameters controlling the infection dynamics in different countries we next constructed dynamic epidemiological models for multiple countries and. from the group of countries, we selected countries, comprising a combination of early, mid and late stage of infection, and fitted their confirmed (co), recovered(re) and dead(de) population trajectories (methods for details). the standard susceptible, infected, recovered (sir), or seir(e = exposed) model did not simultaneously fit the trajectories co/re/de in most of the countries (data not shown), but, implementing a quarantine compartment (q), which provided a time delay between infected and removed compartments, dramatically improved the fit quality. the q compartment also ensured a distinction between infected and identified (q) and infected but unidentified(i) subjected in a population. the seiqr model divides the population in five compartments namely susceptible (s), exposed (e), infected (i), quarantined (q) and removed (r), which contain both recovered and dead population [ ] . figure a shows the structure of the seiqr model. here a susceptible person can be exposed to the infection through transmission from an infected person. after exposure, the symptoms are exhibited within an incubation time and the infected individual either recovers or dies after a time, represented by a recovery or death rate. figure c shows cartoon trajectories of confirmed, recovered and dead population which depicts the key qualitative feature -confirmed > recovered > dead. dynamics of the system are captured by a set of coupled ordinary differential equations (details in methods). the calibration data for each country comprises the time courses of the number of confirmed, recovered and dead people. through model fitting we estimated the parameters that best explains the co/re/de trajectories simultaneously of each country. model fitting also includes a lockdown function ( figure b ). the lock down is introduced in the model through a reduction in the transmission rate that follows an inverse sigmoid function. the process of lockdown is controlled by three variables-time of lockdown (start time of lockdown implementation) , strength of lockdown (the extent of lockdown in a country, . would mean % lockdown implemented) and the effectiveness of lockdown (how fast the maximum lockdown is . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) achieved from the lockdown starting time point); during the calibration these parameters were also estimated for each country. the assumption is rooted in the fact that once an infected person is tested positive he/she will be quarantined, thus, only the infected but untested subjects can further infect the susceptible. next we extracted the daily confirmed cases from the fitted cumulative trajectories from the model and compared it with data. figure further, we also observed a large variability in effective lockdown among countries (cv= %), suggesting plausible influence of different social structures within countries in the implementation. this may result from multiple implicit factors specific to a country such as socio-economic structure, state healthcare, population size or other similar factors. as observed from the model, the infection rates substantially vary from country to country. here, we ask the pertinent question why the infection rate and it's reduction vary from one country to another. the socio-economic factors like health infrastructure, demography or population size may influence the infection rate depending on how quickly and efficiently a country's health care facilities react to emergencies. similarly, the reaction can also be limited by the country's population density or demography with respect to age distribution, as it is in general expected that the younger population would be able to react to a new infection . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint more efficiently compared to the older population. in fact, the death rate indeed is substantially high for older people with covid infection [ ] . here, in order to explore social, economic and demographic factors which may influence infection rate of the model, we extracted medical infrastructure, health care spending, demography and population density datasets for all the countries and a correlation analysis based on linear correlation were performed. using the fitted trajectories from the model, values were first calculated (methods) over time for all the countries r ( figure a ) and the initial , after days ( ) were extracted from the time course. correlation analysis of , with the health care and demographic factors were performed separately. although was not found to be correlated with any of the parameters, values show significant correlation with r doctors/ , life expectancy and test per million ( figure b ). other factors like hospital beds/ and health care spending tend to show some negative correlation as noticed from the scatter plot, however, the correlations are not significant due to the relatively small number of samples/country number used for fitting. the initial outbreak although does not depend on the heath-care facility, in absence of early lockdown, how effectively the countries would react to contain the reproduction number, can be correlated to their health infrastructure. however, importantly, the pandemic has affected almost all the countries in the world, irrespective of their healthcare or socio-economic structure, and the need of the moment is to devise scientifically informed strategies to manipulate the spread of infection and minimize the loss of human life which can perhaps be adopted by most countries tailored to their infection status. in an attempt to look for such general strategies to circumvent the infection we systematically explored the calibrated seiqr models further. to understand the relative sensitivity of the model parameters such as β( susceptible → exposed), α cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . implementation window for the 'time of lockdown' is already missed, but , although not the most sensitive α among all parameters can still be tuned anytime by changing the testing and quarantine strategies. notably, the effect of variation (in the range chosen for sensitivity analysis, [ . - . ]* fitted) has diverse α α sensitivity profile in the group of countries; countries like south korea is extremely sensitive to variation α where it is known that the testing and quarantining is one of the most rigorous. to understand how the manipulation of might change the long term infection dynamics in the present scenario, we next simulated α the models for days, with lock down. from the simulated time course (figure a ,b, shown for india and korea, two representative countries with high differences in quarantine rate and time to infection peak positions), peak position from the start of the infection, the shift between undetected infection(i) peak and the tested and 'confirmed' peak were estimated for the countries. our analysis showed peak position (tp) is negatively correlated with the quarantine rate, indicating that the more quarantine facilitates an earlier peak ( figure c ). this suggests the infection time can be manipulated by quarantining more people. the peak shift(ts), or the time between the confirmed and undetected infected peak position, is also smaller if the quarantine rate is high, indicated by the negative correlation between ts and quarantine rate (figure ,d) . subsequently, the fraction of undetected infection is also low if the quarantine rate is high for a given country( figure e ). these results suggest that by quarantining a lot of infected people through testing, the infection dynamics and time to peak can be closely predicted with lesser error. additionally, this may lead to faster exit from the first wave of infection, as seen in countries like korea. we also observed correlation of tp, ts and fraction of undetected infection with the incubation rates ( figure e , f, g). this is due to the correlation between incubation and quarantine rates in the calibrated models. testing and quarantine rate the trajectory remains practically unchanged( figure a ). however, as the lockdown is lifted, fold increase in (sapin, usa) appears not sufficient to contain the infection and a much larger nd α . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint wave can emerge if testing rate is ramped up only fold( figure d-e) ; india, on the other hand doesn't show dramatic changes in total number of infection post lockdown with the same increase in value ( figure f ). α we also explored how the total susceptible population size (absolute number of succestable subjects in a population is typically unknown in reality, hence, here for each country the susceptible population size is determined by fitting a population size around the total number of tests carried out in that country) might affect the observed result. figure s -s shows that the peak of daily confirmed cases for a country and its time to exit from the first wave can robustly be captured in the models for a range of susceptible population size (tested for [ . - fold] of fitted population size). typically, when lock down is removed, the transmission rate (β) would increase substantially. the long term simulation for india, usa and spain predicted various features of their confirmed time series by the end of june, for varying degrees of quarantine rate, with or without lockdown. for instance, for india the expected number of confirmed cases are estimated to be thousands by the end of june when the lockdown continues and thousands more cases will be added if lock down is removed ( figure a , b).however, for both spain and the usa a substantial change in total confirmed cases could be observed (figure a,b) . the daily confirmed cases show a similar trend for both usa and spain, but for india, the post lockdown changes in daily cases are relatively less ( figure c ). this indicates different countries may have different infection spread dynamics after the lockdown is lifted. as seen in figure d , a fold increase in quarantine dramatically reduces the fraction of undetected infections in the (model)population, both pre and post lockdown, for all the countries. the increased quarantine rates can facilitate the arrival of the peak a bit earlier for countries like india where peak is yet to arrive, especially, when the lock down is removed( figure e ). we also calculated the value just after the lock down is removed. for these countries, an increase in the value of is observed r r as the lockdown is lifted but the value can be substantially suppressed by five fold increase in the r quarantine rate for india. where the % increase in r due to removal of lock down can be effectively circumvented by % reduction in r by five fold increase in the quarantine rate ( figure f ). but, both for spain and usa, a dramatic increase in is observed which can not be compensated by a five fold increase in the r quarantine rate ( figure f ). thus, for spain and the usa, we explored if much higher quarantine rates would be required to compensate for the enhanced resulting from the lock down release. we performed a set of simulations by r systematically increasing the value to times of it's fitted value for each country. now, for both spain and α the usa a fold increase in quarantine rate is able to drastically reduce the peak of the second wave ( figure ). quantitatively, our simulations suggest that both the usa and spain require different degrees of change in this paper, using an epidemic model coupled with statistical regression models we quantitatively explored the time series of infection spread in different countries for the covid outbreak and its relation with quarantine measures as well as medical infrastructure. the reproduction numbers of this pandemic are found to be comparable to the sars-cov values [ , ] and much higher than the mers infection [ , ] . we employed the mathematical model and fitted the confirmed, recovered and dead population trajectories from countries where the countries are a combination of early, mid and late stage infections for the first wave of covid infection. the fitted mathematical models display large variabilities in the infection rate among countries as well as the reduction in their infection rates over time, primarily, due to implementation of the social distancing measures. we show that the variabilities can be correlated to some extent by disparate healthcare infrastructure. in the european countries, the infection has spread faster either due to strong airline connection with wuhan or due to the cold climate but they could control the reproduction number( ) with r time and the first wave of infection is almost over for many such countries (figure ). the lockdown measure to implement social distancing which is implemented in almost every country infected with covid , is a necessary measure to reduce the infection spread, but how well a country is sampling its population for testing and further how well they quarantine the infected population are also important factors during the lockdown. lockdown is a preparatory measure for the health care system to reorganize itself to deal with the situation since long term lock down would be detrimental to the economy of any country [ ] . . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . in line with the other epidemic models, such as sir or seir models, we assumed a constant initial susceptible population in the fitting process which calculated based on the tests per million conducted in a country. however the actual susceptible population size is unknown and it may be different from the tested population size in either direction. as a result, the number of infected people from the data only captures the infected people out of the tested sample. so to understand the effect of population size on infection peak time and time of completion of the first infection wave, we varied the initial population size in [ . [ ] [ ] [ ] [ ] fold of its fitted population size. absolute population size does impact the height of peak in each country tested, but the time to peak and the time for completion of the first wave could robustly be captured by varying size of initial susceptible population. typically the actual infected number of people is expected to be higher than the sampled one's. this is one of the reasons why increased testing rate is so important in capturing the real magnitude of the infection (and not only the dynamics), in addition to the need of quarantining infectious people to reduce infection spread. however, the projection can provide us with a lower bound on the estimated time to contain the infection so that we can remain prepared. in conclusion, in developing countries like india with high population density and size, early implementation of lockdown was critical where the delay in lockdown such as in italy or spain could have had a much more serious impact due to inadequate health infrastructure. however, reopening the economy is also an impending necessity in many countries under lock down. thus, to minimize the health hazards of social proximity while being able to continue economic activities will require careful planning and implementation. we propose strategies where rigorous quarantining of the infected subjects is argued as the only effective measure to effectively deal with infection spread post lockdown. as a policy measure, our model suggests that quarantine and testing should be increased substantially after the lockdown is lifted, in order to contain the infection in the coming months. the effective increase in quarantine measure is found to be country specific, depending on the transmission or incubation rates. in our analysis, we assumed a full lockdown removal. a partial or periodic lockdown removal coupled with increased quarantine rate can also be explored to deal with the situation as studied elsewhere [ ] . as there are uncertain components like the number of subjects comprising the susceptible population size in such sir/seir/seiqr models, we also need to be careful about the possible acceleration in the disease spread due to lockdown removal, as a small unidentified fraction of infected population during the lockdown removal can potentially remain unidentified due to the long incubation period characteristic to this infection. the spanish flu pandemic in in fact came back again in a few weeks after the first wave was apparently contained and the second wave was much bigger than the first one [ ] . so, even if the first wave of the current corona pandemic is over for many countries, the global population and policy makers need to remain pragmatically careful for possible subsequent waves [ ] and should stratize to maximally quarantine the early susceptible population. in the fight against covid , it seems critical to act early and act with full force; at the same time, . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint controlling overhyped panic stemming from either political polarization or media misinformation [ ] could also be prioritized to bring forward a robust and collaborative global effort to fight the pandemic. the seiqr model: the model comprises of susceptible(s), exposed(e), infected(i), quarantined(q), removed(r, contains two compartments 'recovered' and 'dead' ) the equations are the lockdown is opened by modifying the ρ(t) function such that ρ(t) returns to from its lockdown status to no-lockdown( ) status in a designated time . model calibration involves minimizing an objective function that gives best fit parameter sets for confirmed, recovered and dead populations for a given country simultaneously. we fitted the time series provided by jhu csse at github [ ] to the seiqr model developed in the study and minimized the objective function using the . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . lsqnonlin function of matlab which minimizes differences in the sum of squares between model and data. to fit the observed cumulative confirmed trajectory for a given country, [quarantined + recovered + dead] from the model is fitted against the confirmed data. the objective function is thus minimized to achieve the best fits for all three trajectory types simultaneously. this was repeated for all the countries independently. the value is calculated using the r package in r [ ] . we took the time course data of the daily confirmed r cases with a sliding window of days in order to calculate the value locally with time. r package takes the log ( ) . the value of incubation time is generated from a gamma distribution with mean as and a standard t deviation of . in order to perform the calculation of . the authors declare no conflict of interest. the description of the seiqr model: the model utilized to fit the cumulative confirmed, recovered and dead cases comprises susceptible, exposed, infected, quarantined, recovered and dead compartments. the . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint lockdown is implemented through a sigmoid function as indicated. the quarantined, recovered and dead cases together comprise the confirmed cases. the seiqr models fit the data for countries as indicated for the cumulative confirmed, recovery and death cases. the figures indicate the cumulative data and the corresponding fit based on the seiqr model. the fitted model also reproduces the daily cases. the daily infected cases were calculated from the fitted confirmed trajectories and the data was calculated from the respective cumulative data trajectories of the respective countries. the effect of lock down removal in india, spain and the usa. the simulation trajectories for daily confirmed cases are shown for three countries and different quarantine rates with lockdown and lockdown removal, as indicated. the quarantine rates are increased on the th day (after nd jan, , the first respored day of infection in wuhan) and lockdown removal on the same day is considered for these simulations.. is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint figure : optimal, country specific change in quarantine rate can potentially circumvent the infection spread post lockdown. the simulated trajectories for daily confirmed cases when quarantine rate is increased on th day and lockdown is lifted on the day for the three countries. similar results were obtained when both quarantine rate and lockdown removal times are chosen as the same. the three panels depict the current situation, the situation with quarantine rate increased on th day in presence of lockdown, and lockdown removed days after changes in the quarantine rates, respectively, as indicated. the simulated trajectories for lockdown, presence and absence, coupled to varying quarantaine rates, and, with different population sizes, is shown for spain. the simulated trajectories for lockdown, presence and absence, coupled to quarantaine rates, and, with different population sizes, is shown for usa. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint figure : the simulated trajectories for lockdown, presence and absence, coupled to quarantaine rates, and, with different population sizes, is shown for india. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint the demand for inpatient and icu beds for covid in the us: lessons from chinese cities italy hospitals at virus limit covid infections rise in new york with peak weeks away draft landscape of covid candidate vaccines how will country-based mitigation measures influence the course of the covid epidemic? epidemiology and transmission of covid in shenzhen china: analysis of cases and , of their close contacts data-driven modeling reveals a universal dynamic underlying the covid pandemic under social distancing projecting the transmission dynamics of sars-cov- through the postpandemic period science epidemic situation and forecasting of covid in and outside china yubei huanga age-structured impact of social distancing on the covid epidemic in visualizing data using t-sne" (pdf) maaten laurens van der approximated and user steerable tsne for progressive visual analytics nonlinear dimension reduction for eeg-based epileptic seizure detection exploring nonlinear feature space dimension reduction and data representation in breast cadx with laplacian eigenmaps and t-sne the protein-small-molecule database, a non-redundant structural resource for the analysis of protein-ligand binding single-cell transcriptomics reveals gene expression dynamics of human fetal kidney development a seiqr model for pandemic influenza and its parameter identification population-level covid mortality risk for non-elderly individuals overall and for nonelderly individuals without underlying diseases in pandemic epicenters john p.a. ioannidis transmission dynamics of the etiological agent of sars in hong kong: impact of public health interventions transmission dynamics and control of severe acute respiratory syndrome transmission characteristics of mers and sars in the healthcare setting: a comparative study the role of superspreading in middle east respiratory syndrome coronavirus (mers-cov) transmission cross-protection between successive waves of the - influenza pandemic: epidemiological evidence from us army camps and from britain using social and behavioural science to support covid- pandemic response the r package: a toolbox to estimate reproduction numbers for epidemic outbreaks key: cord- -fwamdr authors: oztig, lacin idil; askin, oykum esra title: human mobility and covid- : a negative binomial regression analysis date: - - journal: public health doi: . /j.puhe. . . sha: doc_id: cord_uid: fwamdr abstract objectives this study aimed to examine the link between human mobility and the number of covid- infected people in countries. study design our dataset covers countries for which complete data are available. in order to analyze the link between human mobility and covid- infected people, our study focused on the volume of air travel, the number of airports and the schengen system. methods in order to analyze the variation in covid- infected people in countries, we used negative binomial regression analysis. results our findings suggest a positive relationship between higher volume of airline passenger traffic carried in a country and higher numbers of covid- patients. we further found that countries which have a higher number of airports are associated with higher number of covid- cases. schengen countries, countries which have higher population density and higher percentage of elderly population are also found to be more likely to have more covid- cases than other countries. conclusions the paper brings a novel insight into the covid- pandemic from a human mobility perspective. future research should assess the impacts of the scale of sea/bus/car travel on the epidemic. the findings of this paper are relevant for public health authorities, community and health-service providers and policy-makers. the globalized world, in which the scale of the movement of people is at unprecedented scale is susceptible to the spread of diseases on a global scale. with sophisticated transport networks that have increased reach, the speed of travel and the volume of passengers, "pathogens and their vectors can now move further, faster and in greater numbers than ever before". the global spread of covid- that has led to the infection, and deaths, of thousands of people at a rapid scale, is indicative of how infectious diseases can become a global health problem that have the ability to reach more people, and at a faster rate, in an increasingly globalized world. throughout history, in addition to human migration, trade caravans, religious pilgrimages, and military manoeuvres played a central role in the spread of diseases. during the middle ages, trade routes between europe and asia were instrumental in the spread of the plague into europe. in the s, the population of the new world suffered from infectious diseases brought by european explorers. the second voyage of christopher columbus to the caribbean in brought small pox to the region. in the small pox epidemic, thousands of indigenous inhabitants of the caribbean region died. in the th and th centuries, ships from africa not only brought slaves, but also smallpox and fever-carrying mosquitoes to the new world. overall, the pathogens carried by migrants had devastating consequences for native americans who had no immunity for them. the confluence of american troops with european and african troops in france, and the development of new virus strains, created a permissive environment for the influenza pandemic that resulted in the deaths of approximately million people in a year. the pandemic that erupted in china spread to the world within six months. in , a small pox epidemic erupted in the autonomous province of kosovo of (the then named) yugoslavia on april th . epidemiologic and serologic investigations revealed that small pox was imported to yugoslavia from a hajji pilgrim who had visited mecca and returned to the country by bus via iraq (where small pox cases were reported at the time). as a result of the smallpox outbreak, people were infected, among which people died. global travel, given the unprecedented volume, speed, and reach, is an important factor in the rapid spread of current diseases. the study by olsen et al. indicates that many sars-infected people traveled on commercial aircraft. the study further revealed that after one flight carrying people (among which one person was symptomatic), sars developed in people. illness in passengers was related to the physical proximity to the symptomatic person. while sars spread to countries ( cases) and mers spread to countries ( cases), covid- has spread to more than countries and infected more than a million people in the world, initiating an unprecedented global crisis. wuhan, the epicenter of the pandemic, is central china's major air and train transportation hub. as of , in wuhan, international outbound air travel constituted . % of all outbound air travel, while the top domestic outbound air routes constituted . %. high air and train traffic across china due to the lunar new year spring festival, that started on january th , appeared to have played a facilitating role in the spread of covid- throughout the country and abroad. the first covid- case outside china (a traveler from wuhan) was reported to the who by the thai government on january th . three days later, the japanese government informed the who of its first confirmed infection in a traveler from wuhan. strikingly, due to china's lockdown of the coronavirus-hit hubei province on january rd, many people left wuhan, which has resulted in the spreading of the diseases in and outside china. soon afterwards, india, philippines, russia, spain, sweden, and the uk confirmed their first cases. based on the findings of the previous literature and the current trends in the spread of covid- , we hypothesize that in countries in which there is a high mobility of people, the number of covid- infected people are correspondingly higher. we also hypothesize that there is a positive association between high numbers of airports in a country and high numbers of covid- infected patients, and that schengen countries are more likely to have higher numbers of covid- infected patients than non-schengen countries. the dependent variable of this study is the number of covid- infected people. the data on covid- cases is extracted from the official site of who published as of april rd . we analyzed countries for which the complete data on independent and control variables are available. it should be noted that our dependent variable consists of cases that are reported to the who. depending on the late development of/lack of testing equipments and the numbers of tests administered to individuals, the actual number of covid- infected people in countries might be much higher. lack of adequate testing, or some cases, any testing, in many countries might be affecting the availability and accuracy of data. for instance, the full impact of covid- on india (the world's second most populous nation), indonesia (the world's fourth most populous nation), african nations, and various smaller countries remains unknown. this constitutes a limitation to our study. as covid- is reported to have emerged in china and then spread to other countries, we do not include china in our analysis. we operationalize human mobility by looking at the number of airline passengers carried into the countries. the data are extracted from world development indicators. airline passengers include both domestic and international aircraft passengers of air carriers registered in the country. we note that the most recent data on the airline passengers is from . although the data does not correspond to actual human mobility as of , we assume that the pattern of air travel is unchanged until the start of the pandemic. we measure airport numbers and the schengen system as factors that facilitate human mobility. the data on airport numbers are extracted from the world factbook of the central intelligence agency. we code schengen countries as and otherwise. we control for population density in our analysis. in countries with high population density, people have contact with large numbers of people which facilitate person-to-person spread of many infectious diseases. furthermore, the elderly people are more susceptible to infections "because of waning cell-mediated immunity and impaired host defenses but also because of chronic diseases and use of drugs and treatments that may be immunosuppressive". by bearing in mind the fact that there is no scientifically established relationship between immunity and the risks of contracting covid- disease, we control for the percentage of elderly people in population our analysis. the data on population density and the percentage of elderly people ( and above) are extracted from world development indicators. in order to analyze the variation in covid- infected people across countries, we use negative binomial regression (nbr) model. nbr is based on the poisson-gamma mixture distribution. it is useful for predicting count-based data. we choose this method because our dependent variable (the number of covid- infected people) consists of only non-negative integer values and the variance of the dependent variable is greater than the mean. the dependent variable is substantially positively-skewed and kurtotic where is a vector of estimated coefficients of exploratory variables including the percentage of elderly people in population, the logarithm of the population density, the number of airline passengers, the number of airport and the schengen system. the vector of coefficients is then estimated by maximizing the logarithm of the likelihood function given below. one of the important properties of the poisson distribution is that the mean and the variance are equal to the parameter. however, the assumption of identical mean and variance was not satisfied for the data used in this study ( = , . and + = , . ). the greater ratio of variance to mean leads to over-dispersion frequently caused by heterogeneity among observations. thus, we apply nbr to overcome this problem of over-dispersion. a gamma-distributed error term is added to the eq ( ) in order to relax the pr assumption by including additional randomness. where , follows gamma distribution with mean and variance -. the nbr distribution has a mean and variance + -. whereis the overdispersion parameter used as a measure of dispersion. in analyzing the variation in the dependent variable, the following model is considered: ln num. of. covid infected = > + ? * old + . * log _popdensity + e * log _airtransfer + h * log _airportnumber + j * schengen table shows the estimates of model parameters ( m ), standard errors (std err of m ), % ci for the m by profiling the likelihood function, incident rate ratios (irrs) and goodness-of-fit statistics such as cragg-uhler pseudo-r², logarithmic likelihood and akaike information criteria (aic). the estimated coefficients of all variables used in this study are statistically significant (at least % confidence level) and in the positive direction. countries that have higher volume of airline passengers (irr= . , p< . ); higher number of airports (irr= . , p< . ); higher population density (irr= . , p< . ); higher percentage of elderly population (irr= . , p< . ), and schengen countries (irr= . , p< . ) are found to be more likely to have higher numbers of covid- infected cases than other countries. table . this study answers the question of why some countries have higher numbers of covid- infected people compared to others. analysis of the data suggests a link between the scale of human mobility and the number of covid- patients in countries. our results indicate a positive association between the magnitude of airline travel and high numbers of covid- infected patients. furthermore, we find that countries which have higher number of airports, schengen countries, countries which have higher population density and higher percentage of elderly population are found to be more likely to have more covid- cases than other countries. the quick spread of covid- appears to be propelled by "superspreading". superspreading refers to heightened transmission of the disease to at least eight contacts and has been observed for several infectious diseases including sars, mers, and influenza. our study suggests that better connected areas are more likely to be infected first and have more infections initially (but it is still too early to report the potential consequences on less well-connected areas that may become infected in due course). there are a number of limitations in this article. while we measured human mobility by looking at the volume of air travel, future studies can provide a comprehensive analysis on the impact of sea/bus/train/car travels on the spread of covid- . patients zero and their travel history will provide important insights into cross-country comparisons. in addition, when a virus arrives in a country, its contagion and spread hinges on local transmission pathways and public health provision. efforts and (relative) successes of countries in handling the covid- crisis should be analyzed in a comparative manner. furthermore, we note that certain emerging trends might influence general applicability of the findings as we move into the future. for example, in addition to the reduced volume of travel, increased testing and future development of vaccines might also affect the applicability of the findings with passage of time. previous studies found that airport screening measures failed in halting the spread of viruses. in the context of superspreading of covid- , airports are more likely to be rearranged so as to minimize the risk of contagion. researchers should contemplate on new techniques and methods at airports for the maximum safety of passengers and staff against pandemical diseases. there are also issues that urgently need to be further studied, such as the link between public health provision and covid- mortality rates. our study indicates a positive relationship between the percentage of elderly population and covid- cases. recent developments reveal that the virus has the potential to affect all age cohorts. future studies can comparatively examine the spread and the mortality rate of covid- in countries with younger population and those with aging populations. psychological impacts of the covid- pandemic also need to be systematically studied. the long-term implications of the covid- pandemic on countries' health systems and global health policymaking and management strategies will also provide interesting avenues of research for further researchers. global transport networks and infectious disease spread geography of infectious diseases princes and peasants: smallpox in history the burdens of disease iberia and the americas: culture, politics, and history: a multidisciplinary encyclopedia the burdens of disease global transport networks and infectious disease spread the great influenza: the epic story of the pandemic global transport networks and infectious disease spread epidemiologic aspects of small pox in yugoslavia in travel and the emergence of infectious diseases transmission of the severe acute respiratory syndrome on aircraft nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study world health organization. who statement on novel coronavirus in thailand world health organization. novel coronavirus -japan (ex-china) the novel coronavirus disease (covid- ) outbreak trends in mainland china: a joinpoint regression analysis of the outbreak data from nowcasting and forecasting the potential domestic and international spread of the -ncov outbreak originating in wuhan, china: a modelling study coronavirus disease (covid- ) situation reports central intelligence agency, the world factbook population mobility and the geography of microbial threats population mobility and the geography of microbial threats population density (people per sq. km. of land area) wuhan novel coronavirus (covid- ): why global control is challenging? wuhan novel coronavirus (covid- ): why global control is challenging? border screening for sars evaluation of border entry screening for infectious diseases in humans key: cord- -ndfzn hh authors: austin, kelly f. title: degradation and disease: ecologically unequal exchanges cultivate emerging pandemics date: - - journal: world dev doi: . /j.worlddev. . sha: doc_id: cord_uid: ndfzn hh an estimated percent of new infectious diseases are zoonotic in origin, directly resulting from human and animal interactions (cdc, ). new diseases like covid- most often originate from biodiversity hotspots such as tropical rainforests, and forest loss represents one of the most significant forms of environmental degradation facilitating new human and animal interactions. a political-economy approach illuminates how trade inequalities lead to the exploitation of the environment and people in poor nations, creating conditions under which pandemics like covid- appear. cross-national patterns in deforestation and forest use illuminate how consumers in the global north are keenly tied to the emergence of zoonotic diseases. an estimated percent of new infectious diseases are zoonotic in origin, directly resulting from human and animal interactions (centers for disease control, ) . a number of these diseases have made headlines in recent years, including zika, ebola, sars, avian influenza, mers and, of course now, covid- . but it is not the animals and insects themselves that are to blame for ''giving" humans infections, whether spread by viruses, parasites, fungi, or bacteria. rather, anthropogenic environmental transformations driven by capitalist development are forcing humans and animals to come into contact in new ways. zoonotic diseases are those caused by germs spreading between animals and people. the united nations environment programme (unep, ) identifies that the central sources of zoonosis emergence include deforestation, intensive farming, illegal and poorly regulated wildlife trade, and climate change. not only are these causes due to human activities, but the disproportionate concentration of them in less-developed countries and among disadvantaged populations can be easily traced to global inequalities in access to power and resources (e.g. rice, rice, , . a political economy approach illuminates that the exploitation of the environment and people, especially in poorer countries, creates conditions under which pandemics like covid- appear. new diseases most often originate from biodiversity hotspots such as tropical rainforests, and forest loss represents one of the most significant forms of environmental degradation facilitating new human and animal interactions (centers for disease control, ; bloomfield, mcintosh, & lambin, ) . cross-national patterns in deforestation and forest use illuminate how consumers in the global north are keenly tied to the emergence of zoonotic diseases. global patterns in poverty and environmental degradation go hand-in-hand, with places like sub-saharan africa, se asia, and latin america facing the highest levels of poverty and environmental transformation, including the destruction of forest ecosystems (world resources institute, ) . it is no coincidence that resource-rich countries of the global south have remained poor and degraded -these regions were initially plundered for key commodities, such as coffee, timber, rubber, precious metals, iron, sugar, and cotton during colonial times, propelling northern industrialization and economic development (e.g. mcmichael, ; wallerstein, ) . the colonial project cemented an international division of labor, wherein poorer countries focus on the production and export of agricultural products and raw materials, which are more damaging to the environment and less profitable in comparison to the production processes of affluent nations with highvalue industries and services (e.g. mcmichael, ; rice, ; wallerstein, ) . primary sector specialization in the periphery is upheld today through path dependencies, as well as a variety of policies and practices enacted by core governments, core-based transnational corporations, and international development institutions, such as the world bank, international monetary fund, and world trade organization, often under the doctrine of ''free trade" (e.g. mcmichael, ; oulu, ; pacheco, ; shandra, leckband, & london, ). their ideology is based on the concept of ''comparative advantage", arguing that poor nations have natural endowments in growing food and harvesting timber and other commodities given their richness in resources and location in https://doi.org/ . /j.worlddev. . - x/Ó elsevier ltd. all rights reserved. tropical and sub-tropical zones. however, such approaches ignore the environmental costs of specialization, not to mention the disparate profits garnered from unequal trade relationships (e.g. pacheco, ; rice, rice, , wallerstein, ) . indeed, critical scholars in fields of political economy note that poorer countries tend to have much higher rates of environmental degradation such as forest loss, despite that the overall consumption of forest resources among people in less-developed countries is relatively low (e.g. jorgenson, austin, & dick, ; rice, rice, , ). conversely, more-developed countries have very modest levels of deforestation within their borders, or are even experiencing growth in forests, but have the greatest rates of consumption of forest products (e.g. jorgenson et al., ). this uneven international structure, often referred to as the ''consumption -degradation paradox", is explored by utilizing the concept of ecologically unequal exchange. this perspective, espoused in world-systems and dependency thinking, asserts that more-developed countries externalize or displace their consumption-based costs to lessdeveloped countries through inequitable specializations in production and trade (e.g. bunker, ; rice, rice, , wallerstein, ) . the unequal distribution of the costs and benefits of environmental transformation across countries reinforces existing socio-economic inequalities, and also has important political consequences due to the intensification of power relations (oulu, ) . a number of empirical studies of ecologically unequal exchange indeed find that the global organization of production facilitates greater resource degradation in poorer countries relative to rich countries, especially for outcomes such as deforestation and biodiversity loss, which have keen relevance to facilitating cross-species disease transmission (e.g. burns, kick, & davis, ; jorgenson et al., ; shandra et al., ). these patterns also mirror climate change dynamics; poor countries tend to suffer the most deleterious effects of climate change despite that developed countries have the most responsibility for global greenhouse gas emissions, considering historical and current levels of pollution (e.g. roberts & parks, ) . there is already clear evidence of the impact of climate change on mosquito-borne diseases, where even very minute increases in temperature are facilitating the spread of mosquitoes to new areas where people lack immunity to the diseases they carry (e.g. patz & olson, ) . it is often the bats, rats, and mosquitoes that remain in degraded environments, and thus are usually the species that transmit zoonotic diseases to people (unep, ) . many of the studies utilizing ecologically unequal exchange perspectives find that some key agricultural products consumed in the global north disproportionately drive peripheral deforestation and biodiversity loss, including beef, palm oil, coffee, and cocoa (e.g. austin, austin, , bennett, ravikumar, & paltán, ; noble, ; shandra et al., ; vijay, pimm, jenkins, & smith, ) . the regions that produce these products tend to not be consumers themselves; for example, in most coffee-and cocoa-producing countries, well over % of coffee and cocoa is exported to developed countries in north america and europe (austin, ; noble, ) . palm oil is used in around half of all processed grocery store products, including some brands of frozen pizza, margarine, candy bars, and peanut butter, as well as body creams, soaps, makeup, candles and detergents (mba, dumont, & ngadi, ) . the united states is one of the global leaders in beef consumption, devouring on average nearly lb per person per year (usda, ) . in this way, populations in the global north are acutely connected to the environmental degradation in poorer countries that causes new infectious diseases to appear. the advent of pandemics is not an inevitability. the observed relationship between environmental transformations and disease emergence is not something that just happens ''naturally" in foreign, tropical countries, or because of the actions of ''backwards" people. consumption levels and habits in affluent countries, which are supported through deep and historically-embedded international inequalities in trade and production, accelerate and concentrate degradation in poor countries and, therefore, increase possibilities for zoonotic spillover in these places. it is important to recognize that small frontier farmers who live on the edges of forested expanses often drive a significant amount of direct tree felling and land-use change in less-developed countries (lopez-carr & burgdorfer, ; painter & durham, ; rudel, ) . however, it is not poor, rural farmers who are directly to blame. large-scale cattle ranchers and commercialized agricultural export producers often push out small-scale rural peasants who have already deforested limited areas of land for subsistence farming (e.g. carr, ; lopez-carr & burgdorfer, ; painter & durham, ) . as lands become consolidated and sold off to large-holders, this indirectly motivates new deforestation by pushing frontier farmers into untouched areas where they initiate primary forest loss to gain tenure to land. rural frontier migrants tend to be poor, have low levels of education, and have very limited wage labor prospects; they are forced to transform environments, and sometimes, hunt or purchase wild game to secure food for their household (bloomfield et al., ; carr, ; rudel, ) . thus, it is structural inequalities in trade and development that cause impoverished, rural populations to often be directly involved in the first instances of zoonotic spillover. linking the emergence of new diseases to the unequal distribution of environmental harms expands on ecologically unequal exchange perspectives in unique ways. this body of theory often adopts a more materials approach, articulating ecologically unequal exchange as characterized by asymmetrical trade flows of natural resources and energy from poor countries to rich ones (e.g. hornborg, ; oulu, ) . i expand on this line of thinking to demonstrate that the unjust concentration of environmental degradation in poorer countries enables physical, germ exchanges across bodies, from animals to humans, generating new diseases that further threaten development and well-being. ecologically unequal exchanges at a global level facilitate disease exchanges on a species level. the world resources institute ( ) reports that the most recent years have been among the worst on record for rates of tropical forest loss. tropical, biodiverse ecosystems are predicted to face increasing pressures in the coming years, especially from expansions in agriculture, road construction, mining, large-scale infrastructure projects, and encroachment into protected areas (laurance, sayer, & cassman, ; sonter, herrera, & barrett, ) . global climate change is also intensifying; was the second hottest year on record worldwide (noaa, ). as environmental degradation and changes continue to grow in scale and scope, there is heightened potential of creating more deadly pandemics in the future (unep, ) . not only are additional ''novel" diseases likely to emerge, but old or ''forgotten" diseases are also expected to experience a resurgence, such as malaria and dengue fever. while scientific research has long demonstrated the link between human-animal interactions and cross-species disease transmission, often overlooked are the broader conditions that facilitate, accelerate, and locate such relationships in certain areas. inequalities lead to the displacement of environmental externalities among poor people (e.g. oulu, ; rice, ; roberts & parks, ) . environmental changes that create new human and animal exchanges occur most commonly in less-developed countries due to structural inequalities. demand for commodities from affluent consumers in the global north drives a significant amount of peripheral deforestation (e.g. austin, ; jorgenson et al., ; leblois, damette, & wolfersberger, ; vijay et al., ) . the populations responsible for the consumption of resources are located far from the sites of degradation and zoonotic spillover. while infectious diseases can easily circulate back to affect people in developed countries, as we clearly see with covid- and its initial concentration in more-developed asia, europe, and the united states, people in poor countries may ultimately be most vulnerable, given their weak infrastructure and prevalence of other health conditions, such as malnutrition (e.g. gilbert et al., ) . these factors, most certainly, can also be traced to neoliberal development dynamics that facilitate austerity and the prioritization of economic growth over human welfare (e.g. kingston, ; frame, ; stubbs, kentikelenis, stuckler, mckee, & king, ) . capitalist globalization creates economic power structures that allow for separation between responsibility and vulnerability. undoubtedly, understanding and mitigating the underlying anthropogenic causes of environmental degradation deserves vigilant attention. ecosystem and biodiversity preservation are integral in mitigating pathogen spillovers (unep, ) . new priority must be given to reducing consumption levels, eliminating trade and economic inequalities, limiting environmental externalities, and creating sustainable production systems for people and the environment. a disease-or germ-specific response is never going to be enough. on average, a new disease surfaces in humans every four months (unep, ) . unless global environmental, health, and development issues are addressed holistically, new pandemics will continue to appear. the current coronavirus crisis provides us with the unique and necessary opportunity to reimagine and restructure our relationship with the environment. international policy and development initiatives must prioritize health and environmental well-being. however, significant challenges remain as those with decisionmaking power align with the beneficiaries of the current economic order (e.g. mcmichael, ) . in order to create sustainable and effective interventions, there must be recognition of the larger causes of global environmental degradation, including northern consumption levels and profit-making, and how the unequal distribution of environmental harms globally reflects and reproduces international inequalities. the 'hamburger connection' as ecologically unequal exchange: a cross-national investigation of beef exports and deforestation in less-developed countries coffee exports as ecological, social, and physical unequal exchange: a cross-national investigation of the java trade the political ecology of oil palm company-community partnerships 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the case study of agricultural expansion and its impacts on tropical nature what has driven deforestation in developing countries since the s? evidence from new remote-sensing data deforestation drivers: population, migration, and tropical land use development and social change: a global perspective palm oil: processing, characterization and utilization in the food industry -a review chocolate and the consumption of forests: a cross-national examination of ecologically unequal exchange in cocoa exports core tenets of the theory of ecologically unequal exchange the social causes of environmental destruction in latin america malaria risk and temperature: influences from global climate change and local land use practices agricultural expansion and deforestation in lowland bolivia: the import substitution versus the structural adjustment model ecological unequal exchange: international trade and uneven utilization of environmental space in the world system the transnational organization of production and uneven environmental degradation and change in the world economy a climate of injustice: global inequality, north-south politics, and climate policy tropical forests: regional paths of destruction and regeneration in the late twentieth century ecologically unequal exchange and deforestation: a cross-national analysis of forestry export flows mining drives extensive deforestation in the brazilian amazon the impact of imf conditionality on government health expenditure: a cross-national analysis of west african nations frontiers : emerging issues of environmental concern data products the impacts of oil palm on recent deforestation and biodiversity loss the modern world-system i: capitalist agriculture and the origins of the european world-economy in the th century was the second-worst year on record for tropical tree cover loss the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord- - lf cp authors: timen, aura; hulscher, marlies e.j.l.; vos, dieuwke; van de laar, marita j.w.; fenton, kevin a.; van steenbergen, jim e.; van der meer, jos w.m.; grol, richard p.t.m. title: control measures used during lymphogranuloma venereum outbreak, europe date: - - journal: emerg infect dis doi: . /eid . sha: doc_id: cord_uid: lf cp to assess the response to the reemergence of lymphogranuloma venereum, we conducted a cross-sectional survey by administering a structured questionnaire to representatives from european countries. responses were received from countries. the ability to respond quickly and the measures used for outbreak detection and control varied. evidence-based criteria were not consistently used to develop recommendations. we did not develop criteria to determine the effectiveness of the recommendations. the degree of preparedness for an unexpected outbreak, as well as the ability of countries to respond quickly to alerts, varied, which indicates weaknesses in the ability to control an outbreak. more guidance is needed to implement and evaluate control measures used during international outbreaks. to assess the response to the reemergence of lymphogranuloma venereum, we conducted a cross-sectional survey by administering a structured questionnaire to representatives from european countries. responses were received from countries. the ability to respond quickly and the measures used for outbreak detection and control varied. evidence-based criteria were not consistently used to develop recommendations. we did not develop criteria to determine the effectiveness of the recommendations. the degree of preparedness for an unexpected outbreak, as well as the ability of countries to respond quickly to alerts, varied, which indicated weaknesses in the ability to control an outbreak. more guidance is needed to implement and evaluate control measures used during international outbreaks. r esponding effectively to international communicable disease emergencies is a complex process that involves national and international cooperation. efforts should be aimed at managing patient care and containing the disease by interrupting the chain of transmission ( , ) . the severe acute respiratory syndrome outbreak has shown the need for being prepared and being able to deal with international emergencies in a consistent way; all countries need to be prepared and able to respond to an outbreak. countries throughout europe have developed preparedness plans to face a possible pandemic caused by a new infl uenza virus. but even with a well-acknowledged threat like an infl uenza pandemic, differences in preparedness between countries exist ( , ) . the differences might be even greater when timely control measures are needed for outbreaks that remain unnoticed for a long time. systems for surveillance and outbreak management among european countries differ, as do their health policies and guidelines. we wondered whether these differences could lead to different outbreak control measures and therefore to differences in the effectiveness of these control measures. we studied the quality and timeliness of public health actions during the reemergence of lymphogranuloma venereum (lgv) among men who have sex with men (msm) in europe from january to february . in january , the european surveillance of sexually transmitted infections network (essti) issued an international alert. this action was considered a trigger for countries to identify possible cases; defi ne, inform, and investigate the population at risk; and to implement control measures. the resurgence of lgv in europe contained many features similar to an infectious disease emergency: it occurred unexpectedly; there was delay in the recognition of cases, which allowed the disease to spread within the risk group; and there was no preconceived outbreak control plan. moreover, in many countries, lgv is not reportable and surveillance is voluntary. our study of the response to this lgv outbreak demonstrates the need for a unifi ed response to new, unexpected, infectious diseases. we assessed the similarities and differences in how various countries managed the lgv outbreak to identify common practices and to formulate criteria for improving the response to international outbreaks. the items on the questionnaire were based on a framework derived from the literature about outbreak management ( , ( ) ( ) ( ) . in addition, to assess the quality of the development and implementation of key recommendations for controlling the outbreak, we used parts of the international agree instrument (www.agreecollaboration.org) for appraising guidelines and guideline development programs. the questionnaire was divided into sections. the fi rst section was dedicated to the alert and initial response to lgv and included questions about actions taken after the essti alert, risk assessment, and occurrence of cases. the second section included questions about the development of outbreak control measures and gathered information about how evidence was collected and analyzed, how measures were formulated, when experts were consulted, and how recommendations were updated. the third section included questions about the content of outbreak control measures (i.e., case identifi cation, case defi nitions, laboratory confi rmation, treatment, reporting, and interventions for health professionals and the groups at risk). the fourth section addressed implementing outbreak control measures (i.e., strategies, dissemination of information, targets for monitoring effectiveness, and additional resources). questionnaires were completed electronically or on paper, and data were analyzed by spss . (chicago, il, usa). lgv is a sexually transmitted infection (sti) caused by chlamydia trachomatis serovars l , l , and l . contrary to infection with other serovars, infections with c. trachomatis l - are not limited to the mucosa but rather are often invasive and can spread to the lymph nodes, which results in a more severe clinical outlook. in industrialized countries, cases are incidentally imported from tropical and subtropical areas where the disease is endemic ( ) . public health measures are usually restricted to contact tracing and adequate management of sex partners in individual cases; outbreak management is not needed. by the end of , cases had been reported to the public health authorities in the netherlands, followed by a substantial increase in cases in subsequent months. the cases were seen among msm. clinical signs were mostly gastrointestinal and included proctitis, purulent or mucous anal discharge, and constipation ( ) . in the early days of the outbreak, the potential for international spread was recognized because patients reported having had sexual contacts in other countries such as belgium, the united kingdom, and france ( ) . to create awareness, a message was sent through the early warning and reporting system of the european union and through the essti. since then, lgv cases have been identifi ed in several european countries, the united states ( ) , and canada ( ) . most patients were hiv positive ( ) , and some were hepatitis c positive ( ) . the questionnaire was sent to countries; of these countries had reported outbreaks of lgv in the past. completed questionnaires were received from countries (austria, belgium, denmark, finland, france, germany, ireland, italy, the netherlands, norway, portugal, scotland, slovenia, spain, sweden, switzerland, united kingdom, and turkey). of the questionnaires, were completed by medical doctors, by medical epidemiologists, and by researchers/microbiologists. in countries (belgium, ireland, portugal, slovenia, and sweden), the questionnaire was fi lled in by or more experts from different areas of expertise. the countries that did not respond to either the questionnaire or the electronic reminders (slovak republic, poland, malta, latvia, iceland, cyprus, estonia, and greece) were excluded from the analysis. a complete overview of the activities reported for controlling lgv and their development and implementation is given in the tables and . after the essti alert in january , timely national alert and response systems were set up by of the responding countries. these systems included provisional control guidelines ( countries), voluntary reporting ( countries), and tools for disseminating information to health professionals ( countries). of the countries who undertook early alert and response activities, also reported cases. the main objectives of the alert were active case fi nding ( countries), assessing the size and nature of the outbreak ( countries), and providing appropriate clinical care ( countries). in countries, the initial alert and response were undertaken by professionals from the sti surveillance system in collaboration with specialists in outbreak control. in the other countries, only surveillance specialists were involved. five countries had a national outbreak management team or advisory committee that provided scientifi c advice on surveillance and outbreak management. the multidisciplinary outbreak management teams always included epidemiologists and microbiologists; less frequently included were molecular biologists, dermatovenereologists, genitourinary specialists, and communicable disease control specialists. in country, communication experts and social scientists also participated in the outbreak management teams. no general practitioners, nurses, patients, or policymakers were involved in outbreak management teams. of the countries, control measures were aimed primarily at identifying new cases ( countries) and promoting awareness among the risk group ( countries) and sti clinics ( countries). a risk assessment was performed by countries. when developing recommendations for outbreak control, criteria varied with the countries (tables and ) . evidence was systematically collected by literature ( countries) and electronic database searches ( countries). informal consensus procedures were mostly used to formulate recommendations ( countries) based on experiencebased analysis of evidence ( countries). procedures for updating control measures were available in countries. a total of countries developed national, multidisciplinary guidelines for lgv control, of which issued authorization procedures for the guidelines. active case fi nding was initiated by countries and contact tracing by . five countries implemented both. information activities for the group at risk were performed by countries and countries alerted their sti clinics. an overview of all the control measures is given in the tables and . a total of respondents (denmark, germany, norway, sweden, spain, united kingdom, scotland, austria, the netherlands, ireland, and belgium) used an identical case defi nition for confi rmed cases: msm or sexual contacts of patients with lgv, who had anorectal or inguinal syndrome and positive nucleic acid amplifi cation tests (naat) for chlamydia trachomatis genotype l , l , or l . from these countries, case defi nitions were also issued for probable and possible cases and differed widely according to laboratory criteria. laboratory diagnosis of c. trachomatis was performed by naat on the following samples: rectal swabs ( countries), biopsy material from lesions ( countries), urethral swabs ( countries), and urine ( countries). genotyping to confi rm the presence of serovars l -l was also available from countries. supplementary testing of patients for concurrent stis was recommended as follows: hiv ( countries), syphilis ( countries), hepatitis c ( countries), hepatitis b ( countries), and neisseria gonorrhoeae ( countries). with respect to antimicrobial therapy, various regimens and different doses were used. for countries doxycycline ( mg ×/day for days) was the fi rst choice of treatment. alternatives mentioned were tetracycline ( g/ day), minocycline ( mg loading dose followed by mg ×/day), and erythromycin ( mg ×/day). clinical and laboratory follow-up of the patients was performed by countries. the control measures were implemented by disseminating educational materials in countries, disseminating national bulletins in , and holding meetings and conferences for professionals in countries. most countries ( / ) had the risk group help disseminate information. targets to monitor the effectiveness of recommendations were not formulated by any country. this outbreak of lgv had special features with high clinical and public health signifi cance. first, recognition of cases was diffi cult due to the unusual clinical presentation that mimics infl ammatory bowel disease. second, the diagnosis of lgv involved invasive procedures for collecting samples and required naat, which were not licensed for rectal specimens. furthermore, patients mostly belonged to sex networks of msm in large cities with numerous anonymous partners from different countries ( ) and where (international) contact tracing was diffi cult. in most european countries, lgv is not notifi able by law so cases are likely to be dealt with outside the public health domain. the potential of unnoticed further spread and the risk for simultaneous transmission of other infections, such as hiv and syphilis, increased the public health importance of this outbreak. differences were seen between countries with respect to ability to rapidly respond and implement measures that are needed to detect or to control a possible outbreak. countries that reported cases of lgv were more likely to recommend control measures although measures were also needed to detect possible cases. to identify and diagnose cases, clinical specialists and public health physicians, as well as the risk group, must be aware of the outbreak, particularly for an lgv outbreak. lgv is a rare disease in europe, and often healthcare workers are not aware of the clinical features of the disease. outbreak control measures require collaboration between persons in multiple specialties, such as specialists in surveillance, communicable disease control, health promotion, and physicians involved in the direct patient care (venereologists, genitourinary medicine specialists, gastroenterologists, microbiologists) that do not necessarily work together in other circumstances. in this outbreak, information from the surveillance systems was as important for health providers as for policymakers; this information had to lead to immediate recognition of a public health threat and direct action. emerging infectious diseases • www.cdc.gov/eid • vol. , no. , april however, in the management of lgv patients, differences were seen between countries with respect to case defi nitions, laboratory testing, and antimicrobial drug treatment. with most patients belonging to international sex networks, uniform diagnostic procedures and treatment protocols would have been helpful for ensuring a uniform approach to outbreak control. furthermore, control measures were impaired because in many countries lgv is not a notifi able disease; therefore, there is no legal basis for disclosing names of sexual contacts to facilitate contact tracing and prevent further spread. contact tracing was made even more diffi cult because of the numerous anonymous sexual contacts in various european cities. criteria for evidence-based development of recommendations were not always consistently used to extract and analyze evidence for best practices during the lgv outbreak, which led to differences in outbreak management. specifi c targets for monitoring the effectiveness of recommendations were not formulated by any country. one strong point was the acknowledgment by many countries of the importance of having the risk group, msm, disseminate alerts and advocate awareness. until now, the reemergence of lgv has affected msm in european countries. the essti alert prompted these countries to take action to identify cases early, improve the management of cases, and assess the size of the outbreak. of the respondents, stated that they had not taken any action at this stage for various reasons: they did not receive the alert (turkey, slovenia) or they did not participate in the essti (switzerland). coordination at the european level should encourage and monitor the response of all countries to alerts. our study has some limitations. we assumed that all countries that were participating in the essti network in had also been informed about the lgv outbreak. later, it became clear that the countries that had joined the european union on may , , did not receive the es-sti alert. because only of these new european union member countries completed the questionnaire, it was also impossible to assess how outbreak control measures were developed and implemented. another limitation inherent to the method used was that not all key persons involved in the control of lgv were able to fi ll out the questionnaire. as the questionnaire was sent to the country representatives in the essti, it is possible that not all relevant information was available on the control measures and activities that had taken place at regional or local levels. furthermore, the quality of the outbreak management process and the development of outbreak measures could only be assessed indirectly on the basis of the answers to the questionnaire because only a few countries provided more detailed documents like guidelines or articles. the lgv outbreak is still ongoing in europe, and since the completion of this study more countries may have undertaken measures to identify and treat cases and to prevent further transmission. our fi ndings are helpful for understanding the responses to unexpected disease outbreaks. however, we do acknowledge that lgv is an sti (rather than a quickspreading communicable, airborne disease) and therefore, affects a minority of sexually active citizens (msm) in the country. communicable diseases differ from other health threats or crises because they spread from person to person. therefore, problems are often not restricted to country. various specifi c interventions are therefore justifi ed by the difference in local systems, cultures, and situations. however, the principles of outbreak response are general, and countries can learn from each other. this study shows that countries have varying degrees of ability to respond quickly to an unexpected outbreak; these fi ndings expose weaknesses in the outbreak control capacity in europe. although important steps have been taken for improvement ( ) , the quality of lgv outbreak control in europe could benefi t from uniform approaches in controlling other infectious diseases with potential for international spread and from exchanging information between countries. the challenge for the future will be to coordinate outbreak management in various countries for which continuity and coherence are essential. this study shows that coordination should at least aim to provide guidance as to when and how alerts should be implemented by various countries as well as to establish uniform case defi nitions and ensure the availability of optimal diagnostic facilities. we also show a lack of common strategies and that these should be developed with respect to treatment algorithms and contact tracing. furthermore, quality systems following the whole chain of outbreak management (alert, outbreak control measures, implementation, and evaluation) are needed. these systems should be based on standard approaches to outbreak management followed by external review of implemented measures. more international collaboration is needed to improve response and to ensure high standards of practice in managing international outbreaks and threats caused by emerging or reemerging stis. crisis situations increase the chance of overlooking essential steps in outbreak management because of time constraints, uncertainty, and the lack of substantial evidence in effective approaches to controlling new diseases. furthermore, during outbreaks, key recommendations involve quick decision-making by professionals who often have no time for reevaluation. although this need for quick decisions has been acknowledged for other threats like avian fl u, sars, or bioterrorism, little experience has been acquired with managing outbreaks of stis. our systematic approach could be helpful in preparing for or assessing the response to all kinds of public health emergencies. communicable disease outbreaks involving more than one country: systems approach to evaluating the response control of communicable disease manual world health organization. checklist for infl uenza epidemic preparedness. who/cds/csr/gip/ . . geneva: the organization how prepared is europe for pandemic infl uenza? analysis of national plans world health organization. revision of the international health regulations lymphogranuloma venereum preliminary report of an outbreak of lymphogranuloma venereum in homosexual men in the netherlands, with implications for other countries in western europe resurgence of lymphogranuloma venereum in western europe: an outbreak of chlamydia trachomatis serovar l proctitis in the netherlands among men who have sex with men increasing rates of sexual transmitted diseases in homosexual men in western europe and the united states: why? canadian lgv working group. emergence of lymphogranuloma venereum in canada lymphogranuloma venereum among men who have sex with men-the netherlands a cluster of acute hepatitis c virus infection among men who have sex with men-results from contact tracing and public health implications first case of lgv confi rmed in barcelona update on the european lymphogranuloma venereum epidemic among men who have sex with men address for correspondence: aura timen email: aura.timen@rivm.nl emerging infectious diseases • www.cdc.gov/eid • llc is pleased to provide online continuing medical education (cme) for this journal article, allowing clinicians the opportunity to earn cme credit. medscape, llc is accredited by the accreditation council for continuing medical education (accme) to provide cme for physicians ama pra category credits™. physicians should only claim credit commensurate with the extent of their participation in the activity. all other clinicians completing this activity will be issued a certifi cate of participation. to participate in this journal cme activity: ( ) review the learning objectives and author disclosures; ( ) study the education content md, has disclosed no relevant fi nancial relationships. cme author charles p we thank the members of the essti steering group and representatives from the countries who participated in the survey. this research was supported by a grant from the netherlands organization for health research and development (zonmw).mrs timen is a senior consultant on communicable disease control at the centre for infectious diseases of the national institute of public health and the environment (rivm), the netherlands. her main interest is the quality of outbreak management. key: cord- - uiaruhg authors: balmford, ben; annan, james d.; hargreaves, julia c.; altoè, marina; bateman, ian j. title: cross-country comparisons of covid- : policy, politics and the price of life date: - - journal: environ resour econ (dordr) doi: . /s - - - sha: doc_id: cord_uid: uiaruhg coronavirus has claimed the lives of over half a million people world-wide and this death toll continues to rise rapidly each day. in the absence of a vaccine, non-clinical preventative measures have been implemented as the principal means of limiting deaths. however, these measures have caused unprecedented disruption to daily lives and economic activity. given this developing crisis, the potential for a second wave of infections and the near certainty of future pandemics, lessons need to be rapidly gleaned from the available data. we address the challenges of cross-country comparisons by allowing for differences in reporting and variation in underlying socio-economic conditions between countries. our analyses show that, to date, differences in policy interventions have out-weighed socio-economic variation in explaining the range of death rates observed in the data. our epidemiological models show that across countries a further week long delay in imposing lockdown would likely have cost more than half a million lives. furthermore, those countries which acted more promptly saved substantially more lives than those that delayed. linking decisions over the timing of lockdown and consequent deaths to economic data, we reveal the costs that national governments were implicitly prepared to pay to protect their citizens as reflected in the economic activity foregone to save lives. these ‘price of life’ estimates vary enormously between countries, ranging from as low as around $ , (e.g. the uk, us and italy) to in excess of $ million (e.g. denmark, germany, new zealand and korea). the lowest estimates are further reduced once we correct for under-reporting of covid- deaths. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. sars-cov- , the virus which causes the covid- disease, is a zoonotic pathogen which emerged in wuhan in late (huang et al. ) . at the time of writing, in early july , it had already claimed the lives of over half a million people globally (beltekian et al. ). in the usa covid- deaths now exceed the number of us military deaths arising from all conflict since the second world war (statista ) while in the uk the four weeks to th april saw more londoners lose their lives to covid- than during the deadliest four week period of the blitz (morris and barnes ) . this death toll is only the extremely saddening tip of the much larger iceberg of disruption that covid- has caused and continues to cause. confirmed cases across the world now exceed eleven million (beltekian et al. ) and the true infection rate is likely far higher. each case imposes a real cost on every infected individual. while symptoms may sound innocuous, including a dry cough, fever, and tiredness (who a; verity et al. ) , longer term this morbidity is likely to impose significant costs on sufferers' health, including potentially permanent lung damage or fibrosis associated with impacts upon the heart, kidneys and brain (citroner ) , all of which are likely to have negative consequences for future well-being and productivity. moreover, alongside the vast disruption that the virus itself has caused directly, preventative measures have caused further disarray in the economy. at present, there are no known specific treatments or available vaccines to either cure or prevent covid- infections (who b). therefore governments world-wide have relied upon preventative measures which aim to reduce the number of people exposed to the virus, and lower the effective reproductive number (the average number of new cases per infection, known as r), ideally suppressing it below a value of at which point the number of active cases decreases over time (ferguson et al. ) . while some of these measures impose relatively little personal or economic cost (such as simple hand hygiene and the use of face masks), the failure of such measures to stem the rapid world-wide spread of the virus has necessitated international "stay at home" lockdown requirements, entailing significant impacts across the global economy. the international monetary fund (imf) predicts a contraction in global gdp of three percent in -a decline of . % relative to its october forecast-and a decrease which it describes as being "much worse than during the - financial crisis" (imf a). short term effects are even more extreme. for example, in the uk, gdp fell by . % in april (ons a), while those claiming unemployment benefits rose nearly % to over million (ons b), although even this is dwarfed by the % increase in us unemployment over the same period (aratani ). globally sovereign debt is also soaring: predicted to grow nearly % to $ trillion in (standard and poor ) as administrations around the world race to protect cash-strapped companies from going out of business in order to prevent further unemployment. at the human level, lives and livelihoods have been turned upside-down. hence the true economic costs are more diverse and quite possibly more severe than that captured by financial metrics alone. they include negative ramifications for people's mental health (pancani et al. ; chaix et al. ; branley-bell and talbot ) ; increased kurmann et al. ( ) note that small business employment contracted by % (over . million) between mid-february and mid-april since when over million had been rehired to the end of june . prevalence of domestic violence (mclay ); and likely reduce the educational achievement of today's children (pinto and jones ; van lancker and parolin ) . as with previous financial crises (hoynes et al. ) and pandemics (nikolopoulos et al. ) , the virus and the economic fall-out are disproportionately affecting people from disadvantaged groups and lower-income households. black, asian and minority ethnic people are more likely to be infected and die (bhala et al. ; garg ; khunti et al. ; yancy ; public health england ) ; and lower-income households are less likely to be able to work from home, so face greater negative income shocks (hanspal et al. ; hensvik et al. ) , just as poorer countries are likely to suffer more than richer nations (hevia and neumeyer ) . as is well known, different countries have had very different death tolls. the usa currently has the highest death toll in the world, already exceeding , deaths (as of th july ). in contrast, vietnam-which recorded its first case just days after the usais yet to experience a single death. understanding what drives these differences is clearly crucial, potentially enabling improved responses to the continuing covid- outbreak and future pandemics. this paper begins to answer the critical question of why different countries have suffered different death rates, and what we can learn for future policy. the remainder of the paper is set out as follows. in sect. we first compare the numbers of deaths attributed to covid- across all oecd countries. the paper briefly focusses upon the uk as an example of a broader pattern; that public reporting of numbers related to the pandemic can be somewhat misleading. next, we control for any within-country under-reporting by analysing the overall increase in all deaths above what would be seasonally expected. assessing these 'excess deaths' data suggests that in most nations for which information is available official reporting of covid- tends to explain most of this unexpected mortality. however, analysis also reveals some clear exceptions, such as in the netherlands, spain and the uk where more than % of all covid- deaths seem likely to have not been counted as such. addressing such reporting problems is an essential element of providing the informational base required for an evidence-based policy response to this and any future pandemics. in sect. we assess the impact of government decisions regarding lockdown, their effectiveness and the policy trade-off between economic activity and health risk that they reveal. accepting that they are a conservative estimate of the total impact of the pandemic, officially attributed covid- deaths are used to investigate the price of life implied by lockdown policies. first we use a simple regression analysis to show that differences in mortality rates between countries are not driven by factors which are beyond the short term control of policy makers-such as differences in income and equality which, at least within the time available to fight coronavirus are effectively fixed. this in turn allows us to examine the degree of control which policymakers do have at their disposal, such as the rapidity of lockdown imposition and the duration of such controls. we use country-specific susceptible-exposed-infected-recovered (seir) models, similar to the approach of ferguson et al. ( ) , to ask how changes in the timing of lockdown measures affect the current death toll. our analyses provide good evidence that these policy tools actually determine the majority of variation in covid- impacts between countries. finally, we link these estimates to financial data to reveal a huge variation in the implied price of life across countries. section concludes. table presents the number of tests, cases and deaths that are officially recorded as (at least in part) caused by covid- across all oecd countries as of th june (data from our world in data; beltekian et al. ) . as mentioned, and considered in greater detail subsequently, these official estimates are likely to under-estimate deaths from covid- . however, the degree of under-reporting is far from constant across countries. for example, while almost all countries only counted deaths which had been confirmed to be linked to covid- , belgium adopts a much broader approach also including deaths where covid- is merely suspected as a contributory factor (chini ) . this results in much higher death rates than in other countries. arguably adopting the belgian approach internationally might provide a more accurate picture of covid- mortality. it is worth drawing attention to the very substantial variation in tests, recorded covid- case numbers and official death tolls across countries. adjusting for population, iceland has undertaken far more testing per capita than any other oecd country, at over k/ million compared to just k/million in mexico. much media attention has been expended upon reporting cumulative covid- numbers in each country. in terms of cases the roughly million cases reported in the usa is indeed a prominent result. however, unsurprisingly it is the total numbers of deaths by country which has attracted more attention and again the us total of well over , deaths is eye-catching. however, this media and policy-maker focus upon totals disguises the true comparison of these figures in failing to make even the most basic of adjustments for variation in population size between countries. once this is done then the death rate per million shown in the final column of table reveals a substantially different story. here we need to rule belgium out of comparison because its addition of suspected covid- deaths to the confirmed deaths reported by other countries, upwardly inflates its death rate. given this, the death rate reported in the uk is the highest amongst all of the oecd, exceeding even those of spain and italy which experienced their first major outbreaks much earlier on in the pandemic. it is worth highlighting how reporting elsewhere can be somewhat misleading. we do so by focussing on the uk as this is the country we are most familiar with, but the story is highly likely to be similar elsewhere. figure graphs the development of total recorded deaths (vertical axis) for a selection of countries over roughly the first days since each country recorded its th death (horizontal axis). this graph and its selection of countries is dictated by that which the uk government chose to highlight for comparison at its daily coronavirus press briefings. setting aside for the moment the us trend, clear separation can be observed between those countries such as germany and korea, which rapidly entered into lockdown and quickly controlled the growth of the virus, and those countries such as the uk and spain, the figure is a redrawing of one which was displayed daily at the uk press briefing from th march until being left out of daily briefings from th may onwards. speeches by the prime minister on covid- had been conducted before then (for example on the th and th march) but they only became a daily occurrence with a relatively standardised format from th march onwards. slides from these briefings are available here: https ://www.gov.uk/gover nment /colle ction s/slide s-and-datas ets-to-accom pany-coron aviru s-press -confe rence s. where lockdown was delayed resulting in a higher plateau. this is the first indication of the positive effects of early lockdown action, which we consider further subsequently. the uk government's decision to only display the total number of deaths in each of the countries shown took no account of even basic differences between countries such as population size; and as table has already shown, this makes fair comparison of death rates difficult. it might seem unusual to fail to make such basic adjustments, however the choice of such a display by the government is one which shows the uk cumulative total initially below that of european neighbours such as italy and spain and consistently dwarfed by that for the us, rising to more than twice the uk level. the fact that the us population is more than five times that of the uk, and that therefore per capita rates were much higher in the uk, is not obvious in this display. during the early days of the coronavirus outbreak, this omission of per capita data and focus upon cumulative totals allowed the uk government to make cross country comparisons which indicated that the country appeared to be faring better than many international counterparts (such sentiments are clear in transcripts of the verbal explanation which accompanied the graph, presented in online appendix ). for example, on the st april, the graph was described by the uk government as showing "it has not been as severe here as in france, and we are just tucked in under the usa and obviously italy on a different trajectory". however, as the pandemic developed so the performance of the uk relative to these other countries worsened. this situation was exacerbated by an outcry against the uk government's use of statistics based only upon deaths within hospitals rather than also including those in the community, ignoring obvious discrepancies such as a clear rise in deaths within care homes into which elderly hospital patients had been moved without testing for coronavirus (discombe ; grey and macaskill ) . shifting to reporting deaths from all settings revealed that the uk was faring far worse than nearly all other cumulative deaths (vertical axis) plotted for various countries (as selected for comparison in uk government briefings) over approximately the first days since each country recorded its fiftieth death (horizontal axis). note that spain's apparent decrease in cumulative deaths around day is an artefact of their reporting problems countries and indeed in per capita terms was experiencing one of the highest death rates globally (beltekian et al. ) . the impact upon the official narrative presented at uk press briefings was swift and noticeable. while initially much emphasis had been placed upon the uk's apparently favourable performance compared to other nations, now government officials started to mention the difficulty of making cross country comparisons, as highlighted by the pink dots at the top of fig. (and data presented in online appendix ). these caveats increased in both regularity and stridency until, on th may , cross country comparisons were removed from government press conferences. we have no reason to suspect that the uk government was unique in attempting to provide a positive representation of trends. however, a failure to provide clear and objective information is a well acknowledged cause of mistrust in authority (kavanagh and rich ) and is corrosive to public life at any time, but particularly in a pandemic where trust in institutions is vital. in undertaking cross-country comparisons of the impacts of covid- a first issue to be tackled is the difference in national approaches to reporting. this can be seen even in the reporting of testing statistics, differences which some authorities have argued may be politically motivated (norgrove ) . likewise, some countries (e.g. belgium) are far more likely than others to ascribe a death as caused by covid- (chini ) . given these concerns, we complement our comparisons of official covid- statistics with analysis of patterns in excess mortality data. here we define excess mortality for a country as the deviation in mortality rate during the period january to april compared to a baseline of expected deaths from previous years. excess mortality data is therefore not biased by differential rates of covid- testing or legislation on ascribing cause of death. there are however important caveats to the excess mortality figures. such numbers do not exclusively capture the increase in mortality that is directly caused by the presence of the novel virus. in addition, people may be less likely to visit hospital and therefore less likely to get treated for what are, in normal times curable diseases, thus tragically dying at a higher rate (thornton ) . similarly, first response services may get overwhelmed and therefore be less able to respond to life threatening emergencies such as heart attacks and strokes, again causing higher than expected death rates (oke and heneghan ) . acting in the opposite direction, government responses to coronavirus such as lockdown, may reduce the number of deaths from other causes; transmission rates for other communicable diseases are likely to be suppressed while a reduction in travel reduces the mortality associated with traffic accidents (alé-chilet et al. ). it is therefore not a priori obvious whether excess mortality is positive or negative. nonetheless, comparison of excess mortality with official covid- deaths will provide a more informed picture of the overall impacts of the pandemic within and across countries. table presents excess mortality data for the subset of oecd countries for which it is available. in general, the data are from the economist ( ) but are supplemented for some countries by data from other sources. baseline mortality is typically calculated as the mean number of deaths occurring in january-april - . excess deaths are calculated as the difference between the number of deaths observed in january-april and baseline mortality. the final column is the ratio of excess death to cumulative deaths at the end of april for each country, as reported by our world in data (beltekian et al. ), calculated as: the heterogeneity that was present in the statistics of officially recorded covid- deaths is also present in the excess mortality data. some countries, such as austria, iceland and portugal see only very marginal increases in death rates as compared with background death. there are countries which appear to do even better; denmark, finland, germany, israel and norway all observing fewer deaths than expected. as discussed above, these negative excess death numbers could be the result of measures to combat covid- reducing other-cause mortality, or from previous years used to calculate the baseline number of deaths being particularly bad. indeed does seem to have been a year with relatively few deaths from influenza (center for disease control ). at the other extreme, countries which appear worst hit based upon the officially recorded per capita death data are also those experiencing the highest percentage increase in mortality: belgium, spain and the uk all record deaths that are more than % higher than expected. note that italy too may well have been in this list, but the data for italy is only available to th march, about the time the country experiences its peak daily mortality. turning to the ratio of excess deaths to officially reported deaths, again there appears considerable heterogeneity across countries, suggesting countries are indeed measuring the death toll from the pandemic by very different yard sticks. generally, countries officially reporting high deaths tolls are also those which have the highest ratio of excess deaths to officially reported deaths. indeed, austria, iceland and portugal report more covid- deaths than the excess deaths they experience. it is worth noting this is not to say that these ( ) ratio = excess deaths∕officially reported deaths the other data sources used for particular countries are: austria -http://www.stati stik.at/web_de/stati stike n/mensc hen_und_gesel lscha ft/bevoe lkeru ng/gesto rbene /index .html); belgium-https ://epist at.wivisp.be/momo/; finland -https ://pxnet .stat.fi/pxweb /pxweb /en/kokee llise t_tilas tot/kokee llise t_tilas tot__vamuu _koke/statfi n_vamuu _pxt_ ng.px/; iceland-https ://hagst ofa.is/utgaf ur/tilra unato lfrae di/danir -tt/; ireland (note these are death registrations rather than government figures)-https ://rip.ie/death notic es/all; israel-https ://www.healt h.gov.il/units offic e/hd/ph/epide miolo gy/pages /epide miolo gy_repor t.aspx?wpid=wpq &pn= ; new zealand-https ://www.newsr oom.co.nz/ / / / , , /arethere -hidde n-covid - -death s-in-nzs-stati stics ; spain (importantly accessed on th june, after there was a major addition to the figures)-https ://www.scb.se/conte ntass ets/edc b f ad d e ed / - - %e % % pre limin ar-stati stik-over-doda-inkl-eng.xlsx; usa-https ://data.cdc.gov/ nchs/exces s-death s-assoc iated -with-covid - /xkkf-xrst. even among the countries for which data is available, mortality data are only available for a few months of the year, generally at least to the end of april, hence the focus january-april deaths. data tend to be aggregated to the week level, hence the exact endpoint is rarely th april . rather, the last day used in is determined by the data availability, and chosen to be as close as possible to th april. in all cases, we compare like-for-like, such that the baseline deaths are recorded over the same time period. likewise, the cumulative death toll we use to calculate the ratio of excess to reported death is that which was officially reported on the last day of the mortality data we use for each country. for some countries data availability means this is not possible. for austria, belgium and germany it is - ; iceland and usa use - ; for spain baseline deaths are modelled by momo. countries are recording deaths as covid- when they are not; rather it is entirely plausible the interventions to prevent covid- in these countries have suppressed other deaths too. at the other extreme, some countries, notably the netherlands, spain and the uk, have ratios which imply upwards of % of covid- deaths that are occurring are not being officially recorded. there are of course outliers to the overall pattern. belgium, france and sweden, have ratios below despite having high per capita death tolls. likewise, chile and new zealand have very high ratios, but these are almost certainly an artefact of them having so few covid- deaths by the end of april, rather than because of under-reporting in each nation. to recap, there are vast differences in the number of cases and deaths caused by coronavirus in different countries. this heterogeneity does not merely disappear when we account for potentially different reporting guidelines in each country; rather it may even be exacerbated. so what could be driving these patterns? while most countries chose to implement a relatively similar policy response, they did so at different times in their respective pandemics and some have been criticised for only belatedly imposing lockdown. there is some early correlative evidence that differences in current death tolls could be explained by lockdown date (burn-murdoch and giles ) and we now move to consider this issue in greater detail. our investigations of the potential impact of different approaches to reporting show the usefulness of an internationally agreed standard for assessing the impact of the pandemic. however, in the absence of such a standard we use national official estimates of covid- mortality to understand the impact of lockdown policies. data is supplied by the our world in data programme (beltekian et al. ). an initial task was to estimate the overall impact which policy responses could plausibly have had on covid- mortality. to achieve this we undertook regression analysis examining the extent to which variation in covid- deaths across all oecd countries might be explained by socio-economic and demographic differences which no government could reasonably be expected to address during the timescale of a pandemic. a number of such exogenous determinants have already been highlighted in the literature. of these one of the most clearly established mortality risk factors is a positive association with age; all other things considered, older sufferers are more likely to die from contracting covid- than are younger people (dowd et al. ) . therefore, across countries, populations which include a greater proportion of elderly people are likely to report higher death tolls. similarly, those living in closer proximity to others may be more likely to pass on and contract the respiratory disease, hence variation in population density across nations may be a determinant of covid- deaths (rocklöv and sjödin ) . beyond simple average population density, the degree to which populations are clustered in large urban centres may influence covid- -related mortality (stier et al. ) . health outcomes might also differ because of within-country variation in wealth (marmot ) which we capture in our regression by controlling for the gini coefficient of income inequality for each country. richer nations are likely better placed to limit the spread of pandemics (e.g. hosseini et al. ), hence we use per capita gdp as a regressor to net-out cross-country differences owing to wealth. finally, previous studies (e.g. fraser et al. ) have highlighted that early detection may play a crucial role in halting virus spread, hence it seems plausible that countries which were exposed to covid- earlier in the pandemic, and that therefore had less time to prepare, faced worse consequences. to account for this, we use the regressor "warning days"-the length of time (in days) between the who declaring that the covid- outbreak was a "public health emergency of international concern" on th january and the country recording its th confirmed case (who c). the linear regression we use, details of which are presented alongside full results in online appendix , is deliberately simple and we are not claiming that the model necessarily captures causal relationships. however, even after including the list of exogenous factors which have been hypothesised to be major socio-economic and demographic drivers of cross-country variation in mortality rates, over % of the cross-country variation in covid- mortality differences remains unexplained. covid- deaths vary greatly across countries due to factors beyond socio-economics and demographics; the major remaining determinant is the policy responses implemented by national governments of which the most obvious difference is when different countries implemented lockdown. to investigate the impact of lockdown upon cross-country variation in covid- mortality we calibrate country-specific seir models. seir models have a long history of development (li and muldowney ) with applications across a variety of infectious diseases including measles (bolker ), hiv (shaikhet and korobeinikov ) and ebola (lekone and finkenstadt ) . more recently seir models have also been applied to covid- (e.g. annan ; flaxman et al. ; pei et al. ) . however, as far as we are aware, ours is the first study to use the seir modelling framework to examine the effects of lockdown timing across multiple countries in the same study, and the first to combine these results with financial forecasts to obtain cross-country implied price of life estimates. price of life estimates derived in this paper are of critical importance given that government intervention has the ability to save life, yet trades-off against other goods. for example, closing schools is expected to reduce the transmission of infectious disease, hence decreasing the number of lives lost in a pandemic by imposing a human capital cost on today's children (viner et al. ) . likewise, there is evidence that the more stringent the government intervention to reduce the spread of coronavirus, the fewer lives that have been lost (stojkoski et al. ). this too is not free: we all pay with restrictions on our basic freedoms. beyond coronavirus, governments spend money and introduce legislation which imposes significant costs on society in a variety of sectors: healthcare (nice ), road safety (dft ), and safety at work legislation (hse ). governments also often have to consider multiple policy options for issues of environmental concern, be that considering pollution (ackerman and heinzerling ) , climate change (stern ) or biodiversity loss (ellis et al. ) . here too, lives can be saved and lost as a consequences of policy decisions. hence understanding how governments should value life is of critical concern. indeed, a significant section of relevant policy documents is occupied by discussion of the value which a government should place on statistical life when evaluating policy (e.g. the green book; h.m. treasury ). in the case of coronavirus, there are already studies which aim to assess the economic value of particular policy interventions by reducing the number of lives lost. hale et al. ( ) ask: how much of one year's consumption would an individual be willing to forgo in order to reduce the mortality associated with covid- , suggesting the answer lies in the range one-quarter to one-half depending on exact mortality rates. underpinned by assumptions about the rate of transmission and how policies may affect this, greenstone and nigam ( ) show the economic benefit of social distancing measures in the usa to be very substantial-about $ trillion. similarly, thunström et al. ( ) use initial global estimates for the basic reproductive rate, and assume decreases to transmission from policy intervention from studies on spanish flu, to go further. they conduct a cost-benefit analysis for similar measures, again in the usa, showing that the net benefits exceed $ . trillion. gandjour ( ) and holden and preston ( ) conduct similar cost-benefit style analyses for germany and australia, respectively, both highlighting that lockdown comes out net positive. here we ask a different but related question. not whether lockdown makes economic sense, but rather what the timing of interventions reveal about the relative prices different governments place on their citizens' lives. we focus on countries with very different mortality rates and intervention timing-if there are discrepancies between countries for the price of life, they are most likely to be shown in this set of countries. in china, lockdowns were implemented on a province-by-province basis on very different dates. therefore, at the country-level our gdp calculations would be incomparable with other nations. to overcome this challenge, we additionally parameterise an epidemiological model for hubei, the province worst hit by the pandemic. we use the results from hubei in our price of life calculations to maintain comparability across countries. to be clear, the implied price of life should not be regarded as comparable to the value of a statistical life (vsl). specifically, vsl is a concept from normative economicshow much consumption should governments be willing to trade-off for an increase in the number of lives saved. this is a question which can be answered through stated-preference methods as has been done elsewhere (e.g. alberini ; carthy et al. ; jones-lee ) . rather, the implied price of life we calculate can be seen as an answer to the positive economics question of how governments actually do price lives saved in terms of consumption lost when making policy decisions. the key insight is that as the pandemic progressed governments continually had to decide when the moment was right to introduce a lockdown. earlier lockdowns would save more lives, but likely impose greater immediate costs upon the economy. likewise, delaying lockdown also delays the point at which a government becomes either morally or legally responsible for addressing the costs which such restrictions impose upon business. therefore, ex-ante the expectation was that earlier lockdown meant greater financial cost. expost, it seems governments may have been somewhat wrong to make that assumption as longer-term earlier lockdowns actually appear to be associated with shorter overall lockdown length, as is clear in online appendix , which in turn result in lower long-term economic costs (balmford et al. ). nonetheless, early imposition of lockdown imposed the certainty of cost, while a delay held out the possibility that the epidemic may turn out to be less severe than expected. gambler governments chose to delay rather than act. the chosen date of lockdown reveals a government's preferences regarding the trade-off between avoided deaths and gdp losses. relative to the chosen lockdown date, a later lockdown would have cost more lives, but reduced the financial impact. in its choice of lockdown date a government implicitly accepted the associated gdp loss rather than bear a greater death toll. earlier lockdowns would have had the reverse effect; saving more lives but at a greater cost to the economy. in choosing not to enter lockdown earlier, the government rejected the higher financial cost of earlier lockdown in favour of more deaths. hence, we are able to calculate both accepted and rejected prices for human lives: upper and lower bounds for the implied price of life in each country. a criticism of this method may be that decision makers at the time were unaware of the benefits of lockdown for public health. the evidence, however, points to the contrary. for example, it was reported in the print media at least as early as th march that the lockdown in wuhan was showing signs of slowing the spread of coronavirus (qin ) . within the uk there is evidence that scientific advisors notified the uk government of the benefits of lockdown two weeks prior to its imposition (barlow ) . calculations of the implied price of life for each country require two data points. first, the differential effect on human lives lost from a marginal change in lockdown date. second, the marginal effect on gdp from the same change in lockdown date. we use a compartmental epidemiological model to simulate the epidemic in each country and in particular to predict the outcomes of the counterfactual scenarios in which lockdown dates are changed. in this type of model, at any moment in time the population of a region or country is distributed between compartments according to disease status, and the function of the model is to describe (and predict) how the population flows between these that such a trade-off is inevitable and in principal morally defensible is not questioned, indeed it follows logically from the vsl. increasing economic costs impact upon human welfare. an approach which says that every life is of infinite value would impose infinite costs upon the economy, resulting in far greater losses of human wellbeing (and almost certainly life) than acting in a way which imposes an implicit and non-infinite price on life. it is the cross-country comparison of that implicit price which is examined here. our focus on gdp reflects both the ubiquity of this measure and a lack of available, robust, economic estimates of the wider welfare impacts of lockdown. to better understand some of those wider costs, we direct the interested reader to: branley-bell and talbot, ; burki, ; cash and patel, ; chaix et al., ; mclay, ; pancani et al., ; pinto and jones, ; sud et al., ; van lancker and parolin, . while driven out of necessity, we think that a focus solely on gdp is also justified. our interest is in the relative price of life across country. even accounting for the external costs, the relative pattern for price of life would remain; it could only be eroded if these external costs are disproportionately larger for countries with lower gdp-based price-of-life estimates. indeed grant shapps, a uk government minister, was questioned on th march , a full week before the uk entered lockdown, regarding why the uk was following the example of other countries in implementing a lockdown given evidence that such a response seemed to work. a summary of the interview is available on the sky website here: https ://news.sky.com/video /coron aviru s-uk-appro ach-entir elyscien ce-led-grant -shapp s- . there is also a video of the interview on the sky facebook channel here: https ://www.faceb ook.com/watch /?v= . compartments as the epidemic progresses. in the seir model which we are using, there are four compartments corresponding to susceptible (i.e., not infected, but vulnerable to the disease), exposed (a latent stage usually lasting a few days, where the victim has been infected but is not yet infectious), infectious (at which point they can pass the disease on to others), and removed (meaning they are no longer infectious and may be either recovered from the disease and immune, or else dead). in more complex models, the population may also be subdivided according to age and other factors, with each subdivision being compartmentalised according to disease status as previously described. this would allow for a more detailed representation of the structure of society and the progress of the epidemic as it spreads through the population, but such detail would greatly increase computational demands (especially for large ensembles of simulations as we are using here) and is not necessary for this work. for a full description of the model we are using, see annan and hargreaves ( ) and also house ( ) where the underlying model equations were originally presented. the flow of the population between the compartments depends on parameters which we estimate by fitting the model to observational data for each country. this model fitting process follows the standard bayesian paradigm of defining prior distributions for uncertain parameters, running the model numerous times with parameters sampled from these priors, and calculating the likelihood on the basis of how well the model outputs match the specific observational data that we are using. this process (using a markov chain monte carlo approach) is described in detail in annan and hargreaves ( ) . this approach requires around , model simulations for each experiment (i.e. country) and the results are represented by an ensemble of model simulations that samples our posterior probability distribution. one critical parameter of the model, which has been widely discussed in the literature and media, is the reproductive number or r, which is the number of new cases that each infectious case generates in a fully susceptible population. if r is greater than , the epidemic initially exhibits exponential growth until it infects a sufficiently high proportion of the population that the remaining susceptible fraction substantially shrinks. if r is less than , the epidemic decays, again exponentially. in our estimation procedure, we assume that all uncertain model parameters are fixed in time apart from r, which is treated as piecewise constant. we consider three discrete periods within which r is constant. first, there is an initial period prior to "lockdown" controls being imposed by governments. a new, lower value for r is then assumed to apply during the period of strict controls, with a third value applying after the controls are significantly relaxed. country specific lockdown dates that we use are detailed in online appendix . in reality, r and other model parameters are likely to vary somewhat during these periods but this piecewise constant approach has been widely used and captures the dominant features of the system (e.g. flaxman et al. ) . due to serious limitations in the testing and reporting of case numbers, we rely exclusively on daily reported death numbers for the calibration of our model. again, this is a common approach which is justified on the basis that the reporting of deaths is usually far more consistent and reliable than case numbers which depend strongly on testing capacity and policy. an alternative approach would be to use the number of excess death. while this may better reflect the number of deaths caused by covid than reported death statistics, daily excess death data are not available. moreover, the key results in the model are driven by changes in the rate of infection, hence even if death numbers in a particular country are underestimated due to systematic biases, this will not usually bias the estimates of model parameters. therefore to calibrate the models we use daily reported deaths from our world in data up to th june (beltekian et al. ) , and later suggest how accounting for excess mortality would alter our estimates. the prior estimate for r after the release of lockdown is taken to be n( , . ) which represents our assumption that the policies are intended to be as open as possible while keeping the epidemic controlled. in many cases, there are insufficient data to constrain this prior estimate strongly, and therefore it plays a greater role in our results than the priors used in earlier phases of the epidemic. estimates of all the r values, as well as our priors, are detailed in online appendix . lockdown clearly reduces the infection rate across the board. easing lockdown allows the infection rates to increase again. figure compares observed and modelled deaths in the uk, showing deaths on the (exponential) vertical axis over time. modelled mortality (the solid line) closely matches the actually observed deaths (circles), illustrating that the modelling framework is flexible enough and the methodology sufficiently rigorous that the epidemiological model well replicates the observed patterns in the uk. indeed, only on days do observed deaths fall outside the % confidence interval (shaded area), and all such occurrences are in the postlockdown period when the number of daily deaths is comparatively low. similarly, close relationships are displayed for the other countries in the equivalent plots (online appendix ), highlighting that the model well captures the country specific pandemic pathways. in order to calculate the effects of changing the dates of lockdown, we use the fitted parameter values, and perform simulations in which the date of imposing lockdown is changed-either delayed or advanced by days. we also explore advancing or delaying lockdown by or days, results of which are presented in online appendix . this approach is similar to that of others (e.g. flaxman et al. ) in which the effects of policies have been analysed. since we are using a single date to represent the net effect of multiple policies which were introduced across a period of several days, it would be more precise to interpret these scenarios as representing a change in the timing of all such policies by the given number of days. likewise, we identify the impact of lockdown using within-country variation in the rate of infection. therefore, to the extent that the stringency of policy interventions vary between countries, our simulations reflect the same countryspecific set of policy interventions of the same stringency being implemented either earlier or later. that said, the lockdown is widely believed to be the most important of these measures (flaxman et al. ) and so we consider our interpretation to be a reasonable approximation of the impacts of lockdown and variation therein. differences in total mortality for each country dependent on date of lockdown are calculated to th june . we also calculate the number of deaths that likely would have occurred were no lockdown implemented, again to the th june . for illustrative purposes, the graph of predicted daily deaths for the uk under such a scenario is in online appendix . in all cases, no correction is made for the possibility that hospitals got overwhelmed, causing an increase in infection-fatality ratios. to the extent that such an outcome would have occurred, yet more lives would have been lost under the delayed-and no-lockdown scenarios. the graphs are similar for all other countries, and hence not displayed here. table highlights the likely impacts of lockdown policy. it is clear that the imposition of lockdown likely saved in excess of million lives across the countries we examine. this overall analysis of lockdown is similar to that of flaxman et al. ( ) and comparison of overlapping results shows that they are in most cases strikingly similar. however, we caution against over-interpreting the result: it is likely that even without a formal lockdown, people would have socially distanced and engaged in other behaviours to limit covid- deaths. nevertheless, earlier governmental action would have saved a large numbers of lives, particularly in countries such as the uk and us who acted relatively late. prelockdown reproduction rates are substantially greater than one, hence across all countries, longer delays result in exponentially greater losses of life. the previous sub-section presented clear evidence that the choice of when to impose lockdown drastically affects the likely number of deaths. moreover, there is significant heterogeneity across countries in the number of lives that would have been saved had lockdown been implemented just days earlier or later. how does this heterogeneity translate into the implied price of life across countries? to assess the price of life we require estimates of the financial cost of lockdown on gdp. we first assume that the full cost of any extension to the length of lockdown is felt in the year . therefore, we estimates the cost to gdp by comparing the last imf forecasts of national gdp in prior to the pandemic (from october ; imf ) with their most recent forecast for (april , imf b). further assumptions are needed to understand the cost of a marginal extension to lockdown. the first is the relationship between lockdown length and cost to gdp. in line with the best available evidence, from studies in the us (walmsley et al. ) and thirty panglobal countries (with a focus on european nations, fernandes ), length of lockdown appears to be directly proportional to the percentage gdp loss. of course, not all of the gdp loss associated with an extended lockdown is the result of the policy decision alone: progression of the pandemic sufficient to warrant a lockdown (extension) would reduce gdp outlook anyway and there is good evidence that people were changing their behaviours to enact social distancing in advance of direct regulations (gupta et al. ) . moreover, it is not just the domestic pandemic which causes gdp losses-some is also driven by the state of the virus in other nations owing to trade (mandel and veetil ) . hence we must also make an assumption about how much of the loss in gdp in any given country is the result of the lockdown policy, rather than other factors associated with the ongoing pandemic. andersen et al. ( ) , chronopoulos et al. ( ) and goldsztejn et al. ( ) have all teased apart the effects of lockdown policy from the wider pandemic. all three suggest that the gdp loss caused by lockdown policy is approximately % of the total gdp loss experienced by each country. we note of course that there are reasons to believe this figure could be an over-or under-estimate of the proportion of cost attributable to the lockdown policy, and that this could also vary somewhat by country given that lockdown policy may have different impacts on different industries. nonetheless, we see the . estimate as offering a reasonable ball-park figure, and so adjust predicted gdp losses as per eq. : equation states that the gdp loss caused by changing the length of lockdown by some amount (either , or days; denoted i ), in country j , is calculated as the relative change in lockdown length, multiplied by the predicted change in gdp as forecast by the imf, and ( ) Δgdp ij = Δlockdown length i actual lockdown length j × imf forecast gdp loss j × . andersen et al use data from individual-level transaction data either side of the border between denmark, which imposed a lockdown, and sweden, which did not. denmark saw transactions reduce % in the immediate aftermath of lockdown imposition compared to sweden's % reduction. this suggests that . % of the gdp loss denmark experienced is caused by the lockdown rather than mere pandemic progression. chronopolous et al present evidence from either side of the uk lockdown, again using individualconsumer-level transaction data. this suggests a similar proportion of the overall cost is attributable to the lockdown policy: spending drops by . % in the week following lockdown (week beginning rd march ) relative to the previous period. goldsztejn et al conduct a modelling exercise linking economic data to an seir model for the uk again. this suggests that lockdown accounts for % of the overall economic downturn. as more accurate estimates of this key parameter become available, we would encourage the interested reader to replicate our calculations but with an updated estimate of the proportion of gdp loss attributable to lockdown policy to provide more accurate estimates of the price of life. the proportion of the loss attributable to the policy decision ( . ). we adopt the imf metric for measuring gdp in terms of purchasing power parity international dollars (ppp$) which is held constant such that it is equal to the us dollar. for hubei, we use the same formula as above, however the imf only publishes estimates gdp forecasts at the national level. therefore we partition the effect for hubei alone by multiplying by the proportion of china's gdp which hubei makes up ( . , ) . the necessary data, and calculated gdp outcomes, are presented in online appendix . it is worth highlighting two further implicit assumptions. first, we assume all of the gdp loss a country experiences occurs during the lockdown period. clearly, countries' economies were already contracting pre-lockdown, and likely will take a long time to return to normal functioning post-easement. however, our assumption ensures that the implied price of life we calculate is an upper bound. second, we assume that the date on which lockdown is eased is independent of the date on which lockdown was imposed. this is an open empirical question as it may be that earlier lockdowns halt the spread of the virus quicker, allowing an earlier end to lockdown. if earlier lockdowns result in earlier release this would lower the overall financial burden of lockdown. hence, again our assumption tends towards an upper bound estimate on the price of life. the additional assumption made for hubei may underestimate the price of life there: the contraction in china's gdp is likely most keenly felt in hubei, the worst hit province. our estimates of price of life would increase if we adjusted for this. aside from the caveat with respect to china, while our assumptions influence absolute estimates of the price of life, the only variables affecting the relative prices across countries are: ( ) the number of lives a change in the length of lockdown would save; ( ) the original length of lockdown in a country; and ( ) a country's gdp. these key variables are not assumed. to underscore the point, our assumptions cannot substantially influence the implied relative price of life across countries. to calculate the implied price of life from a change in the length of lockdown of a set number of days, i , for country, j , we link the predicted change in gdp to the change in number of lives lost as in eq. : our primary focus is for the most marginal change in length of lockdown we calculate: imposing lockdown either days earlier or later than its actual date. results for different changes in lockdown date, of and days, are presented in appendices and . these show that relative patterns remain unchanged. table showed that the exponential growth in infections means more lives are lost from a delay, than would be saved by shifting lockdown earlier by the same number of days. in contrast the modelled impact on gdp from moving the lockdown date by a fixed number of days is exactly the same; the only difference is in the sign (earlier lockdowns are a cost to gdp, later lockdowns a benefit). hence, the implied price of life is higher for moving lockdown earlier as opposed to later. ( ) implied price of life ij = Δgdp ij ∕Δlives lost ij moreover, as explained previously, by choosing not to impose lockdowns days earlier governments rejected saving more lives when the price was relatively high. similar logic reveals them to have accepted the implied price of life from a delay; they would rather bear the cost in terms of gdp than as further human lives lost. results from these analysis are presented in table . obviously, estimates for prices countries were willing to pay (accepted) are lower than estimates for the prices countries rejected. in almost all cases the estimates of the price of life are below thresholds typically used to estimate the vsl in cost-benefit analyses. hence, ex-post, it is highly likely lockdown enhance social welfare. as with progression of the pandemic, there is huge heterogeneity in the price of life across countries. comparing across countries those who pursued an early lockdown strategy reveal they are willing to pay a high price to save their citizen's lives, only rejecting prices above $ , , . the highest implied prices are in korea (> $ , , ) and new zealand (> $ , , ), both countries who acted swiftly to suppress the pandemic. however, those countries which imposed lockdown relatively late-on in their respective pandemics were clearly only willing to pay far less to protect lives. belgium, italy and the uk reject prices of life around $ , . clearly, delayed action in the face of exponential growth cost lives, and implied low price of life in those countries imposed lockdowns relatively late in the pandemic. two comparisons make this cross-country variation in the implied price of life particularly clear. first, the accepted price of life in china ($ , ) is about % higher than that for an american ($ , ). this is despite our methods meaning the calculated price of life for china is likely an underestimate. second, compare the acceptable price of life in germany ($ , ) with that in the uk ($ , ). the price of life for a german is nearly an order of magnitude greater than that for a british citizen. that vast difference is despite the two countries being very similar in terms of gdp per capita. these relative implied price of life comparisons are particularly pertinent. our methodology uses ex-post estimates of the number of lives saved to infer what government policy implies for the price of life. yet, these governments were clearly making the decisions ex-ante. nonetheless, these governments were making lockdown decisions at around the same time (except hubei which was far earlier), with nearly identical information sets. thus any differences in relative estimates would hold true even if the pandemic had proved to be far less deadly than it actually is. moreover, this heterogeneity in the price of life is not explained by different values for life. indeed, the implied prices are often far lower than official vsl estimates-seemingly, cash flowing through the market is worth much more than value passing through wellbeing, at least to some countries. the low rejected prices also imply that very few quality ideally we would assess all of the consequences of interventions (e.g. the mental health costs of lockdown) before making such an assertion. however, the difference between vsl values and our price of life estimates suggest that our statement is defensible (certainly for those countries where the latter measures are particularly low). moreover, vietnam would have been included in the modelling exercise, but we were unable to robustly parameterise our epidemiological models as so few cases (let alone deaths, of which there have been none) have occurred. this is true to the extent to which officially reported covid- deaths in china are accurate. if officially reported deaths are far lower than the number of deaths which have actually occurred, this figure may well be an overestimate of the price of life in china. we have not found data from china on excess mortality and so cannot speculate on the degree to which mortality data are accurate. adjusted life years (qalys) are assumed to be saved by governments in reducing covid- -related mortality; otherwise delays to lockdown seem nonsensical. for reference, in the uk the national institute for health and clinical excellence views a qaly costing between £ , and £ , as good value (nice ). as we mentioned when discussing table , those countries with high reported covid deaths, tend to be countries with high ratios of excess mortality to reported death, i.e. there is substantial under-reporting. to examine the extent to which our estimates change when we account for this under-reporting, we focus on the set of countries for which we have reliable estimates of that ratio, and where under-reporting appears prevalent. these countries are: italy, the uk and the usa. the estimates reported in table are calculated by dividing the estimates of the price of life by the ratio of excess mortality to reported deaths (from table ). the intuition behind this is that our estimates of lives saved by lockdowns (used in table ) are based upon reported death data, and hence should be scaled upwards by the degree of under-reporting of deaths. implicit in this correction is the assumption that the ratio of excess death to reported death is constant within a country throughout the pandemic. it is possible that the ratio declines during the tail of the pandemic when covid cases and deaths are less common, and tests more available. nonetheless, our correction offers what is currently the most comparable cross-country figure. table shows that for those countries which under-report covid- deaths, implied price of life is substantially reduced, highlighting once again that earlier lockdowns would have increased social welfare tremendously. for example, in the uk, the country for which we estimate a relatively high rate of under-reporting of covid- deaths, the adjusted rejected price of life is just $ , (equivalent to just over £ , ). the accepted price of life is lower still, at $ , (£ , ). this study has begun to disentangle the extent to which cross-country comparisons of responses to covid- are valid despite difficulties caused by both exogenous factors and differences in testing rates and the recording of cases and deaths. the results presented in this paper suggest that policy interventions may well explain the majority of cross-country variation in officially reported covid- deaths. for some countries, deficiencies in official approaches to the recording of covid- mortality mean that estimates based upon deviation of overall deaths away from the seasonally expected norm may provide a more accurate depiction of fatalities caused by the pandemic. such 'excess death' estimates suggest that in some, highly impacted, countries the actual number of covid- deaths may considerably higher than indicated in official statistics. for example, within the uk it seems that more than a third of covid- deaths may have gone unrecorded. where under-recording is prevalent, then the number of lives lost by delayed intervention (as well as those saved relative to even further delay) is likely to be substantially higher than estimated in this paper. any such under (over) estimation of true deaths would result in an over (under) estimation of the price of life implicit in lockdown decisions. careful consideration of cross-country differences is required if we are to glean the important natural experiment evidence afforded by countries implementing different policy approaches to the pandemic. the results presented in this paper highlight that welldesigned policy can save life. while the economic burden of lockdown is large, comparison with prior decision criteria suggest that such policies generate net benefits for society. pricing the priceless: cost-benefit analysis of environmental protection what is a life worth? robustness of vsl values from contingent valuation surveys activity and the incidence of emergencies: evidence from daily data at the onset of a pandemic pandemic, shutdown and consumer spending: lessons from scandinavian policy responses to covid- tweet posted th model calibration, nowcasting, and operational prediction of the covid- pandemic antconc (version . . ) [computer software covid- : analogues and lessons for tackling the extinction and climate crises tweet posted th coronavirus pandemic (covid- ) (online) sharpening the global focus on ethnicity and race in the time of covid- . the lancet bolker b ( ) chaos and complexity in measles models: a comparative numerical study exploring the impact of the covid- pandemic and uk lockdown on individuals with experience of eating disorders burki tk ( ) cancer care in the time of covid- uk suffers second-highest death rate from coronavirus (online) the contingent valuation of safety and the safety of contingent valuation, part : the cv/sg 'chained' approach has covid- subverted global health? psychological distress during the covid- pandemic in france: a national assessment of at-risk populations why does belgium have so many coronavirus deaths? 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brida, j. g.; limas, e. title: comparisons of covid- dynamics in the different countries of the world using time-series clustering date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: oefmb g in recent months, the world has suffered from the appearance of a new strain of coronavirus, causing the covid- pandemic. there are great scientific efforts to find new treatments and vaccines, at the same time that governments, companies, and individuals have taken a series of actions in response to this pandemic. these efforts seek to decrease the speed of propagation, although with significant social and economic costs. countries have taken different actions, also with different results. in this article we use non-parametric techniques (ht and mst) with the aim of identifying groups of countries with a similar spread of the coronavirus. the variable of interest is the number of daily infections per country. results show that there are groups of countries with differentiated contagion dynamics, both in the number of contagions plus at the time of the greatest transmission of the disease. it is concluded that the actions taken by the countries, the speed at which they were taken and the number of tests carried out may explain part of the differences in the dynamics of contagion. in recent months, the world has suffered from the appearance of a new strain of coronavirus, causing the covid- pandemic. there are great scientific efforts to find new treatments and vaccines, at the same time that governments, companies, and individuals have taken a series of actions in response to this pandemic. these efforts seek to decrease the speed of propagation, although with significant social and economic costs. countries have taken different actions, also with different results. in this article non-parametric techniques (ht and mst) are introduced to identify groups of countries with a similar spread of the coronavirus evolution. the variable of interest is the number of daily infections per country during a period of at least days after the confirmation of the tenth case. the coronavirus propagation is analyzed in terms of a complex system composed of many interacting elements that exhibit numerous forms of emergent collective dynamics (machado and lopes, ) . complex systems cannot be explained by studying the constituent parts in isolation, but by considering the interrelation with the other elements of this system. vasconcelos et al. ( ) analyze the fatality curves of the covid- disease, represented by the cumulative number of deaths, for eight countries: brazil china, france, germany, iran, italy, south korea, and spain. the study model the cumulative number of deaths by applying the richards growth model and find that it describes very well the fatality curves in all cases. the authors also find that -in order to be effective-the countermeasures (i.e. social distancing, quarantine, school closures, etc.) must be taken immediately after the onset of the epidemic. in particular, they find that if the interventions are delayed by ten days the respective efficiencies drop to about % or less. additionally, a delay of additional days brings the efficiency to less than %. manchein et al. ( ) study the growth of the cumulative number of confirmed infected cases by a novel coronavirus until march , . the study focuses on nine countries (brazil, china, france, germany, italy, japan, spain, republic of korea, and usa) and finds that in all cases the cumulative number of confirmed infected cases follows a power-law growth. moreover, by using the distance correlation, the power-law curves between countries are statistically highly correlated. the authors argue that these correlations suggest the universality of such curves around the world. regarding the impact of the countermeasures, the article finds that soft quarantine strategies are inefficient to flatten the growth curves. among the most effective countermeasures to flatten the power laws, the authors identify the social distancing of individuals and also the strategy of identifying and isolating infected individuals which, according to the authors, is the best strategy to flatten the curves. zarikas et al. ( ) present a hierarchical cluster analysis, in which they analyze active cases, active cases per population and active cases per population and per area based on johns hopkins epidemiological data. the analysis identifies four different shapes in the evolution rate of covid- . the first shape corresponds to china, which characterizes by a sharp increase during the first days and then a flattening of the curve . the second shape corresponds to south korea, which is similar to the china´s shape but with a lower number of cases. the third shape is associated to the countries where the cases appeared early, but they have a low number of cases (for example, vietnam, thailand, japan, japan, singapore or nepal). finally, the fourth shape corresponds to countries in which the cases arose since several days, but the sharp increase occurred very recently and the number of cases during last day was very high (for example, usa, france, germany, italy, uk, spain, iran, canada or israel. important to note, as the authors suggest, that the surface area of each country is a parameter influencing the criticality of the situation, i.e. geography matters. chandu ( ) utilizes a k-means clustering algorithm to analyze countries with at least confirmed positive cases. the algorithm groups the countries into two main clusters. the americas, european countries, and australia were members of the same cluster, which is characterized by high covid- case fatality rate, higher proportion of country's population tested covid- positive, higher percentage of gdp spent as public health expenditure, and greater percentage of population being more than years of age. rojas et al. ( ) present an analysis of the states of the united states with the aim of measuring the similarity of covid- time series. in the proposed methodology, infected and deceased persona are jointly analyze and the similarity between time series is measured through the dynamic time warping distance (an extension of the euclidean distance) and nine different clusters are obtained, showing a different pattern in the eastern region and western region of the united states. in this article we use non-parametric techniques (ht and mst) with the aim of identifying groups of countries with a similar spread of the coronavirus. the variable of interest is the number of daily infections per country. the remainder of this paper is organized as follows. in section , the methodology of this paper is presented: hierarchical trees (ht) and the minimum spanning trees (mst). section introduces the data, whereas section presents the empirical results. the final section draws the conclusions. following the methodology developed by mantegna ( ) , in this study the coronavirus propagation is formulated as a network problem, where each country would be represented as a node, and the relationship between each pair of countries as a link. thus, the spread of coronavirus would be a complex network of mutually interacting nodes and each link would represent how similar is the coronavirus dynamics between any pair of countries. the minimal spanning tree (mst) graphs were introduced by kruskal in graph theory (kruskal, ), but they started to be utilized in the realm of econophysics due to the work of mantegna ( ) , who utilized the mst applied to time series data to analyze stock market correlations. the clustering process used to form the mst is known in cluster analysis as the single-linkage clustering method. the main advantage of the mst is that it simplifies comparisons by reducing the number of elements that must be analyzed. moreover, since mst selects the strongest relationships among network nodes, it condenses the core information on the global structure of the network. thus, the general characteristics of the network can be reproduced in the mst (hill, ; kwapień et al., ) . in this article we propose analyzing the evolution of new daily coronavirus cases by using elements of graph theory. thus, the time series of new cases per country will be the nodes of a graph, while the relationships between countries will be represented by the links of the graph. this way, the links correspond to the pearson's correlation distance (mantegna, ) between any pair of countries. following stanley and mantegna ( ) , from . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint these correlation distance we construct the minimum spanning tree (mst), which is the minimal graph that covers all nodes without loops. the first step of this methodology is the calculation of the pearson's correlations between the n Ö n pairs of countries: where r i is the number of new cases in country i. then, the correlation matrix is built with the correlation coefficients ρ i,j . by definition, ρ i,j takes values in the interval (- , ), where - means complete anti-correlation, complete correlation and that the two variables are uncorrelated. this matrix is symmetrical, with ρ i,j = in this main diagonal. as it is well known, the pearson correlation coefficient ( ) does not fulfill the three axioms that define a euclidean metric. for this reason, the correlation matrix is transformed into the correlation distance matrix according que the following formula which fulfills the three axioms of an euclidean distance: then, the distance matrix is used to determine the minimal spanning tree (mst) connecting the n vertices. the mst is constructed following the kruskal's algorithm, which links all the vertices together in a single graph that minimizes the distances between the corresponding time series. then, the distance matrix is used to determine the minimal spanning tree (mst) connecting the n vertices. the kruskal method is implemented by following the next steps. first, the algorithm chooses a pair of nodes with the nearest distance and connects them with a line that is proportional to the distance. then, the algorithm connects another pair of nodes with the second nearest distance. in the third step, the nearest pair that is not connected by the same tree is also linked. this step is repeated until all the nodes are connected in a single tree. from the mst we obtain the subdominant ultrametric distance matrix x, which corresponds to the matrix whose elements are the subdominant ultrametric distance d * (i, j). the subdominant ultrametric distance d * (i, j) between the vertices i and j is the maximum value of any correlation distance d(i, j) detected by moving one step from i to j through the shortest path connecting i and j in the mst. the ultrametric distance d * (i, j) between the vertices i and j is then given by: where ((w , w ), (w , w ), ..., (w n− , w n )) shows the minimal path in the mst that connects the vertices i and j, where w = and w n = j. using this formula we compute the ultrametric distance d * (i, j) between each pair of currencies and from it we construct the hierarchical tree (ht), which is represented as a tree known as dendogram. . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint this study compares the active cases per population of countries. for each country, we construct a time series composed by daily data of the number of daily infections per country. each time series considers a period of days after the confirmation of the tenth case, using a moving average smoothing. this way, the analysis of new active cases takes into account the different moments in which the virus began to disseminate in each country. data are obtained from "our world in data" (roser et al., ) , which is built from information supplied by the european centre for disease prevention and control, government reports, oxford covid- government response tracker, world bank -world development indicators, united nations statistics division and eurostat. although this study focuses on new active cases per population, it will also analyze total active cases, new deaths and total deaths per population, new tests and test per , people, the government response stringency index as well as other demographic and socioeconomic indicators. in this section we present the empirical results of this article. figure shows the mst and the corresponding ht. in appendix , table lists the countries belonging to each cluster and figure shows how the clusters are distributed among the different countries belonging to the sample. according to pesudo-f (caliński and harabasz, ) and pseudo-t (duda et al., ) hierarchical clustering stopping rules, three main groups can be identified plus a fourth small group integrated by both mongolia and the series representing the average of all the countries. cluster has members, cluster is integrated by countries and cluster includes countries. within these groups represented in figure , it can be seen that the structure of the network for cluster is linear while for clusters and it has countries with a higher number of connections. a higher number of connections (higher node degree) or a higher number of shortest paths that pass through the node (higher betweenness centrality) imply that these nodes summarize a large amount of information from the network. in other words, it means the data series for these countries represent many of the characteristics of the groups to which they belong. table shows that the nodes with the highest centrality are india, indonesia and mexico for cluster and italy and romania for cluster . india italy indonesia mexico romania table : node degree and node betweenness for the set of countries with the highest betweenness centrality. . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august , . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august , . as showed by figure , each group of countries exhibits a different kind of dynamic behavior. countries in cluster starts with a low number of cases per million, although it maintains an upward trend during the whole period. on the other hand, cluster begins with values between and cases per million and follows a decreasing trend. finally, cluster reaches its peak between the th and th day and immediately starts to decrease. on the other hand, when observing the dynamics within each group of countries, it can be seen that the median represents the trend behavior within each group. how similarity is measured in this work (pearson's correlation coefficient) tends to group countries with similar trends, therefore the three main clusters represent three different dynamic behaviors for the first days: sustained growth, decrease sustained or accelerated growth followed by a decrease in the number of new cases. figure shows examples of the dynamic behavior of countries extracted from each cluster. mexico and argentina, both members of cluster , follow a quite similar upward trend, whereas the paradigmatic case of uruguay (see moreno et al, ) -member of cluster -follows an oscillatory although descending trend. italy is a representative example of cluster , as we mentioned before. we observe that it began with a pronounced increase in new cases, reached its peak between the th and th day and afterwards started a descending trajectory. it is worth to note that cluster is the group with the highest number of cases, as can be seen in figure . in addition, this cluster has had the most pronounced downward trend. this group includes china and italy, countries with an accelerated initial growth. initially they experienced an accelerated rate of contagion, reached their respective peaks and entered sooner into the phase of deceleration. in addition, many of the cluster countries have been the first countries to face covid , in the epidemic stage. we can assume that in the absence of knowledge about this disease and the lack of adequate protocols in early , the virus spread more rapidly through these countries. group is composed of islands and small countries. we can assume that these geographical conditions made it easier for them to isolate themselves once the contagion stage began, preventing the possibility of new infections from people who travel from abroad. total number of deaths and new tests per thousand inhabitants are shown in figure . we . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august , . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august , . observe that groups and began to stabilize between the th and th day, whereas the cluster has maintained a constant growth rate since day . with respect to new tests, group is the one with the highest number, followed by cluster . group registers a lower number of new tests, although with an increasing trend. an interesting result is that the groups of countries that have achieved a drop in the number of cases are those that perform a greater number of tests; moreover, it after days, with a growing trend and a higher number of new cases per million, the countries of cluster are maintained below the number of tests performed. this may mean that, along with other measures, mass testing helps control the spread . figure presents a comparison between groups according to demographic and socioeconomic indicators. from the comparison, we observe that group shows better socioeconomic indicators than the other groups. however it also present higher risk factors due to the age of its population. the former might be related to a greater effectiveness in the effective control of disease, whereas the latter to a higher mortality rates. on the other hand, group has, in median, the largest population, the lowest density, younger population and worse socioeconomic conditions. for most of the indicators, group occupies the intermediate position, except for its population and the proportion of the population with access to basic handwashing facilities. finally, figure presents the stringency index, which is a composite measure based on nine response indicators, including school closures, workplace closures, and travel bans, rescaled to a value from to , where represents the strictest response. the groups reach similar levels of restrictions about days after the first cases, although relevant differences are observed. group progressively increases their controls, which began to stabilize around day . group had the quickest response, reaching its peak before the day . group applied the measures more slowly, following the contagion curve. relationships between the stringency index and data about new cases per million can be established for each group, observing that those countries with a faster government response have been more successful in controlling the disease, while a decrease in the number of new infections does not seem to be related to mobility restrictions more extended in time. an example of this is cluster , which has remained at very high levels of restrictions from the th to the end of the period analyzed without being able to modify the growing trend of new infections. countries in clusters and have progressively reduced restrictions on mobility, following the decrease in new cases in those clusters. three large clusters of countries were identified and each one was associated with three different types of contagion curves. the largest cluster has not reached its maximum yet and maintains a growing trend. it is also noteworthy that cluster has higher levels of poverty, which implies that a significant proportion of the population must seek their livelihood on a daily basis, also related to the lesser scope of their health and social protection systems, in accordance with goutte et al. . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint ( ). for this segment of the population staying at home during the pandemic is a major challenge. this might be one the drivers behind the fact that in cluster the virus continues spreading. this dynamics can be seen also in developed countries with weakened organized labor and job insecurity, because as mckee and stuckler ( ) notes, "even the wealthiest societies are only as strong as their weakest members". the cluster was the first to reach the peak of daily infections and quickly entered into phase of decline. it is worth observing that this group is composed by small countries and islands, which highlights the importance of geography as a key factor (zarikas et al., ) . the cluster had an abrupt increase in new cases and once the maximum was reached it entered into a decreasing phase. this cluster also had both the highest death toll and the oldest age group, which underlines the importance of protecting people in risk factor groups. another important point is the relationship between the stringency index and the contagious curves. we observed that the three groups reached similar levels of restrictions days after their first cases. however, cluster implemented countermeasures days before the other clusters and reached its maximum without experiencing an abrupt jump in the number of cases. this result highlights the importance of a timely response and it is in line with vasconcelos et al. ( ) , in which the authors find that the countermeasures must be taken immediately after the onset of the epidemic. the quality of the health and social protection systems are crucial in this regard since both the level and the speed of the government response will depend on these factors, as can be seen also in armocida et al. ( ) . the levels of trust of citizens in science and institutions and the association between academia and political representatives (see moreno et al. ( ) ) are essential for good management of the situation. an additional implication on this issue is about the dichotomy between the economy and health. countries of clusters and , which have been more aggressive and faster in implementing stayat-home measures and massive testing, have achieved a decrease in the number of new cases and a progressive decrease in restrictions on the mobility, while cluster countries maintain higher restrictions on mobility after one hundred days. lin and meissner ( ) do not find an association between local restriction policies and the economy, although unlike what lin and meissner ( ) suggested, our analysis suggest that these measures could be associated with changes in the number of infections. it is necessary to investigate more about this matter, but it could be thought that there is no dichotomy between health and the economy, but that the best measures for subsequent reactivation of economic activity consist of the rapid response to the pandemic. this aid should cover both health systems and the most vulnerable individuals in society. one important limitation when working with these databases is the possibility of under-reporting of cases, which might imply -among other consequences-that cluster has already reached its maximum or that cluster had a less/more pronounced peak. additionally, it is important to note that at this point it is not clear if all the reported deaths are caused by covid- or if the deaths were caused by a third factor. this might constitute a future research question. in addition, this work may be extended in order to analyze other variables, such as the ratios "deaths / active-cases" and "active-cases / tests" or by utilizing temporal windows to study the clusters dynamics. . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august , . . https://doi.org/ . / the italian health system and the covid- challenge a dendrite method for cluster analysis identification of spatial variations in covid- epidemiological data using k-means clustering algorithm: a global perspective pattern classification and scene analysis the role of economic structural factors in determining pandemic mortality rates: evidence from the covid- outbreak in france international comparisons using spanning trees cluster-based dual evolution for multivariate time series: analyzing covid- on the shortest spanning subtree of a graph and the traveling salesman problem analysis of a network structure of the foreign currency exchange market health vs. wealth? public health policies and the economy during covid- rare and extreme events: the case of covid- pandemic strong correlations between power-law growth of covid- in four continents and the inefficiency of soft quarantine strategies hierarchical structure in financial markets if the world fails to protect the economy, covid- will damage health not just now but also in the future estimation of covid- dynamics in the different states of the united states using time-series clustering coronavirus pandemic (covid- ) an introduction to econophysics modelling fatality curves of covid- and the effectiveness of intervention strategies clustering analysis of countries using the covid- cases dataset key: cord- - yvcl q authors: lawrence, roderick j. title: responding to covid- : what’s the problem? date: - - journal: j urban health doi: . /s - - - sha: doc_id: cord_uid: yvcl q this commentary argues that the coronavirus sars-cov- pandemic should be considered as a transdisciplinary societal challenge that requires coordinated systemic thinking and actions in the context of uncertainty. responses to the propagation of the coronavirus sars-cov- and the health, economic and social impacts of covid- are complex, emergent and unpredictable. we describe the virtuous relations between three prerequisite conditions—multilevel governance, knowledge and types of resources and individual and collective behaviours—that should be combined in transdisciplinary responses. first, multi-level governance of this global pandemic is fundamental. at the outset, we challenge political and public scepticism illustrated by the incapacity of politicians and laypeople to listen and learn from scientific knowledge and professional know-how in the context of uncertainty and vulnerability. governance denotes the way that governments, public administrations, private enterprises and community associations interpret the pandemic, and how they decide collectively to respond to it. in order to reduce known unknowns about this beta-type coronavirus with species jump, the coordinated synthesis of interdisciplinary information and knowledge, professional know-how and individual and social perceptions and understandings are necessary. then this broad understanding can be applied to define the appropriate allocation of many types of resources (e.g. administrative, financial, human, material, medical, pharmaceutical and scientific) necessary to implement effective responses (see fig. ). in contrast to south korea and taiwan, many european countries have reacted by following the propagation of this coronavirus rather than being proactive to prevent it despite the warnings made by scientists from [ ] . the contrasting responses of federal/national, state/regional and city/local authorities between and within countries, since january , illustrate how differently this real-world challenge has been interpreted; for example, comparisons between cities in the lombardy and veneto regions in northern italy highlight successes and shortcomings that can be interpreted as lessons learned [ ] . several types of resources coexist for coordinated action and systemic responses to this extraordinary situation: administrative, behavioural, financial, health care, legal and medical resources, and have been used at different geo-political levels, sometimes in an uncoordinated fashion of 'winner takes all'. notably, some actions have been endorsed by the world health organization (e.g. confinement, quarantine, distancing, testing, washing hands) whereas others have not (e.g. wearing masks in public spaces). the diverse interpretations and responses of governments and public administrations confirm that 'evidence-based policy' is a theoretical concept that is often not applied in current circumstances (like many others including ambient air pollution and passive tobacco smoking). notably, some local authorities in american and european cities have not introduced systematic testing and proactive tracing, or legally binding measures, to protect population health. the second prerequisite condition is the importance of specialised data, information, knowledge and professional know-how required to understand and counteract a new virus for which there is still no proven medical or pharmaceutical remedy. the known unknowns about this coronavirus can be identified and studied using principles of one health, ecological public health, and planetary health during transdisciplinary research and practice in community settings to 'collect facts on the ground' beyond the walls of laboratories [ ] . the nonlinear, uncertain and unpredictable characteristics of this coronavirus are derived from the evolving interfaces between natural ecosystems and human-made environments that accommodate people and all other living organisms that may be vectors of zoonoses including this coronavirus. these novel situations, created by rapid urbanisation in cities and mega-urban regions, can be analysed by interdisciplinary case studies of the multiple consequences of rapid urbanisation. these transdisciplinary case studies should combine biological, epidemiological, medical and veterinary research together with methods of behavioural and social science research. in addition to knowledge and know-how acquired from biological, ecological, health, medical and veterinary sciences, this pandemic confirms the crucial function and contribution of access to many types of resources when they are needed; in particular, sufficient stocks of medical equipment; hospital wards with specialised infrastructure; replenished supplies of pharmaceutical products; adequate numbers of trained and qualified medical doctors, nursing staff and auxiliary personnel in hospitals, medical centres and nursing homes for elderly persons and coordinated uses of all these resources when the virus is first diagnosed in specific localities. we now know from experience in asian countries and italy that the timing of responses to the first diagnosis of this virus in specific cities, and mega-urban regions, is crucial for the effectiveness of counter-measures. the comparison and stark contrast between interventions and resources in asian cities, including seoul, taipei and singapore, compared with london and new york, is a timely reminder that anticipation by proactive thinking, and preemptive measures by prospective planning, vary considerably between countries and cities irrespective of their gdp or political regime. the asian cities learned important lessons from the coronavirus sars-cov- in - , which impacted more than countries, highlighting the fundamental contribution of preemptive measures founded on empirical knowledge. also, national and city comparisons confirm the vital contribution of strategic public health policies after a global shift towards the privatisation of medical and health care services in the last three decades in many countries. ironically, many advocates of laissez-faire and neo-liberal economics now expect governments to intervene to support private enterprises that are financially fragile or bankrupt, fig. effective responses to the complexity, emergence and uncertainty of coronavirus sars-cov- and the compound nature of health, economic and social impacts of covid- require understanding and implementing the virtuous relations between disciplinary knowledge and professional know-how, several types of resources, coordinated multi-level governance, and individual and collective behaviours that should be combined in transdisciplinary contributions. © roderick lawrence including those that failed to provide much needed medical and pharmaceutical equipment currently imported from foreign countries [ ] . the third prerequisite condition that influences effective national, city and communal responses to counteract the transmission of coronavirus concern individual, household and community adherence to behavioural norms and new regulations introduced by national and local governments. some interventions by governments and public administrations concern regulating personal behaviour and interpersonal contacts. for example, norms and rules include different degrees of confinement, controlled access to outdoor public spaces, markets and shops, social distancing, wearing masks and washing hands. public adherence to these norms and rules cannot be assumed owing to cultural, social and psychological reasons including religious customs, spiritual beliefs, group identity and the notion of individual liberty. diverse individual and group perceptions of health risks attributed to coronavirus coexist in societies that have endorsed the supremacy of individualism at the expense of collectivism, the authority of divine providence and rights of humans above all other living organisms on earth. in this context of heterogeneous lifestyles, values and worldviews, appropriate data and information should be effectively communicated to target groups in order to create responsible behaviour not only for individual health, or social well-being, but also for the common good. we now know there are crucial compromises and trade-offs between individual liberty and personal responsibility, as well as fundamental collective choices about how to respond to economic, health and social threats in the context of uncertainty and vulnerability. we also know that a patient-centred strategy that targets highly vulnerable individuals and groups should be complemented by a community-centred approach. the negative impacts of this pandemic confirm a wellknown correlation between socioeconomic inequalities and mortality rates of populations at national, regional and city levels [ ] . while targeting populations should identify and respond to the needs of vulnerable groups, this pandemic confirms that an area-based approach in countries and cities is also pertinent (e.g. wuhan in the province of hubei, china; bergamo and lodi in the province of lombardy, italy). this dual approach, often used in environmental health interventions, underlines the importance of working with an in-depth understanding of the contextual conditions in which the coronavirus has been diagnosed. normative behavioural codes and rules should not ignore the societal context including inter-and intra-urban differences. notably, a who recommendation to wash hands repeatedly is unrealistic for all those people (an estimated million people, % of the world's population) who do not have access to a supply of affordable, clean and safe water [ ] . this brief commentary confirms that our livelihood and our health are strongly influenced by the biological, ecological, financial, political and cultural milieu in which we live. this milieu, our habitat, and our livelihoods, are founded on fundamental monetary and nonmonetary values. the extraordinary situation of the current pandemic should be a catalyst for rethinking the hierarchy of priorities and values used implicitly and explicitly to sustain our societies. the capacity of public authorities, private enterprises, scientists, practitioners and community associations to respond effectively to major public health threats, such as this coronavirus, should be founded on in-depth understanding of the medical, veterinary and societal variables that influence health and quality of life in specific cities. there are significant differences between health impacts in geneva and zurich, switzerland; or between adelaide and sydney in australia; or between boston and new york city in the usa, and these differences need deciphering. in each city, a dual temporal perspective should be used to understand its particularities. initially, short-term responses should respond to patients and curtailing the transmission of the virus within and between cities and countries. this immediate response should be supplemented by mid-and long-term responses founded on strategic actions initiatives that reduce health and economic vulnerability. the growing number of accounts of the impacts of coronavirus in countries and cities north and south of the equator presented by the mass media in recent weeks highlights the shortcomings of neo-liberal economics and the fragility of human life in a world that has been transformed by rapid globalisation and urbanisation. these ongoing processes around the globe have reduced the resilience of many countries and cities to counteract global threats because they have lost their capacity to act autonomously after becoming subservient to global production processes and trade with foreign countries in international markets (e.g. dependent on imported face masks, pharmaceutical products and ventilators from abroad to meet national demand). some wealthy countries, including switzerland, rely heavily on foreign medical and nursing staff to efficiently operate public and private hospitals. surprisingly, some national governments have reacted by reintroducing controls at national borders, which has been ineffective in limiting the propagation of the pandemic to over countries, and the transmission of the virus-provoking excess mortality in countries. global governance is not possible if some countries do not comply with international agreements [ ] . these expressions of nationalism and sovereignty ignore that a global pandemic cannot be contained by closing national borders. the main focus of discussion in european and other countries about the impacts of this pandemic on national economies has concentrated on lower production and consumption (gdp) in , the need for public financial support to maintain private enterprises affected by the pandemic, and grants for employees in the formal sector who have become unemployed. the absence of attention to the impacts of this coronavirus on people working in the informal sector reinforces the lack of concern about health impacts of workers in all sectors (including formal health services, and personal care and welfare) [ ] . it is unrealistic for workers to respect behavioural codes and rules that ignore that person-toperson contact is the basis on which daily work and income depend. media reports indicate that many workers, including doctors and nurses in hospitals and nursing homes, do not have the personal equipment necessary to protect them. finally, public anxiety about this situation, supported by mass media and social networking, should raise major concerns about the quality of life and resilience of all peoples that can be influenced by major ecological threats (e.g. climate change and extreme weather events); economic instability (since in many countries); technological accidents (e.g. fukushima in ) and ongoing civil unrest and warfare in several continents. we need to rethink the real interconnected nature of our lives and the livelihoods of others on earth in contrast to the false claims for nationalism and protectionism in some countries. notably, we recall the plight of many victims of hunger and malnutrition that can be avoided by concerted action. we underline here that about million people die of hunger and malnutrition each year, and million of these are children who starve to death while about a third of all food produced is disposed as waste. likewise, the absurdity of the request for social by staying 'at home' given that not less than million people are declared homeless and . billion are estimated to live in inadequate housing [ ] . the fundamental issue is whether the current pandemic will be a catalyst for collective radical rethinking about the future of 'us and others' in a world that should become more ecologically responsible, more economically just, and more socially equitable for the common good, or a shared quest for returning to 'business as usual'. emerging infections: what have we learnt from sars? lessons from italy's response to coronavius academic institutions and one health: building capacity for transdisciplinary research approaches to address complex health issues at the animal-humanecosystem interface beware the fragility of the global economy global water, sanitation, and health (wash do not violate the international health regulations during the covid- outbreak according to the international labour organization (ilo), about billion people work informally, most of them in emerging and developing countries. see ilo 'women and men in the informal economy: a statistical picture united nations, department of economic and social affairs publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations and invited professor at the international institute for global health at the united nations university (iigh-unu) in - . he has been a member of the scientific advisory board for interdisciplinary and transdisciplinary research at the swiss academy of sciences (scnat) s i n c e key: cord- -mqrx q authors: seabra, claudia; reis, pedro; abrantes, josé luís title: the influence of terrorism in tourism arrivals: a longitudinal approach in a mediterranean country date: - - journal: annals of tourism research doi: . /j.annals. . sha: doc_id: cord_uid: mqrx q abstract this longitudinal study examines the impact that terrorist attacks within a representative group of european countries can have on the tourism demand of a south european country with no record of terrorism attacks. in order to analyze the connections between terrorist attacks and tourists' arrivals, occurred between and the end of , an unrestricted vector autoregressive model was used for multivariate time series analysis. the main results show that terrorist attacks have a strong impact on tourist arrivals and confirm the existence of terrorism spillover, namely the substitution and generalization effects phenomena. terrorism has become an important and recurring topic in the public discourse over the last decades due to the increased frequency of terrorist attacks witnessed (national consortium for the study of terrorism and responses to terrorism, ). since the beginning of the century, and particularly over the last years, several developed and stable countries have witnessed high levels of terrorist events (lanouar & goaied, ) . new york, united states ( ) , madrid and barcelona, spain ( , london and manchester, united kingdom ( , ) , tuusula, finland ( ) , apeldoorn, netherlands ( ), utoya, norway ( ), paris and nice, france ( , brussels, belgium ( ) , sousse, tunisia ( ) , berlin, germany ( ) , istanbul, turkey ( , christchurch, new zealand ( ), colombo, sri lanka ( ) were some of the places that have experienced terrorist attacks, but the list goes on (national consortium for the study of terrorism and responses to terrorism, ). revolutionary and destructive groups carry out attacks all over the world every single day, transforming terrorism into a constant in modern life (coca-stefaniak & morrison, ) . according to the "prospect theory" (tversky & kahneman, ) , tourists are rational consumers who, when confronted with two different options, tend to choose the option that will bring them more potential gains and lower risk (seabra, kastenholz, abrantes, & reis, ) . when tourists perceive the existence of any risk of terrorism, they become more careful as they plan their travel and tend to adopt risk-reducing strategies (fuchs & reichel, ) . tourists are sensitive to terrorism threats and can be flexible in their destination choices (neumayer & plümper, ) , so they will avoid destinations they believe to be connected with that sort of threat (rittichainuwat & chakraborty, turning into a single market, which leads to the standardization of consumer lifestyles and the rising of "global consumers" (hollensen, ) . tourism is one of the most global economic activities and is, therefore, vulnerable to risks that affect any other global business (fennell, ) . the world has become interdependent and tourism crises in one part of the world can have strong repercussions on other locations (lanouar & goaied, ; ritchie, ) . when tourists realize that a destination is unsafe, they replace it with others they consider safer and, in doing so, may damage entire regions that are affected by violence or that tourists consider threatened by terrorism (beirman, ; gu & martin, ; lutz & lutz, ; mansfeld, ; sönmez, ) . this fact draws attention to the spatial patterns of terrorism impacts caused by spillover effect on destinations/regions (Öcal & yildirim, ) . the topic of terrorism spillover effects has produced a considerable amount of literature (veréb, nobre, & farhangmehr, ) . the decline in tourists' arrivals and receipts caused by terrorism is well documented in several countries and regions since the s and has affected countries like spain (enders & sandler, ) , european countries ( (enders, sandler, & parise, ; radić, dragičević, & sotošek, ) , the mediterranean region (drakos & kutan, ) , non-democratic countries and africa (blomberg, hess, & orphanides, ) , the usa (bonham, edmonds, & mak, ; goodrich, ) , israel (eckstein & tsiddon, ; fleisher & buccola, ; morag, ; pizam & fleischer, ) , italy (greenbaum & hultquist, ) , nepal (baral, baral, & nigel, ) , ireland (o'connor, stafford, & gallagher, ) , fiji and kenya (fletcher & morakabati, ) , nigeria (adora, ) ; turkey (feridun, ; ozsoy & sahin, ) , pakistan (raza & jawaid, ) , the middle east (bassil, ) , the caribbean (lutz & lutz, ) , tunisia (lanouar & goaied, ) , and worlwide (liu & pratt, ; llorca-vivero, ; neumayer & plümper, ) . despite all past research conducted on the impacts of terrorism on tourism industry, and bearing in mind recent disturbing events, many sectors are calling for further in-depth analysis of this issue (almuhrzi, scott, & alroiyami, ; saha & yap, ) . people have to learn how to deal with the changes that this new global terrorism context is bringing to tourism (veréb et al., ) and it is crucial to find ways to cope with the disruption in tourist flows in the wake of terrorism events (cohen & cohen, ) . more investigation is required on the impact that terrorism may have on tourist arrivals and it will have to take into account the changes that are affecting the spatial patterns of tourism flows and, specifically, the spillover effects of terrorism (neumayer, ; prideaux, ) . while most empirical studies report the negative spillover effects on tourism demand and receipts caused by the substitution effect affecting countries and regions suffering from terrorism activity, there is no study, to our knowledge, dealing with the effects those events have on a safe country with no record of terrorism attacks. portugal is currently one of the most popular european tourist destinations (world tourism organization, ) and has no history of terrorist attacks ever (national consortium for the study of terrorism and responses to terrorism, ). the country is considered the third most peaceful country in the world by global peace index (institute for economics & peace, ) and clearly benefits from this safe tourist destination image. the main goal of this study is to analyze the influence that terrorist attacks carried out in a representative group of european countries can have on a safe country. this particular study will focus on portuguese tourism demand and will take into account the possible consequences of the so-called spillover effect, particularly the substitution and generalization effects. this paper begins with an outline of the current literature available on tourism consumer behavior regarding terrorism risk and the spillover effects caused by terror. the literature review was used to develop the study's conceptual framework. discussion on the research methodology was the next logical step. using a longitudinal study, this work uses an unrestricted vector autoregressive model to test the conceptual framework. arguments about theoretical and management implications are discussed in the last part of the article. the results of this study demonstrate the existence of the so-called substitution effect caused by terrorism events and add information to the existing literature about the spatial spillover effects of terrorism on tourism activity. it was also possible to create a tour-terror index allowing managers to observe the potential impacts of attacks on tourists' arrivals and receipts in different regions. the definition of terrorism is troublesome. according to previous research (lutz & lutz, ) terrorism is conceptualized, in the global terrorism database, as "the threatened or actual use of illegal force and violence by a non-state actor to attain a political, economic, religious, or social goal through fear, coercion, or intimidation" (national consortium for the study of terrorism and responses to terrorism, ). terrorism attacks generally "appear to be random and dispersed in order to create tension in the widest possible audience" (Öcal & yildirim, , p. ) . tourism demand, as previously established, is particularly sensitive to terrorist attacks, since tourists' choices value safety, tranquility and peace (araña & león, ) . past research has repeatedly proved the strong exposure of tourism industry to terrorism and violence and showed that tourism is one of the economic sectors that are most vulnerable to this threat (araña & leon, ; avraham, ; lanouar & goaied, ; saha & yap, ) . several studies have proved its negative impacts on tourism activity as a whole in the short and long term (araña & león, ; baker, ; liu & pratt, ; pizam & smith, ; sönmez, ) . this is mainly because of the effects that terrorist threats have on tourists' decision-making process (neumayer, ; pizam & fleischer, ; ritchie, ; seabra, abrantes, & kastenholz, ; seabra et al., ; sönmez, apostolopoulos, & tarlow, ; sönmez & graefe, ) . safety is clearly one of tourists' main concerns. it is a basic human need. as such, it affects human behavior in general and consumer behavior in particular (isaac & velden, ) . when people travel, they do not want to feel exposed to situations that will threaten their integrity. tourists are concerned with travelling to a destination where they will be able to fulfill their desires with as little complications and threats to their safety as possible (seabra, dolnicar, abrantes, & kastenholz, ) . safety on vacation and leisure is an expected requirement for any visitor in any destination (baker, ) . therefore, stability is one of the key factors for the development of tourism industry (almuhrzi, scott, & alroiyami, ) . if some event disrupts this balance and causes a risk perception among tourists, it can have both a powerful and negative impact on demand. risk perception relates to the uncertainty of consequences and potential loss (dholakia, ) and is associated with a large number of factors that may influence tourists' decision making. since the first studies on leisure and travelling, seven types of risk perceptions have been considered (rohel & fesenmaier, ) : i) psychological: how travel will affect one's own self-image; ii) social: impacts on social image; iii) financial: the value of money; iv) time: the cost of the time wasted while planning and travelling; v) physical: impacts on physical and psychological wellbeing; vi) satisfaction: probability of experiencing some kind of dissatisfaction with the trip or one of its components; and vii) functional: associated with bad trip organization and malfunction of tourist equipment or transportation. those risks are associated with three travel dimensions: vacation risk, physical-equipment risk and destination risk. focusing specifically on the risk factors connected with tourism destinations, subsequent research drew attention to more specific issues such as: i) health: factors that may cause physical danger, injury or sickness (baker, ; jonas, mansfeld, paz, & potasman, ) ; ii) communication: language and communication barriers that may hinder the connections with locals or service providers (reisinger & mavondo, ) ; iii) natural disasters: the exposure to natural hazards (becken & hughey, ; pearlman & melnik, ) ; iv) crime: several forms of criminality and physical violence (brunt, mawby, & hambly, ; chesney-lind & lind, ; dimanche & leptic, ; michalko, ) ; v) political instability and violence (fletcher & morakabati, ; ioannides & apostolopoulos, ; saha & yap, ; sönmez, ; yap & saha, ) ; and vi) terrorism: probability of being involved in a terrorist attack (baker, ; lanouar & goaied, ; saha & yap, ; seabra et al., ) . terrorism and political instability are the threats that tourists fear the most (sönmez, ) . in fact, the younger generations rank "war, terrorism and political tension" as their top concerns (coca-stefaniak & morrison, ) . previous research reports that terrorism and political instability are "particularly intimidating risks due to the uncontrollable, involuntary and random nature of the potential harm involved in visiting destinations struck by such incidents" (kapuściński & richards, , p. ; see also cavleck, ; heng, ) . that way, the perceived risk of terrorism is more effective and will influence tourists' behaviors and decision-making, regardless of their country of origin or of their cultural background (seabra et al., ) . feridun ( ) suggests the existence of a negative causal effect of terrorism on tourism. raza and jawaid ( ) also proved the unidirectional causal relationship between terrorism and tourism. in their opinion, there is a unique direction of causality that goes from terrorism to tourism. the changes in tourists' decision making caused by perceived risks of terrorist attacks are mainly due to the so-called memory effect. memory effect means any feeling, apprehension, or panic that lead individuals to change their usual behaviors (shin, ) . people create a memory effect after experiencing or after hearing about devastating events that have occurred in a certain place. terrorist events can give rise to a great sensitivity between the tourists' initial memory of a destination andthe posterior image of such destination. this leaves a persistent recollection or memory effect (baggio & sainaghi, ) . past attacks directly influence tourist arrivals in the affected countries due to those negative memories. consequently, tourists will replace their usual leisure destinations with other places they consider safer (lutz & lutz, ) . eventually they will return to their favorite destinations and this is the reason why this memory effect is not permanent, although its effects may last for quite a long time as stated in previous research (baggio & sainaghi, ) . tourists show a high preference for more stable and peaceful geographic areas (araña & león, ; neumayer, ; reisinger & mavondo, ) since their main goal is to relax in an insouciant holiday environment (neumayer, ) . they have a big range of destinations available and, normally, they do not even consider travelling to places located near sites where risky incidents have occurred. they choose alternative destinations with similar characteristics but with a more stable environment (neumayer, ) . this has some negative economic impacts not only on the affected destinations (lanouar & goaied, ; sönmez et al., ) , but also on other nearby places. this is due to the spatial spillover effects (isaac & velden, ; walters & beirman, ) that will affect several destinations and entire regions (radić et al., ) . according to the institute for peace economics (institute for economics & peace, ), the contribution of the tourism sector to gross domestic product in was twice larger in countries where there had been no occurrence of terrorist attacks targeting tourists. between and , tourism average contribution to gross domestic product growth reached . % in countries that had experienced no terrorist attacks against tourists. in countries where attacks deliberately targeted tourists, it amounted to . % only. nowadays, safety is one of tourists' major concerns when they have to choose their travel destination (world tourism organization, ). spatial spillover effects of terrorism on tourism activity: generalization and substitution effects spillover effect, a term which comes from economics, refers to the positive or negative externalities that an economic activity can have on any element not directly associated with that given activity. in tourism, spillover effects are closely related to a spatial perspective. it refers to the inadvertent effects that the tourism industry of a certain region has on tourism flows to other regions. positive spillover effects occur when a region benefits from their neighbors' tourism growth, while the opposite can occur when a destination is affected by negative factors occurred in neighboring regions (yang & wong, ) . previous research on the spillover effects found the existence of two major impacts of terrorism on tourism industry: the generalization and the substitution effects. the "generalization effect" refers to the cognitive biases of tourists who tend to generalize the perceived image of a given destination to a whole region (saha & yap, ) . the generalization effect may cause completely safe countries to witness strong drops in their tourism arrivals and revenues as a result of insecurity episodes in nearby countries (enders et al., ) . empirical evidence showed that perceptions of terrorist threats, war, political instability, and violence in one country tend to make tourists assume that entire regions are risky (sönmez, ; walters & beirman, ) . although some studies have shown that neighboring countries can sometimes benefit from being considered immediate substitutes, it has also been proved that there is always a negative impact on tourist demand in the region where the incident has occurred (gu & martin, ) . mansfeld ( ) proved that tourists who had experienced terrorist events during the arab-israeli conflicts transferred their fear of terrorism to the middle east as a whole. this spillover effect resulted in a negative contagion effect in that region but, on the other hand, had a positive impact on the tourist activity of the mediterranean area. neighboring countries, or countries that share identical characteristics, gain tourists in the same proportion as the less safe countries lose visitors. the different patterns of substitution that affect destinations are commonly represented by concentric rings. the "inner ring" that includes more unstable destinations like egypt, israel, jordan, lebanon, and syria was replaced by an "outer ring" composed of more peacefull and terrorism-free countries, such as cyprus, greece and turkey (mansfeld, ) . wahab ( ) drew attention to the fact that intraregional tourists may be more sensitive to this effect since they seek more peaceful destinations located near places considered to be of higher risk. in his study, he claimed the existence of a positive spillover effect in the case of egypt. however, an interregional tourist may also generalize conflict to an entire region, which may explain the decline in tourist arrivals in iraq's neighboring countries during the gulf war (sönmez, ) . during that period, middle east and eastern mediterranean countries experienced a big decline in tourist arrivals. cyprus, for example, experienced a drop of . million visitors in and of . million in as a result of the perceived risk of terrorism and political instability (goodrich, ) . drakos and kutan ( ) stated that any terrorist or violence event taking place in a particular middle eastern and north african destination will naturally affect tourist's perceptions of another country in that region (drakos & kutan, ) . some years later, kozak and his colleagues also concluded that tourists form overall negative images of entire regions due to terrorism acts (north america and the middle east), health issues (severe acute respiratory syndrome in asia) and political conflicts (africa). tourists change their travel plans when they realize the existence of any potential threat or risk. they assume that incidents that take place in a specific country will affect its neighboring countries as well. this assumption results in a global devastating impact on the region (kozak, crotts, & law, ) . recently, more empirical evidence supported findings that random terrorism acts perpetrated in some countries have an impact on nearby areas not directly subject to such attacks. this was true for kenya, africa (masinde, buigut, & mung'atu, ) and jordan because the violent uprisings in neighboring countries have deeply affected the image of the whole geographic area (liu, schroeder, pennington-gray, & farajat, ) . the "substitution effect" in tourism refers to customers' tendency to replace one destination with another, due to a number of factors that include changes in the elasticity of demand, shifts in price, a desire to try new products or experiences (tribe, ) or because of risk perception (prideaux, ) . using an unrestricted vector autoregressive model to analyze monthly data for spain covering a period of time between and , enders and sandler ( ) identified negative unidirectional causality between terrorism attacks perpetrated by the separatist basque group eta and tourism activity in the country. the authors concluded that the biggest drop in tourists' arrivals occurred three months after the attacks and that a typical transnational terrorist incident can prevent about tourists from visiting a certain country (enders & sandler, ) . enders et al. ( ) , a year later, studied a large sample of european countries between and and determined that tourism reactions occurred mostly within a period of six to nine months after the incident and that there was clear evidence of the replacement of those destinations with others located in different regions (enders et al., ) . gu and martin ( ) analyzed the substitution effect based on tourist arrivals at orlando airport between and . the authors concluded that there was a direct correlation between the increase in terrorist attacks in the middle east and in europe and the number of arrivals recorded at that airport (gu & martin, ) . during their analysis conducted on three mediterranean countries -greece, israel and turkey -, using italy as a control variable, drakos and kutan ( ) tested the cross-country effects of terrorism on tourism in the mediterranean region between and . they concluded that the intensity of terrorism events, measured according to the location (urban vs rural) and the number of fatal casualties, led to shifts in tourist visits that caused positive and negative spillover. the country where the attack took place registered drops in tourist arrivals, while other nearby countries experienced an increase in their visitors. their empirical results revealed that israeli and turkish tourism industries are more sensitive to terrorism than their greek counterpart (drakos & kutan, ) . a study conducted on tourism flows after / in the united states and in hawaii reinforced the findings of earlier studies that showed the existence of that substitution effect. tourists change their travel plans instead of canceling them, giving priority to safer domestic destinations they perceive as less risky. the study results indicate that united states citizens replaced international destinations with hawaii balancing the significant drop of foreign arrivals that followed the / events (bonham et al., ) . focusing on the same period, araña and león ( ) used a discrete choice approach to assess the impact those worldwide events had on the way tourists evaluate the qualities of alternative and competing destinations located in the mediterranean area. the authors concluded that countries with higher proportion of islamic population, such as tunisia and turkey, suffered a more severe negative impact on their competitive value than other destinations, such as canary islands and the balearics, where this proportion was lower (araña & león, ) . using two estimation techniques, neumayer ( ) tested the impact of various forms of political violence on tourism. the cross-country analysis provides empirical evidence for intraregional, negative spillover and cross-regional substitution effects for countries where human rights are violated or where there is evidence of conflicts and other politically motivated violent events. the author concluded that tourists choose alternative destinations with similar characteristics but that are more stable (neumayer, ) . while examining the effects of terrorism on tourism activity in turkey, yaya ( ) found strong evidence that terrorism events in the country have affected the industry and that the madrid bombings had a positive effect on tourist arrivals in turkey. this happened because tourists perceive those two countries as close substitutes for one another (yaya, ) . other studies concluded that while some countries experience a negative indirect effect, terrorist attacks increase tourism demand in other neighboring countries that are known for their low or moderate risk level (saha & yap, ) . this is the case of dubai, for instance, that represents a safe regional alternative to lebanon or syria, two former popular tourism destinations destroyed by war (clancy, ) . a study dealing with the reactions of german tourists to unanticipated shocks and the respective impacts on risk perception and tourism destination selection analyzed several terrorism episodes: / ( ), egypt ( ), tunisia ( ), morocco ( ) and indonesia ( ) . the findings proved that those shocks heavily affected islamic countries and provided a temporary substitution effect in favor of (southern) european countries (ahlfeldt, franke, & maennig, ) . neumayer and plümper ( ) apply a model to explain tourists' arrivals using a lagged dependent variable and other lagged independent variables representing terrorist attacks proxies. using a spatial dyadic approach, the authors concluded that terrorist attacks on tourist destinations in a given country reduce tourist flows due to a substitution effect that is visible at several levels: i) from the countries in which the attacks took place and other similar source markets to a different destination or country; and ii) from the same tourism source market to other similar destinations (neumayer & plümper, ) . as stated, to this day there has been no record of terrorist events in portugal. other european countries such as luxembourg, monaco, lithuania, andorra, malta, montenegro, san marino, and slovenia are safe countries as well. however, none of these countries kept a record of tourism arrivals or receipts. with a large international recognition and several tourism awards granted to its many regions, cities and destinations, portugal has been one of the countries with the best performances in tourism. the country has experienced an average annual growth of % in tourists' arrivals since (world tourism organization, ) . in , portugal received > . million international tourists and . million domestic tourists. the arrivals had a massive impact on tourism receipts that have been growing in a sustained way over these last few years and amounted to > billion american dollars in (instituto nacional de estatística, ; world tourism organization, ). this growth is directly connected to the strategic positioning of the "destination portugal" brand that, in recent years, has brought portugal and other specific portuguese destinations several international awards. over the last years, portugal has won several international awards at the world travel awards: i) portugal "world's best tourist destination" (for the rd year in a row); (ii) lisbon "world's best citybreak destination"; iii) madeira "the best insular destination" (for the th year in a row); iv) sintra-monte da lua parks "the best example of heritage recovery"; v) portugal "the best european and world golf destination" (for the th year in a row); vi) "turismo de portugal" considered the world's best tourism organization, among many others. the image of portugal as a safe tourism destination has led to an exponential increase in tourist arrivals. in fact, portugal was the third safest country in the world in (institute for economics & peace, ) and is currently a huge european tourist attraction. portugal was the country chosen for this study because of its importance and potential and especially because it is regarded as a safe country with no record of terrorist events since ever. in the next subsections, sample and data will be presented. data includes tourists' arrivals in portugal, sorted by region of origin, and the number of terrorist attacks that have occurred in the selected european countries, from to the end of . the main database that supports this study was built upon two different time series sub-databases: i) tourism arrivals in portugal between and and ii) the terrorism events occurred worldwide during the same time period. the first sub-database was obtained from the portuguese public statistical entity (instituto nacional de estatística, ). data provided information about the number of tourists who stayed in any accommodation facility in portugal, between and the end of , sorted by region of origin. a reasonable medium-term time series is required if the analysis applies lagged variables (bell & jones, ) to achieve significant results. the number of guests has significantly increased, surpassing million tourists in (see fig. ). the compound annual growth rate from to was . %, and the number of tourists doubled during that period. over the last years, tourists coming from europe have exceeded the number of domestic tourists. these results reveal the increasing dynamics of the portuguese tourist sector and reflect the country's good and stable political, economic, and social environment. data collected regarding tourists' arrivals included all contributing countries and showed that the most representative emission markets in portugal are: europethe united kingdom, spain, france, and germany; africa -angola; america -brazil, the united states, and canada; asia -china and japan (instituto nacional de estatística, ). the second sub-database, obtained from global terrorism database (national consortium for the study of terrorism and responses to terrorism, ), gathers information about terrorist attacks per country and other aggregate geographic areas between and (see table ). terrorist attacks, according to global terrorism database, are violent incidents triggered by bombing or explosion, arm attacks, assassination, and facility/infrastructure attack caused by terrorist organizations or individuals in a domestic c. seabra, et al. annals of tourism research ( ) as well as in a transnational and international context. for each global terrorism database incident, information is provided on the date and location of the incident, the weapons used and the nature of the target, the number of casualties, and, when identifiable, the group or individual responsible for the attack (national consortium for the study of terrorism and responses to terrorism, ). table provides information about the number of terrorist attacks sorted by country, considering also the injuries and fatalities caused by the events. the main criterion to select the considered countries was the number of terrorist attacks they have experienced between and . the selected countries represent the biggest terrorist targets for each european region, as seen in table (highlighted in light gray). however, some representative countries were selected to avoid multicollinearity. those were countries with the highest rate of terrorist attacks and that had some potential connection with portugal (social, economic or tourist connections). the importance of those countries as emissive markets was also taken into consideration. keeping in mind the tourism regions considered by world tourism organization (world tourism organization, ), the sample includes the united kingdom, for northern europe; the western europe sample includes france and germany; the central/eastern europe sample incorporates russia -russia and ukraine attacks are highly correlated, so this tourism market was an obvious choiceand lastly israel, greece, and spain were part of the southern/mediterranean europe sample. israel was chosen over turkey considering that turkey is strongly correlated with germany that represents an important tourist market for portugal. in addition to being the countries with a higher incidence of terrorist attacks, france, england, germany, greece, and spain are countries that, along with portugal, belong to the european union. they also have ancient and strong foreign commercial relations with portugal (base de dados portugal contemporâneo, a). the first three countries considered are destinations chosen by many portuguese emigrants. therefore, strong communities have been created over the years and strong social relationships were established between different generations of families living both in their home countries and in the different host countries (base de dados portugal contemporâneo, b). those are, furthermore, the most relevant emission markets to portugal. as for central/eastern europe, russia was the country that registered the higher number of attacks. portuguese relationships with russia date back to (russian federation, ) and those relationships are strengthened by commercial links (oil and gas imports) (belyi, ) . currently, a large number of russian tourists choose portugal as their tourism destination. they represent an important asset for tourism due to their number and to their high purchasing power. as far as the south /mediterranean region is concerned israel is, along with spain and greece, the country that has experienced more terrorist attacks. portugal established diplomatic relations with israel in and those relations were reinforced in with the signing of cultural, economic, industrial, technical, and scientific cooperation agreements (república portuguesa, ). the main goal of this study is to analyze the potential connections between terrorist attacks in specific european countries and tourist arrivals in portugal. the countries' political and economic stability, safety and security can be advantages that may attract tourists who have proven to be loyal to destinations that have recently been targeted by terrorist attacks. this study follows the procedure applied by neumayer and plümper ( ) when they used lagged dependent variables. the information about the number of terrorist attacks occurred in a certain country was also taken into account to provide an explanation on tourist arrivals per country of origin. the conceptual autoregressive model has two distinctive independent variables' groups. ( ) one is related with the one-lag period and the two-lag period of the first differences (t -t − period) of the dependent variable values tourist arrivals from any continent or an autoregressive variable. the second, ( ) is related with the first differences (t -t − period) of the one-lag period values of attacks perpetrated against the selected countries, as described in fig. . then, evidence was collected to prove that all the series were non-stationary at levels (time periods) using kendall's tau statistic indicator, also known as dickey-fuller test (gujarati, ). ordinary least squares cannot be trusted because they may cause sweden united kingdom western europe greece israel italy turkey spurious (non-sense) regressions. therefore, differencing the series to make them stationary can be a solution, but it could cause the loss of important long run relationships between levels (gujarati, ). co-integration tests were also performed and led to negative results. thus, and in accordance with previous works, it became clear that an unrestricted vector autoregressive model, using first difference variables would be the best solution (esso, ; gospodinov & pesavento, ; toda & yamamoto, ) to resolve potential non-stationarity series problems (shin, ) . the unrestricted vector autoregressive model method resembles simultaneous-equation modeling as it considers several endogenous variables together. nevertheless, each endogenous variable is explained by its lagged values or past lagged values. the first difference between the variables and their respective lagged values were used towards non-co-integration and non-stationarity at levels (statacorp, ) . the unrestricted vector autoregressive model assumed that all the attacks against the respective countries were exogenous variables in the model. it also considered that there were no or few relationships among them and that the aim would be to study one-way causality relationship between attacks and tourists' arrivals in portugal and not the opposite. since there may be a time lag (one or two-year delay effect) in the impact caused by the terrorist attacks on tourists' arrivals, this study opts to use a one period and a two-period time lag. the study also includes post estimation robustness tests for autocorrelation (lagrange-multiplier test) (statacorp, ) and residual distribution tests, like the jarque-bera test (lutkepohl, ) . fig. shows the specification models used in the estimation. a granger causality test is used (asteriou & hall, ; zivot & wang, ) , suggesting that there is short run causality between the significant independent variables and the dependent variable. tourists' arrivals are an endogenous variable because its value is determined within the model. the terrorists' attacks against countries are exogenous variables, since their value is determined outside the model. in other words, they do not depend on tourist arrivals. there is no correlation between terrorist attacks and the error term whose data represents relevant input to the model. the objective of the analysis is to use terrorists' attacks as determinant variables. this is in line with the methodology used by neumayer and plümper ( ) in which terrorist attacks are exogenous variables that explain the arrivals of western tourists to islamic countries. table demonstrates the descriptive statistics of all variables and table shows the results of the model. data clearly suggests that tourists' arrivals from any country to portugal reflect the impact of a certain memory effect. hence, the first difference of the lagged autoregressive variable is statistically significant with a . % alpha for every equation. the granger causality test applied to the model, and to its respective sub models, one for each dependent variable, demonstrates the existence of unidirectional causal relationship between terrorist attacks and tourist arrivals in this country. the second autoregressive lagged dependent variable has an important impact on tourist arrivals from portugal, europe, africa, and america, but, in contrast, exerts negative impact on the addition of more tourists. tourist arrivals from asia are positively related with the attacks perpetrated in greece, france and in the united kingdom; however, attacks perpetrated in spain move those specific tourists away from portugal and force them to look for other destinations. portuguese domestic tourists appear to be more sensitive to attacks committed in france, spain, and greece. in this case, there is a positive correlation, even if in the case of spain, the level of significance is slightly over %. terrorist attacks perpetrated in israel, the united kingdom, greece, germany, and france directly influence tourist arrivals from europe. in contrast, terrorist attacks perpetrated in spain and russia contribute to dislocate tourists from portugal to other regions. all variables are significant at the . % level. even though there is evidence that all variables concerning tourists from africa are significant at the . % level, the coefficient direction changes in the case of israel, russia, spain, and greece. in fact, only terrorist attacks that took place in israel and greece affect negatively tourist arrivals from africa in portugal, while attacks perpetrated in other countries positively influence arrivals in the country. as far as tourists from america are concerned, it seems that attacks in russia, israel and spain move them away from portugal and force them to choose other destinations, while attacks in france, germany and greece bring those tourists to portugal. tourists from oceania are negatively sensitive to attacks committed in russia and spain. a phenomenon that involves extremely sensitive reaction to terrorist attacks makes tourists replace a destination with other safer countries. post estimation tests to the models revealed the absence of auto-correlation after using the lagrange multiplier test, as null hypothesis of zero autocorrelation could not be rejected and as the null hypothesis under jarque-bera statistic of residuals' normality (statacorp, ) could not be rejected either. despite the importance granted to the effects of terrorism on tourism and in spite of a considerable amount of research conducted on such issue, there have been recent calls for new research on the topic, especially on the consequences that this phenomenon can exert on economy and tourism activity (almuhrzi, scott, & alroiyami, ; saha & yap, ) . this paper represents an effort to close this gap by establishing the connections between terrorist events in some regions and tourist arrivals in other regions. the study takes into account previous literature on spillover effects, specifically those that trigger the substitution and generalization effects that make tourists reject and replace destinations considered unsafe with others they consider safer (gu & martin, ; neumayer, ) . whereas past research analyzes terrorism negative spillover effects on tourism demand, the present study focuses on the effects that terrorism events have on the tourists' arrivals in a safe country that has no record of terrorism attacks. portugal is one of the european tourism destinations that have experienced a higher growth in tourism demand and receipts over the last decades. according to the institute for economics and peace, portugal is one of the world's most peaceful countries (institute for economics & peace, ) and has no record of terrorism events (national consortium for the study of terrorism and responses to terrorism, note: + p < , ; * p < . ; ** p < . ; *** p < . ; d first difference; l, l lags of respective variable; first number in the table is the variable coefficient and the second one in the same column is the z statistics. these are the significant values c. seabra, et al. annals of tourism research ( ) ). the present study demonstrates that terrorist attacks in other countries have an impact on the demand for portuguese tourist accommodations. in turn, the results also show that instability in other countries can have consequences for portuguese tourism arrivals confirming the existence of spillover effect. as far as the effects of terrorist attacks on tourists' arrivals in portugal are concerned, this study allowed the uncovering of interesting results. terrorist events perpetrated in the united kingdom, greece, and france positively affect tourist arrivals from asia. attacks perpetrated in spain, on the contrary, have a negative contribution to tourists' arrivals from asia. in the cases of france and greece, this occurs probably because they are both mediterranean destinations similar to portugal. this result confirms the existence of the substitution effect as well as the presence of the generalization effect (mansfeld, ) . asian countries have a strong historic, economic and even social connection with the united kingdom. natives of those countries are well aware of the attacks committed in the united kingdom through media coverage or through personal information provided by emigrants residing in the country. on the other hand, for asian tourists, spain and portugal belong to the same iberian territory since they are located in the same geographical and risk area. this belief confirms the existence of the generalization effect (enders & sandler, ) . terrorist attacks in france, greece and spain strongly affect portuguese domestic tourism. these are important tourism destinations to portuguese tourists. these results confirm earlier research on unsafety effects and prove that during unsafety times tourists do not stop travelling; alternatively, they choose domestic destinations they consider much safer (bonham et al., ) . terrorist events perpetrated in the united kingdom, france, germany, greece, and israel positively affect tourist arrivals in portugal from european countries. on the other hand, terrorist attacks occurred in russia and spain exert a negative impact on tourists' arrivals from europe. this happens possibly because those countries are geographically located in the center of europe. accordingly, european tourists will choose peripheral countries. this assumption is in accordance with the results obtained by mansfeld ( ) . the united kingdom, france and germany are also important emissive markets to portugal. that means that tourists who come from those parts of the world can feel safer in portugal than in their own countries. since they are intraregional tourists, they have enough information to know which countries are the safest (wahab, ) . in the cases of tourist destination such as greece or israel, the substitution effect involves portugal, probably because the three markets share the same emissive tourist markets. spain and portugal are neighboring countries. terrorist attacks in spain have severe impacts on tourists who come to portugal from asia, oceania, america, and from other european countries. however, tourists coming from africa, namely from angola, a portuguese-speaking african country (palop) and member of the community of portuguese speaking countries (cplp), or from portugal are unbiased and, thus, do not feel that effect. for those tourists, spain and portugal are two different and unrelated nations, even though they are both iberian countries. the overall findings show the existence of the so-called generalization effect (drakos & kutan, ; enders et al., ; kozak et al., ; liu et al., ; masinde et al., ) : a safe country like portugal with no terrorist events can suffer from the impact of episodes of insecurity that took place in spain, a neighboring country. such impact will affect tourism demand. moreover, this work confirms that the generalization effect that over-assumes the similarities of neighboring countries enhances the causal relationship between terrorist attacks and tourist arrivals (feridun, ; raza & jawaid, ) . the attacks perpetrated in russia do not produce changes in the destination choices of tourists coming from european traditional markets and tourists remain faithful to traditional destinations like spain, france, italy, greece, and tunisia, among others. in consequence, there is a decrease in tourists' arrivals in portugal. the attacks committed in the united kingdom, russia, spain, france, and in germany have a positive impact on the increase in tourists from africa who choose portugal as their destination. on the other hand, terrorist incidents in greece and israel seem to have a negative impact on their choice. these results may be due to the cultural and economic proximity of most african countries and specifically of angola, which is portugal's most important african market. terrorist attacks in greece and israel are responsible for the decrease in african tourists' arrivals, probably because instead of coming to portugal they rather choose high level shopping tourism destinations such as italy, france, the united kingdom, and germany. terrorism in greece, germany, and france positively affects tourist arrivals from america, while terrorist events occurred in israel, russia and spain will have a negative effect on the number of american tourists who choose portugal as their destination. the substitution effect is, once again, clear as far as greece is concerned since that destination is quite similar to portugal. germany and france are important markets for brazilian, north american and canadian tourists. however, due to the attacks in germany and france, those tourists decide to come to portugal instead. tourists from america are well aware of the repeated and regular instability and unsafety felt in russia and israel, so any negative event in those countries will force them to choose other traditional or domestic destinations. these findings are in close accordance with previous research conducted by pizam and fleischer ( ) . the influence of the memory effect is clear when past tourist arrivals influence current tourist arrivals. this occurs in all the models except in the case of tourist arrivals from oceania. this means people want to relive pleasant past experiences and return to destinations where they had spent enjoyable moments. this positive feeling reinforces the role played by memory effect when time comes to choose a destination. therefore, the present study reinforces the work carried out by baggio and sainaghi ( ) . asian, european, african, american, and portuguese tourists' experiences in portugal will have a strong and positive impact on the flow of tourists who will choose to visit the country in the coming years. this paper provides a number of theoretical contributions to tourism literature and helps explain the factors that may influence tourist flows. evidence collected show that tourist arrivals and the demand for tourist accommodation depend on international markets and, more specifically, on the existence of terrorist attacks in other countries. these assumptions confirm the existence of c. seabra, et al. annals of tourism research ( ) "global consumers" (hollensen, ) . this study clearly demonstrates the existence of the so-called substitution effect caused by terrorism events. tourists choose destinations perceived as safer instead of places they see as potential terrorist targets, as stated in previous studies (e.g. ahlfeldt et al., ; araña & león, ; bonham et al., ; drakos & kutan, ; enders et al., ; enders & sandler, ; gu & martin, ; neumayer, ; neumayer & plümper, ; yaya, ). secondly, it was possible to confirm the existence of a one-year consumer short memory effect. the increase in tourist arrivals recorded during a certain year-long period has a direct impact on the increase of tourist arrivals that will occur in the following years. this result may be related with the positive image created by tourists' word of mouth or through the repetition effect. however, a longer, two-year memory effect shows different results. tourist arrivals from portugal, europe, africa, and america in a two-year lag reveal an opposite impact on the arrival of tourists in portuguese destinations, confirming the findings of the study conducted by enders and sandler ( ) . this study also contributes to add information to the existing literature that analyzes the effect of terrorist attacks on tourist arrivals according to their geographical origin. the results unveiled by this study allow public and private tourism organizations to create new predictive models or to update those already in motion, by adding new variables to improve their efficiency and increase the knowledge needed to understand and anticipate international tourist behaviors, specifically those that are related with the existence of terrorist attacks in other european regions. moreover, using the theoretical background provided by this paper, it was possible to create an index -tour-terror -that allows managers to observe the potential impacts of attacks perpetrated in a given region on the economy of recipient countries and that will lead to an increase or to a decrease in tourist arrivals. those fluctuations are related with the tourists' characteristics such as their cultural, social, and economic origin. these features may differ from the residents' usual standards but also from those of the average tourist who usually visits the country. accordingly, the tour-terror index determinants of a country may include independent variables like: i) the level of change in tourism demand and supply due to terrorist attacks; ii) the tourist price level structure; iii) tourists' purchasing power parity; iv) the duration of the stay; v) tourist accommodation capacity; vi) the capacity of other related facilities; and vii) human labor capacity. managers should face the fact that terrorist attacks provoke a substitution effect on destination choice behaviors. tourists will replace destinations considered unsafe due to terrorist threats with others considered safer. the physical distance of the tourists' home countries and their cultural and socio-economic traits influence this replacement behavior. in addition, managers must take into account that the substitution effect occurs between the european countries located in central areas and those located in peripheral areas. when terrorist attacks occur in the center of europe, tourists avoid those regions and choose peripheral destinations like portugal. evidence also made it clear that the opposite effect also happens. given the randomness of terrorist attacks, tourism managers should be prepared to alter quickly their marketing strategy, namely their market targeting strategies and promotion campaigns to prevent substitution effect. these specific practical implications are particularly important to tourist companies located in portugal. tourists from angola, brazil, the united states, and canada have proven to be very profitable since they stay longer and purchase high level and luxury products. for that reason, portuguese companies should make them their main target. the first limitation refers to the research settings, namely the fact that the study only considers one country and a -year time lag. more countries or bigger regions and a longer time lag could improve the analysis. a broader period of analysis could prove the relevance of additional factors like price level, crime rates, accommodation profit, price effect and quantity effect registered in portugal, among others. a more detailed analysis could use sub-regions or even countries instead of continents for tourist arrivals. further analysis should study the countries' macro-economic and social-cultural fundamentals to improve the results. managing tourism in nigeria: the security option terrorism and international tourism: the case of germany tourism in the arab world: an industry perspective the impact of terrorism on tourism demand vector autoregressive (var) models and 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of uncertainty the fear of terrorism and shift in cosmopolitan values tourism and terrorism: sinthesis of the problem with emphasis on egypt marketing the middle east in times of political instability-the case of jordan a spatial econometric approach to model spillover effects in tourism flows do political instability, terrorism, and corruption have deterring effects on tourism development even in the presence of unesco heritage? a crosscountry panel estimate terrorism and tourism: the case of turkey vector autoregressive models for multivariate time series she is doing her post-phd on "terrorism and the eu : impact on citizens and organizations" in novasbe. her research interests are: ) safety and terrorism, and ) tourism. email: cseabra@uc pedro reis is a professor at polytechnic institute of viseu. pedro develops his research in: ) finance, ) accounting josé luís abrantes develops his research in: ) marketing, ) tourism, and ) pedagogy key: cord- -ikepr p authors: tulchinsky, theodore h.; varavikova, elena a. title: expanding the concept of public health date: - - journal: the new public health doi: . /b - - - - . - sha: doc_id: cord_uid: ikepr p ancient societies recognized the needs of sanitation, food safety, workers’ health, and medical care to protect against disease and to promote well-being and civic prosperity. new energies and knowledge since the eighteenth century produced landmark discoveries such as prevention of scurvy and vaccination against smallpox. the biological germ theory and competing miasma theory each proved effective in sanitation, and immunization in control of infectious diseases. non-communicable diseases as the leading causes of mortality have responded to innovative preventive care of health risk factors, smoking, hypertension, obesity, physical inactivity, unhealthful diets, and diabetes mellitus. health promotion proved effective to modern public health in tackling disease origins, individual behavior, and social and economic conditions. the global burden of infectious and non-communicable diseases, aging and chronic illness faces rising costs and still inadequate prevention. the evolution of concepts of public health will have to address these new challenges of population health. the development of public health from its ancient and recent roots, especially in the past several centuries, is a continuing process, with evolutionary and sometimes dramatic leaps forward, and important continuing and new challenges for personal and population health and well-being. everything in the new public health is about preventing avoidable disease, injuries, disabilities, and death while promoting and maximizing a healthy environment and optimal conditions for current and future generations. thus, the new public health addresses overall health policy, resource allocation, as well as the organization, management, and provision of medical care and of health systems in general within a framework of overall social policy and in a community, state, national, transnational, and global context. the study of history (see chapter ) helps us to understand the process of change, to define where we came from and where we are going. it is vital to recognize and understand change in order to deal with radical transformations in direction that occur as a result of changing demography and epidemiology, new science, evolving best practices in public health and clinical medicine, and above all inequalities in health resulting from societal system failures and social and economic factors. health needs will continue to develop in the context of environmental, demographic and societal adjustments, with knowledge gained from social and physical sciences, practice, and economics. for the coming generations, this is about not only the quality of life, but the survival of society itself. over the past century there have been many definitions of public health and health for all. mostly they represent visions and ideals of societal and global aspirations. this chapter examines the very base of the new public health, which encompasses the classic issues of public health with recognition of the advances made in health promotion and the management of health care systems as integral components of societal efforts to improve the health of populations and of individuals. what follows in succeeding chapters will address the major concepts leading to modern and comprehensive elements of public health. inevitably, concepts of public health continue to evolve and to develop both as a philosophy and as a structured discipline. as a professional field, public health requires specialists trained with knowledge and appreciation of its evolution, scientific advances, concepts, and best practices, old and modern. it demands sophisticated professional and managerial skills, the ability to address a problem, reasoning to define the issues, and to advocate, initiate, develop, and implement new and revised programs. it calls for profoundly humanistic values and a sense of responsibility towards protecting and improving the health of communities and every individual. in the twenty-first century, this set of values was well expressed in the human development index agreed to by nations (box . ). public health is a multidimensional field and therefore multidisciplinary in its workforce and organizational needs. it is based on scientific advances and application of best practices as they evolve, and includes many concepts, including holistic health, first established in ancient times. the discussion will return to the diversity of public health throughout this chapter and book many times. in previous centuries, public health was seen primarily as a discipline which studies and implements measures for control of communicable diseases, primarily by sanitation and vaccination. the sanitary revolution, which preceded the development of modern bacteriology, made an enormous contribution to improved health, but many other societal factors including improved nutrition, education, and housing were no less important for population health. maternal and child health, occupational health, and many other aspects of a growing public health network of activities played important roles, as have the physical and social environment and personal habits of living in determining health status. in recent decades recognition of the importance of women's health and health inequalities associated with many high-risk groups in the population have seen both successes and failures in addressing their challenges. male health issues have received less attention, apart from issues associated with specific diseases, or those of healthy military personnel. the scope of public health has changed along with growth of the medical, social, and public health sciences, public expectations, and practical experience. taken together, these have all contributed to changes in the concepts and causes of disease. health systems that fail to adjust to changes in fundamental concepts of public health suffer from immense inequity and burdens of preventable disease, disability, and death. this chapter examines expanding concepts of public health, leading to the development of a new public health. public health has evolved as a multidisciplinary field that includes the use of basic and applied science, education, social sciences, economics, management, and communication skills to promote the welfare of the individual and the community. it is greater than the sum of its component elements and includes the art and politics of the funding and coordination of the wide diversity of community and individual health services. the concept of the interdependence of health in body and in mind has ancient origins. they continue to be fundamental to individuals and societies, and part of the fundamental rights of all humans to have knowledge of healthful lifestyles and to have access to those measures of good health that society alone is able to provide, such as immunization programs, food and drug safety and quality standards, environmental and occupational health, and universal access to high-quality primary and specialty medical and other vital health services. this holistic view of balance and equilibrium may be a renaissance of classical greek and biblical traditions, applied with the broad new knowledge and experience of public health and medical care of the nineteenth, twentieth, and the early years of the twenty-first centuries as change continues to challenge our capacity to adapt. the competing nineteenth-century germ and miasma theories of biological and environmental causation of illness each contributed to the development of sanitation, hygiene, immunization, and understanding of the biological and social determinants of disease and health. they come together in the twenty-first century encompassed in a holistic new public health addressing individual and population health needs. medicine and public health professionals both engage in organization and in direct care services. these all necessitate an understanding of the issues that are included in the new public health, how they evolved, interact, are put together in organizations, and are financed and operated in various parts of the world in order to understand changes going on before our eyes. great success has been achieved in reducing the burden of disease with tools and concepts currently at our disposal. the idea that this is an entitlement for everyone was articulated in the health for all concept of alma-ata in . the health promotion movement emerged in the s and showed dramatically effective results in managing the new human immunodeficiency virus (hiv) pandemic and in tackling smoking and other risk factors for non-communicable diseases (ncds). a health in all policy concept emerged in promoting the concept that health should be a basic component of all public and private policies to achieve the full potential of public health and eliminate inequalities associated with social and economic conditions. profound changes are taking place in the world population, and public health is crucial to respond accordingly: mass migration to the cities, fewer children, extended life expectancy, and the increase in the population of older people who are subject to more chronic diseases and disabilities in a changing physical, social, and economic climate. health systems are challenged with continuing development of new medical technologies and related reforms in clinical practice, while experiencing strong influences of pharmaceuticals and the medicalization of health, with prevention and health promotion less central in priorities and resource allocation. globalization of health has many meanings: international trade, improving global communications, and economic changes with increasing flows of goods, services, and people. ecological and climate change bring droughts, hurricanes, arctic meltdown, and rising sea levels. globalization also has political effects, with water and food shortages, terrorism, and economic distress affecting billions of people. in terms of health, disease can spread from one part of the world to others, as in pandemics or in a quiet spread such as that of west nile fever moving from its original middle eastern natural habitat to the americas and europe, or severe acute respiratory syndrome (sars), which spread with lightning speed from chinese villages to metropolitan cities such as toronto, canada. it can also mean that the ncds characteristic of the industrialized countries are now recognized as the leading causes of death in low-and middle-income countries, associated with diet, activity levels, and smoking, which are themselves pandemic risk factors. the potential for global action in health can also be dramatic. the eradication of smallpox was a stunning victory for public health. the campaign to eradicate poliomyelitis is succeeding even though the end-stage is fraught with setbacks, and measles elimination has turned out to be more of a challenge than was anticipated a decade ago, with resurgence in countries thought to have it under control. global health policies have also made the achievements of public-private partnerships of great importance, particularly in vaccination and acquired immunodeficiency syndrome (aids) control programs. there have been failures as well, with very limited progress in human resources development of the public health workforce in low-income countries. the new public health is necessarily comprehensive in scope and it will continue to evolve as new technologies and scientific discoveries -biological, genetic, and sociological -reveal more methods of disease control and health promotion. it relates to or encompasses all community and individual activities directed towards improving the environment for health, reducing factors that contribute to the burden of disease, and fostering those factors that relate directly to improved health. its programs range broadly from immunization, health promotion, and child care, to food labeling and fortification, as well as to the assurance of well-managed, accessible health care services. a strong public health system should have adequate preparedness for natural and human-made disasters, as seen in the recent tsunamis, hurricanes, biological or other attacks by terrorists, wars, conflicts, and genocidal terrorism (box . ) . the concepts of health promotion and disease prevention are essential and fundamental elements of the new public health. parallel scientific advances in molecular biology, genetics and pharmacogenomics, imaging, information technology, computerization, biotechnology, and nanotechnology hold great promise for improving the productivity of the health care system. advances in technology with more effective and less expensive drug and vaccine development, with improved safety and effectiveness, and fewer adverse reactions, will over time greatly increase efficiency in prevention and treatment modalities. the new public health is important as a conceptual base for training and practice of public health. it links classical topics of public health with adaptation in the organization and financing of personal health services. it involves a changed paradigm of public health to incorporate new advances in political, economic, and social sciences. failure at the political level to appreciate the role of public health in disease control holds back many societies in economic and social development. at the same time, organized public health systems need to work to reduce inequities between and inside countries to ensure equal access to care. it also demands special attention through health promotion activities of all kinds at national and local societal levels to provide access for groups with special risks and needs to medical and community health care with the currently available and newly developing knowledge and technologies. the great gap between available capabilities to prevent and treat disease and actually reaching all in need is still the the mission of the nph is to maximize human health and well-being for individuals and communities, nationally and globally. the methods with which the nph works to achieve this are in keeping with recognized international best practices and scientific advances: . societal commitment and sustained efforts to maximize quality of life and health, economic growth with equity for all (health for all and health in all). collaboration between international, national, state, and local health authorities working with public and private sectors to promote health awareness and activities essential for population health. . health promotion of knowledge, attitudes, and practices, including legislation and regulation to protect, maintain, and advance individual and community health. . universal access to services for prevention and treatment of illness and disability, and promotion of maximum rehabilitation. . environmental, biological, occupational, social, and economic factors that endanger health and human life, addressing: (a) physical and mental illness, diseases and infirmity, trauma and injuries (b) local and global sanitation and environmental ecology (c) healthful nutrition and food security including availability, quality, safety, access, and affordability of food products (d) disasters, natural and human-made, including war, terrorism, and genocide (e) population groups at special risk and with specific health needs. . promoting links between health protection and personal health services through health policies and health systems management, recognizing economic and quality standards of medical, hospital, and other professional care in health of individuals and populations. . training of professional public health workforces and education of all health workers in the principles of ethical best practices of public health and health systems. . research and promotion of current best practices: wide application of current international best practices and standards. . mobilizing the best available evidence from local and international scientific and epidemiological studies and best practices recognized as contributing to the overall goal. . maintaining and promoting equity for individual and community rights to health with high professional and ethical standards. source of great international and internal national inequities. these inequities exist not only between developed and developing countries, but also within transition countries, mid-level developing countries, and those newly emerging with rapid economic development. the historical experience of public health will help to develop the applications of existing and new knowledge and societal commitment to social solidarity in implementation of the new discoveries for every member of the society, despite socioeconomic, ethnic, or other differences. political will and leadership in health, adequate financing, and organization systems in the health setting are crucial to furthering health as an objective with defined targets, supported by well-trained staff for planning, management, and monitoring the population health and functioning of health systems. political leadership and professional support are both indispensable in a world of limited resources, with high public expectations and the growing possibilities of effectiveness of public health programs. well-developed information and knowledge management systems are required to provide the feedback and information needed for good management. it includes responsibilities and coordination at all levels of government. non-governmental organizations (ngos) and participation of a well-informed media and strong professional and consumer organizations also have significant roles in furthering population health. no less important are clear designations of responsibilities of the individual for his or her own health, and of the provider of care for humane, high-quality professional care. the complexities and interacting factors are suggested in figure . , with the classic host-agent-environment triad. many changes have signaled a need for transformation towards the new public health. religion, although still a major political and policy-making force in many countries, is no longer the central organizing power in most societies. organized societies have evolved from large extended families and tribes to rural societies, cities, regions, and national governments. with the growth of industrialized urban communities, rapid transport, and extensive trade and commerce in multinational economic systems, the health of individuals and communities has become more than just a personal, family, and/or local problem. an individual is not only a citizen of the village, city, or country in which he or she lives, but a citizen of a "global village". the agricultural revolutions and international explorations of the fifteenth to seventeenth centuries that increased food supply and diversity were followed only much later by knowledge of nutrition as a public health issue. the scientific revolution of the seventeenth to nineteenth centuries provided the basics to describe and analyze the spread of disease and the poisonous effects of the industrial revolution, including crowded living conditions and pollution of the environment with serious ecological damage. in the latter part of the twentieth century, a new agricultural "green revolution" had a great impact in reducing human deprivation internationally, yet the full benefits of healthier societies are yet to be realized in the large populations living in abject poverty in sub-saharan africa, south-east asia, and other parts of the world. global water shortages can be addressed with new methods of irrigation, water conservation and the application of genetic sciences to food production, and issues of economics and food security are of great importance to a still growing world population with limited supplies. further, food production capacity can and must be enlarged to meet current food insecurity, rising expectations of developing nations, and population growth. the sciences of agriculture-related fields, including genetic sciences and practical technology, will be vital to human progress in the coming decades. these and other societal changes discussed in chapter have enabled public health to expand its potential and horizons, while developing its pragmatic and scientific base. organized public health in the twentieth century proved effective in reducing the burden of infectious diseases and has contributed to improved quality of life and longevity by many years. in the last half-century, chronic diseases have become the primary causes of morbidity and mortality in the developed countries and increasingly in developing countries. growing scientific and epidemiological knowledge increases the capacity to deal with these diseases. many aspects of public health can only be influenced by the behavior of and risks to the health of individuals. these require interventions that are more complex and relate to societal, environmental, and community standards and expectations as much as to personal lifestyle. the dividing line between communicable and non-communicable diseases changes over time. scientific advances have shown the causation of chronic conditions by infectious agents and their prevention by curing the infection, as in helicobacter pylori and peptic ulcers, and in prevention of cancer of the liver and cervix by immunization for hepatitis b and human papillomavirus (hpv), respectively. chronic diseases have come to the center stage in the "epidemiological transition", as infectious diseases came under increasing control. this, in part, has created a need for reform in the funding and management of health systems due to rapidly rising costs, aging of the population, the rise of obesity and diabetes and other chronic conditions, mushrooming therapeutic technology, and expanding capacity to deal with public health emergencies. reform is also needed in international assistance to help less developed nations build the essential infrastructure to sustain public health in the struggle to combat aids, malaria, tuberculosis (tb), and the major causes of preventable infant, childhood, and motherhood-related deaths. the nearly universal recognition of the rights of people to have access to health care of acceptable quality by international standards is a challenge of political will and leadership backed up by adequate staffing with public health-trained staff and organizations. the challenges of the current global economic crisis are impacting social and health systems around the world. the interconnectedness of managing health systems is part of the new public health. setting the priorities and allocating resources to address these challenges requires public health training and orientation of the professionals and institutions participating in the policy, management, and economics of health systems. conversely, those who manage such institutions are recognizing the need for a wide background in public health training in order to fulfill their responsibilities effectively. concepts such as objectives, targets, priorities, cost-effectiveness, and evaluation have become part of the new public health agenda. an understanding of how these concepts evolved will help the future health provider or manager to cope with the complexities of mixing science, humanity, and effective management of resources to achieve higher standards of health, and to cope with new issues as they develop in the broad scope of the new public health for the twenty-first century, in what breslow called the "third public health era" of long and healthy quality of life (box . ). health can be defined from many perspectives, ranging from statistics on mortality, life expectancy, and morbidity rates to idealized versions of human and societal perfection, as in the world health organization's (who's) founding charter. the first public health era -the control of communicable diseases. second public health era -the rise and fall of chronic diseases. third public health era -the development of long and high-quality life. preamble to the constitution of the who, as adopted by the international health conference in new york in and signed by the representatives of states, entered into force on april , with the widely cited definition: "health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". this definition is still important conceptually as an ideal accepted as fundamental to public policy over the years. a more operational definition of health is a state of equilibrium of the person with the biological, physical, and social environment, with the object of maximum functional capability. health is thus seen as a state characterized by anatomical, physiological, and psychological integrity, and an optimal functional capability in the family, work, and societal roles (including coping with associated stresses), a feeling of well-being, and freedom from risk of disease and premature death. deviances in health are referred to as unhealthy and constitute a disease nomenclature. there are many interrelated factors in disease and in their management through what is now called risk reduction. in , claude bernard described the phenomenon of adaptation and adjustment of the internal milieu of the living organism to physiological processes. this concept is fundamental to medicine. it is also central to public health because understanding the spectrum of events and factors between health and disease is basic to the identification of contributory factors affecting the balance towards health, and to seeking the points of potential intervention to reverse the imbalance. as described in chapter , from the time of hippocrates and galen, diseases were thought to be due to humors and miasma or emanations from the environment. this was termed the miasma theory, and while without a direct scientific explanation, it was acted upon in the early to mid-nineteenth century and promoted by leading public health theorists including florence nightingale, with practical and successful measures to improve sanitation, housing, and social conditions, and having important results in improving health conditions. the competing germ theory developed by pioneering nineteenthcentury epidemiologists (panum, snow, and budd), scientists (pasteur, cohn, and koch), and practitioners (lister and semmelweiss) led to the science of bacteriology and a revolution in practical public health measures. the combined application of the germ (agent-host-environment) and miasma theories (social and sanitary environment) has been the basis of classic public health, with enormous benefits in the control of infectious and other diseases or harmful conditions. the revolutionary changes occurring since the s have brought about a decline in cardiovascular and cancer mortality, and conceptual changes such as health for all and health in all to bring health issues to all policies at both governmental and individual levels. the concepts of public health advanced with the marc lalonde health field concept (new perspectives on the health of canadians, ) , stating that health was the result of the physical and social environment, lifestyle and personal habits, genetics, as well as organization and provision of medical care. the lalonde report was a key concept leading to ideas advanced at the alma-ata conference on primary care held in and more explicitly in the development of the basis for health promotion as articulated in the ottawa charter of on health promotion. this marked the beginning of a whole new aspect of public health, which proved itself in addressing with considerable success the epidemic of hiv and cardiovascular diseases. in the usa, the surgeon general's reports of on smoking and health, and of defining health targets as national policy promoted the incorporation of "management by objectives" from the business world applied to the health sector (see chapter ). this led to healthy people usa and later versions, and the united nations (un) millennium development goals (mdgs), aimed primarily at the middle-and low-income countries (box . ). the identification of infectious causes of cancers of the liver and cervix established a new paradigm in epidemiology, and genetic epidemiology has important potential for public health and clinical medicine. in the basic host-agent-environment paradigm, a harmful agent comes through a sympathetic environment into contact with a susceptible host, causing a specific disease. this idea dominated public health thinking until the midtwentieth century. the host is the person who has or is at risk for a specific disease. the agent is the organism or direct cause of the disease. the environment includes the external factors which influence the host, his or her susceptibility to the agent, and the vector which transmits or carries the agent to the host from the environment. this explains the causation and transmission of many diseases. this paradigm (figure . ), in effect, joins together the contagion and miasma theories of disease causation. a specific agent, a method of transmission, and a susceptible host are involved in an interaction, which are central to the infectivity or severity of the disease. the environment can provide the carrier or vector of an infective (or toxic) agent, and it also contributes factors to host susceptibility; for example, unemployment, poverty, or low education level. the expanded host-agent-environment paradigm widens the definition of each of the three components ( figure . ), in relation to both acute infectious and chronic noninfectious disease epidemiology. in the latter half of the twentieth century, this expanded host-agent-environment paradigm took on added importance in dealing with the complex of factors related to chronic diseases, now the leading causes of disease and premature mortality in the developed world, and increasingly in developing countries. interventions to change host, environmental, or agent factors are the essence of public health. in infectious disease control, the biological agent may be removed by pasteurization of food products or filtration and disinfection (chlorination) of water supplies to prevent transmission of waterborne disease. the host may be altered by immunization to provide immunity to a specific infective organism. the environment may be changed to prevent transmission by destroying the vector or its reservoir of the disease. a combination of these interventions can be used against a specific risk factor, toxic or nutritional deficiency, infectious organism, or disease process. vaccine-preventable diseases may require both routine and special activities to boost herd immunity to protect the individual and the community. for other infectious diseases for which there is no vaccine (e.g., malaria), control involves a broad range of activities including case finding and treatment to improve the individual's health and to reduce the reservoir of the disease in the population, and other measures such as bed nets to reduce exposure of the host to vector mosquitoes, as well as vector control to reduce the mosquito population. tb control requires not only case finding and treatment, but understanding the contributory factors of social conditions, diseases with tb as a secondary condition (substance abuse and aids), agent resistance to treatment, and the inability of patients or carriers to complete treatment without supervision. sexually transmitted infections (stis) which are not controllable by vaccines require a combination of personal behavior change, health education, medical care, and skilled epidemiology. with non-infectious diseases, intervention is even more complex, involving human behavior factors and a wide range of legal, administrative, and educational issues. there may be multiple risk factors, which have a compounding effect in disease causation, and they may be harder to alter than infectious diseases factors. for example, smoking in and of itself is a risk factor for lung cancer, but exposure to asbestos fibers has a compounding effect. preventing exposure to the compounding variables may be easier than smoking cessation. reducing trauma morbidity and mortality is equally problematic. the identification of a single specific cause of a disease is of great scientific and practical value in modern public health, enabling such direct interventions as the use of vaccines or antibiotics to protect or treat individuals from infection by a causative organism, toxin, deficiency condition, or social factor. the cumulative effects of several contributing or risk factors in disease causation are also of great significance in many disease processes, in relation to infectious diseases such as nutritional status as for chronic diseases such as the cardiovascular group. the health of an individual is affected by risk factors intrinsic to that person as well as by external factors. intrinsic factors include the biological ones that the individual inherits and those life habits he or she acquires, such as smoking, overeating, or engaging in other high-risk behaviors. external factors affecting individual health include the environment, the socioeconomic and psychological state of the person, the family, and the society in which he or she lives. education, culture, and religion are also contributory factors to individual and community health. there are factors that relate to health of the individual in which the society or the community can play a direct role. one of these is provision of medical care. another is to ensure that the environment and community services include safety factors that reduce the chance of injury and disease, or include protective measures; for example, fluoridation of a community water supply to improve dental health, and seat-belt or helmet laws to reduce motor vehicle injury and death. these modifying factors may affect the response of the individual or the spread of an epidemic (see chapter ). an epidemic may also include chronic disease, because common risk factors may cause an excess of cases in a susceptible population group, in comparison to the situation before the risk factor appeared, or in comparison to a group not exposed to the risk factor. these include rapid changes or "epidemics" in such conditions as type diabetes, asthma, cardiovascular diseases, trauma, and other non-infectious disorders. disease is a dynamic process, not only of causation, but also of incubation or gradual development, severity, and the effects of interventions intended to modify outcome. knowledge of the natural history of disease is fundamental to understanding where and with what means intervention can have the greatest chance for successful interruption or change in the disease process for the patient, family, or community. the natural history of a disease is the course of that disease from beginning to end. this includes the factors that relate to its initiation; its clinical course leading up to resolution, cure, continuation, or long-term sequelae (further stages or complications of a disease); and environmental or intrinsic (genetic or lifestyle) factors and their effects at all stages of the disease. the effects of intervention at any stage of the disease are part of the disease process (figure . ). as discussed above, disease occurs in an individual when agent, host, and environment interact to create adverse conditions of health. the agent may be an infectious organism, a chemical exposure, a genetic defect, or a deficiency condition. a form of individual or social behavior, such as reckless driving or risky sexual behavior, may lead to injury or disease. the host may be immune or susceptible as a result of many contributing social and environmental factors. the environment includes the vector, which may be a malaria-bearing mosquito, a contaminated needle shared by drug users, lead-contaminated paint, or an abusive family situation. assuming a natural state of "wellness" -i.e., optimal health or a sense of well-being, function, and absence of disease -a disease process may begin with the onset of a disease, infectious or non-infectious, following a somewhat characteristic pattern of "incubation" described by clinicians and epidemiologists. preclinical or predisposing events may be detected by a clinical history, with determination of risk including possible exposure or presence of other risk factors. interventions, before and during the process, are intended to affect the later course of the disease. the clinical course of a disease, or its laboratory or radiological findings, may be altered by medical or public health intervention, leading to the resolution or continuation of the disease with fewer or less severe secondary sequelae. thus, the intervention becomes part of the natural history of the disease. the natural history of an infectious disease in a population will be affected by the extent of prior vaccination or previous exposure in the community. diseases particular to children are often so because the adult population is immune from previous exposure or vaccinations. measles and diphtheria, primarily childhood diseases, now affect adults to a large extent because they are less protected by naturally acquired immunity or are vulnerable when their immunity wanes naturally or as a result of inadequate vaccination in childhood. in chronic disease management, high costs to the patient and the health system accrue where preventive services or management are inadequate, not yet available, or inaccessible or where there is a failure to apply the necessary interventions. the progress of diabetes to severe complications such as cardiovascular, renal, and ocular disease is delayed or reduced by good management of the condition, with a combination of smoking cessation, diet, exercise, and medications with good medical supervision. the patient with advanced chronic obstructive pulmonary disease or congestive heart failure may be managed well and remain stable with smoking avoidance, careful management of medications, immunizations against influenza and pneumonia, and other prevention-oriented care needs. where these are not applied or if they fail, the patient may require long and expensive medical and hospital care. failure to provide adequate supportive care will show up in ways that are more costly to the health system and will prove more life-threatening to the patient. the goal is to avoid where possible the necessity for tertiary care, substituting tertiary prevention, i.e., supportive rehabilitation to maximum personal function and maintaining a stable functional status. as in an individual, the phenomenon of a disease in a population may follow a course in which many factors interplay, and where interventions affect the natural course of the disease. the epidemiological patterns of an infectious disease can be assessed in their occurrence in the population or their mortality rates, just as they can for individual cases. the classic mid-nineteenth-century description of measles in the faroe islands by panum showed the transmission and the epidemic nature of the disease as well as the protective effect of acquired immunity (see chapter ). similar, more recent breakthroughs in medical, epidemiological, biological, and social sciences have produced enormous benefit for humankind as discussed throughout this text, with some examples. these include the eradication of smallpox and in the coming years, poliomyelitis, measles, leprosy, and other dreaded diseases known for millennia; the near-elimination of rheumatic heart disease and peptic ulcers in the industrialized countries; vast reduction in mortality from stroke and coronary heart disease (chd); and vaccines (against hepatitis b and hpv) for the prevention of cancers. these and other great achievements of the twentieth and early part of the twenty-first centuries hold great promise for humankind in the coming decades, but great challenges lie ahead as well. the biggest challenge is to bring the benefits of known public health capacity to the poorest population of each country and the poorest populations globally. in developed countries a major challenge is to renew efforts of public health capacity to bear on prevention of chronic conditions such as diabetes and obesity, considered to be at pandemic proportions; and the individual and societal effects of mental diseases. in public health today, fears of a pandemic of avian influenza are based on transmission of avian or other animal-borne (zoonotic) prions or viruses to humans and then their adaptation permitting human-to-human spread. with large numbers of people living in close contact with many animals (wild and domestic fowl), such as in china and south-east asia, and rapid transportation around the world, the potential for global spread of disease is almost without historical precedent. indeed, many human infectious diseases are zoonotic in origin and transferred from natural wildlife reservoirs to humans either directly or via domestic or other wild animals, such as from birds to chickens to humans in avian influenza. monitoring or immunization of domestic animals requires a combination of multidisciplinary zoonotic disease management strategies, public education and awareness, and veterinary public health monitoring and control. rift valley fever, equine encephalitis, and more recently sars and avian influenza associated with bird-borne viral disease which can affect humans, each show the terrible dangers of pandemic diseases. ebola virus is probably sustained between outbreaks among fruit bats, or as recently suggested wild or domestic pigs, and may become a major threat to public health as human case fatality rates decline, meaning that patients and carriers, or genetic drift of the virus with possible airborne transmission, may spread this deadly disease more widely than in the past (see chapter ). the health of populations, like the health of individuals, depends on societal factors no less than on genetics, personal risk factors, and medical services. social inequalities in health have been understood and documented in public health over the centuries. the chadwick and shattuck reports of - documented the relationship of poverty and bad sanitation, housing, and working conditions with high mortality, and ushered in the idea of social epidemiology. political and social ideologies thought that the welfare state, including universal health care systems of one type or another, would eliminate social and geographic differences in health status and this is in large part true. from the introduction of compulsory health insurance in germany in the s to the failed attempt in the usa at national health insurance in (see chapters , and ) and the more recent achievements of us president obama in - , social reforms to deal with inequalities in health have focused on improving access to medical and hospital care. almost all industrialized countries have developed such systems, and the contribution of these programs to improve health status has been an important part of social progress, especially since world war ii. but even in societies with universal access to health care, people of lower socioeconomic status (ses) suffer higher rates of morbidity and mortality from a wide variety of diseases. the black report (douglas black) in the uk in the early s pointed out that the class v population (unskilled laborers) had twice the total and specific mortality rates of the class i population (professional and business) for virtually all disease categories, ranging from infant mortality to death from cancer. the report was shocking because all britons have had access to the comprehensive national health service (nhs) since its inception in , with access to a complete range of services at no cost at time of service, close relations to their general practitioners, and good access to specialty services. these findings initiated reappraisals of the social factors that had previously been regarded as the academic interests of medical sociologists and anthropologists and marginal to medical care. more recent studies and reviews of regional, ethnic, and socioeconomic differentials in patterns of health care access, morbidity, and mortality indicate that health inequities are present in all societies including the uk, the usa, and others, even with universal health insurance or services. the ottawa charter on health promotion in placed a new paradigm before the world health community that recognized social and political factors as no less important ion health that traditional medical and sanitary public health measures. these concepts helped the world health community to cope with new problems such as hiv/aidsfor which there was neither a medical cure nor a vaccine to prevent the disease. its control came to depend in the initial decades almost entirely on education and change in lifestyles, until the advent of the antiretroviral drugs in the s. there is still no viable vaccine. although the epidemiology of cardiovascular disease shows the direct relationship of the now classic risk factors of stress, smoking, poor diet, and physical inactivity, differences in mortality from cardiovascular disease between different classes among british civil servants are not entirely explainable by these factors. the differences are also affected by social and economic issues that may relate to the psychological needs of the individual, such as the degree of control people have over their own lives. blue-collar workers have less control over their lives, their working life in particular, than their white-collar counterparts, and have higher rates of chd mortality than higher social classes. other work shows the effects of migration, unemployment, drastic social and political change, and binge drinking, along with protective effects of healthy lifestyle, religiosity, and family support systems in cardiovascular diseases. social conditions affect disease distribution in all societies. in the usa and western europe, tb has re-emerged as a significant public health problem in urban areas partly because of high-risk population groups, owing to poverty and alienation from society, as in the cases of homelessness, drug abuse, and hiv infection. in countries of eastern europe and the former soviet union, the recent rise in tb incidence has resulted from various social and economic factors in the early s, including the large-scale release of prisoners. in both cases, diagnosis and prescription of medication are inadequate, and the community at large becomes at risk because of the development of antibioticresistant strains of tubercle bacillus readily spread by inadequately treated carriers, acting as human vectors. studies of ses and health are applicable and valuable in many settings. in alameda county, california, differences in mortality between black and white population groups in terms of survival from cancer became insignificant when controlled for social class. a -year follow-up study of the county population reported that low-income families in california are more likely than those on a higher income to have physical and mental problems that interfere with daily life, contributing to further impoverishment. studies of the association between indicators of ses and recent screening in the usa, australia, finland, and elsewhere showed that lower ses women use less preventive care such as papanicolaou (pap) smears for cervical cancer than women of higher ses, despite having greater risk for cervical cancer. many factors in ses inequalities are involved, including transportation and access to primary care, differences in health insurance coverage, educational levels, poverty, high-risk behaviors, social and emotional distress, feeling a lack of control over one's own life, employment, occupation, and inadequate family or community social support systems. many barriers exist owing to difficulties in access and the lack of availability of free or low-cost medical care, and the absence or limitations of health insurance is a further factor in the socioeconomic gradient. the recognition that health and disease are influenced by many factors, including social inequalities, plays a fundamental role in the new public health paradigm. health care systems need to take into account economic, social, physical, and psychological factors that otherwise will limit the effectiveness of even the best medical care. the health system includes access to competent and responsible primary care as well as by the wider health system, including health promotion, specific prevention and population-based health protection. the paradigm of the host-agent-environment triad (figures . and . ) is profoundly affected by the wider context. the sociopolitical environment and organized efforts at intervention affect the epidemiological and clinical course of disease of the individual. medical care is essential, as is public health, but the persistent health inequities seen in most regions and countries require societal attention. success or failure in improving the conditions of life for the poor, and other vulnerable "risk groups", affect national or regional health status and health system performance. the health system is meant to reduce the occurrence or bad outcome of disease, either directly by primary prevention or treatment as secondary prevention or by maximum rehabilitation as tertiary prevention, or equally important indirectly by reducing community or individual risk factors. the the effects of social conditions on health can be partly offset by interventions intended to promote healthful conditions; for example, improved sanitation, or through good-quality primary and secondary health services, used efficiently and effectively made available to all. the approaches to preventing disease or its complications may require physical changes in the environment, such as removal of the broad street pump handle to stop the cholera epidemic in london, or altering diets as in goldberger's work on pellagra. some of the great successes of public health have been and continue to be low technology. examples, among many others, include insecticide-impregnated bednets and other vector control measures, oral rehydration solutions, treatment and cure of peptic ulcers, exercise and diet to reduce obesity, hand washing in hospitals (and other health facilities), community health workers, and condoms and circumcision for the prevention of stis, including hiv and cancer of the cervix. the societal context in terms of employment, social security, female education, recreation, family income, cost of living, housing, and homelessness is relevant to the health status of a population. income distribution in a wealthy country may leave a wide gap between the upper and lower socioeconomic groups, which affects health status. the media have great power to sway public perception of health issues by choosing what to publish and the context in which to present information to society. modern media may influence an individual's tendency to overestimate the risk of some health issues while underestimating the risk of others, ultimately influencing health choices, such as occurred with public concern regarding false claims of an association between the measles-mumps-rubella (mmr) vaccine and autism in the uk (see the wakefield effect, chapter ). the new public health has an intrinsic responsibility for advocacy of improved societal conditions in its mission to promote optimal community health. an ultimate goal of public health is to improve health and to prevent widespread disease occurrence in the population and in an individual. the methods of achieving this are wide and varied. when an objective has been defined in "social justice is a matter of life and death. it affects the way people live, their consequent chance of illness, and their risk of premature death. we watch in wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to improve in others. a girl born today can expect to live for more than years if she is born in some countries -but less than years if she is born in others. within countries there are dramatic differences in health that are closely linked with degrees of social disadvantage. differences of this magnitude, within and between countries, simply should never happen. these inequities in health, avoidable health inequalities arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. the conditions in which people live and die are, in turn, shaped by political, social, and economic forces. social and economic policies have a determining impact on whether a child can grow and develop to its full potential and live a flourishing life, or whether its life will be blighted. increasingly the nature of the health problems rich and poor countries have to solve are converging. the development of a society, rich or poor, can be judged by the quality of its population's health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage as a result of ill-health." preventing disease, the next step is to identify suitable and feasible methods of achieving it, or a strategy with tactical objectives. this determines the method of operation, course of action, and resources needed to carry it out. the methods of public health are categorized as health promotion, and primary, secondary, and tertiary prevention (box . ). health promotion is the process of enabling people and communities to increase control over factors that influence their health, and thereby to improve their health (adapted from the ottawa charter of health promotion, ; box . ). health promotion is a guiding concept involving activities intended to enhance individual and community health and well-being (box . ). it seeks to increase involvement and control by the individual and the community in their own health. it acts to improve health and social welfare, and to reduce specific determinants of diseases and risk factors that adversely affect the health, well-being, and productive capacities of an individual or society, setting targets based on the size of the problem but also the feasibility of successful intervention, in a cost-effective way. this can be through direct contact with the patient or risk group, or act indirectly through changes in the environment, legislation, or public policy. control of aids relies on an array of interventions that promote change in sexual behavior and other contributory risks such as sharing of needles among drug users, screening of blood supply, safe hygienic practices in health care settings, and education of groups at risk such as teenagers, sex workers, migrant workers, and many others. control of aids is also a clinical problem in that patients need antiretroviral therapy (art), but this becomes a management and policy issue for making these drugs available and at an affordable price for the poor countries most affected. this is an example of the challenge and effectiveness of health promotion and the new public health. health promotion is a key element of the new public health and is applicable in the community, the clinic or hospital, and in all other service settings. some health promotion activities are government legislative and box . modes of prevention l health promotion -fostering national, community, and individual knowledge, attitudes, practices, policies, and standards conducive to good health; promoting legislative, social, or environmental conditions; promoting knowledge and practices for self-care that reduce individual and community risk; and creating a healthful environment. it is directed toward action on the determinants of health. l health protection -activities of official health departments or other agencies empowered to supervise and regulate food hygiene, community and recreational water safety, environmental sanitation, occupational health, drug safety, road safety, emergency preparedness, and many other activities to eliminate or reduce as much as possible risks of adverse consequences to health. l primary prevention -preventing a disease from occurring, e.g., vaccination to prevent infectious diseases, advice to stop smoking to prevent lung cancer. l secondary prevention -making an early diagnosis and giving prompt and effective treatment to stop progress or shorten the duration and prevent complications from an already existing disease process, e.g., screening for hypertension or cancer of cervix and colorectal cancer for early case finding, early care and better outcomes. l tertiary prevention -stopping progress of an already occurring disease, and preventing complications, e.g., in managing diabetes and hypertension to prevent complications; restoring and maintaining optimal function once the disease process has stabilized, e.g., promoting functional rehabilitation after stroke and myocardial infarction with long-term follow-up care. health promotion (hp) is the process of enabling people to increase control over, and to improve their health. hp represents a comprehensive social and political process, and not only embraces actions directed at strengthening the skills and capabilities of individuals. hp also undertakes action directed towards changing social, environmental, and economic conditions so as to alleviate their impact on public and individual health. health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health. participation is essential to sustain health promotion action. the ottawa charter identifies three basic strategies for health promotion. these are advocacy for health to create the essential conditions for health indicated above; enabling all people to achieve their full health potential; and mediating between the different interests in society in the pursuit of health. these strategies are supported by five priority action areas as outlined in the ottawa charter for health promotion: regulatory interventions such as mandating the use of seat belts in cars, requiring that children be immunized to attend school, declaring that certain basic foods must have essential minerals and vitamins added to prevent nutritional deficiency disorders in vulnerable population groups, and mandating that all newborns should be given prophylactic vitamin k to prevent hemorrhagic disease of the newborn. setting food and drug standards and raising taxes on cigarettes and alcohol to reduce their consumption are also part of health promotion. promoting a healthy lifestyle is a major known obesity-preventive activity. health promotion is provided by organizations and people with varied professional backgrounds working towards common goals of improvement in the health and quality of individual and community life. initiatives may come from government with dedicated allocation of funds to address specific health issues, from donors, or from advocacy or community groups or individuals to promote a specific or general cause in health. raising awareness to inform and motivate people about their own health and lifestyle factors that might put them at risk requires teaching young people about the dangers of sexually transmitted diseases, smoking, and alcohol abuse to reduce risks associated with their social behavior. it might include disseminating information on healthy nutrition; for example, the need for folic acid supplements for women of childbearing age and multiple vitamins for elderly, as well as the elements of a healthy diet, compliance with immunization recommendations, compliance with screening programs, and many others. community and peer group attitudes and standards affect individual behavior. health promotion endeavors to create a climate of knowledge, attitudes, beliefs, and practices that are associated with better health outcomes. international conferences following on from the ottawa charter were held in adelaide in , sundsvall in , jakarta in , mexico in , bangkok in , and nairobi in . the principles of health promotion have been reiterated and have influenced public policy regarding public health as well as the private sector. health promotion has a track record of proven success in numerous public health issues where a biomedical solution was not available. the hiv/aids pandemic from the s until the late s had no medical treatment and control measures relied on screening, education, lifestyle changes, and supportive care. health promotion brought forward multiple interventions, from condom use and distribution, to needle exchanges for intravenous drug users, to male circumcision in high-prevalence african countries. medical treatment was severely limited until art was developed. the success of art also depends on a strong element of health promotion in widening the access to treatment and the success of medications to reduce transmission, most remarkably in reducing maternal-fetal transmission (see chapter ). similarly, in the battle against cardiovascular diseases, health promotion was an instrumental factor in raising public awareness of the importance of management of hypertension and smoking reduction, dietary restraint, and physical exercise. the success of massive reductions in stroke and chd mortality is as much the result of health promotion as of improved medical care (see chapter ). the character of public health carries with it a "good cop, bad cop" dichotomy. the "good cop" is persuasive and educational trying to convince people to do the right thing in looking after their own health: diet, exercise, smoking cessation, and others. on the other side, the "bad cop" role is regulatory and punitive. public health has a serious responsibility and role in the enforcement of laws and regulation to protect the public health. some of these are restrictive box . elements of health promotion . address the population as a whole in health-related issues, in everyday life as well as people at risk for specific diseases. . direct action to risk factors or causes of illness or death. . undertake activist approach to seek out and remedy risk factors in the community that adversely affect health. . promote factors that contribute to a better condition of health of the population. . initiate actions against health hazards, including communication, education, legislation, fiscal measures, organizational change, community development, and spontaneous local activities. . involve public participation in defining problems and deciding on action. . advocate relevant environmental, health, and social policy. . encourage health professional participation in health education and health advocacy. . advocate for health based on human rights and solidarity. . invest in sustainable policies, actions, and infrastructure to address the determinants of health. . build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and health literacy. . regulate and legislate to ensure a high level of protection from harm and enable equal opportunity for health and well-being for all people. . partner and build alliances with public, private, nongovernmental, and international organizations and civil society to create sustainable actions. . make the promotion of health central to the global development agenda. of individual rights that may damage other people or are requirements based on strong evidence of benefits to population health. readily accepted are food and drug standards, such as pasteurization of milk, and iodization of salt; requirements to drive on the right-hand side of the road (except in some countries such as the uk), to wear seat belts and for motorcyclists to wear safety helmets; and not smoking in public places. enforcement of these and similar statutory or regulatory requirements is vital in a civil society to protect the public from health hazards and to protect people from harm and exploitation by unscrupulous manufacturers and marketing. cigarette advertising and sponsorship of sports events by tobacco companies are banned in most upper income countries. the use of transfats in food manufacturing and baking is now banned and salt reduction is being promoted and even mandated in many us local authorities to reduce cardiovascular disease. advertising of unhealthy snack foods on children's television programs and during child-watching hours is commonly restricted. banning high-sugar soda drink distribution in schools is a successful intervention to reduce the current child obesity epidemic. melamine use in milk powders and baby formulas, which caused widespread illness and death of infants in china, is now banned and a punishable offence for manufacture or distribution in china and worldwide. examples of this aspect of public health are mentioned throughout this text, especially in chapters and on nutrition, and environmental and occupational health, respectively. the regulatory enforcement function of public health is sometimes controversial and portrayed as interference with individual liberty. fluoridation of community water supplies is an example where aggressive lobby groups opposing this safe and effective public health measure are still common. this is discussed in chapter . equally important is the public health policy issue of resource allocation and taxation for health purposes. taxation is an unpopular measure that governments must employ and enforce in order to do the public's business. the debate over the patient protection and affordable care act (ppaca or "obamacare"), discussed elsewhere in this and other chapters, shows how bitter the arguments can become, yet the goal of equality of access to health care cannot be denied as a public good, demonstrably contributing to the health of the nation. primary prevention refers to those activities that are undertaken to prevent disease or injury from occurring at all. primary prevention works with both the individual and the community. it may be directed at the host to increase resistance to the agent (such as in immunization or cessation of smoking), or at environmental activities to reduce conditions favorable to the vector for a biological agent, such as mosquito vectors of malaria or dengue fever. landmark examples include the treatment and prevention of scurvy among sailors based on james lind's findings in a classic clinical epidemiological study in , and john snow's removal of the handle from the broad street pump to stop a cholera epidemic in london in (see chapter ). primary prevention includes elements of health protection such as ensuring water, food and drug, and workplace safety; chlorination of drinking water to prevent transmission of waterborne enteric diseases; pasteurization of milk to prevent gastrointestinal diseases; mandating wearing seat belts in motor vehicles to prevent serious injury and death in road crashes; and reducing the availability of firearms to reduce injury and death from intentional, accidental, or random violence. it also includes direct measures to prevent diseases, such as immunization to prevent polio, tetanus, pertussis, and diphtheria. health promotion and health protection blend together as a group of activities that reduce risk factors and diseases through many forms of intervention such as changing smoking legislation or preventing birth defects by fortification of flour with folic acid. prevention of hiv transmission by needle exchange for intravenous drug users, promoting condom usage, and promoting male circumcision in africa, and the distribution of condoms and clean needles for hivpositive drug users are recent examples of primary prevention associated with health promotion programs. primary prevention also includes activities within the health system that can lead to better health. this may mean, for example, setting standards and to reduce hospital infections, and ensuring that doctors not only are informed of appropriate immunization practices and modern prenatal care or screening programs for cancer of the cervix, colon, and breast, but also are aware of their vital role in preventing cardiovascular and other non-communicable diseases. in this role, the health care provider serves as a teacher and guide, as well as a diagnostician and therapist. like health promotion, primary prevention does not depend on health care providers alone; health promotion works to increase individual and community consciousness of self-care, mainly by raising awareness and information levels and empowering the individual and the community to improve self-care, to reduce risk factors, and to live healthier lifestyles. secondary prevention is early diagnosis and management to prevent complications from a disease. public health interventions to prevent the spread of disease include the identification of sources of the disease and the implementation of steps to stop it, as shown in snow's closure of the broad street pump. secondary prevention includes steps to isolate cases and treat or immunize contacts so as to prevent further cases of meningitis or measles, for example, in outbreaks. for current epidemics such as hiv/aids, primary prevention is largely based on education, abstinence from any and certainly risky sexual behavior, circumcision, and treatment of patients in order to improve their health and to reduce the risk of spread of hiv. for high-risk groups such as intravenous drug users, needleexchange programs reduce the risk of spread of hiv, and hepatitis b and c. distribution of condoms to teenagers, military personnel, truck drivers, and commercial sex workers helps to prevent the spread of stis and aids in schools and colleges, as well as among the military. the promotion of circumcision is shown to be effective in reducing the transmission of hiv and of hpv (the causative organism for cancer of the cervix). all health care providers have a role in secondary prevention; for example, in preventing strokes by early identification and adequate care of hypertension. the child who has an untreated streptococcal infection of the throat may develop complications which are serious and potentially life-threatening, including rheumatic fever, rheumatic valvular heart disease, and glomerulonephritis. a patient found to have elevated blood pressure should be advised about continuing management by appropriate diet and weight loss if obese, regular physical exercise, and long-term medication with regular follow-up by a health provider in order to reduce the risk of stroke and other complications. in the case of injury, competent emergency care, safe transportation, and good trauma care may reduce the chance of death and/or permanent handicap. screening and high-quality care in the community prevent complications of diabetes, including heart, kidney, eye, and peripheral vascular disease. they can also prevent hospitalizations, amputations, and strokes, thus lengthening and improving the quality of life. health care systems need to be actively engaged in secondary prevention, not only as individual doctors' services, but also as organized systems of care. public health also has a strong interest in promoting highquality care in secondary and tertiary care hospital centers in such areas of treatment as acute myocardial infarction, stroke, and injury in order to prevent irreversible damage. measures include quality of care reviews to promote adequate longterm postmyocardial infarction care with aspirin and betablockers or other medication to prevent or delay recurrence and second or third myocardial infarctions. the role of highquality transportation and care in emergency facilities of hospitals in public health is vital to prevent long-term damage and disability; thus, cardiac care systems including publicly available defibrillators, catheterization, the use of stents, and bypass procedures are important elements of health care policy and resource allocation, which should be accessible not only in capital cities but also to regional populations. tertiary prevention involves activities directed at the host or patient, but also at the social and physical environment in order to promote rehabilitation, restoration, and maintenance of maximum function after the disease and its complications have stabilized. the person who has undergone a cerebrovascular accident or trauma will reach a stage where active rehabilitation can help to restore lost functions and prevent recurrence or further complications. the public health system has a direct role in the promotion of disability-friendly legislation and standards of building, housing, and support services for chronically ill, handicapped, and elderly people. this role also involves working with many governmental social and educational departments, but also with advocacy groups, ngos, and families. it may also include the promotion of disability-friendly workplaces and social service centers. treatment for conditions such as myocardial infarction or a fractured hip now includes early rehabilitation in order to promote early and maximum recovery with restoration to optimal function. the provision of a wheelchair, walkers, modifications to the home such as special toilet facilities, doors, and ramps, along with transportation services for paraplegics are often the most vital factors in rehabilitation. public health agencies work with groups in the community concerned with promoting help for specific categories of risk group, disease, or disability to reduce discrimination. community action is often needed to eliminate financial, physical, or social barriers, promote community awareness, and finance special equipment or other needs of these groups. close follow-up and management of chronic disease, physical and mental, require home care and ensuring an appropriate medical regimen including drugs, diet, exercise, and support services. the follow-up of chronically ill people to supervise the taking of medications, monitor changes, and support them in maximizing their independent capacity in activities of daily living is an essential element of the new public health. public health uses a population approach to achieve many of its objectives. this requires defining the population, including trends of change in the age and gender distribution of the population, fertility and birth rates, spread of disease and disability, mortality, marriage and migration, and socioeconomic factors. the reduction of infectious disease as the major cause of mortality, increased longevity coupled with declining fertility rates, resulted in changes in the age composition, or a demographic transition. demographic changes, such as fertility and mortality patterns, are important factors in changing the age distribution of the population, resulting in a greater proportion of people surviving to older ages. declining infant mortality, increasing educational levels of women, the availability of birth control, and other social and economic factors lead to changes in fertility patterns and the demographic transition -an aging of the population -with important effects on health service needs. the age and gender distribution of a population affects and is affected by patterns of disease. change in epidemiological patterns, or an epidemiological shift, is a change in predominant patterns of morbidity and mortality. the transition of infectious diseases becoming less prominent as causes of morbidity and mortality and being replaced by chronic and non-infectious diseases has occurred in both developed and developing countries. the decline in mortality from chronic diseases, such as cardiovascular disease, represents a new stage of epidemiological transition, creating an aging population with higher standards of health but also long-term community support and care needs. monitoring and responding to these changes are fundamental responsibilities of public health, and a readiness to react to new, local, or generalized changes in epidemiological patterns is vital to the new public health. societies are not totally homogeneous in ethnic composition, levels of affluence, or other social markers. on one hand, a society classified as developing may have substantial numbers of people with incomes that promote overnutrition and obesity, so that disease patterns may include increasing prevalence of diseases of excesses, such as diabetes. on the other hand, affluent societies include population groups with disease patterns of poverty, including poor nutrition and low birth-weight babies. a further stage of epidemiological transition has been occurring in the industrialized countries since the s, with dramatic reductions in mortality from chd, stroke and, to a lesser extent, trauma. the interpretation of this epidemiological transition is still not perfectly clear. how it occurred in the industrialized western countries but not in those of the former soviet union is a question whose answer is vital to the future of health in russia and some countries of eastern europe. developing countries must also prepare to cope with increasing epidemics of non-infectious diseases, and all countries face renewed challenges from infectious diseases with antibiotic resistance or newly appearing infectious agents posing major public health threats. demographic change in a country may reflect social and political decisions and health system priorities from decades before. russia's rapid population decline since the s, china's gender imbalance with a shortage of millions of young women, egypt's rapid population growth outstripping economic capacity, and many other examples indicate the severity and societal importance of capacity to analyze and formulate public health and social policies to address such fundamental sociopolitical issues. aging of the population is now the norm in most developed countries as a result of low birth and declining mortality rates. this change in the age distribution of a population has many associated social and economic issues as to the future of social welfare with a declining age cohort to provide the workforce. the aging population requires pension and health care support which make demands of social security systems that will depend on economic growth with a declining workforce. in times of economic stress, as in europe, this situation is made more difficult by longstanding short working weeks, early pension ages, and high social benefits. however, this results in unemployment among young people in particular and social conflict. the interaction of increasing life expectancy and a declining workforce is a fundamental problem in the high-income countries. this imbalance may be resolved in part through productivity gains and switching of primary production to countries with large still underutilized workforces, while employment in the developed countries will depend on service industries including health and the economic growth generated by higher technology and intellectual property and service industries. the challenge of keeping populations and individuals healthy is reflected in modern health services. each component of a health service may have developed with different historical emphases, operating independently as a separate service under different administrative auspices and funding systems, competing for limited health care resources. in this situation, preventive community care receives less attention and resources than more costly treatment services. figure . suggests a set of health services in an interactive relationship to serve a community or defined population, but the emphasis should be on the interdependence of these services with one other and with the comprehensive network in order to achieve effective use of resources and a balanced set of services for the patient, the client or patient population, and the community. clinical medicine and public health each play major roles in primary, secondary, and tertiary prevention. each may function separately in their roles in the community, but optimal success lies in their integrated efforts. allocation of resources should promote management and planning practices to assist this integration. there is a functional interdependence of all elements of health care serving a definable population. the patient should be the central figure in the continuum or complex of services available. effectiveness in use of resources means that providing the service most appropriate for meeting the individual's or group's needs at a point in time are those that should be applied. this is the central concept in currently developing innovations in health care delivery in the usa with organizations using terms such as patient centered medical home, accountable care organizations (acos), and population health management systems, which are being promoted in the obamacare health reforms now in process (see chapter ) (shortell et al., ) . separate organization and financing of services place barriers to appropriate provision of services for both the community and the individual patient. the interdependence of services is a challenge in health care organizations for the future. where there is competition for limited resources, pressures for tertiary services often receive priority over programs to prevent children from dying of preventable diseases. public health must be seen in the context of all health care and must play an influential role in promoting prevention at all levels. clinical services need public health in order to provide prevention and community health services that reduce the burden of disease, disability, and dependence on the institutional setting. health was traditionally thought of as a state of absence of disease, pain, or disability, but has gradually been expanded to include physical, mental, and societal well-being. in , c. e. a. winslow, professor of public health at yale university, defined public health as follows: "public health is the science and art of ( ) preventing disease, ( ) prolonging life, and ( ) winslow's far-reaching definition remains a valid framework but is unfulfilled when clinical medicine and public health have financing and management barriers between them. in many countries, isolation from the financing and provision of medical and nursing care services left public health with the task of meeting the health needs of the indigent and underserved population groups with inadequate resources and recognition. health insurance organizations for medical and hospital care have in recent years been more open to incorporating evidence-based preventive care, but the organization of public health has lacked the same level of attention. in some countries, the limitations have been conceptual in that public health was defined primarily in terms of control of infectious, environmental, and occupational diseases. a more recent and widely used definition is: "public health is the science and art of preventing disease, prolonging life, and promoting health through the organized efforts of society." this definition, coined in in the public health in england report by sir donald acheson, reflects the broad focus of modern public health. terms such as social hygiene, preventive medicine, community medicine, and social medicine have been used to denote public health practice over the past century. preventive medicine is the application of preventive measures by clinical practitioners combining some elements of public health with clinical practice relating to individual patients. preventive medicine defines medical or clinical personal preventive care, with stress on risk groups in the community and national efforts for health promotion. the focus is on the health of defined populations to promote health and well-being using evidence-based guidelines for cost-effective preventive measures. measures emphasized include screening and follow-up of chronic illnesses, and immunization programs; for example, influenza and pneumococcal pneumonia vaccines are used by people who are vulnerable because of their age, chronic diseases, or risk of exposure, such as medical and nursing personnel and those providing other personal clinical services. clinical medicine also deals in the area of prevention in the management of patients with hypertension or diabetes, and in doing so prevents the serious complications of these diseases. social medicine is also primarily a medical specialty which looks at illness in an individual in the family and social context, but lacks the environmental and regulatory and organized health promotion functions of public health. community health implies a local form of health intervention, whereas public health more clearly implies a global approach, which includes action at the international, national, state, and local levels. some issues in health can be dealt with at the individual, family, or community level; others require global strategies and intervention programs with regional, national, or international collaboration and leadership. the social medicine movement originated to address the harsh conditions of the working population during the industrial revolution in mid-nineteenth-century europe. an eminent pioneer in cellular pathology, rudolph virchow provided leadership in social medicine powered by the revolutionary movements of , and subsequent social democrat political movements. their concern focused on harsh living and health conditions among the urban poor working class and neglectful political norms of the time. social medicine also developed as an academic discipline and advocacy orientation by providing statistical evidence showing, as in various governmental reports in the mid-nineteenth century, that poverty among the working class was associated with short life expectancy and that social conditions were key factors in the health of populations and individuals. this movement provided the basis for departments in medical faculties and public health education throughout the world stressing the close relationship between political priorities and health status. this continued in the twentieth century and in the usa found expression in pioneering work since the s at montefiore hospital in new york and with victor sidel, founding leader of the community health center movement the usa from the s. in the twenty-first century this movement continues to emphasize relationships between politics, society, disease, and medicine, and forms of medical practice derived from it, as enunciated by prominent advocates such as harvardbased paul farmer in haiti, russia and rwanda, and in the uk by martin mckee and others (nolte and mckee, ) . similar concepts are current in the usa under headings such as family medicine, preventive medicine, and social medicine. this movement has also influenced sir michael marmot and others in the world health commission of health inequalities of , with a strong influence on the un initiative to promote mdgs, whose first objective is poverty reduction (commission on inequalities report ). application of the idea of poverty reduction as a method of reducing health inequalities has been successful recently in a large field trial in brazil showing greater reduction in child mortality where cash bonuses were awarded by municipalities for the poor families than that observed in other similar communities (rasella, ). in the usa, this movement is supported by increased health insurance coverage for the working poor, with funding for preventive care and incentives for community health centers in the obamacare plan of for implementation in the coming years to provide care for uninsured and underserved populations, particularly in urban and rural poverty areas. the political aspect of social medicine is the formulation of and support for national initiatives to widen health care coverage to the percent of the us population who are still uninsured, and to protect those who are arbitrarily excluded owing to previous illnesses, caps on coverage allowed, and other exploitative measures taken by private insurance that frequently deny americans access to the high levels of health care available in the country. the ethical base of public health in europe evolved in the context of its successes in the nineteenth and early twentieth centuries along with ideas of social progress. but the twentieth century was also replete with extremism and wide-scale abuse of human rights, with mass executions, deportations, and starvation as official policy in fascist and stalinist regimes. eugenics, a pseudoscience popularized in the early decades of the twentieth century, promoted social policies meant to improve the hereditary qualities of a race by methods such as sterilization of mentally handicapped people. the "social and racial hygiene" of the eugenics movements led to the medicalization of sterilization in the usa and other countries. this was adopted and extended in nazi germany to a policy of murder, first of the mentally and physically handicapped and then of "racial inferiors". these eugenics theories were widely accepted in the medical community in germany, then used by the nazi regime to justify medically supervised killing of hundreds of thousands of helpless, incapacitated individuals. this practice was linked to wider genocide and the holocaust, with the brutalization and industrialized murder of over million jews and million other people, and corrupt medical experimentation on prisoners. following world war ii, the ethics of medical experimentation (and public health) were codified in the nuremberg code and universal declaration of human rights based on lessons learned from these and other atrocities inflicted on civilian populations (see chapter ). threats of genocide, ethnic cleansing, and terrorism are still present on the world stage, often justified by current warped versions of racial hygienic theories. genocidal incitement and actual genocide and terrorism have recurred in the last decades of the twentieth century and into the twenty-first century in the former yugoslav republics, africa (rwanda and darfur), south asia, and elsewhere. terrorism against civilians has become a worldwide phenomenon with threats of biological and chemical agents, and potentially with nuclear capacity. asymmetrical warfare of insurgencies which use innocent civilians for cover, as with other forms of warfare, carries with it grave dangers to public health, human rights, and international stability, as seen in the twenty-first century in south sudan, darfur, dr congo, chechnya, iraq, afghanistan, and pakistan. in , kerr white and colleagues defined medical ecology as population-based research providing the foundation for management of health care quality. this concept stresses a population approach, including those not attending and those using health services. this concept was based on previous work on quality of care, randomized clinical trials, medical audit, and structure-process-outcome research. it also addressed health care quality and management. these themes influenced medical research by stressing the population from which clinical cases emerge as well as public health research with clinical outcome measures, themes that recur in the development of health services research and, later, evidence-based medicine. this led to the development of the agency for health care policy and research and development in the us department of health and human services and evidence-based practice centers to synthesize fundamental knowledge for the development of information for decision-making tools such as clinical guidelines, algorithms, or pathways. clinical guidelines and recommended best practices have become part of the new public health to promote quality of patient care and public health programming. these can include recommended standards; for example, follow-up care of the postmyocardial infarction patient, an internationally recommended immunization schedule, recommended dietary intake or food fortification standards, and mandatory vitamin k and eye care for all newborns and many others (see chapter ). community-oriented primary care (copc) is an approach to primary health care that links community epidemiology and appropriate primary care, using proactive responses to the priority needs identified. copc, originally pioneered in south africa and israel by sidney and emily kark and colleagues in the s and s, stresses medical services in the community which need to be adapted to the needs of the population as defined by epidemiological analysis. copc involves community outreach and education, as well as clinical preventive and treatment services. copc focuses on community epidemiology and an active problem-solving approach. this differs from national or larger scale planning that sometimes loses sight of the local nature of health problems or risk factors. copc combines clinical and epidemiological skills, defines needed interventions, and promotes community involvement and access to health care. it is based on linkages between the different elements of a comprehensive basket of services along with attention to the social and physical environment. a multidisciplinary team and outreach services are important for the program, and community development is part of the process. in the usa, the copc concept has influenced health care planning for poor areas, especially provision of federally funded community health centers in attempts to provide health care for the underserved since the s. in more recent years, copc has gained wider acceptance in the usa, where it is associated with family physician training and community health planning based on the risk approach and "managed care" systems. indeed, the three approaches are mutually complementary (box . ). as the emphasis on health care reform in the late s moved towards managed care, the principles of copc were and will continue to be important in promoting health and primary prevention in all its modalities, as well as tertiary prevention with followup and maintenance of the health of the chronically ill. copc stresses that all aspects of health care have moved towards prevention based on measurable health issues in the community. through either formal or informal linkages between health services, the elements of copc are part of the daily work of health care providers and community services systems. the us institute of medicine issued the report on primary care in , defining primary care as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing the majority of personal health care needs, developing a sustained partnership with patients and practicing in the context of the family and the community". this formulation was criticized by the american public health association (apha) as lacking a public health perspective and failing to take into account both the individual and the community health approaches. copc tries to bridge this gap between the perspectives of primary care and public health. the community, whether local, regional, or national, is the site of action for many public health interventions. moreover, understanding the characteristics of the community is vital to a successful community-oriented approach. by the s, new patterns of public health began to emerge, including all measures used to improve the health of the community, and at the same time working to protect and promote the health of the individual. the range of activities to achieve these general goals is very wide, including individual patient care systems and the community-wide activities that affect the health and well-being of the individual. these include the financing and management of health systems, evaluation of the health status of the population, and measures to improve the quality of health care. they place reliance on health promotion activities to change environmental risk factors for disease and death. they promote integrative and multisectoral approaches and the international health teamwork required for global progress in health. the definition of health in the charter of the who as a complete state of physical, mental, and social well-being had a ring of utopianism and irrelevance to states struggling to provide even minimal care in severely adverse political, economic, social, and environmental conditions (box . ). in , a more modest goal was set for attainment of a level of health compatible with maximum feasible social and economic productivity. one needs to recognize that health and disease are on a dynamic continuum that affects everyone. the mission for public health is to use a wide range of methods to prevent disease and premature death, and improve quality of life for the benefit of individuals and the community. the world health organization defines health as "a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity" (who constitution, ) . in at the alma-ata conference on primary health care, the who related health to "social and economic productivity in setting as a target the attainment by all the people of the world of a level of health that will permit them to lead a socially and economically productive life". three general programs of work for the periods - , - , and - were formulated as the basis of national and international activity to promote health. in , the who, recognizing changing world conditions of demography, epidemiology, environment, and political and economic status, addressed the unmet needs of developing countries and health management needs in the industrialized countries, calling for international commitment to "attain targets that will make significant progress towards improving equity and ensuring sustainable health development". the object of the who is restated as "the attainment by all peoples of the highest possible level of health" as defined in the who constitution, by a wide range of functions in promoting technical cooperation, assisting governments, and providing technical assistance, international cooperation, and standards. in the s, most industrialized countries were concentrating energies and financing in health care on providing access to medical and hospital services through national insurance schemes. developing countries were often spending scarce resources trying to emulate this trend. the who was concentrating on categorical programs, such as eradication of smallpox and malaria, as well as the expanded program of immunization and similar specific efforts. at the same time, there was a growing concern that developing countries were placing too much emphasis and expenditure on curative services and not enough on prevention and primary care. the world health assembly (wha) in endorsed the primary care approach under the banner of "health for all by the year " (hfa ) . this was a landmark decision and has had important practical results. the who and the united nations children's fund (unicef) sponsored a seminal conference held in alma-ata, in the ussr ( kazakhstan), in , which was convened to refocus health policy on primary care. the alma-ata declaration stated that health is a basic human right, and that governments are responsible to assure that right for their citizens and to develop appropriate strategies to fulfill this promise. this proposition has come to be increasingly accepted in the international community. the conference stressed the right and duty of people to participate in the planning and implementation of their health care. it advocated the use of scientifically, socially, and economically sound technology. joint action through intersectoral cooperation was also emphasized. the alma-ata declaration focused on primary health care as the appropriate method of assuming adequate access to health care for all (box . ). many countries have gradually come to accept the notion of placing priority on primary care, resisting the temptation to spend high percentages of health care resources on high-tech and costly medicine. spreading these same resources into highly costeffective primary care, such as immunization and nutrition programs, provides greater benefit to individuals and to society as a whole. alma-ata provided a new sense of direction for health policy, applicable to developing countries and in a different way than the approaches of the developed countries. during the s, the health for all concept influenced national health policies in the developing countries with signs of progress in immunization coverage, for example, but the initiative was diluted as an unintended consequence by more categorical programs such as eradication of poliomyelitis. for example, developing countries have accepted immunization and diarrheal disease control as high-priority issues and achieved remarkable success in raising immunization coverage from some percent to over percent in just a decade. developed countries addressed these principles in different ways. in these countries, the concept of primary health care led directly to important conceptual developments in health. national health targets and guidelines are now common in many countries and are integral parts of box . declaration of alma-ata, : a summary of primary health care (phc) . reaffirms that health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity, and is a fundamental human right. existing gross inequalities in the health status of the people, particularly between developed and developing countries as well as within countries, are of common concern to all countries. . governments have a responsibility for the health of their people. the people have the right and duty to participate in planning and implementation of their health care. . a main social target is the attainment, by all peoples of the world by the year , of a level of health that will permit them to lead a socially and economically productive life. . phc is essential health care based on practical, scientifically sound, and socially acceptable methods and technology. . it is the first level of contact of individuals, the family, and the national health system bringing health care as close as possible to where people live and work, as the first element of a continuing health care process. . phc evolves from the conditions and characteristics of the country and its communities, based on the application of social, biomedical, and health services research and public health experience. . phc addresses the main health problems in the community, providing promotive, preventive, curative, and rehabilitative services accordingly. . phc includes the following: (a) education concerning prevailing health problems and methods of preventing and controlling them (b) promotion of food supply and proper nutrition (c) adequate supply of safe water and basic sanitation (d) maternal and child health care, including family planning (e) immunization against the major infectious diseases (f) prevention of locally endemic diseases (g) appropriate treatment of common diseases and injuries (h) the provision of essential drugs (i) relies on all health workers … to work as a health team. . all governments should formulate national health policies, strategies and plans, mobilize political will and resources, used rationally, to ensure phc for all people. national health planning. reforms of the nhs -for example, as discussed in chapter , remuneration increases for family physicians and encouraging group practice with public health nursing support -have become widespread in the uk. leading health maintenance organizations, such as kaiser permanente in the usa and district health systems in canada, have emphasized integrated approaches to health care for registered or geographically defined populations (see chapters - ). this approach is becoming common in the usa in acos, which will be fostered by the obamacare legislation (ppaca). this systematic approach to individual and community health is an integral part of the new public health. the interactions among community public health, personal health services, and health-related behavior, including their management, are the essence of the new public health. how the health system is organized and managed affects the health of the individual and the population, as does the quality of providers. health information systems with epidemiological, economic, and sociodemographic analysis are vital to monitor health status and allow for changing priorities and management. well-qualified personnel are essential to provide services, manage the system, and carry out relevant research and health policy analysis. diffusion of data, health information, and responsibility helps to provide a responsive and comprehensive approach to meet the health needs of the individual and community. the physical, social, economic, and political environments are all important determinants of the health status of the population and the individual. joint action (intersectoral cooperation) between public and non-governmental or community-based organizations is needed to achieve the well-being of the individual in a healthy society. in the s and s, these ideas contributed to an evolving new public health, spurred on by epidemiological changes, health economics, the development of managed care linking health systems, and prepayment. knowledge and self-care skills, as well as community action to reduce health risks, are no less important in this than the roles of medical practitioners and institutional care. all are parts of a coherent holistic approach to health. the concept of selective primary care, articulated in by walsh and warren, addresses the needs of developing countries to select those interventions on a broad scale that would have the greatest positive impact on health, taking into account limited resources such as money, facilities, and human resources. the term selective primary care is meant to define national priorities that are based not on the greatest causes of morbidity or mortality, but on common conditions of epidemiological importance for which there are effective and simple preventive measures. throughout health planning, there is an implicit or explicit selection of priorities for allocation of resources. even in primary care, selection of targets is a part of the process of resource allocation. in modern public health, this process is more explicit. a country with limited resources and a high birth rate will emphasize maternal and child health before investing in geriatric care. this concept has become part of the microeconomics of health care and technology assessment, discussed in chapters and , respectively, and is used widely in setting priorities and resource allocation. in developing countries, cost-effective primary care interventions have been articulated by many international organizations, including iodization of salt, use of oral rehydration therapy (ort) for diarrheal diseases, vitamin a supplementation for all children, expanded programs of immunization, and others that have the potential for saving hundreds of thousands of lives yearly at low cost. in developed countries, health promotions targeted to reduce accidents and risk factors such as smoking, high-fat diets, and lack of exercise for cardiovascular diseases are low-cost public health interventions that save lives and reduce the use of hospital care. targeting specific diseases is essential for efforts to control tb or eradicate polio, but at the same time, development of a comprehensive primary care infrastructure is equally or even more important than the single-disease approach. some disease entities such as hiv/aids attract donor funding more readily than basic infrastructure services such as immunization, and this can sometimes be detrimental to addressing the overall health needs of the population and other neglected but also important diseases. the risk approach selects population groups on the basis of risk and helps to determine interventional priorities to reduce morbidity and mortality. the measure of health risk is taken as a proxy for need, so that the risk approach provides something for all, but more for those in need, in proportion to that need. in epidemiological terms, these are people with higher relative risk or attributed risk. some groups in the general population are at higher risk than others for specific conditions. the expanded programme on immunization (epi), control of diarrhoeal diseases (cdd), and acute respiratory disease (ard) programs of the who are risk approaches to tackling fundamental public health problems of children in developing countries. public health places considerable emphasis on maternal and child health because these are vulnerable periods in life for specific health problems. pregnancy care is based on a basic level of care for all, with continuous assessment of risk factors that require a higher intensity of follow-up. prenatal care helps to identify factors that increase the risk for the pregnant woman or her fetus/newborn. efforts directed towards these special risk groups have the potential to reduce morbidity and mortality. high-risk case identification, assessment, and management are vital to a successful maternal care program. similarly, routine infant care is designed not only to promote the health of infants, but also to find the earliest possible indications of deviation and the need for further assessment and intervention to prevent a worsening of the condition. low birth-weight babies are at greater risk for many short-and long-term hazards and should be given special treatment. all babies are routinely screened for birth defects or congenital conditions such as hypothyroidism, phenylketonuria, and other metabolic and hematological diseases. screening must be followed by investigating and treating those found to have a clinical deficiency. this is an important element of infant care because infancy itself is a risk factor. as will be discussed in chapters and and others, epidemiology has come to focus on the risk approach with screening based on known genetic, social, nutritional, environmental, occupational, behavioral, or other factors contributing to the risk for disease. the risk approach has the advantage of specificity and is often used to initiate new programs directed at special categories of need. this approach can lead to narrow and somewhat rigid programs that may be difficult to integrate into a more general or comprehensive approach, but until universal programs can be achieved, selective targeted approaches are justifiable. indeed, even with universal health coverage, it is still important to address the health needs or issues of groups at special risk. working to achieve defined targets means making difficult choices. the supply and utilization of some services will limit availability for other services. there is an interaction, sometimes positive, sometimes negative, between competing needs and the health status of a population. public health identifies needs by measuring and comparing the incidence or prevalence of the condition in a defined population with that in other comparable population groups and defines targets to reduce or eliminate the risk of disease. it determines ways of intervening in the natural epidemiology of the disease, and develops a program to reduce or even eliminate the disease. it also assesses the outcomes in terms of reduced morbidity and mortality, as well as the economic justification in cost-effectiveness analysis to establish its value in health priorities. because of the interdependence of health services, as well as the total financial burden of health care, it is essential to look at the costs of providing health care, and how resources should be allocated to achieve the best results possible. health economics has become a fundamental methodology in policy determination. the costs of health care, the supply of services, the needs for health care or other health-promoting interventions, and effective means of using resources to meet goals are fundamental in the new public health. it is possible to err widely in health planning if one set of factors is overemphasized or underemphasized. excessive supply of one service diminishes the availability of resources for other needed investments in health. if diseases are not prevented or their sequelae not well managed, patients must use costly health care services and are unable to perform their normal social functions such as learning at school or performing at work. lack of investment in health promotion and primary prevention creates a larger reliance on institutional care, driving health costs upwards, and restricting flexibility in meeting patients' needs. the interaction of supply and demand for health services is an important determinant of the political economy of health care. health and its place in national priorities are determined by the social-political philosophy and resource allocation of a government. the case for action, or the justification for a public health intervention, is a complex of epidemiological, economic, and public policy factors (table . ). each disease or group of diseases requires its own case for action. the justification for public health intervention requires sufficient evidence of the incidence and prevalence of the disease (see chapter ). evidence-based public health takes into account the effectiveness and safety of an intervention; risk factors; safe means at hand to intervene; the human, social, and economic cost of the disease; political factors; and a policy decision as to the priority of the problem. this often depends on subjective factors, such as the guiding philosophy of the health system and the way it allocates resources. some interventions are so well established that no new justification is required to make the case, and the only question is how to do it most effectively. for example, infant vaccination is a cost-effective and cost-beneficial program for the protection of the individual child and the population as a whole. whether provided as a public service or as a clinical preventive measure by a private medical practitioner, it is in the interest of public health that all children be immunized. an outbreak of diarrheal disease in a kindergarten presents an obvious case for action, and a public health system must respond on an emergency basis, with selection of the most suitable mode of intervention. the considerations in developing a case for action are outlined above. need is based on clinical and epidemiological evidence, but also on the importance of an intervention in the eyes of the public. the technology available, its effectiveness and safety, and accumulated experience are important in the equation, as are the acceptability and affordability of appropriate interventions. the precedents for use of an intervention are also important. on epidemiological evidence, if the preventive practice has been seen to provide reduction in risk for the individual and for the population, then there is good reason to implement it. the costs, risks and benefits must be examined as part of the justification to help in the selection of health priorities. health systems research examines the efficiency of health care and promotes improved efficiency and effective use of resources. this is a vital function in determining how best to use resources and meet current health needs. past emphasis on hospital care at the expense of less development of primary care and prevention is still a common issue, particularly in former soviet and developing countries, where a high percentage of total health expenditure goes to acute hospital care with long length of stay, with smaller allocation to preventive and community health care. the result of this imbalance is high mortality from preventable diseases. new drugs, vaccines, and medical equipment are continually becoming available, and each new addition needs to be examined among the national health priorities. sometimes, owing to cost, a country cannot afford to add a new vaccine to the routine. however, when there is good evidence for efficacy and safety of new vaccines, drugs, diagnostic methods or other innovations, it could be applied for those at greatest risk. although there are ethical issues involved, it may be necessary to advise parents or family members to purchase the vaccine independently. clearly, recommending individual purchase of a vaccine is counter to the principle of equity and solidarity, benefiting middleclass families, and providing a poor basis of data for evaluation of the vaccine and its target disease. on the other hand, failure to advise parents of potential benefits to their children creates other ethical problems, but may increase public pressure and insurance system acceptance of new methods, e.g., varicella and hpv vaccines. mass screening programs involving complete physical examinations have not been found to be cost-effective or to significantly reduce disease. in the s and s, routine general health examinations were promoted as an effective method of finding disease early. since the late s, a selective and specific approach to screening has become widely accepted. this involves defining risk categories for specific diseases and bearing in mind the potential for remedial action. early case finding of colon cancer by routine fecal blood testing and colonoscopy has been found to be effective, and pap smear testing to discover cancer of the cervix is timed according to risk category. screening for colorectal cancer is essential for modern health programs and has been adopted by most industrialized countries. outreach programs by visits, telephones, emails or other modern methods of communication are important to contact non-attenders to promote utilization, and have been shown to increase compliance with proven effective measures. these programs are important for screening, follow-up, and maintenance of treatment for hypertension, diabetes, and other conditions requiring long-term management. screening technology is changing and often the subject of intense debate as such programs are costly and their cost-effectiveness is an important matter for policy making: screening for lung cancer is becoming a feasible and effective matter for high-risk groups, whereas breast cancer screening frequency is now in dispute; while nanotechnology and bioengineering promises new methods for cancer screening. the factor of contribution to quality of life should be considered. a vaccine for varicella is justified partly for the prevention of deaths or illness from chickenpox. a stronger the right to health public expectation and social norms argument is often based on the fact that this is a disease that causes moderate illness in children for up to weeks and may require parents to stay home with the child, resulting in economic loss to the parent and society. the fact that this vaccination prevents the occurrence of herpes zoster or shingles later in life may also be a justification. widespread adoption of hepatitis b vaccine is justified on the grounds that it prevents cancer of the liver, liver cirrhosis, and hepatic failure in a high percentage of the population affected. how many cases of a disease are enough to justify an intervention? one or several cases of some diseases, such as poliomyelitis, may be considered an epidemic in that each case constitutes or is an indicator of a wider threat. a single case of polio suggests that another persons are infected but have not developed a recognized clinical condition. such a case constitutes a public health emergency, and forceful organization to meet a crisis is needed. current standards are such that even one case of measles imported into a population free of the disease may cause a large outbreak, as occurred in the uk, france, and israel during through , by contacts on an aircraft, at family gatherings, or even in medical settings. a measles epidemic indicates a failure of public health policy and practice. screening for some cancers, such as cervix and colon, is cost effective. screening of all newborns for congenital disorders is important because each case discovered early and treated effectively saves a lifetime of care for serious disability. assessing a public health intervention to prevent the disease or reduce its impact requires measurement of the disease in the population and its economic impact. there is no simple formula to justify a particular intervention, but the cost-benefit approach is now commonly required to make such a case for action. sometimes public opinion and political leadership may oppose the views of the professional community, or may impose limitations of policy or funds that prevent its implementation. conversely, professional groups may press for additional resources that compete for limited resources available to provide other needed health activities. both the professionals of the health system and the general public need full access to health-related information to take part in such debates in a constructive way. to maintain progress, a system must examine new technologies and justify their adoption or rejection (see chapter ). the association between health and political issues was emphasized by european innovators such as rudolf virchow (and in great britain by edwin chadwick; see chapter ) in the mid-nineteenth century, when the conditions of the working population were such that epidemic diseases were rife and mortality was high, especially in the crowded slums of the industrial revolution. the same observations led bismarck in germany to introduce early forms of social insurance for the health of workers and their families in the s, and to britain's national health insurance, also for workers and families. the role of government in providing universal access to health care was a struggle in individual countries during the twentieth century and lasting into the second decade of the twenty-first century (e.g. president obama's affordable health care act of ). as the concept of public health has evolved, and the cost effectiveness of medical care has improved through scientific and technological advances, societies have identified health as a legitimate area of activity for collective bargaining and government. with this process, the need to manage health care resources has become more clearly defined as a public responsibility. in industrialized countries, each with very different political make-up, national responsibility for universal access to health has become part of the social ethos. with that, the financing and managing of health services have developed into part of a broad concept of public health, and economics, planning, and management have come to be part of the new public health (discussed in chapters - ). social, ethical, and political philosophies have profound effects on policy decisions including allocation of public monies and resources. investment in public health is now recognized as an integral part of socioeconomic development. governments are major suppliers of funds and leadership in health infrastructure development, provision of health services, and health payment systems. they also play a central role in the development of health promotion and regulation of the environment, food, and drugs essential for community health. in liberal social democracies, the individual is deemed to have a right to health care. the state accepts responsibility to ensure availability, accessibility, and quality of care. in many developed countries, government has also taken responsibility to arrange funding and services that are equitably accessible and of high quality. health care financing may involve taxation, allocation, or special mandatory requirements on employers to pay for health insurance. services may be provided by a state-financed and -regulated service or through ngos and/or private service mechanisms. these systems allocate between percent and percent of gross national product (gnp) to health services, with some governments funding over percent of health expenditure; for example, canada and the uk. in communist states, the state organizes all aspects of health care with the philosophy that every citizen is entitled to equity in access to health services. the state health system manages research, staff training, and service delivery, even if operational aspects are decentralized to local health authorities. this model applied primarily to the soviet model of health services. these systems, except for cuba, placed financing of health low on the national priority, with funding less than percent of gnp. in the shift to market economies in the s, some former socialist countries, such as russia, are struggling with poor health status and a difficult shift from a strongly centralized health system to a decentralized system with diffusion of powers and responsibilities. promotion of market concepts in former soviet countries has reduced access to care and created a serious dilemma for their governments. former colonial countries, independent since the s and s, largely carried on the governmental health structures established in the colonial times. most developing countries have given health a relatively low place in budgetary allotment, with expenditures under percent of gnp. since the s, there has been a trend in developing countries towards decentralization of health services and greater roles for ngos, and the development of health insurance. some countries, influenced by medical concepts of their former colonial master countries, fostered the development of specialty medicine in the major centers with little emphasis on the rural majority population. soviet influence in many ex-colonial countries promoted state-operated systems. the who promoted primary care, but the allocations favored city-based specialty care. israel, as an ex-colony, adapted british ideas of public health together with central european sick funds and maternal and child health as major streams of development until the mid- s. a growing new conservatism in the s and s in the industrialized countries is a restatement of old values in which market economics and individualistic social values are placed above concepts of the "common good" of liberalism and socialism in its various forms. in the more extreme forms of this concept, the individual is responsible for his or her own health, including payment, and has a choice of health care providers that will respond with high-quality personalized care. market forces, meaning competition in financing and provision of health services with rationing of services, based on fees or private insurance and willingness and ability to pay, have become part of the ideology of the new conservatism. it is assumed that the patient (i.e., the consumer) will select the best service for his or her need, while the provider best able to meet consumer expectations will thrive. in its purest form, the state has no role in providing or financing of health services except those directly related to community protection and promotion of a healthful environment without interfering with individual choices. the state ensures that there are sufficient health care providers and allows market forces to determine the prices and distribution of services with minimal regulation. the usa retains this orientation in a highly modified form, with percent of the population covered by some form of private or public insurance systems (see chapters and ). modified market forces in health care are part of health reforms in many countries as they seek not only to ensure quality health care for all but also to constrain costs. a free market in health care is costly and ultimately inefficient because it encourages inflation of provider incomes or budgets and increasing utilization of highly technical services. further, even in the most free market societies, the economy of health care is highly influenced by many factors outside the control of the consumer and provider. the total national health expenditure in the usa rose rapidly until reaching over . percent of gross domestic product (gdp) in , the highest of any country, despite serious deficiencies for those without any or with very inadequate health insurance (in total more than percent of the population). this figure compares to some . percent of gdp in canada, which has universal health insurance under public administration. following the defeat of president clinton's national health program, the conservative congress and the business community took steps to expand managed care in order to control costs, resulting in a revolution in health care in the usa (see chapters and ). in the - decade health expenditure in the usa is expected to rise to . percent of gdp, partly owing to increased population coverage with implementation of the ppaca (obamacare). reforms are being implemented in many "socialized" health systems. these may be through incentives to promote achievement of performance indicators, such as full immunization coverage. others are using control of supply, such as hospital beds or licensed physicians, as methods of reducing overutilization of services that generates increasing costs. market mechanisms in health are aimed not only at the individual but also at the provider. incentive payment systems must work to protect the patient's legitimate needs, and conversely incentives that might reduce quality of care should be avoided. fee-for-service promotes high rates of services such as surgery. increasing private practice and user fees can adversely affect middle-and low-income groups, as well as employers, by raising the costs of health insurance. managed care systems, with restraints on fee-for-service medical practice, have emerged as a positive response to the market approach. incentive systems in payments for services may be altered by government or insurance agencies in order to promote rational use of services, such as reduction of hospital stays. the free market approach is affecting planning of health insurance systems in previously highly centralized health systems in developing countries as well as the redevelopment of health systems in former soviet countries. despite political differences, reform of health systems has become a common factor in virtually all health systems since the s, as each government searches for costeffectiveness, quality of care, and universality of coverage. the new paradigm of health care reform sees the convergence of different systems to common principles. national responsibility for health goals and health promotion leads to national financing of health care with regional and managed care systems. most developed countries have long since adopted national health insurance or service systems. some governments may, as in the usa, insure only the highest risk groups such as the elderly and the poor, leaving the working and middle classes to seek private insurers. the nature and direction of health care reform affecting coverage of the population are of central importance in the new public health because of its effects on allocation of resources and on the health of the population. the effects of the economic crisis in the usa are being felt worldwide. while the downturn has largely occurred in wealthier nations, the poor in low-income countries will be among those affected. past economic downturns have been followed by substantial drops in foreign aid to developing countries. as public health gained from sanitary and other control measures for infectious diseases, along with mother and child care, nutrition, and environmental and occupational health, it also gained strength and applicability from advances in the social and behavioral sciences. social darwinism, a political philosophy that assumed "survival of the fittest" and no intervention of the sate to alleviate this assumption, was popular in the early nineteenth century but became unacceptable in industrialized countries, which adopted social policies to alleviate the worst conditions of poverty, unemployment, poor education, and other societal ills. the political approach to focusing on health and poverty is associated with jeremy bentham in britain in the late eighteenth century, who promoted social and political reform and "the greatest good for the greatest number", or utilitarianism. rudolf virchow, an eminent pathologist and a leader in recognizing ill-health and poverty as cause and effect, called for political action to create better conditions for the poor and working-class population. the struggle for a social contract was promoted by pioneer reformists such as edwin chadwick (general report on the sanitary condition of the labouring population of great britain, ), who later became the first head of the board of health in britain, and lemuel shattuck (report of a general plan for the promotion of public and personal health, ) . shattuck was the organizer and first president of the american statistical association. the social sciences have become fundamental to public health, with a range of disciplines including vital statistics and demography (seventeenth century), economics and politics (nineteenth century), sociology (twentieth century), history, anthropology, and others, which provide collectively important elements of epidemiology of crucial significance for survey methods and qualitative research (see chapter ). these advances contributed greatly to the development of methods of studying diseases and risk factors in a population and are still highly relevant to addressing inequalities in health. individuals in good health are better able to study and learn, and be more productive in their work. improvements in the standard of living have long been known to contribute to improved public health; however, the converse has not always been recognized. investment in health care was not considered a high priority in many countries where economic considerations directed investment to the "productive" sectors such as manufacturing and large-scale infrastructure projects, such as hydroelectric dams. whether health is a contributor to economic development or a drain on societies' resources has been a fundamental debate between socially and market-oriented advocates. classic economic theory, both free enterprise and communist, has tended to regard health as a drain on economies, distracting investment needed for economic growth. as a result, in many countries health has been given low priority in budgetary allocation, even when the major source of financing is governmental. this belief among economists and banking institutions prevented loans for health development on the grounds that such funds should focus on creating jobs and better incomes, before investing in health infrastructure. consequently, the development of health care has been hampered. a socially oriented approach sees investment in health as necessary for the protection and development of "human capital", just as investment in education is needed for the long-term benefit of the economy of a country. in , the world bank's world development report: investing in health articulated a new approach to economics in which health, along with education and social development, is seen as an essential precondition for and contributor to economic development. while many in the health field have long recognized the importance of health for social and economic improvement, its adoption by leading international development banking may mark a turning point for investment in developing nations, so that health may be a contender for increased development loans. the concept of an essential package of services discussed in that report establishes priorities in low-and middle-income countries for efficient use of resources based on the burden of disease and cost-effectiveness analysis of services. it includes both preventive and curative services targeted to specific health problems. it also recommends support for comprehensive primary care, such as for children, and infrastructure development including maternity and hospital care, medical and nursing outreach services, and community action to improve sanitation and safe water supplies. reorientation of government spending on health is increasingly being adopted, as in the uk, to improve equity in access for the poor and other neglected sectors or regions of society with added funding for relatively deprived areas to improve primary care services. differential capitation funding as a form of affirmative action to provide for highneeds populations is a useful concept in public health terms to address the inequities still prevalent in many countries. as medical care has gradually become more involved in prevention, and as it has moved into the era of managed care, the gap between public health and clinical medicine has narrowed. as noted above, many countries are engaged in reforms in their health care systems. the motivation is largely derived from the need for cost containment, but also to extend health care coverage to underserved parts of the population. countries without universal health care still have serious inequities in distribution of or access to services, and may seek reform to reduce those inequities, perhaps under political pressures to improve the provision of services. incentives for reform are needed to address regional inequities, and preserving or developing universal access and quality of care, but also on inequities in health between the rich and the poor countries and within even the wealthy countries. in some settings, a health system may fail to keep pace with developments in prevention and in clinical medicine. some countries have overdeveloped medical and hospital care, neglecting important initiatives to reduce the risk of disease. the process of reform requires setting standards to measure health status and the balance of services to optimize health. a health service can set a target of immunizing percent of infants with a national immunization schedule, but requires a system to monitor performance and incentives for changes. a health system may also have failed to adapt to changing needs of the population through lack, or misuse, of health information and monitoring systems. as a result, the system may err seriously in its allocation of resources, with excessive emphasis on hospital care and insufficient attention to primary and preventive care. all health services should have mechanisms for correctly gathering and analyzing needed data for monitoring the incidence of disease and other health indicators, such as hospital utilization, ambulatory care, and preventive care patterns. for example, the uk's nhs periodically undertakes a restructuring process of parts of the system to improve the efficiency of service. this involves organizational changes and decentralization with regional allocation of resources (see chapter ). health systems are under pressures of changing demographic and epidemiological patterns as well as public expectations, rising costs of new technology, financing, and organizational change. new problems must be continually addressed with selection of priority issues and the most effective methods chosen. reforms may create unanticipated problems, such as professional or public dissatisfaction, which must be evaluated, monitored, and addressed as part of the evolution of public health. literacy, freedom of the press, and increasing public concern for social and health issues have contributed to the development of public health. the british medical community lobbied for restrictions on the sale of gin in the s in order to reduce the damage that it caused to the working class. in the late eighteenth and the nineteenth centuries, reforms in society and sanitation were largely the result of strongly organized advocacy groups influencing public opinion through the press. such pressure stimulated governments to act in regulating the working conditions of mines and factories. abolition of the slave trade and its suppression by the british navy in the early nineteenth century resulted from successful advocacy groups and their effects on public opinion through the press. vaccination against smallpox was promoted by privately organized citizen groups, until later taken up by local and national government authorities. advocacy consists of activities of individuals or groups publicly pleading for, supporting, espousing, or recommending a cause or course of action. the advocacy role of reform movements in the nineteenth century was the basis of the development of modern organized public health. campaigns ranged from the reform of mental hospitals, nutrition for sailors to prevent scurvy and beriberi, and labor laws to improve working conditions for women and children in particular, to the promotion of universal education and improved living conditions for the working population. reforms on these and other issues resulted from the stirring of the public consciousness by advocacy groups and the public media, all of which generated political decisions in parliaments (box . ). such reforms were in large part motivated by fear of revolution throughout europe in the mid-nineteenth century and the early part of the twentieth century. trade unions, and before them medieval guilds, fought to improve hours, safety, and conditions of work, as well as social and health benefits for their members. in the usa, collective bargaining through trade unions achieved wage increases and widespread coverage of the working population under voluntary health insurance. unions and some industries pioneered prepaid group practice, the predecessor of health maintenance organizations and managed care or the more recent acos (see chapters and ). through raising public consciousness on many issues, advocacy groups pressure governments to enact legislation to restrict smoking in public places, prohibit tobacco advertising, and mandate the use of bicycle helmets. advocacy groups play an important role in advancing health based on disease groups, such as cancer, multiple sclerosis, and thalassemia, or advancing health issues, such as the organizations promoting breastfeeding, environmental improvement, or smoking reduction. some organizations finance services or facilities not usually provided within insured health programs. such organizations, which can number in the hundreds in a country, advocate the importance of their special concern and play an important role in innovation and meeting community health needs. advocacy groups, including trade unions, professional groups, women's groups, self-help groups, and many others, focus on specific issues and have made major contributions to advancing the new public health. the history of public health is replete with pioneers whose discoveries led to strong opposition and sometimes violent rejection by conservative elements and vested interests in medical, public, or political circles. opposition to jennerian vaccination, the rejection of semmelweiss by colleagues in vienna, and the contemporary opposition to the work of great pioneers in public health such as pasteur, florence nightingale, and many others may deter or delay implementation of other innovators and new breakthroughs in preventing disease. although opposition to jenner's vaccination lasted well into the late nineteenth century in some areas, its supporters gradually gained ascendancy, ultimately leading to the global eradication of smallpox. these and other pioneers led the way to improved health, often after bitter controversy on topics later accepted and which, in retrospect, seem to be obvious. advocacy has sometimes had the support of the medical profession but elicited a slow response from public authorities. david marine of the cleveland clinic and david cowie, professor of pediatrics at the university of michigan, proposed the prevention of goiter by iodization of salt. marine carried out a series of studies in fish, and then in a controlled clinical trial among schoolgirls in - , with startlingly positive results in reducing the prevalence of goiter. cowie campaigned for the iodization of salt, with support from the medical profession. in , he convinced a private manufacturer to produce morton's iodized salt, which rapidly became popular throughout north america. similarly, iodized salt came to be used in many parts of europe, mostly without governmental support or legislation. iodine-deficiency disorders (idds) remain a widespread condition, estimated to have affected billion people worldwide in . the target of international eradication of idds by was set at the world summit for children in , and the who called for universal iodization of salt in . by , nearly percent of households in developing countries consumed adequately iodized salt. china and nigeria, have had great success in recent years with mandatory salt fortification in increasing iodization rates, in china from percent to percent in years. but the problem is not yet gone and even in europe there is inadequate standardization of iodine levels and population follow-up despite decades of work on the problem. professional organizations have contributed to promoting causes such as children's and women's health, and environmental and occupational health. the american academy of pediatrics has contributed to establishing and promoting high standards of care for infants and children in the usa, and to child health internationally. hospital accreditation has been used for decades in the usa, canada, and more recently in australia and the uk. it has helped to raise standards of health facilities and care by carrying out systematic peer review of hospitals, nursing homes, primary care facilities, and mental hospitals, as well as ambulatory care centers and public health agencies (see chapter ). public health needs to be aware of negative advocacy, sometimes based on professional conservatism or economic self-interest. professional organizations can also serve as advocates of the status quo in the face of change. opposition by the american medical association (ama) and the health insurance industry to national health insurance in the usa has been strong and successful for many decades. the passage of the ppaca has been achieved despite widespread political and public opposition, yet was sustained in the us supreme court and is gaining widening popular support as the added value to millions of formerly uninsured americans becomes clear. in some cases, the vested interest of one profession may block the legitimate development of others, such as when ophthalmologists lobbied successfully against the development of optometry, now widely accepted as a legitimate profession. political activism for reform in nineteenth-century britain led to banning and suppressing the slave trade, improvements in working conditions for miners and factory workers, and other major political reforms. in keeping with this tradition, samuel plimsoll ( - ), british member of parliament elected for derby in , conducted a solo campaign for the safety of seamen. his book, our seamen, described ships sent to sea so heavily laden with coal and iron that their decks were awash. seriously overloaded ships, deliberately sent to sea by unscrupulous owners, frequently capsized, drowning many crew members, with the owners collecting inflated insurance fees. overloading was the major cause of wrecks and thousands of deaths in the british shipping industry. plimsoll pleaded for mandatory load-line certificate markers to be issued to each ship to prevent any ships putting to sea when the marker was not clearly visible. powerful shipping interests fought him every inch of the way, but he succeeded in having a royal commission established, leading to an act of parliament mandating the "plimsoll line", the safe carrying capacity of cargo ships. this regulation was adopted by the us bureau of shipping as the load line act in and is now standard practice worldwide. jenner's discovery of vaccination with cowpox to prevent smallpox was adopted rapidly and widely. however, intense opposition by organized groups of antivaccinationists, often led by those opposed to government intervention in health issues and supported by doctors with lucrative variolation practices, delayed the implementation of smallpox vaccination for many decades. ultimately, smallpox was eradicated in , owing to a global campaign initiated by the who. opposition to legislated restrictions on private ownership of assault weapons and handguns is intense in the usa, led by well-organized, well-funded, and politically powerful lobby groups, despite the amount of morbidity and mortality due to gun-associated violent acts (see chapter ). fluoridation of drinking water is the most effective public health measure for preventing dental caries, but it is still widely opposed, and in some places the legislation has been rescinded even after implementation, by wellorganized antifluoridation campaigns. opposition to fluoridation of community water supplies is widespread, and effective lobbying internationally has slowed but has not stopped progress (see chapter ). despite the life-saving value of immunization, opposition still exists in and harms public health protection. opposition has slowed progress in poliomyelitis eradication; for example, radical islamists killed polio workers in northern nigeria in , one of the last three countries with endemic poliomyelitis. resistance to immunization in the s has resulted in the recurrence of pertussis and diphtheria and a very large epidemic of measles across western europe, including the uk, with further spread to the western hemisphere in - (see chapter ). progress may be blocked where all decisions are made in closed discussions, not subject to open scrutiny and debate. public health personnel working in the civil service of organized systems of government may not be at liberty to promote public health causes. however, professional organizations may then serve as forums for the essential professional and public debate needed for progress in the field. professional organizations such as the apha provide effective lobbying for the interests of public health programs and can have an important impact on public policy. in mid- , efforts by the secretary of health and human services in the usa brought together leaders of public health with representatives of the ama and academic medical centers to try to find areas of common interest and willingness to promote the health of the population. in europe too, increasing cooperation between public health organizations is stimulating debate on issues of transnational importance across the region, which, for example, has a wide diversity of standards on immunization practices and food policies. public advocacy has played an especially important role in focusing attention on ecological issues (box . ). in , greenpeace, an international environmental activist group, fought to prevent the dumping of an oil rig in the north sea and forced a major oil company to find another solution that would be less damaging to the environment. an explosion on an oil rig in the gulf of mexico in led to enormous ecological and economic damage as well as loss of life. damages levied on the responsible company (british petroleum) amount to some $ . billion dollars and several criminal negligence charges are pending. greenpeace also continued its efforts to stop the renewal of testing of atomic bombs by france in the south pacific. international protests led to the cessation of almost all testing of nuclear weapons. international concern over global warming has led to growing efforts to stem the tide of air pollution from fossil fuels, coal-burning electrical production, and other manifestations of carbon dioxide and toxic contamination of the environment. progress is far from certain as newly enriched countries such as china and india follow the rising consumption patterns of western countries. public advocacy and rejection of wanton destruction of the global ecology may be the only way to prod consumers, governments, and corporate entities such as the energy and transportation industries to change direction. the pace of change from fossil fuels is slow but has captured public attention, and private companies are seeking more fuel efficiency in vehicles and electrical power production, mainly though the use of natural gas instead of fuel oil and coal for electricity production or better still by wind and solar energy. the search for "green solutions" to the global warming crisis has become increasingly dynamic, with governments, the private sector, and the general public keenly aware of the importance of the effort and the dangers of failure. in the latter part of the twentieth century and the early twenty-first century, prominent international personalities and entertainers have taken up causes such as the removal of land mines in war-torn countries, illiteracy in disadvantaged advocacy is a function in public health that has been important in promoting advances in the field, and one that sometimes places the advocate in conflict with established patterns and organizations. one of the classic descriptions of this function is in henrik ibsen's play an enemy of the people, in which the hero, a young doctor, thomas stockmann, discovers that the water in his community is contaminated. this knowledge is suppressed by the town's leadership, led by his brother the mayor, because it would adversely affect plans to develop a tourist industry of baths in their small norwegian town in the late nineteenth century. the young doctor is taunted and abused by the townspeople and driven from the town, having been declared an "enemy of the people" and a potential risk. the allegory is a tribute to the man of principle who stands against the hysteria of the crowd. the term also took on a far more sinister and dangerous meaning in george orwell's novel and in totalitarian regimes of the s to the present time. populations, and funding for antiretroviral drugs for african countries to reduce maternal-fetal transmission of hiv and to provide care for the large numbers of cases of aids devastating many countries of sub-saharan africa. rotary international has played a key role in polio eradication efforts globally. the public-private consortium global alliance for vaccines and immunization (gavi) has been instrumental in promoting immunization in recent years, with participation by the who, unicef, the world bank, the gates foundation, vaccine manufacturers, and others. this has had an important impact on extending immunization to protect and save the lives of millions of children in deprived countries not yet able to provide fundamental prevention programs such as immunization at adequate levels. gavi has brought vaccines to low-income countries around the world, such as rotavirus vaccine, pentavalent vaccine in myanmar, and pneumococcal vaccine for children in countries in sub-saharan africa, including dr congo. the bill & melinda gates foundation pledged us $ million in to establish gavi, with us $ million per year and us $ billion in to promote the decade of vaccines. international conferences help to create a worldwide climate of advocacy for health issues. international sanitary conferences in the nineteenth century were convened in response to the cholera epidemics. international conferences continue in the twenty-first century to serve as venues for advocacy on a global scale, bringing forward issues in public health that are beyond the scope of individual nations. the who, unicef, and other international organizations perform this role on a continuing basis (see chapter ). criticisms of this approach have focused on the lack of similar effort or donors to address ncds, weak public health infrastructure, and that this frees national governments from responsibility to care for their own children. no one can question, however, that this kind of endeavor has saved countless lives and needs the backing of other aid donors and national government participation. consumerism is a movement that promotes the interests of the purchaser of goods or services. in the s, a new form of consumer advocacy emerged from the civil rights and antiwar movement in the usa. concern was focused on the environment, occupational health, and the rights of the consumer. rachel carson stimulated concern by dramatizing the effects of ddt on wildlife and the environment but inadvertently jeopardized anti-malarial efforts in many countries. this period gave rise to environmental advocacy efforts worldwide, and a political movement, the greens, in western europe. ralph nader showed the power of the advocate or "whistle-blower" who publicizes health hazards to stimulate active public debate on a host of issues related to the public well-being. nader, a consumer advocate lawyer, developed a strategy for fighting against business and government activities and products which endangered public health and safety. his book unsafe at any speed took issue with the us automobile industry for emphasizing profit and style over safety, and led to the enactment of the national traffic and motor safety act of , establishing safety standards for new cars. this was followed by a series of enactments including design and emission standards and seat-belt regulations. nader's work continues to promote consumer interests in a wide variety of fields, including the meat and poultry industries, and coal mining, and promotes greater government regulatory powers regarding pesticide usage, food additives, consumer protection laws, rights to knowledge of contents, and safety standards. consumerism has become an integral part of free market economies, and the educated consumer does influence the quality, content, and price of products. greater awareness of nutrition in health has influenced food manufacturers to improve packaging, content labeling, enrichment with vitamins and minerals, and advertisement to promote those values. low-fat dietary products are available because of an increasingly sophisticated public concerned over dietary factors in cardiovascular diseases. the same process occurred in safe toys and clothing for children, automobile safety features such as mandatory use of car seats for infants, and other innovations that quickly became industry standards in the industrialized world. dangerous practices such as the use of lead paint in toys and melamine contamination of milk products from china capture the public attention quickly and remind public health authorities of the importance of continuous alertness to potential hazards. consumerism can also be exploited by pharmaceutical companies with negative impacts on the health system, especially in the advertising of health products which leads to unnecessary visits to health providers and pressure for approval to obtain the product. the internet has provided people with access to a vast array of information and opinion, and to current literature otherwise unavailable because of the often inadequate library resources of medical and other health professionals. the very freedom of information the internet allows, however, also provides a vehicle for extremist and fringe groups to promote disinformation such as "vaccination causes autism, fluoridation causes cancer", which can cause considerable difficulties for basic public health programs or lead to self-diagnosis of conditions, with often disastrous consequences. advocacy and voluntarism go hand in hand. voluntarism takes many forms, including raising funds for the development of services or operating services needed in the community. it may take the form of fund-raising to build clinics or hospitals in the community, or to provide medical equipment for elderly or handicapped people; or retirees and teenagers working as hospital volunteers to provide services that are not available through paid staff, and to provide a sense of community caring for the sick in the best traditions of religious or municipal concerns. this can also be extended to prevention, as in support for immunization programs, assistance for the handicapped and elderly in transportation, meals-on-wheels, and many other services that may not be included in the "basket of services" provided by the state, health insurance, or public health services. community involvement can take many forms, and so can voluntarism. the pioneering role of women's organizations in promoting literacy, health services, and nutrition in north america during the latter part of the nineteenth and the early twentieth centuries profoundly affected the health of the population. the advocacy function is enhanced when an organization mobilizes voluntary activity and funds to promote changes or needed services, sometimes forcing official health agencies or insurance systems to revise their attitudes and programs to meet these needs. by the early s, canada's system of federally supported provincial health insurance plans covered all of the country. the federal minister of health, marc lalonde, initiated a review of the national health situation, in view of concern over the rapidly increasing costs of health care. this led to articulation of the "health field concept" in , which defined health as a result of four major factors: human biology, environment, behavior, and health care organization (box . ). lifestyle and environmental factors were seen as important contributors to the morbidity and mortality in modern societies. this concept gained wide acceptance, promoting new initiatives that emphasized health promotion in response to environmental and lifestyle factors. conversely, reliance primarily on medical care to solve all health problems could be counterproductive. this concept was a fundamental contributor to the idea of health promotion later articulated in the ottawa declaration, discussed below. the health field concept came at a time when many epidemiological studies were identifying risk factors for cardiovascular diseases and cancers that related to personal habits, such as diet, exercise, and smoking. the concept advocated that public policy needed to address individual lifestyle as part of the overall effort to improve health status. as a result, the canadian federal government established health promotion as a new activity. this quickly spread to many other jurisdictions and gained wide acceptance in many industrialized countries. concern was expressed that this concept could become a justification for a "blame the victim" approach, in which those ill with a disease related to personal lifestyles, such as smokers or aids patients, are seen as having chosen to contract the disease. such a patient might then be considered not to be entitled to all benefits of insurance or care that others may receive. the result may be a restrictive approach to care and treatment that would be unethical in the public health tradition and probably illegal in western jurisprudence. this concept was also used to justify withdrawal from federal commitments in cost sharing and escape from facing controversial health reform in the national health insurance program. during the s and s, outspoken critics of health care systems, such as ivan illytch, questioned the value of medical care for the health of the public. this became a widely discussed, somewhat nihilistic, view towards medical care, and was influential in promoting skepticism regarding the value of the biomedical mode of health care, and antagonism towards the medical profession. in , thomas mckeown presented a historicalepidemiological analysis showing that up to the s, medical care had only a limited impact on mortality rates, although improvements in surgery and obstetrics were notable. he showed that crude death rates in england averaged about per population from to , declining steeply to per in , per in , and per in , when medical care became truly effective. mckeown concluded that much of the improvement in health status over the past several centuries was due to reduced mortality from infectious diseases. this he related to limitation of family size, increased food supplies, improved nutrition and sanitation, specific preventive and therapeutic measures, and overall gains in quality of life for growing elements of the population. he cautioned against placing excessive reliance for health on medical care, much of which was of unproved effectiveness. this skepticism of the biomedical model of health care was part of wider antiestablishment feelings of the s and s in north america. in , milton roemer pointed out that the advent of vaccines, antibiotics, antihypertensives, and other medications contributed to great improvements in infant and child care, and in the management of infectious diseases, hypertension, diabetes, and other conditions. therapeutic gains continue to arrive from teaching centers around the world. vaccine, pharmaceutical, and diagnostic equipment manufacturers continue to provide important innovations that have major benefits, but also raise the cost of health care. the latter issue is one which has stimulated the search for reforms, and search for lower cost technologies such as in treatment of hepatitis c patients, a huge international public health issue. the value of medical care to public health and vice versa has not always been clear, either to public health personnel or to clinicians. the achievements of modern public health in controlling infectious diseases, and even more so in reducing the mortality and morbidity associated with chronic diseases such as stroke and chd, were in reality a shared achievement between clinical medicine and public health (see chapter ). preventive medicine has become part of all medical practice, with disease prevention through early diagnosis and health promotion through individual and community-focused activities. risk factor evaluation determines appropriate screening and individual and community-based interventions. medical care is crucial in controlling hypertension and in reducing the complications and mortality from chd. new modalities of treatment are reducing death rates from first time acute myocardial infarctions. better management of diabetes prevents the early onset of complications. at the same time, the contribution of public health to improving outcomes of medical care is equally important. control of the vaccine-preventable diseases, improved nutrition, and preparation for motherhood contribute to improved maternal and infant outcomes. promotions of reduced exposure to risk factors for chronic disease are a task shared by public health and clinical medical services. both clinical medicine and public health contribute to improved health status. they are interdependent and rely on funding systems for recognition as part of the new public health. during the s, many new management concepts emerged in the business community, such as "management by objective", a concept developed by peter drucker at general motors, with variants such as "zero-based budgeting" developed in the us department of defense (see chapter ). they focused the activities of an organization and its budget on targets, rather than on previous allocation of resources. these concepts were applied in other spheres, but they influenced thinking in health, whose professionals were seeking new ways to approach health planning. the logical application was to define health targets and to promote the efficient use of resources to achieve those targets. this occurred in the usa and soon afterwards in the who european region. in both cases, a wide-scale process of discussion and consensus building was used before reaching definitive targets. this process contributed to the adoption of the targets by many countries in europe as well as by states and many professional and consumer organizations. the usa developed national health objectives in for the year and subsequently for the year , with monitoring of progress in their achievement and development of further targets for and now for . beginning in , state health profiles are prepared by the epidemiology program office of the centers for disease control and prevention based on health indicators recommended by a consensus panel representing public health associations and organizations. the eight mdgs adopted by the un in include halving extreme poverty, reducing child mortality by twothirds, improving maternal health, halting the spread of hiv/aids, malaria, and other diseases, and providing universal primary education, all by the target date of . the mdgs form a common blueprint agreed to by all countries and the world's leading development institutions. the process has galvanized unprecedented efforts to meet the needs of the world's poorest, yet reviews of progress indicate that most developing nations will not meet the targets at current rates of progress. the united nations development programme (undp) global partnership for development report on the mdgs states that if the national development strategies and initiatives are supported by international development partners, the goals can be achieved by . the mdgs were adopted by over nations and provided guidance for national policies and for international aid agencies. the focus was on middle-and low-income countries and their achievements have been considerable but variable (see box . and chapter ) . as of july , extreme poverty was falling in every region, the poverty reduction target had been met, the world had met the target of halving the proportion of people without access to improved sources of water, and the world had achieved parity in primary education between girls and boys. further progress will require sustained political commitment to develop the primary care infrastructure: improved reporting and epidemiological monitoring, consultative mechanisms, and consensus by international agencies, national governments, and non-governmental agencies. the achievement of the targets will also require sustained international support and national commitment with all the difficulties of a time of economic recession. nevertheless, defining a target is crucial to the process. there are encouraging signs that national governments are influenced by the general movement to place greater emphasis on resource allocation and planning on primary care to achieve internationally recognized goals and targets. the successful elimination of smallpox, rising immunization coverage in the developing countries, and increasing implementation of salt iodization have shown that such goals are achievable. while the usa has not succeeded in developing universal health care access, it has a strong tradition of public health and health advocacy. federal, state, and local health authorities have worked out cooperative arrangements for financing and supervising public health and other services. with growing recognition in the s that medical services alone would not achieve better health results, health policy leadership in the federal government formulated a new approach, in the form of developing specific health targets for the nation. in , the surgeon general of the usa published the report on health promotion and disease prevention (healthy people). this document set five overall health goals for each of the major age groups for the year , accompanied by specific health objectives. new targets for the year were developed in three broad areas: to increase healthy lifespans, to reduce health disparities, and to achieve access to preventive health care for all americans. these broad goals are supported by specific targets in health priority areas, each one divided into four major categories: health promotion, health protection, preventive services, and surveillance systems. this set the public health agenda on the basis of measurable indicators that can be assessed year by year. reduce child mortality -progress on child mortality is gaining momentum. the target is to reduce by two-thirds, between and , the under- -year-old mortality rate, from children of every dying to of every . child deaths are falling, but much more needs to be done in order to reach the development goal. revitalizing efforts against pneumonia and diarrhea, while bolstering nutrition, could save millions of children. l mdg . improve maternal health -maternal mortality has nearly halved since , but levels are far removed from the target. the targets for improving maternal health include reducing by three-quarters the maternal mortality ratio and achieve universal access to reproductive health. poverty and lack of education perpetuate high adolescent birth rates. inadequate funding for family planning is a major failure in fulfilling commitments to improving women's reproductive health. l mdg . combat hiv/aids, malaria, tuberculosis, and other diseases -more people than ever are living with hiv owing to fewer aids-related deaths and the continued large number of new infections. in , an estimated . million were living with hiv, up percent from . this persistent increase reflects the continued large number of new infections along with a significant expansion of access to lifesaving antiretroviral therapy, especially in more recent years. l mdg . ensure environmental sustainability -the unparalleled success of the montreal protocol shows that action on climate change is within grasp. the th anniversary of the montreal protocol on substances that deplete the ozone layer, in , had many achievements to celebrate. most notably, there has been a reduction of over percent in the consumption of ozone-depleting substances. further, because most of these substances are also potent greenhouse gases, the montreal protocol has contributed significantly to the protection of the global climate system. the reductions achieved to date leave hydrochlorofluorocarbons (hcfcs) as the largest group of substances remaining to be phased out. l mdg . a global partnership for development -core development aid fell in real terms for the first time in more than a decade, as donor countries faced fiscal constraints. in , net aid disbursements amounted to $ . billion, representing . percent of developed countries' combined national income. while constituting an increase in absolute dollars, this was a . percent drop in real terms over . if debt relief and humanitarian aid are excluded, bilateral aid for development programmes and projects fell by . percent in real terms. equitable and sustainable funding of health services. . developing human resources (educational programs for providers and managers based on the principles of the health for all policy). . research and knowledge: health programs based on scientific evidence. . mobilizing partners for health (engaging the media/ television/internet). . policies and strategies for health for all -national, targeted policies based on health for all. a - review has been commissioned by the european office of the who to assess inequalities in the social determinants of health. while health has improved there are still significant inequalities. factors include variance in local, regional, national, and global economic forces. the european union and the european region of who are both working on health targets for the year . there are competing demands in society for expenditure by the government, and therefore making the best use of resources -money and people -is an important objective. the uk has devolved many of the responsibilities to the constituent countries (england, wales, scotland, and northern ireland) within an overall national framework (box . ). of the health consequences of their decisions and to accept responsibility for health. health promotion policy combines diverse but complementary approaches, including legislation, fiscal measures, taxation, and organizational change. it is a coordinated action that leads to health, income, and social policies that foster greater equity. joint action contributes to ensuring safer and healthier goods and services, healthier public services, and cleaner, more enjoyable environments. health promotion policies require the identification of obstacles to the adoption of healthy public policies in non-health sectors, and ways of removing them. built on progress made from the declaration on primary health care at alma-ata, the aim was to make the healthier choice the easier choice for policy makers as well. the logo of the ottawa charter has been maintained by the who as the symbol and logo of health promotion. health promotion represents activities to enhance and embed the concept of building healthy public policy through: l building healthy public policy in all sectors and levels of government and society l enhancing both self help and social support l developing personal skills through information and education for health l enabling, mediating, and advocating healthy public policy in all spheres l creating supportive environments of mutual help and conservation of the natural environment l reorienting health services beyond providing clinical curative services with linkage to broader social, political, economic, and physical environmental components. (adapted from ottawa charter; health and welfare canada and world health organization, ) an effective approach to health promotion was developed in australia where, in the state of victoria, revenue from a cigarette tax has been set aside for health promotion purposes. this has the effect of discouraging smoking, and at the same time finances health promotion activities and provides a focus for health advocacy in terms of promoting cessation of cigarette advertising at sports events or on television. it also allows for assistance to community groups and local authorities to develop health promotion activities at the workplace, in schools, and at places of recreation. health activity in the workplace involves reduction of work hazards as well as promotion of a healthy diet and physical fitness, and avoidance of risk factors such as smoking and alcohol abuse. in the australian model, health promotion is not only the persuasion of people to change their life habits; it also involves legislation and enforcement towards environmental changes that promote health. for example, this involves mandatory filtration, chlorination, and fluoridation for community water supplies, vitamin and mineral enrichment of basic foods. primary care alliances of service providers are organized including hospitals, community health services serving a sub-district population for more efficient and comprehensive care. these are at the level of national or state policy, and are vital to a health promotion program and local community action. community-based programs to reduce chronic disease using the concept of community-wide health promotion have developed in a wide variety of settings. such a program to reduce risk factors for cardiovascular disease was pioneered in the north karelia project in finland. this project was initiated as a result of pressures from the affected population of the province, which was aware of the high incidence of mortality from heart disease. finland had the highest rates of chd in the world and in the rural area of north karelia the rate was even higher than the national average. the project was a regional effort involving all levels of society, including official and voluntary organizations, to try to reduce risk factors for chd. after years of follow-up, there was a substantial decline in mortality with a similar decline in a neighboring province taken for comparison, although the decline began earlier in north karelia. in many areas where health promotion has been attempted as a strategy, community-wide activity has developed with participation of ngos or any valid community group as initiators or participants. healthy heart programs have developed widely with health fairs, sponsored by charitable or fraternal societies, schools, or church groups, to provide a focus for leadership in program development. a wider approach to addressing health problems in the community has developed into an international movement of "healthy cities". following deliberations of the health of towns commission chaired by edwin chadwick, the health of towns association was founded in by southwood smith, a prominent reform leader of the sanitary movement, to advocate change to reduce the terrible living conditions of much of the population of cities in the uk. the association established branches in many cities and promoted sanitary legislation and public awareness of the "sanitary idea" that overcrowding, inadequate sanitation, and absence of safe water and food created the conditions under which epidemic disease could thrive. in the s, iona kickbush, trevor hancock, and others promoted renewal of the idea that local authorities have a responsibility to build health issues into their planning and development processes. this "healthy cities" approach promotes urban community action on a broad front of health promotion issues (table . ). activities include environmental projects (such as recycling of waste products), improved recreational facilities for young people to reduce violence and drug abuse, health fairs to promote health awareness, and screening programs for hypertension, breast cancer, and other diseases. it combines health promotion with consumerism and returns to the tradition of local public health action and advocacy. the municipality, in conjunction with many ngos, develops a consultative process and program development approach to improving the physical and social life of the urban environment and the health of the population. in , the healthy cities movement involved countries with cities in europe, canada, the usa, the uk, south america, israel, and australia, an increase from cities in . the model now extends to small municipalities, often with populations of fewer than , . networks of healthy cities are the backbone of the movement, with more than member towns and cities across europe. the choice of core themes offers the opportunity to work on priority urban health issues that are relevant to all european cities. topics that are of particular concern to individual cities and/or are challenging and cutting edge for innovative public health action are especially emphasized. healthy cities encourages and supports experimentation with new ideas by developing concepts and implementing them in diverse organizational contexts. a healthy city is a city for all its citizens: inclusive, supportive, sensitive and responsive to their diverse needs and expectations. a healthy city provides conditions and opportunities that encourage, enable and support healthy lifestyles for people of all social groups and ages. a healthy city offers a physical and built environment that encourages, enables and supports health, recreation and well-being, safety, social interaction, accessibility and mobility, a sense of pride and cultural identity and is responsive to the needs of all its citizens. the apha's formulation of the public health role in , entitled the future of public health in america, was presented at the annual meeting in . the apha periodically revises standards and guidelines for organized public health services provided by federal, state, and local governments ( table . ). these reflect the profession of public health as envisioned in the usa where access to medical care is limited for large numbers of the population because of a lack of universal health insurance. public health in the usa has been very innovative in determining risk groups in need of special care and finding direct and indirect methods of meeting those needs. european countries such as finland have called for setting public health into all public policy, which reflects the vital role that local and county governments can play in developing health-oriented policies. these include policies in housing, recreation, regulation of industrial pollution, road safety, promotion of smoke-free environments, bicycle paths, health impact assessment, and many other applications of health principles in public policy. public health involves both direct and indirect approaches. direct measures in public health include immunization of children, modern birth control, and chronic disease case finding -hypertension, diabetes, and cancer. indirect methods used in public health protect the individual by community-wide means, such as raising standards of environmental safety, ensuring a safe water supply, sewage disposal, and improved nutrition (box . ). in public health practice, the direct and indirect pproaches are both relevant. to reduce morbidity and mortality from diarrheal diseases requires an adequate supply of safe water and waste disposal, and also education of the individual in hygiene and the mother in use of ort, and rotavirus vaccination of all children. the targets of public health action therefore include the individual, family, community, region, or nation, as well as a functioning and health system adopting current best practices for health care and health protection. the targets for protection in infectious disease control are both the individual and the total group at risk. for vaccine-preventable diseases, immunization protects the individual but also has an indirect effect by reducing the risk even for non-immunized persons. in control of some diseases, individual case finding and management reduce risk of the disease in others and the community. for example, tb requires case finding and adequate care among high-risk groups as a key to community control. in malaria control, case finding and treatment are essential together with environmental action to reduce the vector population, to prevent transmission of the organism by the mosquito to a new host. control of ncds, where there is no vaccine for mass application, depends on the knowledge, attitudes, beliefs, and practices of individuals at risk. in this case, the social context is of importance, as is the quality of care to which the individual has access. control and prevention of noninfectious diseases involve strategies using individual and population-based methods. individual or clinical measures include professional advice on how best to reduce the risk of the disease by early diagnosis and implementation of appropriate therapy. population-based measures involve indirect measures with government action banning cigarette advertising, or direct taxation on cigarettes. mandating food quality standards, such as limiting the fat content of meat, and requiring food labeling laws are part of the control of cardiovascular diseases. the way individuals act is central to the objective of reducing disease, because many non-infectious diseases are dependent on behavioral risk factors of the individual's choosing. changing the behavior of the individual means addressing the way a person sees his or her own needs. this can be influenced by the provision of information, but how someone sees his or her own needs is more complex than that. an individual may define needs differently from the society or the health system. reducing smoking among women may be difficult to achieve if smoking is thought to reduce appetite and food intake, given the social message that "slim is beautiful". reducing smoking among young people is similarly difficult if smoking is seen as fashionable and diseases such as lung cancer seem very remote. recognizing how individuals define needs helps the health system to design programs that influence behavior that is associated with disease. public health has become linked to wider issues as health care systems are reformed to take on both individual and population-based approaches. public health and mainstream medicine have found increasingly common ground in addressing the issues of chronic disease, growing attention to health promotion, and economics-driven health care reform. at the same time, the social ecology approaches have shown success in slowing major causes of disease, including heart disease and aids, and the biomedical sciences have provided major new technology for preventing major health problems, including cancer, heart disease, genetic disorders, and infectious diseases. technological innovations unheard of just a few years ago are now commonplace, in some cases driving up costs of care and in others replacing older and less effective care. at the same time, resistance of important pathogenic microorganisms to antibiotics and pesticides is producing new challenges from diseases once thought to be under control, and newly emerging infectious diseases challenge the entire health community. new generations of antibiotics, antidepressants, antihypertensive medications, and other treatment methods are changing the way many conditions are treated. research and development in the biomedical to improve the quality of public health practice and performance of public health systems sciences are providing means of prevention and treatment that profoundly affect disease patterns where they are effectively applied. the technological and organizational revolutions in health care are accompanied by many ethical, economic, and legal dilemmas. the choices in health care include heart transplantation, an expensive life-saving procedure, which may compete with provision of funds and labor resources for immunizations for poor children or for health promotion to reduce smoking and other risk factors for chronic disease. new means of detecting and treating acute conditions such as myocardial infarction and peptic ulcers are reducing hospital stays, and improving long-term survival and quality of life. imaging technology has been an important development in medicine since the advent of x-rays in the early twentieth century. technology has forged ahead with high-technology instruments and procedures, new medication, genetic engineering, and important low-technology gains such as impregnated bed nets, simplified tests for hiv and tb, and many other "game changers". new technologies that can enable lower cost diagnostic devices, electronic transmission, and distant reading of transmitted imaging all open up possibilities for advanced diagnostic capacities in rural and less developed countries and communities. molecular biology has provided methods of identifying and tracking movement of viruses such as polio and measles from place to place, greatly expanding the potential for appropriate intervention. the choices in resource allocation can be difficult. in part, these add political commitment to improve health, competent professionally trained public health personnel, the public's level of health information, and legal protection, whether through individuals, advocacy, or regulatory approaches for patients' rights. these are factors in a widening methodology of public health. the centers for disease control and prevention (morbidity and mortality weekly report) in summarized great achievements of public health in the usa, with an extension of the lifespan by over years and improvements in many measures of quality of life. they were updated in a similar summary report in , showing continuous progress, and a global version which was also encouraging in its scope of progress (table . ). these achievements were also seen in all developed countries over the past century and are beginning to be seen in developing countries as well. they reflect a successful application of a broad approach to prevention and health promotion along with improved medical care and growing access to its benefits. in the past several decades alone, major new innovations are leading to greater control of cardiovascular disease, cancer prevention, and many other improvements to health affecting hundreds of millions of people. a similar report by the cdc shows global progress in the first decade of the twenty-first century, while mdg reports show progress on all eight target topics, although not at uniformly satisfactory rates. these achievements are discussed throughout this text. this successful track record is very much at the center of a new public health involving a wide range of programs and activities, shown to be feasible and benefiting from continuing advances in science and understanding of social and management issues affecting health care systems worldwide. public health issues have received new recognition in recent years because of a number of factors, including a growing understanding among the populace at different levels in different countries that health behavior is a factor in health status and that public health is vital for protection against natural or human-made disasters. the challenges are also increasingly understood: preparation for bioterrorism, avian influenza, rising rates of diabetes and obesity, high mortality rates from cancer, and a wish for prevention to be effective. health systems offer general population benefits that go beyond preventing and treating illness. appropriately designed and managed, they: l provide a vehicle to improve people's lives, protecting them from the vulnerability of sickness, generating a sense of life security, and building common purpose within society l ensure that all population groups are included in the processes and benefits of socioeconomic development l generate the political support needed to sustain them over time. health systems promote health equity when their design and management specifically consider the circumstances and needs of socially disadvantaged and marginalized populations, including women, the poor, and groups who experience stigma and discrimination, enabling social action by these groups and the civil society organizations supporting them. health systems can, when appropriately designed and managed, contribute to achieving the millennium development goals. the mdgs selected by the un in have eight global targets for the year , including four directly related to public health (discussed above, box . ). these are a recognition and a challenge to the international community and public health as a profession and as organized systems. formal education in newly developing schools of public health is increasing in europe, including many countries of eastern europe, and beginning to develop in india and sub-saharan africa. but there is delay in establishing centers of postgraduate education and research in many developing countries which are concentrating their educational resources on training physicians. many physicians from developing nations are moving to the developed countries, which have become dependent on these countries for a significant part of their supply of medical doctors. progress in implementation of the mdgs is mixed in sub-saharan africa, making some progress in immunization, but falling back on other goals. proposals to renew global health targets following the end-stage of the mdg health goals will need to add a focus on ncds, which account for percent of global deaths, including . million premature deaths below the age of (undp). economic growth has been hampered by the global recession since , which will affect continued progress with many other factors of changing population dynamics, the economics of prevention versus expensive treatment costs, and the high costs of health care. environmental degradation with high levels of carbon dioxide contamination is a growing concern, with disastrous global warming and consequent effects of drought, flooding, hurricane, and elevated particulate matter-induced asthma and effects on cardiovascular disease. the potential for the development of basic and medical sciences in genetics, nanotechnology, and molecular biology shows enormous promise for health benefits as yet unimagined. at the same time, the effectiveness of health promotion has shown dramatic successes in reducing the toll of aids, reducing smoking, and increasing consciousness of nutrition and physical fitness in the population, and of the tragic effects of poverty and poor education on health status. the ethics of public health issues are complex and changing with awareness that failure to act on strong evidence-based policies is itself ethically problematic. the future of public health is not as a solo professional sector; it is at the heart of health systems, without which societies are open to chronic and infectious diseases that are preventable, affecting the society as a whole in economic and development matters. there is an expanding role of private donors in global health efforts, such as the rotary club and the polio eradication program, gavi with immunization and bed-nets in sub-saharan africa, and bilateral donor countries' help in reducing the toll of aids in sub-saharan africa. the new public health has emerged as a concept to meet a whole new set of conditions, associated with increasing longevity and aging of the population, with the post-world war ii baby-boom generation reaching the over- age group facing the growing importance of chronic diseases. inequalities in health exist in and between affluent and developing societies, as well as within countries, even those having advanced health care systems. regional inequalities are seen across the european region in an east-west gradient and globally a north-south divide of extremes of inequality. the global environmental and ecological degradation and pollution of air and water present grave challenges for developed and developing countries worldwide. yet optimism can be derived from proven track records of success in public health measures that have already been implemented. many of the underlying factors are amenable to prevention through social, environmental, or behavioral change and effective use of medical care. the new public health idea has evolved since alma-ata, which articulated the concept of health for all, followed by a trend in the late s to health in all policies and establishing health targets as a basis for health planning. during the late s and early s, the debate on the future of public health in the americas intensified as health professionals looked for new models and approaches to public health research, training, and practice. this debate helped to redefine traditional approaches of social, community, and preventive medicine. the search for the "new" in public health continued with a return to the health for all concept of alma-ata (renewed in ) and a growing realization that the health of both the individual and the society involves the management of personal care services and community prevention, with a comprehensive approach taking advantage of advancing technology and experience of best practices globally. the new public health is an extension of the traditional public health. it describes organized efforts of society to develop healthy public policies: to promote health, to prevent disease, and to foster social equity within a framework of sustainable development. a new, revitalized public health must continue to fulfill the traditional functions of sanitation, protection, and related regulatory activities, but in addition to its expanded functions. it is a widened philosophy and practical application of many different methods of addressing health, and preventing disease and avoidable death. it necessarily addresses inequities so that programs need to meet special needs of different groups in the population according to best standards, limited resources, and population needs. it is proactive and advocates interventions within legal and ethical limits to promote health as a value in and of itself and as an economic gain for society as well for its individual members. the new public health is a comprehensive approach to protecting and promoting the health status of the individual and the society, based on a balance of sanitary, environmental, health promotion, personal, and community-oriented preventive services, coordinated with a wide range of curative, rehabilitative, and long-term care services. it evolves with new science, technology, and knowledge of human and systems behavior to maximize health gains for the individual and the population. the new public health requires an organized context of national, regional, and local governmental and non-governmental programs with the object of creating healthful social, nutritional, and physical environmental conditions. the content, quality, organization, and management of component services and programs are all vital to its successful implementation. whether managed in a diffused or centralized structure, the new public health requires a systems approach acting towards achievement of defined objectives and specified targets. the new public health works through many channels to promote better health. these include all levels of government and parallel ministries; groups promoting advocacy, academic, professional, and consumer interests; private and public enterprises; insurance, pharmaceutical, and medical products industries; the farming and food industries; media, entertainment, and sports industries; legislative and law enforcement agencies; and others. the new public health is based on responsibility and accountability for defined populations in which financial systems promote achievement of these targets through effective and efficient management, and cost-effective use of financial, human, and other resources. it requires continuous monitoring of epidemiological, economic, and social aspects of health status as an integral part of the process of management, evaluation, and planning for improved health. the new public health provides a framework for industrialized and developing countries, as well as countries in political-economic transition such as those of the former soviet system. they are at different stages of economic, epidemiological, and sociopolitical development, each attempting to ensure adequate health for its population with limited resources. the challenges are many, and affect all countries with differing balances, but there is a common need to seek better survival and quality of life for their citizens (table . ). the object of public health, like that of clinical medicine, is better health for the individual and for society. public health works to achieve this through indirect methods, such as by improving the environment, or through direct means such as preventive care for mothers and infants or other atrisk groups. clinical care focuses directly on the individual patient, mostly at the time of illness. but the health of the individual depends on the health promotion and social programs of the society, just as the well-being of a society depends on the health of its citizens. the new public health consists of a wide range of programs and activities that link individual and societal health. the "old" public health was concerned largely with the consequences of unhealthy settlements and with safety of food, air, and water. it also targeted the infectious, toxic, and traumatic causes of death, which predominated among young people and were associated with poverty. a summary of the great achievements of public health in the twentieth and in the early twenty-first century in the industrialized world is included in chapter and throughout this text. these achievements are reflective of public health gains throughout the industrialized world and are encourage and leverage national, state, and local partnerships to build a stronger foundation for public health preparedness and investigate health problems and health hazards in the community . inform, educate, and empower people about health issues . mobilize community partnerships to identify and solve health problems . develop policies and plans that support individual and community health efforts . enforce laws and regulations that protect health and ensure safety evaluate effectiveness, accessibility, and quality of personal and population-based health services vision, mission and goals guidelines on food fortification with micronutrients. who, geneva. alliance for health policy and systems research essential public health services healthy communities, . model standards for community attainment of the year national health objectives determinants of adult mortality in russia: estimates from sibling data commission on social determinants and health. closing the gap in a generation: health equity through action on the social determinants of health compression of morbidity in the elderly institute of medicine. who will keep the public healthy? educating public health professionals for the st century global alliance for vaccine and immunization (gavi) chronic disease prevention and the new public health the evolution, impact and significance of healthy cities/healthy communities world health organization. ottawa charter for health promotion: an international conference on health promotion behavioral and social sciences and public health at cdc. mmwr health in all policies: seizing opportunities, implementing policies. ministry of social affairs and health new perspectives on the health of canadians: a working document new perspective on the health of canadians: years later the us healthy people initiative: its genesis and its sustainability mortality from cardiovascular and cerebrovascular diseases in europe and other areas of the world: an update strategic review of health inequalities in england post. department of health primary care (extended version): ten key actions could globally ensure a basic human right at almost unnoticeable cost public health in europe: power, politics, and where next health: a vital investment for economic development in eastern europe and central asia. european observatory on health systems and policies. who, european regional office it is not just the broad street pump addressing the epidemiologic transition in the former soviet union: strategies for health systems and public health reform in russia what is the "new public health"? millenium development goals: progress chart united nations development programme, millennium development goals. eight goals for healthy people healthy people. the surgeon general's report on health promotion and disease prevention the millennium development goals: a cross-sectoral analysis and principles for goal-setting after selective primary health care: an interim strategy for disease control in developing countries declaration of alma-ata. international conference on primary health care healthy cities networks across the who, european region preamble to the constitution of the world health organization as adopted by the international health conference regional office for europe. health -health for all in the st century. who regional office for europe, copenhagen. world health organization, . regional office for europe. who european healthy cities network. available at:. who regional office for europe leading health indicators selected for incorporate the original objectives in healthy people , which served as a basis for planning public health activities for many state and community health initiatives. for each of the leading health indicators, specific objectives and subobjectives derived from healthy people are used to monitor progress. the specific objectives set for healthy people are listed in box . . thirteen new topic areas are listed for , such as older adults, genomics, dementias, and social determinants of health. these provide guidelines for national, state, and local public health agencies as well as insurance providers, primary care services, and health promotion advocates. a key issue will be in reducing regional, ethnic, and socioeconomic health disparities.the process of working towards health targets in the usa has moved down from the federal level of government to the state and local levels. professional organizations, ngos, as well as community and fraternal organizations are also involved. the states are encouraged to prepare their own targets and implementation plans as a condition for federal grants, and many states require county health departments to prepare local profiles and targets.diffusion of this approach encourages state and local initiatives to meet measurable program targets. it also sets a different agenda for local prestige in competitive terms, with less emphasis on the size of the local hospital or other agencies than on having the lowest infant mortality or the least infectious disease among neighboring local authorities. the who european region document "health -health for all in the st century" addresses health in the twentyfirst century, with principles and objectives for improving the health of europeans, within and between countries of europe. the health targets include: . closing the health gap between countries. . closing the health gap within countries. . a healthy start in life (supportive family policies). . health of young people (policies to reduce child abuse, accidents, drug use, and unwanted pregnancies). . healthy aging (policies to improve health, self-esteem, and independence before dependence emerges). . improving mental health. . reducing communicable diseases. . reducing non-communicable diseases. . reducing injury from violence and accidents. . a healthy and safe physical environment. . healthier living (fiscal, agricultural, and retail policies that increase the availability of and access to and consumption of vegetables and fruits). . reducing harm from alcohol, drugs, and tobacco. . a settings approach to health action (homes should be designed and built in a manner conducive to sustainable health and the environment). . multisectoral responsibility for health. . an integrated health sector and much stronger emphasis on primary care. . managing for quality of care using the european health for all indicators to focus on outcomes and compare the effectiveness of different inputs. the uk national health service (nhs) has semi-autonomous units in england, scotland, wales, and northern ireland. they are funded from the central uk nhs but with autonomy within national guidelines. the nhs has defined national health outcomes for improvements grouped around five domains, each comprised of key indicators aimed at improving health with reducing inequalities. l preventing people from dying prematurely from causes amenable to health care for all ages: l the target diseases include cardiovascular, respiratory, and liver diseases, and cancer (with focus on cancer of breast, lung, and colorectal cancer) l reducing premature death in people with serious mental illnesses l reducing infant mortality, neonatal mortality, still births, and deaths in young children l increasing -year survival for children with cancer. health improvement; help people to live healthy lifestyles, healthy choices, reduce health inequalities, protection from major incidents and other threats, while reducing health inequalities. l health care, public health and preventing premature mortality; reduce the numbers of people living with preventable ill-health and people dying prematurely, while reducing the gap between communities.source: uk department of health. available at: https://www.gov.uk/government/organisations/department-of-health/about#our-priorities, https:// www.gov.uk/government/uploads/system/uploads/attachment_data/ file/ /improving-outcomes-and -supporting-transparency-part- a.pdf. pdf, and https://www.gov.uk/government/uploads/system/uploads/attach-ment_data/file/ / -nhs-outcomes-framework- - .pdf. pdf [accessed june ] . national policy in health ultimately relates to health of the individual. the various concepts outlined in the health field concept, community-oriented primary health care, health targets, and effective management of health systems, can only be effective if the individual and his or her community are knowledgeable participants in seeking solutions. involving the individual in his or her own health status requires raising levels of awareness, knowledge, and action. the methods used to achieve these goals include health counseling, health education, and health promotion (figure . ).health counseling has always been a part of health care between the doctor or nurse and the patient. it raises levels of awareness of health issues of the individual patient. health education has long been part of public health, dealing with promoting consciousness of health issues in selected target population groups. health promotion incorporates the work of health education but takes health issues to the policy level of government and involves all levels of government and ngos in a more comprehensive approach to a healthier environment and personal lifestyles.health counseling, health education, and health promotion are among the most cost-effective interventions for improving the health of the public. while costs of health care are rising rapidly, demands to control cost increases should lead to greater emphasis on prevention, and adoption of health education and promotion as an integral part of modern life. this should be carried out in schools, the workplace, the community, commercial locations (e.g., shopping centers), and recreation centers, and in the political agenda.psychologist abraham maslow described a hierarchy of needs of human beings. every human has basic requirements including physiological needs of safety, water, food, warmth, and shelter. higher levels of needs include recognition, community, and self-fulfillment. these insights supported observations of efficiency studies such as those of elton mayo in the famous hawthorne effect in the s, showing that workers increased productivity when acknowledged by management in the objectives of the organization (see chapter ). in health terms, these translate into factors that motivate people to positive health activities when all barriers to health care are reduced.modern public health faces the problem of motivating people to change behavior; sometimes this requires legislation, enforcement, and penalties for failure to comply, such as in mandating car seat-belt use. in other circumstances it requires sustained performance by the individual, such as the use of condoms to reduce the risk of sti and/or hiv transmission. over time, this has been developed into a concept known as knowledge, attitudes, beliefs, and practices (kabp), a measurable complex that cumulatively affects health behavior (see chapter ). there is often a divergence between knowledge and practice; for example, the knowledge of the importance of safe driving, yet not putting this into practice. this concept is sometimes referred to as the "kabp gap". the health belief model has been a basis for health education programs, whereby a person's readiness to take action for health stems from a perceived threat of disease, a recognition of susceptibility to disease and its potential severity, and the value of health. action by an individual may be triggered by concern and by knowledge. barriers to appropriate action may be psychological, financial, or physical, including fear, time loss, and inconvenience. spurring action to avoid risk to health is one of the fundamental goals in modern health care. the health belief model is important in defining any health intervention in that it addresses the emotional, intellectual, and other barriers to taking steps to prevent or treat disease.health awareness at the community and individual levels depends on basic education levels. mothers in developing countries with primary or secondary school education are more successful in infant and child care than less educated women. agricultural and health extension services reaching out to poor and uneducated farm families in north america in the s were able to raise consciousness of safe self-health practices and good nutrition, and when this was supplemented by basic health education in schools, generational differences could be seen in levels of awareness of the importance of balanced nutrition. secondary prevention with diabetics and patients with chd hinges on education and awareness of nutritional and physical activity patterns needed to prevent or delay a subsequent myocardial infarction. the who sponsored the first international conference on health promotion held in ottawa, canada, in ( figure . ) . the resulting ottawa charter defined health promotion and set out five key areas of action: building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services. the ottawa charter called on all countries to put health on the agenda of policy makers in all sectors and at all levels, directing them to be aware a typical healthy city has a population in the multiple thousands, often multilingual, with an average middleclass income. a healthy cities project builds a coalition of municipal and voluntary groups working together in a continuing effort to improve quality of service, facilities, and living environment. the city is divided into neighborhoods, engaged in a wide range of activities fostered by the project. municipalities have traditionally had a leading role in sanitation, safe water supply, building and zoning laws and regulation, and many other responsibilities in public health (see chapter ). the healthy cities or communities movement has elevated this to a higher level with policies to promote health in all actions. some examples are listed of municipal, advocacy group, and higher governmental activities for healthier city environments: working with senior levels of government, other departments in the municipalities, religious organizations, private donors, and the ngo sector to innovate and especially to improve conditions in poverty-afflicted areas of cities is a vital role for health-oriented local political leadership. human ecology, a term introduced in the s and revived in the s, attempted to apply theory from plant and animal life to human communities. it evolved as a branch of demography, sociology, and anthropology, addressing the social and cultural contexts of disease, health risks, and human behavior. human ecology addresses the interaction of humans with and adaptation to their social and physical environment.parallel subdisciplines of social, community, and environmental psychology, medical sociology, anthropology, and other social sciences contributed to the development of this academic field with wide applications in health-related issues. this led to the incorporation of qualitative research methods alongside the quantitative research methods traditionally emphasized in public health, providing crucial insights into many public health issues where human behavior is a key risk factor.health education developed as a discipline and function within public health systems in school health, rural nutrition, military medicine, occupational health, and many other aspects of preventive-oriented health care, and is discussed in later chapters of this text. directed at behavior modification through information and raising awareness of consequences of risk behavior, this has become a longstanding and major element of public health practice in recent times, being almost the only effective tool to fight the epidemic of hiv and the rising epidemic of obesity and diabetes.health promotion as an idea evolved, in part, from marc lalonde's health field concepts and from growing realization in the s that access to medical care was necessary but not sufficient to improve the health of a population. the integration of the health behavior model, social ecological approach, environmental enhancement, or social engineering formed the basis of the social ecology approach to defining and addressing health issues (table . ).individual behavior depends on many surrounding factors, while community health also relies on the individual; the two cannot be isolated from one another. the ecological perspective in health promotion works towards changing people's behavior to enhance health. it takes into account factors not related to individual behavior, which are determined by the political, social, and economic environment. it applies broad community, regional, or national approaches that are needed to address severe public health problems, such as controlling hiv infection, tb, malnutrition, stis, cardiovascular disorders, violence and trauma, and cancer. beginning to affect the health situation in countries in transition from the socialist period. countries emerging from developing status are also showing signs of mixed progress in the dual burden of infectious and maternal/child health issues, along with growing exposure to the chronic diseases of developed nations such as cardiovascular diseases, obesity, and diabetes. the new public health synthesizes traditional pub lic health with management of personal services and community action for a holistic approach. evaluation of costeffective public health and medical interventions to reduce the burden of disease also contributes to the need to seek and apply new approaches to health. the new public health will continue to evolve as a framework drawing on new ideas, science, technology, and experiences in public health throughout the world. it must address the growing recognition of social inequality in health, even in developed countries with universal health programs with improved education and social support systems. for a complete bibliography and guidance for student reviews and expected competencies please see companion web site at http://booksite.elsevier.com/ bibliography key: cord- - fzbbn authors: nagano, hitoshi; puppim de oliveira, jose a.; barros, allan kardec; costa junior, altair da silva title: the ‘heart kuznets curve’? understanding the relations between economic development and cardiac conditions date: - - journal: world dev doi: . /j.worlddev. . sha: doc_id: cord_uid: fzbbn as countries turn wealthier, some health indicators, such as child mortality, seem to have well-defined trends. however, others, including cardiovascular conditions, do not follow clear linear patterns of change with economic development. abnormal blood pressure is a serious health risk factor with consequences for population growth and longevity as well as public and private expenditure in health care and labor productivity. this also increases the risk of the population in certain pandemics, such as covid- . to determine the correlation of income and blood pressure, we analyzed time-series for the mean systolic blood pressure (sbp) of men’s population (mmhg) and nominal gross domestic product per capita (gdppc) for countries from to using regression and statistical analysis by pearson’s correlation (r). our study finds a trend similar to an inverted-u shaped curve, or a ‘heart kuznets curve’. there is a positive correlation (increase gdppc, increase sbp) in low-income countries, and a negative correlation in high-income countries (increase gdppc, decrease sbp). as country income rises people tend to change their diets and habits and have better access to health services and education, which affects blood pressure. however, the latter two may not offset the rise in blood pressure until countries reach a certain income. investing early in health education and preventive health care could avoid the sharp increase in blood pressure as countries develop, and therefore, avoiding the ‘heart kuznets curve’ and its economic and human impacts. the relation between economic development and health outcomes puzzles both economists and public health scholars (clark, ) . in recent decades, most countries advanced in nominal gross domestic product per capita (gdppc), but not in all health indicators (braveman et al., ; banerjee, ) . some health indicators, such as child mortality or malnutrition, seem to have a well-defined declining trend as countries and individuals turn wealthier (burkitt, ; fedorov & sahn, ; fogel, ; chen, lei, & zhou, ) . however, others, such as cardiovascular and various non-communicable diseases, do not follow clear patterns of change with economic development. socioeconomic factors, such as economic resources (e.g. income), inequality, social relations, education and occupation, are commonly used to explain health outcomes and investments (aly & grabowski, ; braveman et al., ; clark, ; jürges, kruk, & reinhold, ; woolf et al., ; brunello, fort, schneeweis, & winter-ebmer, ; lundborg, nilsson, & rooth, ) . for example, higher education is a strong indicator for normal blood pressure (colhoun, hemingway, & poulter, ; conen, glynn, ridker, buring, & albert, ; danaei et al., ) . certain studies mention that income and education are inversely associated with cardiovascular diseases, and low socio-economic condition is related to a higher prevalence of cardiovascular risk factors, such as high blood pressure (colhoun et al., ; braveman et al., ) . there is also a correlation between income https://doi.org/ . /j.worlddev. . - x/Ó elsevier ltd. all rights reserved. inequality and health outcomes, including cardiac conditions (kim, kawachi, vander hoorn, & ezzati, ; dewan et al., ) . the blood pressure is defined in technical terms as a result of cardiac output versus peripheral vascular resistance, but its composition depends on certain risk factors; some of which have relations with economic development and demographic features. the intrinsic factors are the genetic predisposition, age, gender and race (colhoun et al., ) . the extrinsic factors that affects it negatively are the lack of exercise, poor diet, obesity, excess salt, alcohol abuse, smoking and stress (colhoun et al., ; braveman et al., ; conen et al., ) , which are also related to socioeconomic status . in poor countries with an increase in income, there is a tendency to consume goods and services not previously available widely such as more carbohydrates, red meat, industrialized food, alcoholic beverages, and cigarettes (burkitt, ) . there is a higher consumption of kilocalories per capita per day as one has more income available for food consumption or has access to novel food products (dragone & ziebarth, ) ; people eat more but not necessarily better. healthy foods (e.g., non-transfats, reduced saturated fat and healthy oils) are generally more expensive and not commonly available for low-income people (fogel, ; danaei et al., ; banerjee, ; chow et al., ; ortega et al., ) . poor countries and poorer income groups also have less access to good health services, which may affect the access to preventive measure to reduce the risk of cardiovascular diseases. on the other hand, the poor also has a low use of individual motorized modes of transport, and large part of the population uses non-motorized modes (e.g. walking or cycling) (gwilliam, ; ahmad & puppim de oliveira, ) , which may provide some regular physical activity. as countries and certain groups of the population become richer, they have more resources to invest in health services, but their diets and life styles also change, not always in a healthier direction. for example, as india develops, richer households have higher chances to present individuals with high blood pressure and cardiac conditions (barik, desai, & vanneman, ) . thus, economic development can both contribute to minimize certain cardiac risk factors and exacerbate others. this study adds to the efforts to assess the impact of economic development on certain health outcomes. we use the male systolic blood pressure (sbp) as the health indicator. sbp is commonly used for individual and public health management. abnormal sbp can be a serious concern for a person or society as it is a risk factor for cardiovascular and kidney diseases (danaei et al., ) , with consequences not only for the population's health conditions and longevity but for public and private expenditure in health care (lee & kim, ; danaei et al., ; vallejo-torres & morris, woolf et al., . moreover, cardiovascular conditions can increase the risk of a person in epidemic outbreaks. for example, people with cardiovascular disease are at a higher risk of getting severe covid- disease (who, ). cardiovascular diseases have also a huge impact on productivity and the economy (leal, luengo-fernández, gray, petersen, & rayner, ) , which can economically justify certain measures to subsidize health care. thus, economic growth and health present a two-way relationship. sustained economic growth can lead to more investment in health, and consequently better health conditions. on the other hand, improved health of the population positively impacts labor productivity and human capital formation (atun & gurol-urganci, ) . however, we ask the following broad question, which is not consistently answered by the literature: is there any recognizable shape in the trends relating blood pressure and countries' income? several studies identify certain trends in the risk factors as societies develop but they are not conclusive on the relation between gdppc and blood pressure. for example, one study pointed that national income had a positive correlation with sbp among other risk factors in but the slope of this association became negative for women in (danaei et al., ) . mean blood pressure seems to have significantly dropped in high-income western countries between and , but it rose in other parts of the world, particularly in developing countries, such as many in sub-saharan africa (ncd, ) . other research outcomes identify trends in cardiac conditions among different social groups or races in a certain country (barik et al., ) . there are also studies that provide insights at the micro perspective, looking at the relation between sbp and education, access to health services and professional categories (conen et al., ) . they are important to identify how different contexts and development factors affect blood pressure, but there is no study that provides a consistent macro perspective trend between an economic development indicator and blood pressure. this relation is relevant to justify investments in health at the early stages of development in order to avoid cardiac problems in the future and their consequences on human development. in this regard, a crucial point for understanding how to improve public health in the development process is what an increase in income of countries means for the general health of their populations, particularly blood pressure (sbp) in this research. thus the contribution of this paper is to identify a general relationship between economic development and blood pressure, as the existing studies are not conclusive. the concept of the kuznets curve seems relevant to be tested in this context, as some studies already point rise and fall of blood pressure with different national incomes (danaei et al., (danaei et al., , ncd, ) . simon kuznets developed a breakthrough work on the relations between economic development and socioeconomic indicators. using empirical data, he was the first to describe the relationship between inequality and income, known as the 'kuznets curve' (kuznets (kuznets , . later on, though the original curve has been contested (atkinson & brandolini, ) , similar curves were noticed when plotting economic development and different forms of environmental degradation, such as air pollution or deforestation, defining what is called the 'environmental kuznets curve' (grossman & krueger, ; stern, common, & barbier, ; bhattarai & hammig, ; baland, bardhan, das, mookherjee, & sarkar, ) . kuznets curves have been determined for child labor (kambhampati & rajan, ) and tested for material use and carbon intensity (pothen & welsch, ; roberts & grimes, ) . moreover, empirically, per capita income can be associated with different environmental and socioeconomic indicators, which in turn are related to health (gangadharan & valenzuela, ; soares, ) . kuznets-like curves have been identified for certain health parameters such as injuries and life expectancy (bishai, quresh, & p. james p & ghaffar a. , ; clark, ) , and obesity (grecu & rotthoff, ) . concentration indices as a measure of health inequalities have also been observed to show a kuznets' curve behavior (costa-font, hernandez-quevedo, & sato, ) . thus, we decided to check whether the relation between blood pressure and gdppc follow a trend like a ''heart kuznets curve". if it follows, what would be the measures to tunnel through the curve and avoid the heart effects of economic development? for answering those questions, we evaluated the relationship between per capita gdp (gdppc) and systolic blood pressure (sbp) of men's populations, as an indicator of health. we assessed public time-series databases for countries, which contains compiled indicators of blood pressure and economic conditions in several categories. in particular, two main variables were chosen for this study: ) the mean systolic blood pressure (sbp) of men's population (mmhg), age standardized mean (icl, ) . ) nominal gross domestic product (gdp) per capita (gdppc) in american dollars (us$), in constant prices (the world bank, ). we collected data from to from these two different databases at gapminder (gapminder, ) . we used this period because, while the dataset for gdppc spans for a wide range of years, the historic series of sbp of men's populations in the public database we used is limited to to (gapminder ) . the mean sbp of the male population, age standardized mean counted in mm-hg, came from the database of the global burden of metabolic risk factors of chronic diseases collaborating group hosted at the school of public health, imperial college (icl, ). the mean is calculated as if each country had the same age composition as the world population, what minimize the aging bias. regarding the use of the sbp and its mean value, it is worth noticing that: (i) systolic blood pressure has been a better predictor of future events with high accuracy compared to diastolic blood pressure (sever, ) ; and (ii) reference studies use the mean as the reference of comparison between demographics and geography (ncd, ; ncd, ) . the gdp data comes from the world bank's world development indicators and represents the gross domestic product per capita (gdppc), nominal in constant us$ prices. we used nominal gdp instead of purchasing power parity (ppp) as the estimations of the former seems less controversial for long periods (taylor & taylor, ) . thus, the inflation, but not the differences in the cost of living between countries, has been taken into account (the world bank, ). in order to categorize countries, we used the gdppc average of four years, namely , , and . the country income categories were defined as: (a) low income countries: gdppc < us$ , ; (b) lower-mid: gdppc ranging from us$ , to us$ , ; (c) upper-mid: gdppc ranging from us$ , to us$ , ; (d) high: gdppc > us$ , (the world bank, ). we discarded countries with missing data and kept only countries with a minimum number of consecutive observations of both variables, which resulted in a dataset of countries (see the list of countries by categories of gdppc in table in annex i). we utilized r (v . . ) and python (v . ) languages as the tools for data formatting, transformations, visualization, statistical analysis by pearson's correlation (r) and regression analysis. built-in regression functions in r were utilized. in addition, we relied on open-source libraries: pandas (mckinney, ), ggplot (wickham, ) and seaborn (waskom, ) . when applicable, z-scores on time-series data was used. this corresponds to series transformation of the series fx i ginto another series fz i gand is given by where x and s x correspond to the mean and sample standard deviation of fx i g, respectively. for the sake of completeness, pearson' correlation r xy of series fx i g and fy i g, both with n elements, is calculated by where s x and s y correspond to the sample standard deviation of fx i g and fy i g, respectively. nevertheless, the choice of any research methodology has its limitations. in this case the following limitations can be identified with their justifications: (i) other risk factors could have been utilized. however, measurements of sbp represents one of the easiest, most inexpensive and widespread exams, when compared to other cardiovascular risk factors that require blood tests (e.g., diabetes). this allowed us to analyze longer time series for a large number of countries. (ii) a descriptive statistic approach is used instead of multiple regression analyses (with multiple explaining factors), since it provides a simpler, clear and visual evidence of our findings. a faceted approach, by gpppc-based country segmentation was used to achieve the outcome objectives. (iii) restriction to male population in the sample. men are more prone to hypertension than women in similar ages and, when affected by this condition present a greater blood pressure load on the organs (eison, phillips, ardeljan, & krakoff, ; reckelhoff, ) . thus, we decided to take male sbp as the population risk factor since it is a more stringent scenario. nevertheless, these questions should be further investigated in longitudinal population-based analyses in future studies. in general, gdp per capita (gdppc) increased over the years for almost all the countries and most of the countries had significant changes (increase or decrease) in sbp, with fewer countries with a neutral variation (only observations where À . < r < . ). fig. a shows the relation between gdppc and sbp for a sample of countries, which are representative of their income categories. the different colors represent the gdppc groups and dot sizes represent years (larger dot closer to , smaller dot closer to ). fig. a was our first plot, which motivated us to pursue further investigation of these associations for other countries, as it shows a trend of a kuznets curve. in fig. b , we grouped the countries in different bins classified by r-value. furthermore, we subgrouped each bin according to four different gdppc groups and we utilized the same color cue for gdppc group as in fig. a . we observe negative correlations between gdppc and sbp for high income countries as also shown in recent studies (ncd, ) . all countries with high gdppc presented r < À . , except three: united arab emirates, brunei and south korea. moreover, for the range À . < r < À . , we notice exclusively high gdppc countries. in contrast, low gdppc countries concentrates in the right side of the histogram, with more instances of positive correlation than negative. thus, we can infer that there is a positive correlation (increase gdppc, increase sbp) in low-income countries, and a negative correlation in high-income countries (increase gdppc, decrease sbp). thus, we decided to analyze the scores for all countries in the chosen time range . fig. shows the z-score of the gdppc and sbp for each one of gdppc groups. this transformation was necessary to evaluate the common trends per group, given that each country showed different spans across each variable. for example, mozambique, uganda, sudan and bhutan have different sbp spans (see fig. a ). all countries are plotted, along with a fitted linear regression line and % confidence interval, and respective p-values. the z-score allows us to normalize country variables, in order to capture the most dominant trend concerning each group. we observe that there is a monotonic trend on the line inclination, as we traverse the gdppc groups from low to high, resembling a kuznets curve; what we call 'heart kuznets curve' (see an illustration of it in fig. b ). in order to further discuss the steepness of the sbp, we chose a subset of countries variation, where the effects on general population are more detrimental. fig. a displays the increase in sbp according to gdppc, only for countries with positive pearson's correlations. the calculated coefficient per country denotes the sbp increase in mmhg for each additional us dollar in gdppc. fig. b shows the histogram of the regression coefficient for the gdppc groups as defined above. fig. b indicates that lower gdppc countries showed a sharper increase in sbp per dollar of increase in gdppc, when compared to higher income countries. in poorer countries, the mmhg increase is even steeper. countries that had very low income (gdppc below us$ in ) such as mozambique, uganda and sudan experienced a steeper increase in sbp, around mmhg during the analyzed period. for example, ethiopia had a coefficient of around . mmhg/us$, so for each additional us$ dollar in gdppc, the sbp increased . mmhg. on average, for us $ increase in gdppc, a mmhg rise in sbp is observed. in contrast, for the same gdppc increase, a gentler rise was observed for countries with slightly higher gdppc, such as egypt and fiji, where the sbp increased less than mmhg throughout the entire time series. for example, nicaragua showed a coefficient of around . mmhg/us$, thus on average equivalent to a . mmhg for every us$ increase in gdppc. in several countries, gdppc showed a steady increase along the years, which could lead us to believe that time could be the most important determinant. however, a comparison was made of the correlations of a) sbp versus gdppc and b) sbp versus time, showing much stronger correlation with gdppc (we provide additional results and discussions in annex ii). on the negative correlation countries, we plotted a sample of countries in fig. a and the histogram of negative linear regression coefficients in fig. b . clearly, the majority of such countries in this set belong to high income gdppc group. however, there are few outliers with a negative mmhg/us$ values that are low and lower-mid income countries. these are: (i) low: burundi, guinea-bissau, comoros, madagascar, zimbabwe, ghana (ii) lower-mid: colombia, ecuador, bolivia, syria, bulgaria, morocco, el salvador, tunisia, peru, belize, swaziland, romania in order to look further into this relationship, we performed a detrended correlation analysis (see annex iii). we found reasonable arguments to support our findings on the ''positive slope" of the sbp/gdppc relationship, which is related to the poorer countries. for the wealthier the trend of sbp decrease could have more influence of other factors, in addition to the gdppc increase. there are many studies analyzing blood pressure and cardiovascular conditions and treatments in specific countries, ethnicities or populations (gupta, al-odat, & gupta, ; ikeda, gakidou, hasegawa, & murray, ; fezeu, kengne, balkau, awah, & mbanya, ) or risk factors such as age (rodriguez, labarthe, huang, & lopez-gomez, ) . early exploratory studies already identified the changes in cardiovascular conditions as countries develop and modernize (burkitt, ; trowell, ) . previous comprehensive studies at a global scale also exist (kearney et al., ; kim et al., ; chow et al., ; ncd, ) , but they generally make a longitudinal analysis aggregated by country, income inequality or region, not correlating with income per capita in a consistent manner. our study revealed the pattern of a 'heart kuznets curve', showing a consistent positive correlation (increase gdppc, increase sbp) in low-income countries and the opposite in high-income countries (increase gdppc, decrease sbp). as countries' incomes increase sbp tends to increase up to a certain income, when the sbp tends to decline with the increase of gdppc, as in fig. b . in this aspect, south korea is an emblematic case of the 'heart kuznets curve' (see fig. a ). it is the only country among all countries in the sample that started the series as a low-mid income country in (gdppc of us$ , ) and ended up as a highincome country in (gdppc of us$ , ). most of the countries stayed in the same gdppc group or crossed to the next adjacent group. the increase of sbp in south korea was observed in the initial years of our series, with a turning point of gdppc around us $ , . as the gdppc continued to increase over this point, we observed an sbp decrease in the latter years of the series. even though south korea's overall pearson's r is neutral (r = . ), this breakdown into two different moments of the country matches earlier observations of the differences by income and reinforces the existence of the correlation and the idea of the 'heart kuznets curve'. south korea was able to consistently provide a better income and improve their socioeconomic status and at the same time reduce sbp after certain income to reverse the rising sbp trend. as the incomes in a poor country increase, the diet of the population changes rapidly increasing sbp, but the health services and education for the prevention of heart problems may not improve at the same pace to offset the changes in sbp caused by changes in diet (fuster, ; danaei et al., ; ncd, ) . thus, though increase in countries' income tends to provide more access to health services, as countries invest more in health systems and individuals have more income to invest in health care, this may not compensate the negative changes in sbp until a country reaches a certain income per capita, as good quality public health care for the majority of the population takes time to be properly built and may not be a priority for policymakers at early economic development stage (makhoul, ) . at a certain income, it is noticed an inflection point in the sbp trend (in south korea at around us$ , of gdppc). the health system and health education improves to make access to health services (e.g., regular blood pressure checks and advice from a cardiologist or nutritionist) and preventive care (e.g., education for awareness about the importance of a more balanced diet) sufficiently more common for the population to a point to revert the rising trend in sbp (danaei et al., ; ncd, ) . another important determinant of sbp is physical activity, which has also some relations with economic development. regular physical activity is associated with a substantial reduction in cardiovascular disease risks, even in groups with high risks (humphreys, mcleod, & ruseski, ) . in rapid developing economies, urbanization (especially improved housing and transport infrastructure) and industrialization leads to profound shifts not only in how people eat, but how they move, work and exercise (chow et al., ; danaei et al., ) . people tend to move from agricultural jobs, which tend to require more physical activities, to work in offices, shops or industrial plants. as individuals get richer, they also tend to move from non-motorized (e.g., walk or bicycle) to use more motorized transportation (gwilliam, ; ahmad & puppim de oliveira, ) . thus, lack of physical activities among the population seems to become more common as a country's income rises. as the prevalence of a sedentary lifestyle increases, the risk of heart problems increases. for instance, an isolated risk factor, such as obesity per se, is not the only or the most important factor to determine health. the overweight and active people can be healthier than skinny and sedentary people. the metabolically healthy overweight and well-educated people may not suffer from conditions such as diabetes or high blood pressure (de backer & de bacquer, ; ortega et al., ) . obesity has also socioeconomic causes, such as income and education, and has significant economic impacts (cawley, ) . social programs, such as cash transfers, and work activity have ambiguous effects on weight (levasseur, ; feng, li, & smith, ) . health specialists suggest the implementation of recommendations regarding diet and physical activity should be a top priority for all (de backer & de bacquer, ; chow et al., ; danaei et al., ) , including economic incentives such as taxes on unhealthy food and drinks (cawley, ) . as income rises over certain point, health advice and education tend to improve and make people more aware of the importance of physical activity and diet, contributing to reduce sbp (braveman et al., ; danaei et al., ) . thus, increase in income alone is not translated into wellness automatically. it may worsen the risk factors for cardiovascular disease, if health education and access to health care does not come together with the higher incomes. maybe the effective access to these services happen just after a certain income turning point. therefore, a country with rising income does not always mean becoming a healthier country. how could we then turn income into (heart) health? besides aggregate income, income inequality is also correlated to health outcomes and inequity in health service access (clark, ; kim et al., ; baland et al., ; vallejo-torres & morris, ) . reducing inequalities can widen the access to quality health services. moreover, health information and education can transform one's behavior (colhoun et al., ; conen et al., ; brunello et al., ) , as education is an important socioeconomic factor determinant of blood pressure progression and a powerful and independent predictor (braveman et al., ; conen et al., ) , though not stronger than gdppc (see annex iv). a better income should also come with improvement in health education to reduce health risks (conen et al., ; jurges et al. ; woolf et al., ; lundborg et al., ) . for example, higher income individuals reduce more the intake of fat than poorer one when receiving hypertension diagnosis (zhao, konishi, & glewwe, ) . other factors, such as mother's education, are key for improving nutrition in their children (behrman, deolalikar, & wolfe, ) . socioeconomic determinants are strongly associated to health risk factors, which affects cardiovascular diseases (conen et al., ; danaei et al., ) . as large part of the world population is poor or has low income (pew research center, ) , in order to improve global health inequities, policy makers, including those in governments and international organizations, should develop new approaches to control these major risks for cardiovascular diseases in poorer countries in a more effective manner (friedrich, ) . in general, investments in health tend to address the need of the ruling privileged elites and not the wider population (makhoul, ; mobarak, rajkumar, & cropper, ) , which are also more vulnerable to economic crises in terms of health (pradhan, saadah, & sparrow, ; shkolnikov, cornia, leon, & meslé, ) . health problems can have a significant impact on the wealth of elders (lee & kim, ) . public programs that improve access to health services can reduce health inequalities and have significant impact on the most vulnerable ( van de gaer, vandenbossche, figueroa, ; bagnoli, ) . in turn, healthier societies can be more productive. poor children with more access to public health care improve their attendance and scores (alcaraz, chiquiar, orraca, & salcedo, ) . there are opportunities through the understanding that there is a 'heart kuznets curve' for designing a better investment strategy in health care and health education that can lead to better lifestyles and reduce the risks of high sbp at early stages of development, improving the general health of the population and saving large amounts of resources in the later stages of economic development. young adults with good cardiovascular health result in lower future costs in health care (schiman et al., ) . public policies can help, informing and providing the knowledge and infrastructure to change habits (e.g., areas to exercise, opportunities for activity using non-motorized transportation). investments in health education and services to avoid cardiovascular diseases in early stages of development can also mitigate the climbing costs of the health systems. income and health of populations and countries are reciprocally related. we found a strong relationship between gross domestic product per capita (gdppc) and population's blood pressure, following a 'heart kuznets curve'. in countries with low and medium income, the increase in gdppc increased the mean systolic blood pressure (sbp) between and . in rich countries, there was reduction of the average blood pressure with increase in income. furthermore, the poorer the country is, more acute sbp jumps with rising incomes were observed. however, the heart kuznets curve is not deterministic and valid for all countries and all conditions. kuznets curves in other areas have been contested in several grounds, including inequality (frazer, ) and environmental pollution, showing that the inverted-u shape can occur only under certain policy conditions (ezzati, singer, & kammen, ) . in health policy, removal of user fees tends to increase access to health services in countries in early stages of development, particularly for those more vulnerable (hangoma, robberstad, & aakvik, ) . also, there are ways countries can better steward their health systems to be more effective in the use of resources and the achievement of health outcomes (brinkerhoff, cross, sharma, & williamson, ; chan et al., ) . in addition to those pointed out in methodology section, our study has limitations. despite the strong correlation in some countries, we understand that within the same country there are various population groups with different socio-economic status. countries also have distinct age distribution and ethnicities. it could be revealing to perform a deeper analysis into micro regions to better understand the behavior of individuals and groups and its relation to systemic blood pressure in different socio-political and cultural contexts. moreover, the relations between changes in income, changes in other socioeconomic factors and cardiovascular risk factors should be empirically tested through further quantitative and qualitative studies with multiple independent variables. we tested the correlation between education (mean years of schooling) and sbp, and though these two variables are correlated, the correlation between gdppc and sbp is stronger (annex iv, fig. ) . nevertheless, education and other factors, such as investments in health infrastructure, have an important impact on sbp, and future research could identify macro trends in those factors. a myriad of other variables, including mental and psychological factors, such as stress caused by economic instability, working conditions or vulnerability to natural disasters, also have influence in cardiac conditions, as pointed by some studies (katsouyanni, kogevinas, & trichopoulos, ; kivimäki et al., ) . in developing countries, other factors, such as socio-economic vulnerability or poor urban conditions, which could increase stress, could be further investigated to identify any trends (suchday, kapur, ewart, & friedberg, ) . thus, we suggest further studies involving several independent variables, such as using multiple regressions, for future research, as the objective of this study was limited to the macro trends in the relation between two variables (income per capita and blood pressure). finally, studies using other proxies of economic development and blood pressure could be carried out to check the robustness of the trends we identified in this study. rise in blood pressure has created a growing global burden for the current and future generations (olsen et al., ) . it also increases the risks of the population in certain pandemics, such as the covid- (who, ) . the un development agenda in its sustainable development goal ('ensure healthy lives and promote well-being for all at all ages') calls for a ''strengthened capacity of all countries in health risk reduction and management" (un, ) . despite the trends in improvement in income in most countries in the last decades, this is apparently not associated with an improvement in health education, access to health care and recommendations to prevent cardiovascular diseases by necessary changes in lifestyles in developing countries. the epidemic of cardiovascular problems and other non-communicable diseases can be prevented in many countries in the future with investments in building capacity for promoting health education and preventive services in the early stages of economic development. thus, we could tunnel through or avoid the 'heart kuznets curve' in many situations. annex ii -correlation of year/sbp and gdppc/sbp it can be argued that sbp increase in lower income countries is more associated with temporal trends than with the increase or decrease of gdppc. temporal changes could for example be associated with adoption of western diet, if we accept that globalization had such a worldwide effect over the analyzed timeframe. thus, we decided to compare the correlation between sbp and year with the correlation of gdppc and sbp. fig. shows that the bulk of countries show up above the equality line (y = x). even though the values in x-axis show density spread in (- , ) interval, y-axis values are more concentrated in the upper quadrants. in other words, the sbp's correlation with gdppc is in general higher than time (year). moreover, this effect is more pronounced for low income countries. to further exemplify the lesser association with time trends, we plot in fig. three low income countries, namely niger, mozambique and senegal. in all, we see: (i) decreasing sbp accompanied by decrease gdppc, followed by increase in both as time evolves; and (ii) a weak correlation with time. the correlation of these three countries are shown in table . all three countries show up in the upper quadrants of fig. a , where niger and senegal in the left handside. we believe that temporal trends observed in the period, for example globalization of food culture, are less contributing factors compared with income. in this annex, we report the correlations after applying first difference in both sbp and gdppc time series (fig. ) . we observe low and lower-mid countries with positive correlations, but not as high as the correlations observed in fig. . still, if we combine low & lower-mid countries, approximately % present correlation above . . see table . on the other hand, we could not observe a pattern for the distribution for countries with higher income. in fact, those countries now show up in the positive territory and span a larger range of correlations. sbp trend downward with gdppc increase, but the inferences that additional wealth alone may bring better health could not fully verified. in summary, from this analysis we argue that the ''positive slope" portion of the kuznets curve has a more solid reasoning, with evidence also from annex ii, while the ''negative slope" part can be more influenced by other factors in place, though gdppc still has a strong correlation with sbp. in 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how are income and wealth linked to health and longevity? does information on health status lead to a healthier lifestyle? evidence from china on the effect of hypertension diagnosis on food consumption we declare no direct sources of financial assistance. we acknowledge the support of fgv for the institutional research efforts for this research to be completed. the authors declare that they have no conflict of interest. key: cord- -v g dq p authors: dönmez, nergis feride kaplan; atalan, abdulkadir; dönmez, cem Çağrı title: desirability optimization models to create the global healthcare competitiveness index date: - - journal: arab j sci eng doi: . /s - - -w sha: doc_id: cord_uid: v g dq p the aim of this research is to enhance desirability optimization models to create a global healthcare competitiveness index (ghci) covering countries with gross domestic product per capita (gdp pc) of over $ , . the ghci is defined as an index that reveals the progress and quality of the healthcare systems in countries providing their patients with easier access opportunities to healthcare services within the scope of this work. methods of statistical analysis have been adopted together with optimization models and techniques in this research. the optimum and feasible values of the factors considered influential on objective functions have been determined as the basis of healthcare expenditure (he) and ghci in those relevant countries. those released optimum outcomes are displayed between . and . in terms of desirability value. the ghci values of those aforementioned countries range from to . the computed average of the ghci values of those countries is estimated as . . finally, ghci values of countries have been calculated to set the current basis of desirability optimization models. these findings will be deemed as the basic essence of those prospective theories to be established for the future researches to constitute a new index to measure the competitiveness of healthcare systems in various countries all over the world. the perspective toward the importance of the healthcare has already changed considerably in time. globally, healthcare is accepted as the second largest sector after manufacturing businesses in terms of economy. this situation has triggered the development and growth of the healthcare sector [ ] . a competitive atmosphere is created for patients to receive faster and easier health services by means of healthcare institutions. accordingly, as the level of welfare of people increases, they demand higher quality of healthcare services from hospitals. all of these are particularly inspiring investors to promote quality assurance in healthcare systems of countries [ ] . it is desirable for people to have high patient satisfaction by receiving high-quality services conveniently at healthcare institutions. especially, in european countries, people travel to other cities or countries because of poorquality healthcare services in the city where the patients are located. with the emergence of such a situation, many researches have been conducted to provide an easy, fast, and inexpensive healthcare service for patients [ , ] . factors that enable patients to have an access to healthcare have been taken into consideration in such studies, but these studies have been performed for local situations rather than general conditions. in this study, a general view is presented considering the factors that form the infrastructure of the health systems of countries. a study measuring health system performance covering countries was conducted by the world health organization (who) in . five main factors defined as health, health inequality, responsiveness-level, responsiveness-distribution, and fair-financing were determined, and regression equations were formed in this study. the correlation between these factors and health system performance was emphasized. these factors were limited to [ , ] , and a weighted value was given for each factor. thus, the overall efficiency calculation was made in all who member countries, and their health systems were listed. however, this study does not include any factors regarding the economic data and health infrastructures of countries. we would like to emphasize that it would not be appropriate to make a comparison between the study conducted by who and our study. because of the fact that the parameters discussed were different and that approximately years had elapsed, there was no consistent comparison. many methods have been developed in terms of both engineering and management to solve health problems. especially, management approaches have been widely applied in the field of healthcare [ ] [ ] [ ] . addressing managerial implications for the provision of medical devices [ ] , increasing the types of services, providing improved management information systems [ ] , employing skilled managers in their fields, patient case management, health quality assurance systems, and so on are important on behalf of the managers in determining the applicable strategies by taking into consideration in the field of healthcare management. thus, the effects of healthcare problems are finally concluded with implications by the research conducted by healthcare managers [ ] . however, since healthcare problems are very specific issues or unique problems, such as avoiding vital harm to patients, insufficient resources, poor healthcare services, and medication error, researchers have adopted algorithms and optimization models in order to solve these issues [ ] . therefore, optimization techniques are indispensable methods of management, engineering, and business applications. the purpose of using optimization, also named as operation research (or), is to provide maximum benefits (such as revenue and production) and minimize loss (such as costs, expenditure, defects, and waiting time). optimization applications vary widely according to the areas where they are used, such as energy, automotive, manufacturing, transportation, and logistic. optimization techniques have been exploited to solve problems in healthcare systems, which are among the most trend topics of recent years [ ] . commonly, optimization models have been developed to optimize the schedule of resources of the healthcare systems. in addition, optimization models have been established for the management of healthcare materials for logistics [ ] , for emergency services, to reduce waiting time for patients and to reduce expenditure or cost of treatment on healthcare facilities [ ] . however, these methods have been used limitedly in the field of healthcare. the reason for this is that work or patient flows have a stochastic structure rather than a deterministic structure in the healthcare systems. stochastic constructions are usually explained by nonlinear equations, which means the analysis of mathematical modeling is both difficult and long-lasting in parabolic situations. statistical analysis is an alternative method for solving healthcare problems [ ] . in particular, statistical methods have been used to make predictions for management of the healthcare system in the future based on past data and experience. especially, regression analysis was most widely used among statistical methods by researchers [ ] . for this reason, regression analyses are considered as a good forecasting tool for the future. nevertheless, this tool is not sufficient to use solutions alone in healthcare area, because of the fact that the statistical analysis obtained provides only information about what the current system will achieve in the future, not the future goals of these systems. consequently, statistical analysis was used together with optimization technique in this study. in addition to statistical analysis, calculation of ghci values belonging to countries was provided by using desirability optimization technique. formulations were obtained by considering the lower and upper limits of the factors' values considered on the basis of this method. besides, it was possible to clearly show the traces of the factors on which they affect the response that was the objective function of the optimization model with the developed methodology. the problem statement which is an optimization model with the help of statistical analysis was developed to create ghci to measure the structural and economic status of healthcare of considered countries in this research. while the economic development of the countries has been measured with the global competitiveness index (gci) studies so far, in this study, we wanted to examine the development levels of the healthcare systems of the countries by creating a ghci [ ] . up till now, the quality of healthcare has only been determined on the basis of patient satisfaction [ ] . this criterion was measured according to questionnaire surveys, so the numerical data and analysis were disregarded in the studies [ ] . patient satisfaction and employee performance were measured using questionnaire or verbal interview method to determine the quality of healthcare [ ] . however, it is obvious that the results of such methods are weak in terms of accuracy or not enough to reflect the real problems of healthcare. for this reason, different methods have to be used to obtain the quantitative and tangible results. through this research, the results of the analysis with the numerical data by quality tools have led to touchable solutions for quality of the healthcare and allowed the detection of the future problems [ ] . we believe that this study will be a good source for future studies in terms of the measuring method of the healthcare quality. also, this study will have significance in theory as it promotes a new index to measure the competitiveness of healthcare system across different countries. this study has come to fruition in four parts. in the first section, the studies in the literature have been discussed. the methodology of the study was considered in the second section. the factors affecting the healthcare systems were determined, and methodologies of the study were constructed on this part. the statistical, optimum, and feasible results were obtained with the developed method for ghci, and the ghci values belonging to the countries were calculated and ranked in the third section of the study. in the last section, conclusion about the study has been provided. the method used in the study consists of two parts as statistical phase and optimization phase. ghci values of the countries considered were calculated by developing nonlinear optimization models based on statistical optimization technique. as shown by the flowchart in fig. , there are eight key steps as definition of inputs as decision variables, historical data collection, obtaining descriptive statistical information about the collected data and removing decision variables that are not statistically significant, determining the limits of decision variables, the decision variables and objective functions, creating the optimization models, and succeeding the optimum results for decision variables and objective functions in order to create ghci of the countries considered. in the statistical analysis stage, the statistical significance of the factors was analyzed to define the decision variables and the limits of these variables in the statistical analysis stage. optimization models containing decision variables that have an impact on the objective functions were developed, and optimum values of decision variables and objective functions were obtained in the optimization stage. finally, after calculating ghci optimization values not included in the flowchart, an index was created to list the healthcare systems of the countries considered in this study. the resources of the healthcare system of the countries were calculated by the world bank database as the number of beds, doctors, and nurses and midwives per persons. however, for the analysis of these data to be consistent, the total number of these sources was calculated as below: where x ij is defined as a decision variable and i denotes the resources of healthcare of the countries and j represents the names of the countries. in this equation, i only symbolizes the number of beds, doctors, and nurses and midwives per ( ) x ij = total x ij persons, but since there are more than one factor in the study, i notation representing the factors was used in general terms. likewise, j notation expresses generally the names of the countries considered in the study rather than writing them separately. a total − x ij refers to the total number of factors i for beds, doctors, and nurses and midwives in country j. the factors affecting healthcare systems were evaluated in two parts that were defined as structural and economical. the factors come from the resources that build the substructure of the healthcare system in the first part. the most important assessment for measuring the performance of a country's healthcare system is the relationship between resources and outcomes [ ] . some of these factors are doctors, assistant doctors, nurses, officers, patient rooms, beds, triage rooms, laboratories fulfillments of clinical requirements, general behavior of doctors, registration and administrative procedures, infrastructure and amenities, professional performance of doctors, and facilities at reception and outpatient department area [ ] . these resources must be supplied and managed properly in a healthcare system. nevertheless, deficiencies in the management of these resources are affecting the quality of healthcare in the negative direction [ ] . generally believed, physicians, nurses, and beds construct the infrastructure of the healthcare systems [ ] . thus, the numbers of physicians, nurses, and beds [ ] that were used in this study were the most employed parameters in the researches [ ] . we evaluated the effects of each resource on the different levels on of the outcomes and analyzed healthcare resources individually. the life expectancy [ ] factor discussed was also considered among the structural factors in this study. especially, this factor may be more effective in state and private healthcare systems. as a result of the previous studies, there was a strong connection between hes and life expectancy [ ] . the main reason for this deal was that people with high levels of prosperity are increasing their hes because people want to live longer. in this case, states or private enterprises need to increase their hes. in terms of economy, there are many factors that are influential in the healthcare system level headedly. there are two economic factors that are gross domestic product (gdp) and gross domestic product per capita (gdp pc) of the countries considered to be influential on the healthcare systems. countries with gdp pc of ten thousand dollars or more were regarded in this study. moreover, in the studies carried out in terms of the relation between healthcare and income level, a positive correlation appears to exist between the income per capita and life expectancy [ ] . hes were considered as responses or dependent factors/ variables influenced by the independent factors. most of studies covered at most six and few independent factors in the calculation of index scores. generally, scientists suggested that the four independent variables, such as the number of physicians, nurses, beds, and healthcare expenditure per capita, were effective and reliable on the healthcare systems of countries. he data of countries [ ] were calculated by the percentages of countries dependent on gdp [ ] . a statistical analysis of how these factors affect he has been shown as the result. hes of countries were considered as response variables. it was seen that hes in economically developed countries are higher than those in developing countries. as a result of the statistical optimization analysis, the six important factors of which were gross domestic product, gross domestic product per capita, life expectancy, the number of beds, the number of nurses and midwives, and the number of physicians considered were more influential on hes as revealed in this study. optimization models were developed with the help of mathematical equations of the developed desirability functions. developed mathematical models are provided to minimize the amount of hes besides of maximization of ghci with objective function. the desirability analysis and optimization techniques have been merged to create the main methodology of this study. the desirability equations obtained as a result of statistical analysis and the ghci values belonging to the countries were calculated to construct the optimization models. contemplating types of factors among the countries with index i and j all notations are presented in table . in the optimization model developed when decision variables are created for each country or each factor, there were decision variables generated in total. likewise, a total of constraints were created by considering the lower and upper limits of each factor, in addition to contemplating the nonnegative constraint in the optimization model. the method of desirability has been developed to obtain the best results for multiple reactions or factors acting as a process. (this method is widely used for multi-objective optimization models.) it produces the best response values of the factors to minimize, maximize, or reach the target value of the specifications. while statistical analysis gives mostly linear regression equations, the equilibrium found due to the weighted factor values in the desirability technique has a nonlinear characteristic. before constructing the optimization models, it is necessary to consider the function of desirability according to the results to be obtained as a result of statistical analysis. the factors affecting the response function directly influence the desirability function [ ] . in short, it is desirable that the factors affecting the main response values are at the target values which are measured by the value of desirability. the best result is gained as this value goes from zero to one. the complete desirability function includes the upper and lower bound values of the factors that have an effect on the responses. ghci was created separately for each factor. ghci formula was obtained by geometric mean of these factors. however, the values of ghci and he are converted into the following formula in order to get a meaningful and accurate result. thus, the value of ghci and he was placed between and . where d * denotes the geometric mean of the desirability indexes of the factors. d , d , d , … , d n take a value between and . if it is the worst and undesirable value. n indicates the number of factors and since there are six factors in this study, n = is written. there were six different factors in this research, and the expansion of these factors on the desirability formulas as objective functions for the optimization models was shown as below: where l , l , l , … , l and l , l , l , … , l are the lower and upper specification limit of the responses, the power w , w , w , … , w correspond to the weighted factor, and it is the parameter that determines the shape of d , d , d , … , d n . . c is a multiplier that was used to have the result obtained have normal values in the equations. to find n factors' values, the value of each response value is expressed as y , y , y , … , y . the following developed equations have been used as objective functions with the constraints to determine the competitiveness indexes of a country's healthcare systems. in this part, as a result of statistical analysis, finding the best solution and the results obtained in optimization models have been discussed. furthermore, calculating the ghci values of the countries considered, the advancement levels of the health systems of these countries have been ranked. this section provides general information about the collected data for statistical analysis and shows the accuracy of the analysis. the precision of the factors with the effects was measured on the response's variables. decision variables named as independent factors were abbreviated as gross domestic product, gdp; gross domestic product per capita, gdp pc; life expectancy, le; the number of beds, b ; the number of nurses and midwives, nw; and the number of physicians, md. the statistical analysis of factors and healthcare expenditure for factor i the country of j in the year y ∀ y ∈ � response variables are illustrated in table . the results of statistical analysis showed that the accuracy of the collected values had high values of r . the accuracy of the statistical analysis of this study was estimated as . % of the r value and . % of the adjusted r value. the effects of the determined factors on the ghci were examined based on hes. the importance of a factor on the response depends on the p-value of the factor as a result of the statistical analysis. contribution ratios were calculated as percentage of contributions to the total sequential sum of squares of each source in table . higher percentages of contributions rates indicated that it calculated more variation on the responses. the most important factor was found as gdp pc by country in the statistical analysis. (p-value of gdp pc was computed as zero.) gdp, the numbers of nurses, physicians, and beds were found to be more impressive factors on hes and ghci. however, these results indicated that ghci were not influenced by the hes of countries. thus, this factor was excluded in the application optimization model to calculate optimum values of remained factors, which was defined as an objective function. note that the effects of factors considered for ghci were measured as non-interactively. optimization mathematical models for optimizing both the factors and the objective functions (or response) were developed to compute the optimal and feasible values. these values show the necessary data to compete for a country in the field of healthcare. considering the factors analyzed, the calculated values were higher than the mean of the data of countries. as a result of the statistical analysis revealed, sixth of the important factors discussed was more effective on hes and ghci in this study. figure shows the variation in the optimum and feasible results obtained for ghci and hes according to d*. the optimum point was located between . and . of d* (with the creation of graphic for feasible solutions, the d value was calculated as . maximum and the minimum value as . , respectively) shown in fig. . the optimal point located to be within the feasible region, but two different objective functions (for different directions: max-min) ensure that the solution was nonlinear. the objective functions and the factors constituting the constraints that have optimum and feasible values are demonstrated in table to determine the individual effects of the factors that could affect the response and *statistically significant (p-value < . ), **at the margin of statistical provisionally significance (p-value < . ) contribution: displays the percentage that each source contributes to the total variation in the response ci: confidence interval is an interval estimation type for the actual values of an unknown population parameter calculated from the statistics of the observed data p-value: the p-value is a probability that measures the evidence against the null hypothesis the values that each factor takes outside of optimum values were seen to affect the objective function either in the positive or negative direction. according to table , as gdp pc values of the factors increase, the value of the objective functions defined ghci and he decrease. this had a negative effect on ghci, while it had a positive effect on hes. the bidirectional tendency in the objective functions leaded to the transformation of the developed optimization models into nonlinear mathematical equations. on the reverse side, the values of gdp increase among the factors, the value of the objective function assigned ghci increases and the value of the objective function assigned he decreases. we could mention gdp and gdp pc are bidirectional tendency for the healthcare system of the country with the increase in life expectancy values as well as bidirectional effects on the healthcare system of a country. in terms of the resources, healthcare had different situations for ghci and hes. the values of the rest of these sources, except nw, affect the objective functions to a certain extent. however, the numerical increase in these two resources reaching a certain number did not affect the value of ghci and hes as well. in addition, md and b factors did not have any effect on the desirability function defined d*. the effect of the factors affecting the healthcare system on ghci and he is shown in fig. . the calculation of the optimum values for each factor was completed by considering the d* value. areas formed constitute the feasible zone for the objective functions in fig. a -l. the most important point to be considered in these figures was that the factors that were effective in the healthcare system have the maximum values for the ghci value (local maximum), forcing it to be at a minimum level (local minimum) for he. there are two different behaviors in order to get the optimum values of the factors. the factors desire to get the maximum value for ghci and want to get the minimum values for he based on constructed optimization models. therefore, d* values were calculated from different ranges for each figure. in addition, although he and ghci were defined as two independent objective functions, ghci was affected by hes. our findings inferred that he should continue to improve ghci so that ghci can become a much better forecaster of the quality of healthcare. the optimization model with statistical analysis has been developed to demonstrate the competitiveness of the healthcare systems of the countries covered in this study. country selected rankings were made by calculating the ghci scores of the countries with this study on healthcare. we aimed to show that a country with a high ghci score has a quality and competitive health system. thus, the healthcare systems with high ghci score will have the ability to offer a better service to the patients. the ghci scores of the countries ranged from to . the average of the ghci values of the countries was calculated . . when the ghci scores were examined, it was found that the highest value was in the usa ( . ) and the lowest value was in qatar ( . ) (see table ). the ghci score of many countries was below the optimum ghci value. only seven out of countries were above the optimum ghci value. the ghci score of countries was above the average ghci score. the rest of these countries need to improve their ghci scores immediately. the results of this study partially coincide with the results obtained in several studies. the increase in hes is caused by various factors, such as aging of the population, medical technology, and developments in living standards. in the context of the investigations, as people's quality of life and their willingness to live increases, hes increase. in terms of the data, it is seen that hes are high in economically developed countries further than developing countries [ ] . in terms of the healthcare, policies of governments are examined, and it is desirable to reduce the he which is a burden on the country's economy. according to observations, it was determined that the values of hes fluctuated from country to country. the levels of hes were mainly calculated as high in usa, japan, germany, france, and uk, while hes were estimated low particularly in cyprus, lithuania, estonia, latvia, and croatia. comparing different countries defined locational, we can advocate that in the european region, where there was a high number of developed countries, and the level of hes was the highest compared to the other location. as a remarkable point, there are large differences in hes among european countries. for instance, in the level of he in germany, france was higher than the level of he in finland and greece. obviously, we can conclude that there was an imbalance in the hes of countries close to each other. the most noteworthy factor in countries with above average ghci value is the amount of gdp in these countries. it should be noted that the fact that the amount of the hes is high in a country does not mean that it has a quality healthcare system. indeed, the patient satisfaction surveys support this outcome in most of these countries. according to the government policies in these countries, it is a common idea to reduce hes. the countries with high hes (such as uk, canada, japan, italy, germany, france, and usa) healthcare systems are needed to be examined in detail. it is inevitable that countries with social and nonsocial healthcare systems will have an impact on hes. when we look at health services in a comparative way, the high proportion of elderly people from the scandinavian countries has become a major challenge in the delivery of healthcare. likewise, the length of waiting times due to the density of the elderly has become unacceptable for england. in this regard, there is the pressure of providing the service to be provided in the health sector to its citizens before overseas people. despite the revised health system in the usa, there are sectoral problems due to the increasing cost of health expenditures. although most of the citizens in the country have complementary supplementary insurance, they cannot get a comprehensive service. in this regard, in order to receive full-scale healthcare, out of the country are mostly exported from the usa. however, the usa is still at the top of the list of competitive health sectors because it maintains its position as the most advanced country in terms of private healthcare management and innovation. this study has also its limitations. for example, the indices such as the number of private and public hospitals of a country were not able to be considered in this study because of lack of information about them. however, our independent variable as the number of beds or exam rooms instead of the number of hospitals was considered in the optimization models. another limitation was about the data being relatively short-term. we recommend that we use decision variables to predict long-term global healthcare index five years and beyond. we have taken a small step to compare several factors that may impact the ghci. we found that two economic dimensions can be better indicators than he even though he is also a good predicting variable for high-quality healthcare service. we encourage for further refinement of the ghci by including healthcare resources (types of hospitals, technicians, technology, etc.) and the components of healthcare (governments as a rule/law maker, pharmaceutics sector, healthcare insurance companies, etc.) so that it can become a more reliable index. thus, it may be able to better predict future ghci. since there are limited studies on this subject (being the first study on this subject), this study is very important for future studies in order to calculate the index of healthcare systems for cities or countries. healthcare dates back ancient times depending on the development of the world and humanity. applications of the politics in terms of health system have been determined, and adapting it to the changing world scheme, the process of drawing up different approaches for each term have been considered in a methodology in relation to the approaches of national and international elements affecting that period. the rise in the cost and expenditure of healthcare during this process is now determined by many variables, on the one hand, with the use of high technology to provide healthcare, the existence of expensive treatment methods in the form of supply, on the other hand, rise in income, improvements in the living standards, demographic changes, etc., in the form of demand. the existence of these items necessitates the application of changes. when health sector is considered socioeconomically, the main reason why developments in health sector should be mostly financed: a) by public sector and b) by private sector is regarded as a problem to be dealt with is related to finance and carrying out this organization. as the corona virus (covid- ) , which emerged in chine and spread around the world, bringing out global health and economic problems along with, the importance of public sector has once been shown to be highly important in the field of healthcare. as a consequence, it is necessary that public should carry out an effective and leading service regarding the evaluation of health system and healthcare because the most important reason of this situation is the conversion of a health system, which has a social structure, to a nonsocial structure. the basis of this study was to develop optimization models to use the healthcare economics of the countries more efficiently. in these models, the constraints were derived from the factors that affect the healthcare economics besides healthcare systems. thus, the optimum and feasible values of the factors as well as the ghci and he data were calculated in this study. according to the results of the study, we proved that allocating too much he budgets (that can be regarded as waste) does not guarantee to have a high-quality healthcare system in a country. index of healthcare competitiveness shows how good the quality service is in the healthcare field of countries. this index determines the ease or difficulty of receiving services of patients from hospitals or other health institutions. taking the results obtained into consideration in this paper, the competitiveness of a country's healthcare system will only be possible if it carries optimum or feasible values. we have concluded that countries under these values have low quality of healthcare systems. on the centrality of strategic human resource management for healthcare quality results and competitive advantage accessibility testing of european health-related websites 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design of healthcare facilities oecd: oecd data health care resources impact of health system inputs on health outcome: a multilevel longitudinal analysis of botswana national antiretroviral program world population review: life expectancy by country human development in poor countries: on the role of private incomes and public services oecd: oecd data health expenditure (percent of gdp) world bank: world health organization global health expenditure database. health expenditure, total (% of gdp) optimization of correlated multiple quality characteristics using desirability function conflict of interest the authors declare that they have no conflict of interest. key: cord- -yuuumno authors: zarikas, vasilios; poulopoulos, stavros g.; gareiou, zoe; zervas, efthimios title: clustering analysis of countries using the covid- cases dataset date: - - journal: data brief doi: . /j.dib. . sha: doc_id: cord_uid: yuuumno there is a worldwide effort of the research community to explore the medical, economic and sociologic impact of the covid- pandemic. many different disciplines try to find solutions and drive strategies to a great variety of different very crucial problems. the present study presents a novel analysis which results to clustering countries with respect to active cases, active cases per population and active cases per population and per area based on johns hopkins epidemiological data. the presented cluster results could be useful to a variety of different policy makers, such as physicians and managers of the health sector, economy/finance experts, politicians and even to sociologists. in addition, our work suggests a new specially designed clustering algorithm adapted to the request for comparison of the various covid time-series of different countries. infectious diseases hierarchical analysis applied to covid- epidemiological data to cluster countries with respect to active cases, active cases per population and active cases per population and per area how data were acquired johns hopkins university https://www.arcgis.com/apps/opsdashboard/index.html#/bda fd b e ecf data are in raw format and have been analysed. csv files with data has been uploaded. the data were collected for the period from th of january till th of april . the data used here are extracted from the specific site created from john hopkins university on covid- (https://www.arcgis.com/apps/opsdashboard/index.html#/bda f d b e ecf ). excel was used first to collect and integrate all the time series data. an algorithm to provide consistent clustering of various countries with respect to active cases, active cases per population and active cases per population and per area was developed. mathematica and spss were used to run the relevant code.  these data are useful because various countries are clustered based on covid- epidemiological data, which can be helpful to objectively distinguish countries with different covid- spread and results.  a variety of different policy makers, such as physicians and managers of the health sector, economy/finance experts, politicians and sociologists, can benefit from these data.  the clustering provided can further extended to support the identification of possible causes of these different impacts of the pandemic in different countries. thus, the results will help researchers to decide how to design more extended research.  the clustering algorithm applied suits perfectly to the specific problem of time-series concerning variables related to active cases of an infectious disease. the initial data used here are extracted from the specific site created from john hopkins university on covid- (https://www.arcgis.com/apps/opsdashboard/index.html#/bda fd b e ecf ). due to low number of cases in the beginning of the pandemic in many countries, the first day used here is the th of january , while the last day used is the th of april . excel was used to collect and integrate all the time series data. an algorithm to provide consistent clustering of various countries with respect to active cases, active cases per population and active cases per population and per area was developed. mathematica and spss were used to run the relevant code. the final data are the number of cases per day and per date (figure ), the number of cases/ million inhabitants per day and per date (figure ), the number of cases/population/land area per day and per date ( figure ). moreover, this final dataset contains the results of our algorithm for the clustering of these countries for each one of the above cases (figures , , ). the final dataset can be retrieved from mendeley dataset, http://dx.doi.org/ . /kg dst p. . figure shows, at the left, the evolution of cases in each country, starting from the first day of a covid- case, for the thirty countries with the older cases (starting from th of january ) and, at the right, the countries with the highest number of cases. there is a significant difference in the evolution rate of covid cases among the countries of the left or of the right part of this figure. these countries follow some particular shapes: . the first shape corresponds to china: a very sharp increase the first days, an ever sharper after days of the beginning ( th of january) and, then, a flattening of the curve after more days. . the second shape corresponds to south korea, where a similar curve as china appears, increase and flattening, but with very low number of cases comparing to china. . the third case corresponds to the countries where the cases appeared quite early, but they have a quite low number of cases until today (countries such as vietnam, thailand, japan, japan, singapore or nepal) . the fourth shape corresponds to the countries, such as usa, france, germany, italy, uk, spain, iran, canada or israel, where the cases appeared since several days, but the sharp increase appeared very recently with a very high number of cases during last days. from this point of view, the countries can be clustered using our specific algorithm. using the hierarchical analysis, the clustering of figure (left) is obtained using the par day data (left part of figure ). as the countries have cases on a very different number of days, the clustering is based on the first days of the time series. figure shows that china, due to its particular shape, form one cluster alone. next clustering isolates iran from the other countries. the third clustering isolates italy, the fourth a cluster of three countries: israel, spain and south korea, while all other countries are together. a next calculation, not taking into consideration the previous countries, gives the results of the right part of figure . here, belgium and germany form the first cluster. the second clustering isolates france uk and sweden from the other countries. inside this cluster, france is isolated form the other two countries. the clustering of the other counties gives two clusters, one of japan, lebanon and egypt, with japan being alone in a subsequent clustering. the cluster of the other countries isolates singapore, then usa and then vietnam, a cluster of all other countries, except nepal, sri lanka and cambodia being at the end. the clustering using the date data is also performed. this figure completely changes the clustering. here, usa is isolated from the first round, then china from the second, then italy from the third. the fourth round groups clusters, one of spain, one of germany, one of france and iran and one of the other countries. next clustering isolates uk, and then south korea and uk from the other countries. however, the previous analysis does not take into consideration the population of each country. a thousand active cases is china or in luxembourg, countries with a population of almost . million people the first and , people the latter, don't have the same importance. for this reason, figure shows the number of cases for each one million of inhabitants of each country. taking the population into consideration, the situation is completely different. san marino is the country with the highest number of cases per population, followed by andorra, luxembourg, iceland, spain, switzerland, italy, monaco, belgium, france, austria, germany, portugal, norway, netherlands and the usa, the country with the higher number of cases today. left part of figure shows that the thirty countries with the longest time series of cases are not always in the worst case. again, the shapes of these countries are very different. as previously, four different shapes can be recognized, but the countries of the third and fourth group so not always remain in their respected groups. figure shows that the countries with the most critical situation are different than the countries revealed from figure . figure shows the clustering of these countries, in per date basis. san marino is isolated from the first clustering. second round isolated three countries: andorra, iceland and luxembourg (andorra is isolated from the other two in the next round) and the other countries. next round isolates a cluster containing spain, switzerland, liechtenstein and italy, one of monaco, austria and belgium (monaco is isolated in the next round) and all the other counties remain together. fig. . clustering of the countries using the cases/population per date data. however, another parameter influencing the criticality of the situation is the surface area of each country. a thousand cases in australia or taiwan, two countries with quite similar population, but very different land area (australia is times larger than taiwan) do not have the same effect on the covid- epidemics. for this reason, figure shows the results of figure divided by the land area. the situation is very different from figure . figure reveals that the countries with the most critical situation are the small countries. monaco is in the first case, far from the second country which is san marino. andorra, lichtenstein, luxembourg, malta, bahrein, barbados, antigua, grenada and singapore follow. left part of figure shows that the thirty countries with the longest time series of cases are is generally in less critical situation than the countries of the right side. hierarchical clustering of these countries (figure , left) shows that monaco is isolated from the first round and san marino from the second, while all other countries remain together. removing monaco and san marino, a cluster with liechtenstein and andorra and one with malta and luxembourg is obtained, while all other countries remain together (figure , right). clustering with respect to active cases means that the elements of these clusters are countries that have similar time evolution of the active cases, which in turn means that they have faced similar stresses to the health system (with exception countries that performed extensive test to the general population; these countries are very few taiwan, south korea, germany). clustering with respect to active cases per population means that the countries that belong to the same cluster have experienced similar stresses to the society and the economy. finally, clustering with respect to active cases per population per area is useful for driving conclusions about the impact of the disease that spreads more easily in densely populated areas (countries that have dense big cities are more vulnerable). a requirement for "comparison of time series" is not a clear enough task since it includes many different aspects. moreover, this topic is not a fully studied statistical problem to its entire mathematical completeness. the various challenges of the comparison between two or more time series include series with different sampling frequencies or different lengths or different scales. furthermore, the question could focus on differentiating or likening certain characteristic values, means, trends, patterns of periodicity observed or forecast values. in the problem we want to analyze, in the present work, we need to find one meaningful way from the medical perspective to compare the time series of covid- regarding active cases or similar variables. the statistical analysis of different time series is a very useful method for many different disciplines. some well-known methods are the autoregressive moving average (arma) and fourier analysis [ ] . regarding the utilization of different time series sometimes the goal is to uncover similarities and patterns that perhaps appear in the data. various techniques have been used, such us indexing, classification, clustering or detection/identification of abnormal or specific characteristics [ ] [ ] [ ] [ ] . a similarity measure metric or non-metric is always used in such techniques. it is evaluated for two or more time series and returns a value for each one of them. if someone will try to cluster countries with different covid- time series using known algorithms and known statistical packages he will realize immediately that the clustering fails, and the results do not "look" correct. there are many reasons, different lengths, different orders of magnitude, many days with low numbers and sometimes suddenly sharp increases etc. in the present paper, we have developed an algorithm that results to a consistent and reasonable clustering. the code was implemented partially in mathematica and partially in spss. the criterion was the euclidean distance between time series but with emphasis in the data of last days compared to initial days. furthermore, we have also automatically adjusted a common length for all time series keeping the time length that contains large first derivatives and with and without disregarding the data after flattening of the curve (if such a behavior takes place). the overall algorithm follows the concept of hierarchical clustering [ , ] . a high-level description of the pseudo code follows. it was designed for time series x j {t i } with j= ...n, the number of time series of the variable x. each country is denoted with the index j and i= …m is the number of days. -step : keep or disregard terms of the time series in the flattening regime if such regime exists. -step : calculate all the rates of change for every pair x j {t i }, x j {t i+ }, and find number of day k j when for the first time rate appears to be larger than % of the mean value of previous initial rates (that are always small in our time series). -step : for all time series x j {t i } keep terms from i=k…m where k minimum of all k j . -step : run the agglomerative clustering algorithm with single/complete linkage and euclidean distance. time series analysis and its applications clustering of time series data -a survey symbolic time series analysis for anomaly detection: a comparative evaluation semi-supervised time series classification discovering clusters in motion time-series data hierarchical grouping to optimize an objective function slink: an optimally efficient algorithm for the single-link cluster method the authors declare that they have no known competing financial interests or personal relationships which have, or could be perceived to have, influenced the work reported in this article. key: cord- -s mydwff authors: murphy, m. m.; jeyaseelan, s. m.; howitt, c.; greaves, n.; harewood, h.; quimby, k. r.; sobers, n.; landis, r. c.; rocke, k.; hambleton, i. r. title: covid- containment in the caribbean: the experience of small island developing states date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: s mydwff background. small island developing states (sids) have limited absolute resources for responding to national disasters, including health emergencies. since the first confirmed case of covid- in the caribbean on st march , non-pharmaceutical interventions (npis) have been widely used to control the resulting covid- outbreak. we document the variety of government measures introduced across the caribbean and explore their impact on aspects of outbreak control. methods. drawing on publically available information, we present confirmed cases and confirmed deaths to describe the extent of the caribbean outbreak. we document the range of outbreak containment measures implemented by national governments, focussing on measures to control movement and gatherings. we explore the temporal association of containment measures with the start of the outbreak in each country, and with aggregated information on human movement, using smartphone positioning data. we include a set of comparator countries to provide an international context. results. as of th may, the caribbean reported , confirmed cases and deaths. there have been broad similarities but also variation in the number, the type, the intensity, and particularly the timing of the npis introduced across the caribbean. on average, caribbean governments began controlling movement into countries days before their first confirmed case and days before comparator countries. controls on movement within country were introduced days after the first case and days before comparators. controls on gatherings were implemented day before the first confirmed case and days before comparators. confirmed case growth rates and numbers of deaths have remained low across much the caribbean. stringent caribbean curfews and stay-at-home orders coincided with large reductions in community mobility, regularly above %, and higher than most international comparator countries. conclusion. stringent controls to limit movement, and specifically the early timing of those controls has had an important impact on containing the spread of covid- across much of the caribbean. very early controls to limit movement into countries may well be particularly effective for small island developing states. with much of the region economically reliant on international tourism, and with steps to open borders now being considered, it is critical that the region draws on a solid evidence-base to balance the competing demands of economics and public health. one in five members of the united nations (un) are small island developing states (sids); countries with a combined population of around million. ( ) the majority of sids are in the caribbean and pacific, and in addition to common social, economic and environmental vulnerabilities they share limitations related to healthcare provision for rapidly aging populations with high burdens of noncommunicable disease. ( ) ( ) ( ) in the caribbean, there are un recognised sids, with a further island territories without un status and with formal ties to extra-regional un members (usa, uk, france, netherlands). despite this variation in geo-political affiliations, one regional body, the caribbean community (caricom), includes of the caribbean countries and territories as members. serving a combined population of around million people, caricom represents the dominant structure for regional cooperation on economic, political, health and disaster response. ( , ) although many of the island states in the caribbean are classified as high or middle income -a classification that reduces the available international support -there is now global recognition that sids represent a further vulnerable country grouping due to specific economic and climate change disadvantages. ( ) they have limited absolute resources to systematically tackle the complexities of their national health burdens, including responding to acute health emergencies. on march st the first confirmed case of covid- in the caribbean, an italian tourist, was reported in the dominican republic; one month after the first case in italy, and three months after patient zero in china. ( , ) by that time, thousand cases in countries had been confirmed, and the caribbean region, whose economies are heavily dependent on tourist arrivals from europe and north america, was on high alert. on march th , the world health organization declared a global pandemic. as of may , there were . million confirmed cases worldwide, including . million cases in the americas. ( ) since march, caricom had been actively developing regional public health responses to the covid- pandemic. ( ) at the time of the first identified cases among caricom member states, the regional response was in its infancy, and caricom members were also relying on local expertise and international evidence. implemented measures can be broadly classed as non-pharmaceutical interventions (npis). globally, npis are typically introduced as public health responses to outbreaks, and in the case of covid- have been the main method of outbreak control due to the lack of vaccine or pharmaceutical treatment options. ( ) these containment measures are expected to slow the spread of the virus and reduce the severity of the epidemic peak by reducing physical contact, which in turn can reduce disease transmission, and has an ultimate goal of keeping healthcare demand below health system capacity. while there have been many similarities in the decisions by caricom countries to quickly implement npis, there has been distinct variation in the number, the type, the intensity, and particularly the timing of the npis. here we compare national responses across the caribbean ( caricom and two nonmember countries) and explore the potential impact of implemented npis. we focus on npis affecting human movement. in particular, we examine policies related to movement into countries, movement within countries, and control of mass gatherings, against the dynamics of confirmed cases, confirmed deaths, outbreak growth rates, and population mobility. understanding how combinations and timing of npis work, and in which contexts, can inform the continued response to covid- as well as future virulent outbreaks within sids. our main goal was to present a covid- situation analysis for the caribbean region during the initial outbreak period (april and may ). this period broadly represents the time before governments in the caribbean began to gently ease their national containment measures. we present confirmed cases and confirmed deaths to describe the extent of the outbreak across the caribbean. we document the range of containment measures implemented by governments and explore the time between the start of the outbreak in each country and the start of containment. we describe the temporal association of key containment measures and aggregated information on human movement, using smartphone positioning data. ( , ) for selected countries ( caribbean countries, comparator countries), these data describe the change in the number and length of visits to various grouped locations (grocery and pharmacy, parks, transit stations, retail and recreation, residential, and workplaces). the percentage change in movement for each day is compared to average movement on the same day of the week between rd jan and th feb . due to privacy concerns (if somewhere isn't busy enough to ensure anonymity), data from the smaller countries of the caribbean are not publicly available. data are only . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . collected from users who have opted-in to google data collection, so the movement data are indicative not representative of a country's population movement. included countries and territories. our caribbean surveillance work during the covid- outbreak has centred on the caricom member states and associate members (see table ). we included all members in this review and included further caribbean islands that have experienced major covid- outbreaks: cuba and dominican republic. although belize (central america) and guyana and suriname (north-eastern south america) are geographically separated from the caribbean islands they each have strong historical and socio-political links to the caribbean island states. as full members of caricom each of these three territories are integrated into the caribbean political, social, and economic reality. statistical methods. our analyses are descriptive. we explored the extent of the caribbean outbreak in two ways. first, we plotted the cumulative cases and deaths across the caribbean as of -may- , stratifying into caricom and non-caricom states. second, we calculated the growth rate for confirmed cases in each country by using the logarithm of the new daily cases then plotted a -day smoothed average growth rate over time for each country on a heatmap. we described the npis implemented in each country, grouping measures into those controlling movement into the country (border controls, and border closures), those controlling movement within a country (mobility restrictions, curfews, lockdown), and those controlling gatherings (limiting public gatherings, closing public services, and closing schools). these npi groups are described in more detail in box . last, we explored the temporal association of containment measures with outbreak data and with movement data. for each country and for each broad containment group (controlling movement into a country, controlling movement within a country, controlling gatherings), we plotted the number of days between the date of first case and the date of the containment measure. using google data on community movements, we plotted the daily movement reduction (see supplement) and the maximum average weekly movement reduction . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . achieved by each country with available data, linking this timing with the implementation of two key containment measures associated with human movement control (curfews, lockdowns). measure description of measure border controls any measure to intensify border controls, including health checks at border, visa restrictions or suspensions, and requirements for additional health documents. border closure: full all points of entry closed including complete suspension of international flights and/or full airport closure border closure: partial some points of entry into country closed and/or passengers from certain destinations not permitted entry. this also includes any flight suspensions from specific destinations mobility restrictions includes domestic travel restrictions with or without structured or ad-hoc security checks. government order for people to remain in their home between specified hours (mostly at night). lockdown / stay-at-home order: full -hour curfew and/or country under emergency "stay at home" order, and closure of public spaces. only movement of essential workers allowed. only essential services open. lockdown / stay-at-home order: partial as full lockdown, except that some public spaces remain open and/or specific businesses remain open, in addition to essential services. limit public gatherings any measure to ban or reduce the number of people allowed at public gatherings (such as weddings, funerals, religious worship) and social occasions. close businesses or public services any measure to close or limit public access to nonhealthcare public services, and/or private businesses. close schools any measure to close an educational facility, including tertiary education . taxonomy of government measures adapted from assessment capacities project (acaps) www.acaps.org/sites/acaps/files/resources/files/acaps_covid _government_measures_dataset_ .xlsx) . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . in table in figure we visualise the cumulative numbers of confirmed cases and deaths across the caribbean. as similarly, confirmed deaths were dominated by dominican republic ( deaths, . % of all deaths) and to a lesser extent by cuba ( deaths, . % of all deaths). the caricom countries and territories accounted for confirmed deaths, or . % of all deaths. in figure we visualise outbreak growth rates by country. growth rates varied markedly over time in most countries and territories, reflecting periods in each country when higher or lower numbers of cases were identified. caricom countries experienced the outbreak later than comparator countries and have so far maintained lower levels of growth than those seen in comparator countries. as of -may- , twelve out of caribbean territories had kept their maximum growth rates below % and of the remaining ten caribbean territories, maximum growth rates ranged between % (the bahamas, . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . jamaica) and % (dominican republic). most caribbean growth rate trajectories were similar in magnitude to those seen in two asian comparator countries, vietnam ( %) and singapore ( %), indicative of good initial outbreak control. comparator countries saw higher growth rates and a wider range of growth, between % (vietnam) and % (italy). in figure we present containment measures in our three broad categories: measures to control movement into a country, measures to control movement within a country, and measures to control mass gatherings. sixteen out of the caribbean countries implemented a full border closure, compared to of comparator countries (new zealand). roughly equal proportions of caribbean and comparator countries initiated some form of lockdown, but only caribbean countries implemented strict night-time curfews. all countries implemented measures to control gatherings. in figure we present the timing of npis, relative to the date of first confirmed case in each country. broadly, caribbean countries and territories tended to implement npis earlier, compared to the international comparator countries. within the caribbean the order of implementing measures has been control of movement into countries, followed by control of gatherings, and then control of movement within countries. comparator countries tended to follow the same pattern but waited longer before implementation. when examining the spread of npi timings across the caribbean, many caribbean territories followed similar timings to new zealand and iceland. on average, caribbean countries began controlling movements into countries days before the first confirmed case (inter-quartile range (iqr) to days before). this compares to days before the first confirmed case among comparator countries (iqr days before to days after). caribbean countries began controlling movement within a country days after the first confirmed case (iqr days to days after), compared to days after among comparator countries (iqr to days after). caribbean countries began controlling gatherings day before the first confirmed case (iqr days before to days after), compared to days after among comparator countries (iqr to days after). in figure we present the maximum reduction in weekly community movement data in selected caribbean and comparator countries. with the exception of haiti ( % maximum reduction) and . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . jamaica ( % maximum reduction), the largest weekly reductions in movement over a full week were above % in all caribbean countries, over % in / caribbean countries, and over % in caribbean country (barbados). in the comparator countries with available movement data, maximum movement reductions were over % in only / countries (italy, new zealand). the implementation of a major npi to limit movement (curfews and/or lockdowns) was largely followed by a fall in population mobility, but there was much variation in this effect. several countries saw a sharp fall in mobility co-incident with the date of either curfew and/or lockdown implementation (antigua and barbuda, barbados, trinidad and tobago, new zealand, singapore), while for others the decline was either more gradual or less . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . as of monday th may, there were , confirmed cases and confirmed deaths among the caribbean countries and territories. the maximum growth rate in the caribbean was % in the dominican republic, compared to % in the comparator country of italy. caribbean countries were more likely to implement a full border closure and strict night-time curfews. they were also more likely to introduce npi measures earlier than comparator countries relative to the date of their first confirmed case. peak movement reductions were above % in / caribbean countries, and in only / comparator countries. as of may , the caribbean region has broadly achieved initial covid- containment, with the exception of the evolving outbreak on the island of hispaniola. given the struggles some developed comparator countries have had with containment, the low ghs scores across the caribbean, and the benefits of avoiding community transmission due to high national population densities, this is a significant success for the caricom sids. although caribbean countries initially developed their npi implementation strategies using local expertise and international evidence, they nevertheless followed similar initial npi pathways, focusing first on measures to limit movement into their respective countries. these sensible early precautions were an attempt to block imported cases and may be particularly important in small islands with a limited and manageable number of physical entry points. the significance of early border controls and closures should be placed within the economic context of the region. tourism is a dominant revenue stream for many caribbean sids, with their reliance on international arrivals, particularly from europe and north america. governments were aware that border controls and closures would have severe economic effects. weighed against this was the known fragility of regional health systems, and governments were keen to avoid their health systems being overwhelmed by a sharp increase in hospitalisations. using the date of first confirmed case in each country as our indicator, caribbean sids generally implemented npis earlier than our chosen comparator countries. for movements into a country, the caribbean on average implemented controls days before their comparator counterparts. for control of movement within countries, the caribbean implemented controls days before comparators, and for control of gatherings the caribbean on average implemented controls days before comparator countries. this three-to-four week "headstart" by caribbean countries may be partly attributed to the region having seen the outbreak unfold in other parts of the world, and the longer 'grace period' before covid- arrival in the region. it may also . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . reflect governments' recognising the potential for hospitalisations to overwhelm vulnerable health system infrastructures, spurring them into strong and early outbreak suppression. ( ) of the countries in the acaps database, initiated a curfew order, with % of those countries in africa and the americas. in the caribbean, governments quickly passed emergency laws that allowed for enforceable curfews and stay-at-home orders. curfews were common in the caribbean, with populations not allowed to leave their homes for any reason except emergencies (or emergency work). associated punitive measures were regularly significant; in barbados for example, a fine of , barbados dollars (usd , ) or -year in prison were possible. curfews were mostly applied during the hours of darkness, and a logic to this would have been be an attempt to prevent evening gatherings. although curfews were not officially implemented in any of our comparator countries, this may reflect the semantics of terminology, with curfews possibly seen by some governments as sounding overly authoritarian. some countries, without using the term "curfew", operated near curfew-like conditions. italy for example required those leaving their homes to carry movement exemption forms, with fines for breaches of these rules. the stringency of national lockdowns, including curfews seem to impact heavily on community mobility, with countries implementing strict measures seeing stark drops in postimplementation mobility. the extent of a government's willingness to implement and enforce stringent movement restrictions will have been a compromise between the desire to limit transmission and the perceived success of the intervention given known societal norms. a full examination of these influences is important, but beyond the scope of this initial work. among countries for which human mobility data were available ( caribbean countries, comparators) curfews and lockdowns were visually associated with marked falls in human movement. for example, barbados, antigua and barbuda, trinidad and tobago, and new zealand saw sustained post-lockdown drops in excess of percentage points (see supplement for details). in the case of barbados, implementation of curfew followed by lockdown each coincided with clear mobility reductions. it may be that a curfew order acted as a national sensitisation measure for subsequent full lockdown. for the caribbean, the coming weeks and months are likely to involve discussions and actions centred around easing national npis while maintaining broad outbreak containment. a priority is how to safely but effectively re-invigorate international tourism as caribbean islands look to reopen their economies for business. increased tourism from the european and north american markets, which are still grappling to contain the virus, increases the opportunity for imported cases and local transmission. consequently, modified npis that minimise the chance of a renewed outbreak without negatively . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . impacting the tourist experience will need to be envisaged. one potential option is the concept of travel corridors allowing free movement between countries or cities that have good containment, but restricting movement from higher-risk locations to safeguard public health. as timing of npis has emerged as an important factor in containing the outbreak, it should now encourage a proactive approach as countries plan to encourage tourism. national evidence-based risk assessments, drawing on country-level goals and limitations must now be a priority. continued outbreak surveillance remains a critical tool to enable swift action following accelerated transmission. as always, it could be sensible to learn from successful models implemented elsewhere. this descriptive study has limitations. we focus only on npis related to movement and we recognize that other npis such as contact tracing, and isolation and quarantine protocols will have also helped to reduce transmission. we have described the type and timing of npis implemented and have inferred their impact on covid- transmission. however, we have not attempted to quantify these effects, nor have we accounted for other factors that may impact transmission, such as the effect of climate on virus longevity. ( ) the data we use in this article has been drawn from disparate sources, each of which has limitations. the number of cases we report is based on the number of tests performed, and as population-level testing remains economically impractical, no country currently knows the extent of their underlying outbreak. the npi data are drawn partly from informal sources such as media reports with implied quality concerns. to counter this we have made systematic efforts to triangulate our npi information wherever possible. although we have used two quantitative categories to describe the implementation of lockdowns, in reality national stay-at-home orders varied markedly in their stringency and geographical reach. this variation in stringency included country-level differences in what constituted essential services. stringent controls to limit movement, and specifically the early timing of those controls has had an important impact on containing the spread of covid- across much of the caribbean. very early controls to limit movement into the country may well be particularly effective for sids. with much of the region economically reliant on international tourism, and with steps to open borders now being considered, it is critical that the region draws on a solid evidence-base to balance the competing demands of economics and public health. . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . amb express. ; ( ): . . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . . https://www.ecdc.europa.eu/en/publications-data/download-todays-data-geographic-distribution-covid- -casesworldwide (we will update this just before publication). can use my regional report to fill this in -no need to go to the ecdc website… . it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . figure . the number of days between the date of first confirmed case of covid- and the date of introducing the first non-pharmaceutical intervention (npi), stratified by country and by npi type figure . the maximum average weekly reduction in population mobility among caribbean countries and comparator countries . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . supplement . protocol describing systematic search for non-pharmaceutical interventions in caribbean countries and international comparator countries. the acaps covid- government measures database collates non-pharmaceutical interventions (npis) implemented by governments worldwide in response to the coronavirus epidemic. it uses a variety of international and national media sources and includes a secondary review of collated information. measures are grouped into broad categories: movement restriction, social distancing, public health measures, governance and socioeconomic measures, and lockdown. given the rapidly changing nature of national interventions -especially early in the crisis -and the use of unverified data sources, we aimed to validate acaps for the caribbean region and our chosen comparator countries by conducting a review of all listed non-pharmaceutical interventions (npis) and systematically search for missing entries. of the npi groupings detailed in the acaps database, are related to limiting human movement into a country, limiting movement within a country, or limiting gatherings (table , column ). we collapsed these acaps measures into the npi sub-categories (column ), and npi major categories (column ). our npi sub-categories are defined in full in column , and we used these definitions when categorizing individual national npi measures (see table ). . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . we constructed a new dataset comprising row of information for each country / npi sub category combination ( countries and npi sub-categories, creating a dataset of rows of information). using the acaps database as the major information source, and supplementing this source with a predefined list of additional sources (see table ), for each country we documented the existence of npi measures in each npi sub-category, recording the date of implementation, the description of the npi measure, and the data source. this search strategy was performed by two reviewers (mm, kr), with a third reviewer (ch) adjudicating on all discrepant information. this review was planned as a narrative synthesis of evidence, summarizing the npis implemented in each country by the major npi categories and npi sub-categories described in table . further information on data analytics associated with the collected npi data is provided in the main article (methods / statistical methods). . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . world population prospects: the revision, methodology of the united nations population estimates and projections chronic disease and ageing in the caribbean: opportunities knock at the door achieving universal health coverage in small island states: could importing health services provide a solution? the caribbean community port-of-spain declaration on noncommunicable diseases: an overview of a multidisciplinary evaluation determinants of the lethality of climate-related disasters in the caribbean community (caricom): a cross-country analysis monitoring compliance with high-level commitments in health: the case of the caricom summit on chronic non-communicable diseases united nations general assembly. sids accelerated modalities of action (samoa) pathway. resolution adopted by the general assembly on clinical features of patients infected with novel coronavirus in wuhan first cases of coronavirus disease (covid- ) in the who european region world health organization. coronovirus disease (covid- ) situation reports daily data download on the geographic distribution of covid cases worldwide johns hopkins coronavirus resource center covid- community mobility reports google covid- community mobility reports: anonymization process description (version . ) reinterpreting the caribbean impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand. imperial college london country government tourist information and embassies national newspapers and wikipedia key: cord- -lrn wpvj authors: ibrahim, mohamed r.; haworth, james; lipani, aldo; aslam, nilufer; cheng, tao; christie, nicola title: variational-lstm autoencoder to forecast the spread of coronavirus across the globe date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: lrn wpvj modelling the spread of coronavirus globally while learning trends at global and country levels remains crucial for tackling the pandemic. we introduce a novel variational lstm-autoencoder model to predict the spread of coronavirus for each country across the globe. this deep spatio-temporal model does not only rely on historical data of the virus spread but also includes factors related to urban characteristics represented in locational and demographic data (such as population density, urban population, and fertility rate), an index that represent the governmental measures and response amid toward mitigating the outbreak (includes measures such as: ) school closing, ) workplace closing, ) cancelling public events, ) close public transport, ) public information campaigns, ) restrictions on internal movements, ) international travel controls, ) fiscal measures, ) monetary measures, ) emergency investment in health care, ) investment in vaccines, ) virus testing framework, and ) contact tracing). in addition, the introduced method learns to generate graph to adjust the spatial dependences among different countries while forecasting the spread. we trained two models for short and long-term forecasts. the first one is trained to output one step in future with three previous timestamps of all features across the globe, whereas the second model is trained to output steps in future. overall, the trained models show high validation for forecasting the spread for each country for short and long-term forecasts, which makes the introduce method a useful tool to assist decision and policymaking for the different corners of the globe. as a new contagious disease in human inhabitants, covid- , has been currently reaching , confirmed cases with . death in countries across the world (wordometer, ) . although there are a number of the statistical and epidemic models to analyse covid- outbreak, the models are suffering from many assumptions to evaluate the impact of intervention plans which create a low accuracy as well as unsure prediction (hu et al., ) . therefore, there is a vital need to develop new frameworks/methods to curb/control the spread of coronavirus immediately (botha and dednam, ; hu et al., ) . the epidemic outbreak of covid- in literature is investigated using mathematical compartmental model named susceptible-infected-recovered (sir) (kermack and mckendrick, ). the sir model represents a population under three categories: ) susceptible (the number of people presently not infected), ) the number of people currently infected, and ) the number of people either recovered or died. the model describes as differential equations. the model is completely determined by transmission rate, the recovery rate, and the initial condition, which can be estimated using least square error, kalman filtering or bmc. the model is sometimes renamed based on the new parameters such as susceptible-infectious-quarantined-recovered (siqr) or susceptible-exposed-infected-recovered (seir). the main idea in the version of all sirs models are four-fold; first, identification and better understanding current epidemic (crokidakis, ) , second, simulation the behaviour of the system (castro, ) , third, forecasting of the future behaviour (toda, ) , and last, how we control the current situation (sameni, ) . however, the results of the models including accuracy only valid based on their assumptions in a slice of available data/moment and have their scopes to assist healthcare strategies for the decisionmaking process. on the other hand, agent-based modelling is utilised to explore and estimate the number of contagions of covid- , specifically for certain countries (chang et al., ; simha et al., ) . also, statistical methods (singer, ) , simple time series modelling (deb, ) , and logistic map (al-qaness et al., ) are utilised for similar objectives, whereas (botha and dednam, ) , focused on modelling the spread of coronavirus based on the parameters of basic sir in a ( dimensional) iterative maps to provide a wider picture of the globe. petropoulos and makridakis ( ) forecasted the total global spread relying on exponential smoothing model based only on historical data. put all together, the drawbacks of their models are not flexible to fit for each country or region due to the lack of necessary measures, government responses, and spatial factors related to each specific location. there are few examples of predictive modelling of the coronavirus spread based on machine learning approaches, whether through shallow or deep models. while it is can be explained due to the limitation of data since the early stage of the outbreak, it remains an essential tool. according to pham and luengo-oroz ( ), machine learning approaches certainly could assist in forecasting by with improved quality for prediction. one of the few studies is presented by (hu et al., ) . they have applied real-time short-term forecasting using the compiled data from th jan to th feb collected by the world health organization (who) for the provinces of china. the data is trained on a deep learning model for realtime forecasting of new cases for the provinces. their model has the flexibility to be trained at the city, provincial, or national level. besides, the latent variable of the trained model is used to extract necessary features for each region and fed into a k-means to cluster similar features of the infected or recovered features of patients. bearing this in mind, there is still a knowledge gap for machine learning models to predict coronavirus cases at a global as well as regional scales (pham and luengo-oroz, ) . while sir models with their different types, in addition to the aforementioned ones, are essential, the challenges remain in forecasting different regions and countries across the globe with a single model without any assumptions or scenario-based rules, but only with the current situations, features related to countries, and measures amid to reduce the impact of the outbreak. accordingly, in this paper, we introduce a new method of learning and encoding information related to the historical data of coronavirus per country, features of countries, spatial dependencies among the different countries, and last, the time and location-dependent measures taken by each country amid towards reducing the impact of coronavirus. relying on deep learning, we introduce a novel variational long-short term memory (lstm) autoencoder model to forecast the spread of coronavirus per country across the globe. this single deep model aimed to provide robust assistance to policymakers to understand the future of the pandemic at both a global level and country level, for a short-term forecast and long-term one. the main advantages of the proposed method are: ) it can structure and learns from different data sources, either that belongs to spatial adjacency, urban and population factors, or various historical related data, ) the model is flexible to apply to different scales, in which currently, it can provide prediction at global and country scales, however, it can be also applied to city level. and last ) the model is capable of learning global trends for countries that have either similar measures, spread patterns, or urban and population features. after the introduction, the article is structured in five sections. section introduces the method and materials used. in section , we show model evaluations and the experimental results at country and global levels. in section we discuss our results, compare our model to any existing base models and highlights limitations. last, in section we conclude and present our recommendation for future works. the model algorithms are constructed based on four assumptions that we assume the model needs to learn to predict the next day spread: first, the model needs to extract features regarding the historical data of coronavirus spread for a given country bearing in mind the historical values of the virus spread in the other countries simultaneously before it outputs a prediction for a given country. second, before the model gives a predicted value for each country, it should consider the predicted values of all other countries instantaneously, similar to the first point. third, the spatial relationship between different countries is multidimensional; it can vary based on geographical location, adjacency, accessibility, or even policies for banning accessibility. the model needs to deal with variations of time and location of the different inputted scenarios while sampling outcomes. last, apart from the virus features, for each country, there are unique demographic and geographical features that show association to the spread of the virus that may show association with the virus, in which the learning process of the model needs to consider each time before it gives a predicted value. the structure of the input data is key for any model to learn. figure shows the concept of the overall structure of the proposed graph of multi-dimensional data sets for forecasting the spread. it illustrates how different types of data can be linked and clustered for the model to learn the spread of a virus. this data can be seen as dynamic features related to both virus and the location with long temporal scales (i.e. the population data) or short ones ( ). it shows how local and global trend for a virus can be forecasted for a given country ( ), with urban features that include both spatial and demographic factors ( ), that share a spatial weight ( ) with other countries in the graph, whereas government mitigated measures ( ) are applied. put all together, the model needs to differentiate between factors that characterise countries or regions, and those which characterise the virus spread to understand the patterns of spread at global and country levels. to meet these hypotheses and assumptions during the learning process, the architecture of the proposed model is based on the combinations of three main components: ) lstm, ) self-attention, and ) variational autoencoder graph. lstm represents the main component of the proposed model. it has been shown it is the ability to learn long-term dependencies easier than a simple recurrent architecture (goodfellow et al., ; lecun et al., ) . unlike traditional recurrent units, it has an internal recurrence or a self-loop, in which it allows the timestamps to create paths, in which the gradient of the model can flow for a long duration without facing the vanishes issues presented in a normal recurrent unit. even for an lstm with a fixed parameter, the integrated time scale can change based on the input sequence, simply because the constants of time are outputted by the model itself. these self-loops are controlled by a forget gate unit ( ( ) ) for a given time (t) and a cell (i), in which it fits this weight to a scaled is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april , . . value between , with a sigmoid unit ( ). it can be explained as: ( ) = ( + ∑ , ( ) + ∑ , ℎ ( − ) ) ( ) where ( ) is a vector for the current input, ℎ ( ) is a vector for the current hidden layer that contains the outputs of all the lstm cells, are the biases for the forget gates, is the input weights, is the recurrent weights for the forget gates. the internal state of the lstm is updated with a conditioned self-loop weight ( ( ) ) as: ( ) where b represents biases, u represents input weights, w represents the current weights into the lstm cell, and ( ) represents the external input gate unit. it is computed similar to the forget gate but with it is own parameters as: last, the lstm cell output ℎ ( ) can also be controlled and shut off with an output gate ( ) , similar to the aforementioned gate by using a sigmoid unit. the output ℎ ( ) is computed as: represents biases, represents input weights, represents the current, and ᵩ.represents the activation function such as tanh function. put all together, this controls of the time scale and the forgetting behaviour of different units allow the model to learn long-and short-term dependencies for a given vector. not only the model learns from the previously defined timestamps for each country, but also the model could extract features from the other countries at each given timestamp in which the dimension of the input vector, and cell states, includes the dimensions of the different countries. it is worth mentioning that the input for the lstm cells is can be seen as a three-dimensional tensor, representing the sample size for both training and testing, the defined timestamps for the model to look back, and the timestamps of the other countries as a global feature extractor. while the lstm cells learn from their input sequence to output the predicted sequences through the long and short dependencies of the time constants and their additional features for each country, the relations between its inputs remains missing. a self-attention mechanism allows the lstm units to understand the representation of its inputs by relating the positioning of each sequence (goodfellow et al., ; vaswani et al., ) . this mechanism in the case of the proposed model is crucial to assist the model to which piece of information to consider and what to forget when making a prediction. the selfattention mechanism can be explained as: we initialise the first graph based on the spatial weight of the geographical locations of all infected countries (more details will follow in sub-section . . ), however, despite the attempts of trying to create a sophisticated adjacency matrix among the infected countries ( based on flight routes, spatial network, migration network, etc.), the output may misleading for any learning method over time or for a given location. the spatial weight since the outbreak of the model may look completely different from the initial day to the latest day. these due to different policies and measures that are taken by countries. however, due to its high uncertainty and variation. inputting the model with a static graph or even a dynamic one based on limited data may exacerbate the learning process. accordingly. the third vital components in our model represent the variational autoencoder (vae) component that allows the model to generate information from a given input. it can be defined as a generative directed method that makes use of the learned approximate inference (goodfellow et al., ; ha and schmidhuber, ) . the model is based on the idea of passing latent variables to the coded distribution ( ) over samples using a differentiable generator network ( ). subsequently, is sampled from the distribution of ( ; ( )) which is equal to the distribution of ( | ). the model is trained by maximising the lower bound of the variation ℒ( ) that belongs to as: ( ) describes the joint log-likelihood of the visible and hidden variables under the approximate posterior over the latent variables log ( , ), and the entropy of the approximate posterior ℋ( ( | ), in which is chosen to be a gaussian distribution with a noise that is added to the predicted mean value. in traditional variational autoencoder, the reconstruction log-likelihood tries to equalise the approximate posterior distribution ( | ) and the model prior ( | ). however, in the case of our model the encoded ( | ) is conditioned and penalized based on the output of a predicted value of the next forecast of the spread, instead of the log-likelihood of the similarity with ( | ), which will be explained further in the proposed framework. we propose a sequence-to-sequence architecture relying on a mixture of vae and lstm. the model comprises two branches trained in parallel in an end-to-end fashion. figure shows the overall proposed framework. the first branch is a self-attention lstm model that feeds by spatio-temporal data of coronavirus spread per day and per country, the government policies per day and per country, and the urban features per country, in which the vector is repeated to cover the duration of training (the urban features used are three features: population density, urban population percentage and fertility rate, which will be covered in detail in the upcoming section). each input is reshaped as a d tensor of shape (samples, timestamps, number of features x number of countries). the three-input data are concatenated at the last axis of the data (the dimension of the feature) and passed to the first branch of the model through two parts: ) the self-attention lstm sequence encoder, and ) the lstm sequence decoder. the first sequence encodes the input data and extracts features for the second part of the lstm sequence to output the prediction of the spread for the next day (in case of the shortterm forecast) per country. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . in parallel to the self-attention encoder sequence, the second branch of the model is an encoder of vae. it is feed by a spatial matrix of dimensions (number of countries x number of countries) and repeated for the entire duration of training and timestamps (in the next section, more details will follow on how it is selected and computed). this encoder part is mainly a convolution structure, which consists of three d convolution layers of filters , , and respectively, in which they are all of a kernel size of and activated by a relu function and followed by a dropout layer of size . . after the dropout, two lstm layers are followed, in which they contain , lstm cells respectively. the first one is activated by a relu function, whereas the second one by a linear function. a fully connected layer of neurons equivalent to the number of countries is applied. last the latent space is defined with a dimension of , in which the z-values are generated from sampling over the gaussian distribution of the previous inputted layer (as explained in section . . ). to visualise the generated graph for representation purposes, it is worth mentioning that the encoder of the second branch of the model can be decoded to output the generated samples for each predicted sequence by passing it into a decoder vae, where the d convolutions layers are transposed to a final output shape equal to the inputted dimension. as for future work, this could be an interesting approach to understanding the variation of the graph for each predicted day for all countries. both outputs of the self-attention lstm encoder and the encoder of the vae are concatenated over the feature dimension and passed to the lstm decoder sequence, which contains a single lstm layer of cell numbers equal to the total number of countries. it is followed by two fully connected layers of shape size ( x number of countries) for predicting the value of the next day, in case of the short-term forecast, or can be shaped to (numbers of future steps x number of countries) for any number of future steps that model needs to output per each country. data sets are split to training and testing on the first dimension of data shape (the total duration of the temporal data), in a way that the model can be tested on the last days. we trained two different models, one as a single-step model for short-term forecast (one day), whereas the other is trained as a multi-step model ( days forecast). there are two crucial differences between these two models; the output layer, and the dimension of the y-train, and y-test of the first one is shaped as ( x n), whereas in the other model is output layer is shaped as ( x n), despite the number of samples. is the structure of the y-train and y-test. the second issue, is the trained and tested sample is not only reduced by the number of timestampsat the beginning of each sequence-as in the case of the first model, but also reduced by the number of future steps -at the end of the sequence-in the case of the second model. last, based on trial and error, we structured the data based on timestamps for both models to look back for all the input features for each country, in which we found optimal results. the weights of the model are initialised by random weights. the model is compiled based on the backpropagation of error of the stochastic gradient descents, relying on 'adam' optimiser (kingma and ba, ), with a learning rate of . and is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint momentum . . the model is trained for training cycles (epochs). the performance of the proposed method is evaluated based on three different scales; ) a global loss-based evaluation, ) country-based evaluation and last, ) step-based evaluation. the short-term forecast model (single-step model) relies only on the first two evaluation metrics, whereas the multi-step model includes the three levels of evaluations. the first loss function evaluates the overall performance of the model at a global level, in which it influenced the adjustment of the model weights during training for both trained models. it is evaluated based on the mean squared of error (mse) which is calculated as: where m is the total sample, ̂( ) is the predicted values of the test set, and ( ) is the observed values of the test set. we also computed kullback-leibler divergence ( ) or so called 'relative entropy 'which measures the difference between the probability distribution of two sequence. it is a common approach for assessing the vae, nevertheless, it could be a good indicator to evaluate the predicted sequences globally. it is calculated as: where ( ) and ( ) represent the two probability distributions of the two random discrete sequences of . in the case of the model ( ) and ( ) represents the true distribution of data and the predicted one ( ( ) ̂( ) ). it is worth mentioning ( ( )|| ( )) ≠( ( )|| ( )). the second loss evaluates the performance of the model at a local level of each country or region. strictly, ̂( ) and ( ) ideally fit a statistically significant linear model where the strength of the model with r-squared value can be computed for further interpretation, in addition to the computed mse or its root, for each county for the entire duration. similar to the second loss, the performance of the second model (the multistep model) includes a calculated loss (based on the root of the mse) for each predicted step. last, comparing our results to other models remains a challenge due to the absence of a unified model similar to what we have achieved that forecast each country globally, or also due to the absence of general benchmark data with a common evaluation metrics. however, we try our best to compare and discuss the performance of our method to any existing models such simple or deep time-series model for specific countries or at any specific time. to forecast the spread of the coronavirus the next day, we synchronised different types of data to allow the model to learn. this wide range of data comprises the historical data of the coronavirus spread by each country, dynamic policies and government responses that amid to mitigate coronavirus by each timestamp and by each country, static urban features that characterise each country and shows significant correlations with the virus spread, and last, the spatial weight among the different countries. these different data types are integrated and synchronised by countries and -time steps in case of dynamic datato be feed to the introduced framework. we used the historical data for coronavirus spread published by john hopkins university (dong et al., ; jhu csse, ). after integrating this data with following data sources, the version we used, contains timestamps from / / till / / ( days) for regions or countries across the globe as shown in figure for the confirmed cases for the start and end day of the examined duration. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . we used demographic and locational data that represent the population for each region or country from the aforementioned data set (worldometer, ) . there is a wide range of factors, however, we only selected three factors; ) population density, ) fertility rate and ) urban population. the two reasons for selecting these features are: first, the selection is based on enhancing the model prediction after several trial and errors with and without several features. second and most importantly, the selected features show a statistically significant association with the spread of coronavirus over time for all countries across the globe. figure shows the outputs of the spearman correlation for the three selected factors. in figure a, the population density was significant with decaying positive correlation coefficients (rho) from the starting date until before the last days of the examined duration. this means the higher the population density, the more likely a higher coronavirus spread. in figure -b, the fertility rates across the globe show a significant association over the entire tested duration, with negative rho values, which means countries with higher fertility rates are less likely to have a higher spread of coronavirus. this could explain the less spread of the virus in africa (as shown in figure ) , however, this feature may be a time-dependant or due to reporting inaccuracy or the low percentage of virus testing in africa. last, in figure -c, the percentage of the urban population started to show a significant association with the spread of the virus with positive rho values from the middle of the tested duration till the last day. this means the higher the countries with a higher percentage of the urban population, are more likely to have higher coronavirus spread. different countries took and continuously take different measures and responses amid towards coronavirus outbreak. these time and location dependant measures include indicators, which they are: ) school closing, ) workplace closing, ) cancelling public events, ) close public transport, ) public information campaigns, ) restrictions on internal movements, ) international travel controls, ) fiscal measures, ) monetary measures, ) emergency investment in health care, ) investment in vaccines, ) virus testing framework, and ) contact tracing. put all together, oxford covid- government response tracker (hale et al., ) aimed to measure the variation of the government responses weighted by these indicators in a scaled index, so-called stringency index. we used this index to weight the different countries based on the government responses, after integrating and matching the time and location of the previously mentioned data sets. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . we computed a spatially weighted adjacency matrix based on the geolocation of each region or country, relying on the geodesic distance between each region or country. we used haversine formula to compute the distance on the sphere. it calculated as: ( − a) )) ( ) where , represent the origin and destination latitudes in radian respectively, ∆ represents the change between the origin and destination longitudes in radian, and r is the earth's radius. the adjacency matrix is conditioned based primary on eliminating long-distance connections, which can represent the connection between the us and europe, the us and china, and direct connection between china and the rest of the world. this hypothetical assumption came from the early international measured took by the us to ban flight to europe and china for non-american citizens. given, this spatial weight may vary or have a higher degree of uncertainty, the model only self-learns from its representation while it generates various samples with the vae encoder as discussed earlier, instead of using these data as a fixed and constant factor during training and testing. to be in business-as-usual. however, these are only few easily interpretable examples, the challenges for the model is to selflearn the representation of the graph to adjust the different weights and generate graph that could in forecasting the spread globally. in algorithm , we show how we initialised the adjusted spatially weighted matrix for all countries. it attempts to show three main elements for computing the graph: first, it shows how a complete graph between the origin and destination countries is computed. second, how the relative distance is computed and conditioned. and last, it shows how the array is scaled and reshaped. figure shows examples for the variation that could be more significant and realistic for predicting a given day for a given country. for instance, the first graph in figure , can represents countries with strict measures towards international travel, the second one which could be the more likely to be the case during the period of banning travel from us to europe or china for instance, the last two shows how the world more likely to be in business-as-usual. cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . after epochs, the training and testing curves of the model show a steady output with no sign of over fitness, nevertheless, the mse losses for both curves are at a minimum, with values less than . whereas the kl loss for the test set is less than . for both trained model. in figure , we show the distribution of the confirmed and predicted cases globally with the single step model. the total predicted cases per day is a close number to the actual data, with a slightly higher confirmed in africa than what has been confirmed. in figure , we show the sum of the accumulated predicted casespredicted at a country level -across the globe for each day regarding the actual data. the results are highly accurate at a global level, with a fraction difference between the actual and predicted ones on the last examined day / / . the prediction of the model is nonlinear, however, its output at a given sample when it compared to its ground truth is linear. therefore, fitting a linear regression model between the predicted result and the observed one and provide a r-squared . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . value could be a good indicator for understanding the model strength. therefore here, we also show the r-squared value and the root of the mse metrics (rmse) for a linear regression fitted model on the predicted and actual values of our singlestep model. the computed metrics shows a high linear association among them. what makes this method a more reliable one than any simple time-series model is that the predicted global curve to the actual one is outputted without the model learns the actual one or without any explicit rules extracted at the global level to mimic that global spread curve of the virus. the model learns the patterns at country levels, whereas error is minimised at both local and global levels. what makes this a very crucial point to discuss is that changes across the globe more likely to happen at a country level, whereas the global level is rather an impact of the difference countries. not only the model shows higher performance globally but also at a country level. figure (in annexes section) shows the performance of the a single-step model at different countries. overall, the model shows higher performance in countries with higher spread whereas the performance of the model decreases with countries with fewer cases over short period. however, the model shows overall reliable results at a country level. in table , we extend on the evaluation of the single step model. we show further variation of prediction in selected countries in different continents. while the model performance varies from a country to country, overall, it shows a reliable result for at a country level. in table two (in annexes section), we show the performance of the -step model for a group of selected countries. this model is evaluated per country and per step. while the model performance reduces with the increase of the number of steps, compared to the single step model, the result to a higher degree remains consistent at a country level when we reach the -step. in this article, we introduce a state-of-the-art method for predicting the spread of coronavirus for each country across the globe for both short and long-term forecast. it has three main advantages, first, the model learns not only from the historical data but also the applied governmental measures for each country, urban factors, and the spatial graph that represent the dependencies among the different countries. the second advantage of the model is its ability to be applied at various scales. currently, it can forecast the spread at a global and country, and region level (i.e. the case of china, uk), however, it can also be applied at the city level. last, the model can forecast short and long term forecast which could be a reliable tool for decision-making. . base model evaluations there are different attempts for relying on a simple timeseries model whether it is relying on machine learning or a simple mathematical rule for a single country or the total cases globally. however, the drawback in such methods is: first, by fitting an exponential smoothing function to a model with no controlled point would mean the virus will continue to spread, regardless of the number of a population, the action is taken. second, if a simple rule for a given country works for the last days, till when this logic will continue works? what happens when values remain constant, decrease, or even increase at a different rate? there are different possible scenarios that such an approach could not answer. third, despite the first two arguments, how many rules are needed to fit each country globally at a longer period? subjectively, a simple time-series model without considering the factors that characterise countries or policies taken to find "general rules and features" would mean finding simple rules for each country at a given time. in most simple ways, when the curve is only increasing at the initial spread time. cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . last, even if these previous issues are solved, the world is connected, the spatial weights may vary from country to country or day to day based on the restrictions and measures are taken. if there are simple rules that ultimately can fit the entire countries, the challenges would remain in how to weight the changes around the world. most importantly, one single case in one region could influence the spread elsewhere. the generative graph of the model along with other factors of the model empirically has enhanced the predicted values for each country globally (based on trial and errors). however, it remains a challenge that countries with spread over a longer period are more likely to be predicted more accurate than countries with no prior cases. re-training the model with more data in the future would yield better results at both; global and country levels. however, despite data improvement, there are three main domains that the model algorithms can be advanced in future works. first, finding more significant spatial or demographic factors that show significant associations with the spread may also enhance the forecast of the model second, applying the same concept and goals of the model to other subjects of coronavirus, could lead to a better understanding of its future. for instance, estimating deaths or recovery, bearing in mind the health system capability and capacity, in addition to the governmental responses could be another assisting tool. put all together, more data, more factors, different forecasting model could also lead to better long-term forecast ( - months) for each country based on the lesson learned from the global and country-level trends of spread. in this article, we introduced a new deep learning model relying on variational-lstm autoencoder to predict the spread of coronavirus for regions/countries across the globe. the introduced learning process and the structure of the data are keys. the model learned from various types of dynamic and static data, including the historical spread data for each country, urban and demographic features such as urban population, population density, and fertility rate, and government responses for each country amid towards mitigating coronavirus outbreak. also, the model learned to sample different conditions and adjustments of a spatially weighted adjacency matrix among the different infected countries. overall, the model shows high validation for forecasting the spread at global and country levels, which makes it a useful tool to assist decision and policymaking for the different corners of the globe. there are several lessons learned while conducting this research. first, concerning urban features, we found several associations of several factors with the spread of coronavirus globally. most significantly, countries with a higher density of population in one km and larger portion of the population living in urban areas are associated with higher coronavirus spread with different coefficients, and levels of statistical significance during the examined duration, whereas countries with higher fertility rates are associated with fewer spread cases at the given studied period ( / / - / / ). however, we also found an association with other factors that not used in this research such as migration nets. we found that countries with higher migration flows are associated with higher spread which could also be explained with their likelihood of having a higher influx of job opportunities. second, concerning the computed adjacency matrix graph, we found that at very short distances among the different infected countries with coronavirus spread, western european countries (such as germany, italy, spain) are fully or partially connected relative to other countries globally that are same distance they are completely isolated. this can be reflected on the relatively shorter distanceas a physical attribute-as among these countries when it compares to other countries, or the nonphysical accessibility of the european market which could lead to a higher influx of migration and accordingly higher spread cases. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint optimization method for forecasting confirmed cases of covid- in china . a simple iterative map forecast of the covid- pandemic - sir model for covid- calibrated with existing data and projected for colombia modelling transmission and control of the covid- pandemic in australia data analysis and modeling of the evolution of covid- in brazil a time series method to analyze incidence pattern and estimate reproduction number of covid- an interactive web-based dashboard to track covid- in real time deep learning, adaptive computation and machine learning series world models. arxiv cs stat oxford covid- government response tracker [www document novel coronavirus covid- ( -ncov) data repository by johns hopkins csse [www document a contribution to the mathematical theory o f epidemics adam: a method for stochastic optimization deep learning forecasting the novel coronavirus covid- mathematical modeling of epidemic diseases a simple stochastic sir model for covid- infection dynamics for karnataka -learning from europe short-term predictions of country-specific covid- infection rates based on power law scaling exponents susceptible-infected-recovered ( sir ) dynamics of covid- and economic impact attention is all you need covid- coronovirus/ death toll countries in the world by population key: cord- -nrd ajj authors: albi, g.; pareschi, l.; zanella, m. title: relaxing lockdown measures in epidemic outbreaks using selective socio-economic containment with uncertainty date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: nrd ajj after an initial phase characterized by the introduction of timely and drastic containment measures aimed at stopping the epidemic contagion from sars-cov , many governments are preparing to relax such measures in the face of a severe economic crisis caused by lockdowns. assessing the impact of such openings in relation to the risk of a resumption of the spread of the disease is an extremely difficult problem due to the many unknowns concerning the actual number of people infected, the actual reproduction number and infection fatality rate of the disease. in this work, starting from a compartmental model with a social structure, we derive models with multiple feedback controls depending on the social activities that allow to assess the impact of a selective relaxation of the containment measures in the presence of uncertain data. specific contact patterns in the home, work, school and other locations for all countries considered have been used. results from different scenarios in some of the major countries where the epidemic is ongoing, including germany, france, italy, spain, the united kingdom and the united states, are presented and discussed. "phase two" is the key word after the most critical moment of the coronavirus emergency. the end of the pandemic will not immediately correspond to the disappearance of sars-cov . this is why an intermediate phase is being carefully considered, with some activities that can be resumed immediately, regulating the reintegration of workers, for example through indicators measuring the impact of work activities on potential infections, increasing prevention measures, or through so-called immunity passports. several question marks over convalescence times and the real extent of the contagion also raise fears of a second wave. it is essential to build scenarios that will help us understand how the situation might evolve in the future. while in some countries, like italy and france, the debate is open (and also to controversy), between those who would like to restart as soon as possible and those who, on the other hand, as a precautionary measure, would like to postpone the lockdown due to covid- , other countries, like germany and sweden, are preparing to restart (and in some cases the reduction of activity has never been total). the overall objective of this second phase is to limit the major damage to a country's economy caused by the severe lockdown measures, but to avoid restarting the epidemic peak. among the many controversial aspects are, for example, the reopening of schools, sport activities and other social activities at different levels, which, while having less economic impact, have a very high social cost. indeed, it is clear that it is difficult for the population to sustain an excessively long period of lockdown. it is therefore of primary importance to analyze the possibility of relaxing the control measures put in place by many countries in order to make them more sustainable on the socio-economic front, keeping the reproductive rate of the epidemic under control and without incurring health risks [ , , ] . the problem is clearly very challenging, traditional epidemiological models based on the assumption of homogeneous population mixing are inadequate, since the whole social and economic structure of the country is involved [ , , , , , ] . on the other hand, interventions involving the whole population allow to use mathematical descriptions in analogy with classical statistical physics drawing on the statistical characteristics of a very large system of interacting individuals [ , , , , ] . a further problem that cannot be ignored is the uncertainty present in the official data provided by the different countries in relation to the number of infected people. the heterogeneity of the procedures used to carry out the disease positivity tests, the delays in recording and reporting the results, and the large percentage of asymptomatic patients (in varying percentages depending on the studies and the countries but estimated by who at an average of around % of cases) make the construction of predictive scenarios affected by high uncertainty [ , , ] . as a consequence, the actual number of infected and recovered people is typically underestimated, causing fatal delays in the implementation of public health policies facing the propagation of epidemic fronts. in this research, we try to make a contribution to these problems starting from a description of the spread of the epidemic based on a compartmental model with social structure in the presence of uncertain data. this model allows not only to take into account the specific nature of the different activities involved through appropriate interaction functions derived from experimental interaction matrices [ , , , ] but also to systematically include the uncertainty present in the data [ , , , , , ] . the latter property is achieved by increasing the dimensionality of the problem adding the possible sources of uncertainty from the very beginning of the modelling. hence, we extrapolate statistics by looking at the so-called quantities of interest, i.e. statistical quantities that can be obtained from the solution and that give some global information with respect to the input parameters. several techniques can be adopted for the approximation of the quantities of interest. here, following [ ] we adopt stochastic galerkin methods that allow to reduce the problem to a set of deterministic equations for the numerical evaluation of the solution in presence of uncertainties [ , , ] . the main assumption made in this study is that the control measures adopted by the different countries cannot be described by the standard compartmental model but must necessarily be seen as external actions carried out by policy makers in order to reduce the epidemic peak. most current research in this direction has focused on control procedures aimed at optimizing the use of vaccinations and medical treatments [ , , , , ] and only recently the problem has been tackled from the perspective of non-pharmaceutical interventions [ , , , , ] . for this purpose we derive new models based on multiple feedback controls that act selectively on each specific contact function and therefore social activity. based on the data in [ ] this allows to analyze the impact of containment measures in a differentiated way on family, work, school, and other activities. in our line of approach, the classical epidemiological parameters that define the rate of reproduction of the infectious disease are therefore estimated only in the regime prior to lockdown and define an estimate of the reproductive rate in the absence of control. at this stage the estimation mainly serves to calibrate the model parameters and its variability will then be considered in the intrinsic uncertainty of these values. on the contrary, the control action is estimated in the first lockdown phase using the data available to date. phase two, therefore, on the modelling front is characterized by a third temporal region following the first lockdown period, in which social characteristics become essential to quantify the impact of possible decisions of the various governments. this makes it possible to carry out a systematic analysis for different countries and to observe the different behaviour of the control action in line with the dynamics observed and the measures taken by different governments. however, a realistic comparison between countries is an extremely difficult problem that would require a complex phase of renormalization of the data according to the different recording and acquisition methods used. in an attempt to provide comparative results altered as little as possible by assumptions that cannot be justified, we decided to adopt the same criteria for each country and therefore the scenarios presented, although based on realistic values, do not aspire to have the value of a real quantitative prediction. we present different simulation scenarios for various countries where the epidemic wave is underway, including germany, france, italy, spain, the united kingdom and the united states showing the effect of relaxing the lockdown measures in a selective way on the various social activities. the simulations suggest that premature lifting of these interventions will likely lead to transmissibility exceeding one again, resulting in a second wave of infection. on the other hand, a progressive loosening strategy in subsequent phases, as advocated by some governments, shows that, if properly implemented, may be capable to keep the epidemic under control by restarting various productive activities. the starting model in our discussion is a sir-type compartmental model with a social structure and uncertain inputs. the presence of a social structure is in fact essential in deriving appropriate sustainable control techniques from the population for a protracted period, as in the case of the recent covid- epidemic. in addition we include the effects on the dynamics of uncertain data, such as the initial conditions on the number of infected people or the interaction and recovery rates. the heterogeneity of the social structure, which impacts the diffusion of the infective disease, is characterized by a ∈ Λ ⊂ r + representing the age of the individual [ , ] . we assume that the rapid spread of the disease and the low mortality rate allows to ignore changes in the social structure, such as the aging process, births and deaths. furthermore, we introduce the random vector z = (z , . . . , z dz ) ∈ r dz whose components are assumed to be independent real valued random variables taking into account various possible sources of uncertainty in the model. we assume to know the probability density p(z) : r dz → r dz + characterizing the distribution of z. we denote by s(z, a, t), i(z, a, t) and r(z, a, t) the densities at time t ≥ of susceptible, infectious and recovered individuals, respectively in relation to their age a and the source of uncertainty z. the density of individuals of a given age a and the total population number n are deterministic conserved quantities in time, i.e. s(z, a, t) + i(z, a, t) + r(z, a, t) = f (a), hence, the quantities denote the uncertain fractions of the population that are susceptible, infectious and recovered respectively. in a situation where changes in the social features act on a slower scale with respect to the spread of the disease, the socially structured compartmental model with uncertainties follows the dynamics . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint with initial condition i(z, a, ) = i (z, a), s(z, a, ) = s (z, a) and r(z, a, ) = r (z, a). in ( ) the functions β j (z, a, a * ) ≥ represent transmission rates among individuals with different ages related to a specific activity characterized by the set a, such as home, work, school, etc., and γ(z, a) ≥ is the recovery rate which may be age dependent. in the following we assume the quantities β j (z, a, a * ) proportional to the contact rates in the various activities. in the following, we introduce the usual normalization scaling and observe that the quantities s(t), i(t) and r(t) satisfy the sir dynamic where the fraction of recovered is obtained from r(z, t) = − s(z, t) − i(z, t). we refer to [ , , , ] for analytical results concerning model ( ) and ( ) in a deterministic setting. in order to characterize the action of a policy maker introducing a control over the system based on selective containment measures in relation to a specific social activity we consider the following optimal control setting min u∈u j(u) : where u = (u , . . . , u l ) is a vector of controls acting locally on the interaction between individuals of ages a and a * , the function ν j (a, t) > is a selective penalization term and r[i(·, t)] is a suitable linear operator taking into account the presence of the uncertainties z. examples of such operator that are of interest in epidemic modelling are the expectation with respect to uncertainties or relying on deterministic data which underestimate the number of infected where z is a given value such that . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . note that, here we are considering less restrictive conditions on the space of admissible controls than in [ ] . the above minimization is subject to the following dynamics with initial condition i(z, a, ) = i (z, a), s(z, a, ) = s (z, a) and r(z, a, ) = r (z, a). solving the above optimization problem, however, is generally quite complicated and computationally demanding when there are uncertainties as it involves solving simultaneously the forward problem ( )-( ) and the backward problem derived from the optimality conditions [ ] . furthermore, the assumption that the policy maker follows an optimal strategy over a long time horizon seems rather unrealistic in the case of a rapidly spreading disease such as the covid- epidemic. in this section we consider short time horizon strategies which permits to derive suitable feedback controlled models. these strategies are suboptimal with respect the original problem ( )-( ) but they have proved to be very successful in several social modeling problems [ , , , ] . to this aim, we consider a short time horizon of length h > and formulate a time discretize optimal control problem through the functional j h (u) restricted to the interval [t, t + h], as follows subject to recalling that the macroscopic information on the infected is using ( ) we can compute . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . where we assumed ∂r [i(·, t + h)]/∂u j = r [∂i(·, t + h)/∂u j ], to obtain the following nonlinear identities the above assumption on r[·] is clearly satisfied by ( ) and ( ), where in the case of ( ) we used the notation r[s(·, a, t)i(·, a * , t)] = s(z , a, t)i(z , a * , t). introducing the scaling ν j (a, t) = hκ j (a, a * , t) we can apply the instantaneous strategies ( ) into the discrete system ( ) and pass to the limit for h → . the resulting feedback controlled model reads finally, we provide sufficient conditions for the admissibility of the feedback control in terms of the penalization term. in fact, the dynamic must preserve the monotonicity of the susceptible population number s(z, a, t) for each age class and for each single control action over time. by imposing the non-negativity of the total reproduction rate in ( ) we get and assuming β j (z, a, a * ) these inequalities have to be satisfied ∀ a ∈ Λ and for every t ≥ . in the case of a time independent penalization term κ j = κ j (a) we have the following admissibility conditions is defined by ( ) or ( ) andĪ(z) is the maximum reached by the total density of infectious. in this section we present the results of several simulation of the constrained compartmental model with uncertain data. details of the stochastic galerkin method used to deal efficiently with uncertain data may be found in [ , ] . the data concerning the actual number of infected, recovered and deaths in the various country have been taken from the johns hopkins university github repository [ ] ad for the specific case of italy from the github repository of the italian civil protection department [ ] . the social interaction functions β j have been reconstructed from the dataset of age and location specific contact matrices related to home, work, school and other activities in [ ] . finally, the demographic characteristics of the population for the various country have been taken from the united nations world populations prospects . other sources of data which have been used include the coronavirus disease (covid- ) situation reports of the who and the statistic and research coronavirus pandemic (covid- ) from owd . estimating epidemiological parameters is a very difficult problem that can be addressed with different approaches [ , , ] . in the case of covid- due to the limited number of data and their great heterogeneity is an even bigger problem that can easily lead to wrong results. here, we restrict ourselves to identifying the deterministic parameters of the model through a suitable fitting procedure, considering the possible uncertainties due to such estimation as part of the subsequent uncertainty quantification process. more precisely, we have adopted the following two-level approach in estimating the parameters. in the phase preceding the lockdown we estimated the epidemic parameters, and hence the model reproduction number r , in an uncontrolled regime. this estimate was then kept in the subsequent lockdown phase where we estimated as a function of time the value of the control penalty parameter. both these two calibration steps were analyzed under the assumption of homogeneous mixing. therefore, we solved two separate constrained optimization problems. first we estimated β > and γ > by solving in the uncontrolled time interval t ∈ [t , t u ] a least square problem based on minimizing the relative l norm of the difference between the reported number of infected i(t) and recoveredr(t), and the theoretical evolution of the unconstrained model i(t) and r(t). as a function of the penalization introduced on the curve of the infected or recovered we have a better adaptation of the model to the respective curves thus obtaining a range for the reproduction number r . we observed that, in general, fitting the curve of infectious yields a larger estimated reproduction number compared to fitting the curve of recovered. on the other hand, the lack of reliable informations concerning the recovered in early stages of the disease suggests to adapt the model mainly to the curve of infectious and to introduce the uncertainty in the reproductive number using this estimated value as an upper bound of the reproduction number. due to the heterogeneity of the data between the different countries, in order to have comparable results with reproduction numbers r = β/γ ∈ ( . , . ) we constrained the value of β ∈ ( , . ) and the value of γ ∈ ( . , . ). in table ( ) we report the values obtained by averaging the optimization results obtained with a penalization factor of . and − , respectively, over the recovered. next, we estimate the penalization κ = κ(t) > in time by solving in the controlled time interval t ∈ [t u , t c ] for a sequence of time steps t i of size h the corresponding least square problems in [t i + k r h, t i + k r h], k l , k r ≥ integers, and where for the evolution we consider the values β e and γ e estimated in the first optimization step using the curve of infectious. the second fitting procedure has been activate up to last available data with daily time stepping (h = ) and a window of seven days (k l = , k r = ) for regularization along one week of available data. for consistency we performed the same optimization process used to estimate β and γ, namely using two different penalization factors and then averaging the results. these optimization problems have been solved testing different optimization methods in combination with adaptive solvers for the system of odes. the results reported have been obtained using the matlab functions fmincon in combination with ode . the corresponding time dependent values for the controls as well as results of the model fitting with the actual trends of infectious are reported in figure . the trends have been computed using a weighted least square fitting with the model function k(t) = ae bt ( − e ct ). for some countries, like france, spain and italy after an initial adjustment phase the penalty term converges towards a peak and has just started to decrease. this is consistent with a situation in which data concerning the number of reported infectious needs a certain period of time before being affected by the lockdown policy and can also be considered as an indicator of an unstable situation where reducing control may lead to a potential restart of the infectious curve. the penalty terms for the us and the uk clearly indicates that the pandemic is still in its growing phase and the situation is far from a controlled equilibrium state. the only exception is represented by germany where the dynamic corresponds to a significative decrease in the penalization term as a result of a timely implementation of social distancing measures. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . next we focus on the influence of uncertain quantities on the controlled system with homogeneous mixing. according to recent results on the diffusion of covid- in many countries the number of infected, and therefore recovered, is largely underestimated on the official reports, see e.g. [ , ] . one possible way to understand this is based on a renormalization process of the reported data based on the estimated infection fatality rate (ifr) of covid- . although estimating the true ifr is generally hazardous while an epidemic is underway, some studies have estimated an overall ifr around . % with an age dependent credible interval [ , ] . in the sequel we consider a range spanning between . % − . %. on the contrary the current fatality rate (cfr) may vary strongly from country to country accordingly to the differences in the number of people tested, demographics, health care system. one way to have in insight in the uncertainty of data is to use the estimated ifr ranges as normalization factors for the current data reported of total cases i tot . this is done computing an estimated number of total confirmed cases asÎ tot = × d r /ifr, where d r is the total number of confirmed deaths. the results of the variationsÎ tot /i tot for the various countries are summarized in figure and are directly proportional to the cfr of the country. we are aware that the estimate obtained is certainly coarse, nevertheless it allows to get an idea of the disagreement between the data observed and expected in the various countries and therefore to be able to define a common scenario between the various countries. in order to have an insight on global impact of uncertain parameters we consider a twodimensional uncertainty z = (z , z ) with independent components such that i(z, ) = i ( + µz ), r(z, ) = r ( + µz ) . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint and β(z) = β e + α β z , γ(z) = γ e + α γ z ( ) where z , z are chosen distributed as symmetric beta functions in [ , ], i and r are the initial number of reported cases and recovered, and β e , γ e are the fitted values given in table . in the following we will consider µ = (c − ) common for all countries such that e[i(z, )] = ci( ), e[r(z, )] = cr( ) where c = . , the average value from figure . from a computational viewpoint we adopted the method developed in [ ] based on a stochastic galerkin approach. the feedback controlled model has been computed using an estimation of the total number of susceptible and infected reported, namely we have the control term where s r (t) and i r (t) are the model solution obtained from the reported data, and thus i r (t) represents a lower bound for the uncertain solution i(z, t). in figure we report the results concerning the evolution of estimated current infectious cases from the beginning of the pandemic in the reference countries using z ∼ b( , ) and α β = α γ = . in the inset figures the evolution of total cases is reported. the expected number of infectious is plotted with blue continuous line. furthermore, to highlight the country-dependent underestimation of cases we report with dash-dotted lines both the expected evolutions, where the uncertain parameter c > varies from country to country accordingly to the numbers on the top of the red bars in figure . in figure we report the evolution of reproduction number r for the considered countries under the uncertainties in ( ) obtained with α β = − , α γ = and z ∼ b( , ). it has been reported, in fact, that deterministic methods based on compartmental models overestimate the effective reproduction number [ ] . the reproduction number is estimated from being the control u(t) defined in ( ) andt is the country-dependent lockdown time. the estimated reproduction number relative to data is reported with x-marked symbols and represents an upper bound for r (z , t). the first day that the % confidence interval and the expected value fall below is highlighted with a shaded green region. we can observe how the model estimates that for most countries in the first days of april the reproduction number r has fallen below the threshold of . on the other hand, in the uk and the us the same condition was reached between the end of april and the beginning of may. in realistic terms these dates should be considered as overestimates as they are essentially based on observations without taking into account the delay in the data reported. we analyze the effects of the inclusion of age dependence and social interactions in the above scenario. the number of contacts per person generally shows considerable variability depending on age, occupation, country, in relation to the social habits of the population. however, some universal features can be extracted, which emerge as a function of specific social activities. more precisely, we consider the social interaction functions corresponding to the contact matrices in [ ] for the various countries. as a result we have four interaction functions characterized by a = {f, e, p, o}, where we identify family and home contacts with β f , education and school contacts with β e , professional and work contacts with β p , and other contacts with β o . these functions have been reconstructed over the age interval Λ = [ , a max ], a max = using linear interpolation. we report in figure , as an example, the total social interaction functions for the various countries. the functions share a similar structure but with different scalings accordingly to the country specific features identified in [ ] . . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . figure : evolution of current and total cases for each country with uncertain initial data as in ( ) based on the average uncertainty between countries. the % and % confidence levels are represented as shaded and darker shaded areas respectively. the dash-dotted lines denote the expected trends with a country dependent uncertainty from figure . . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . figure : evolution of estimated reproduction number r and its confidence bands for uncertain data in as in ( ) . the % and % confidence levels are represented as shaded and darker shaded areas respectively. the green zones denote the interval between the first day the % confidence band and the expected value fall below . figure : the total contact interaction function β = β f + β e + β p + β o taking into account the contact rates of people with different ages. family and home contacts are characterized by β f , education and school contacts by β e , professional and work contacts by β p , and other contacts by β o . . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . in order to match the age-structured model with the homogeneous mixing model the social functions were normalized using the previously estimated parameters β e and γ e in accordance with we considered a uniform recovery rate, together with an age-related recovery rate [ ] as a decreasing function of the age in the form with r = and c ∈ r such that ( ) holds. clearly, this choice involves a certain degree of arbitrariness since there are not yet sufficient studies on the subject, nevertheless, as we will see in the simulations, it is able to reproduce more realistic scenarios in terms of age distribution of the infected without significantly altering the behaviour relative to the total number of infected. in a similar spirit, to match the single control applied in the extrapolation of the penalization term κ(t) to age dependent penalization factors κ j (a, t) we redistribute their values as where w j (t) ≥ , are weight factors denoting the relative amount of control on a specific activity. in the lockdown period accordingly to other studies [ ] we assume w e = . , w h = . , w p = . , w o = . , namely the largest effort of the control is due to the school closure which as a consequence implies more interactions at home. work and other activities are equally impacted by the lockdown. in particular, these initial lockdown choices make it possible to have a good correspondence between the infectivity curves expected in the age dependent case and in the homogeneous mixing case. therefore, these values have been set homogeneously for each country and correspond to the situation in the first lockdown period. we will discuss possible changes to these choices following a relaxation of the lockdown in the different scenarios presented below. we divided the computation time frame into two zones and used different models in each zone, in accordance with the policy adopted by the various countries. the first time interval defines the period without any form of containment, the second the lockdown period. in the first zone we adopted the uncontrolled model with homogeneous mixing for the estimation of epidemiological parameters. hence, in the second zone we compute the evolution of the feedback controlled age dependent model ( ) with matching (on average) interaction and recovery rates ( ) and with the estimated control penalization κ(t). the initial values for the age distributions of susceptible have been taken from the specific demographic distribution of each country. more difficult is to get the same informations for the infected, since reported data are rather heterogeneous for the various country and the initial number of individuals is very small (we selected a time frame where the reported number of infectious is larger than ). therefore, we tested the available data against a uniform distribution. as there were no particular differences in the results, we decided to adopt a uniform initial distribution of the infected for all countries. in figure we report the age distribution of infected computed for each country at the end of the lockdown period using an age dependent recovery and a constant recovery. the differences in the resulting age distributions are evident. in subsequent simulations, to avoid an unrealistic peak of infection among young people, we decided to adopt an age-dependent recovery [ ] . in the first scenario we analyze the effects on each country of the same relaxation of the lockdown measures at two different times. the first date is country specific accordingly to current available informations, the second is june st for all countries. for all countries we assumed a reduction of individual controls on the different activities by % on family activities, % on work activities and % on other activities without changing the control over the school. the behaviors of the . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . figure : age distribution of infected using constant and age dependent recovery rates as in ( ) at the end of the lockdown period in different countries. curves of infected people together with the relative % confidence bands are reported in figure . the results show well the substantial differences between the different countries, with a situation in the uk and us that seems clearly premature to relax lockdown measures. on the contrary, germany and, to some extent spain, are in the most favorable situation to ease the lockdown without risking a new start of the infection. in all cases, however, it is clear that a further increase in the number of infected people should be expected. in order to highlight the differences in the behaviour of the infection according to the choices related to specific activities, such as school and work, we have considered the effects of a specific lockdown relaxation in these directions. precisely for each country we have identified a range for such loosening which gives an indication of the maximum allowed opening of the activities before a strong departure of the infection. it was assumed to relax the lockdown of the school with a mild resumption of family, work and other activities interactions by % for each % release of the school. the results are reported in figure . next, we perform a similar relaxation process oriented towards productive activities with a reduction of control on such activities at various percentages. here we assumed no impact on school activities and a mild impact on family and other activities with a loosening at % for each % release of the work. the results are given in figure . in both cases, the results show that the selected countries can be divided into groups, germany and spain in a stable downward phase of the epidemic curve, france and italy in a still transitional phase with greater risks in reopening, and the uk and us in full growth phase of the epidemic curve in which any relaxation of lockdown measures leads to a strong restart of the epidemic. one of the major problems in the application of very strong containment strategies, is the difficulty in maintaining them over a long period, both for the economic impact and for the impact on the population from a social point of view. the results of the previous scenarios have shown that it may be possible for some countries, like germany, spain, france, and italy, to relax the lockdown measures albeit with some risk of an increase in the contagion curve. on the contrary, in all scenarios considered, the situation in the uk and the us suggests that any loosening of containment measures should be postponed. in the latter scenario, we consider a strategy based . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . figure : scenario : effect on releasing containment measures in various countries at two different times. in all countries after lockdown we assumed a reduction of individual controls on the different activities by % on family activities, % on work activities and % on other activities by keeping the lockdown over the school. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint figure : scenario : relaxing lockdown measures in a progressive way in two subsequent phases while keeping the epidemic peak under control. in the second phase only productive activities are restarted and partially home interactions and other activities. in a third phase school activities are also partially reopened (see table ). on a two-stage opening of the blocking measures with a progressive approach. this possibility is analysed for the four countries where it might be possible to partially reopen production activities without restarting the contagion curve. for each country we have selected a progressive lockdown relaxation focused mainly on the opening of productive activities in the second phase and with a partial reprise of school activities in the third phase. the reduction of the controls are now country specific and the values are reported in table . in figure we plot the resulting behavior for the expected number of current infectious. the simulations show that for all these countries, it is possible to relax the containment measures in a progressive way by keeping the infection curve under control. however, timing and intensity of the relaxation choices play a fundamental rule in the process. the approach of a second phase of the pandemic into a new normality is full of uncertainties from the point of view of social and economic planning. it is clear to the people that this period cannot be marked by an "all free", by a return to the old normality. for some time to come it will be necessary to respect rules of conduct and hygiene standards to which we have not been accustomed. there are many issues to be addressed, in particular how gradually to reopen the various social and economic activities without creating a new wave of infected and therefore deaths. in order to analyze possible future scenarios, it is essential to have models capable of describing the impact of the epidemic according to the specific social characteristics of the country and the containment actions implemented. in this work, aware of the complexity of the problem, we have tried to provide a suitable modeling context to describe possible future scenarios in this direction. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . home %- % %- % %- % %- % school %- % %- % %- % %- % work %- % %- % %- % %- % other %- % %- % %- % %- % table : scenario : progressive relaxation of lockdown measures for different countries as specific control reduction percentages. results are reported in figure . more precisely, with the aid of a sir model with specific feedback controls on social interactions capable to describe the selective action of a government in opening certain activities such as home, work, school and other activities, we can simulate their future impact with respect to the current epidemic trend. in particular, in an effort to take into account the high uncertainty in the data, the model has been formalized in the presence of uncertain input parameters that allow to explore hypothetical scenarios with appropriate confidence bands. the simulation parameters have been obtained using data coming from several countries with"comparable situations" in terms of epidemic progress, such as italy, france, germany, spain, the united kingdom and the united states. the model is capable to describe accurately the reported data thanks to the introduction of the time dependent control action and therefore to provide potential useful indications thanks to the dependence of interactions between the population from the social context. the results, in accordance with the observations, show situations with different levels of sensitivity to a hypothetical reopening of certain activities. the scenarios presented in order to be able to compare the various realities are largely hypothetical situations but they highlight very well the impact of the different social activities and how some countries such as the united kingdom and the united states are still in an epidemic situation that suggests maintaining the actual lockdown measures before moving to a second phase. on the contrary, the simulations show how germany before the other countries and secondly spain, france and italy, can aim at a gradual reopening of social and economic activities, keeping the epidemic curve under control, provided that they are resumed in a progressive way and within an appropriate time frame. the use of a sir model with social structure modified through appropriate feedback controls allows to obtain simulations in agreement with the current epidemic scenarios in different countries, including germany, france, italy, spain, the united kingdom and the united states. the inclusion of uncertainty about the actual value of the number of infected people makes it possible to analyze the effects of the potential reopening of productive and social activities at different times. a multi-modelling approach aligned with the current epidemiological and demographic data, which includes experimental social interaction matrices for the different countries, permits to contextualize possible future scenarios. further studies are being conducted on geographical dependence through spatial variables. this would make it possible to characterize control measures on a local rather than global basis. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint selective model-predictive control for flocking systems uncertainty quantification in control problems for flocking models kinetic description of optimal control problems and applications to opinion consensus control with uncertain data of socially structured compartmental epidemic models optimal control of a sir epidemic model with general incidence function and a time delays the french connection: the first large populationbased contact survey in france relevant for the spread of infectious diseases time-optimal control strategies in sir epidemic models un)conditional consensus emergence under perturbed and decentralized feedback controls parameter estimation and uncertainty quantification for an epidemic model towards uncertainty quantification and inference in the stochastic sir epidemic model epidemiological models with age structure, proportionate mixing, and cross-immunity optimal control for pandemic influenza: the role of limited antiviral treatment and isolation fitting dynamic models to epidemic outbreaks with quantified uncertainty: a primer for parameter uncertainty, identifiability, and forecasts optimizing vaccination strategies in an age structured sir model uncertainty quantification for kinetic models in socioeconomic and life sciences wealth distribution under the spread of infectious diseases an interactive web-based dashboard to track covid- in real time. the lancet infectious diseases kinetic models for optimal control of wealth inequalities restarting the economy while saving lives under covid- estimating the number of infections and the impact of non-pharmaceutical interventions on covid- in european countries threshold behaviour of a sir epidemic model with age structure and immigration a feedback sir (fsir) model highlights advantages and limitations of infectionbased social distancing spread and dynamics of the covid- epidemic in italy: effects of emergency containment measures mixing in age-structured population models of infectious diseases modeling heterogeneous mixing in infectious disease dynamics the mathematics of infectious diseases analytical and numerical results for the age-structured s-i-s epidemic model with mixed inter-intracohort transmission correcting under-reported covid- case numbers: estimating the true scale of the pandemic a contribution to the mathematical theory of epidemics modeling optimal age-specific vaccination strategies against pandemic influenza an optimal control theory approach to nonpharmaceutical interventions the reproductive number of covid- is higher compared to sars coronavirus estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship optimal, near-optimal, and robust epidemic control social contacts and mixing patterns relevant to the spread of infectious diseases an introduction to uncertainty quantification for kinetic equations and related problems projecting social contact matrices in countries using contact surveys and demographic data github: covid- italia -monitoraggio situazione an empirical estimate of the infection fatality rate of covid- from the first italian outbreak epidemic models with uncertainty in the reproduction estimating the infection and case fatality ratio for coronavirus disease (covid- ) using age-adjusted data from the outbreak on the diamond princess cruise ship age-dependent risks of incidence and mortality of covid- in hubei province and other parts of china hongdou estimation of the reproductive number of novel coronavirus (covid- ) and the probable outbreak size on the diamond princess cruise ship: a data-driven analysis this work has been written within the activities of gnfm and gncs groups of indam (national institute of high mathematics). g. albi and l. pareschi acknowledge the support of miur-prin project , no. kkjp x "innovative numerical methods for evolutionary partial differential equations and applications" and . m. zanella was partially supported by the miur - "dipartimenti di eccellenza" program ( - ) -department of mathematics "f. casorati", university of pavia. key: cord- -xxov x authors: cisneros, b.j. title: safe sanitation in low economic development areas date: - - journal: treatise on water science doi: . /b - - - - . - sha: doc_id: cord_uid: xxov x this chapter presents the advances in sanitation for developing countries as well as the needs in terms of goals, standards, technology, and policy. to understand why a special chapter for low-income areas is needed, it describes the main types of pollutants, their origins, and treatment options. as part of the text and to face the requirements for poor rural and urban areas and water-scarce regions, basic sanitation, wastewater treatment, and water reuse alternatives are described with emphasis on their constraints and limitations for developing countries. some aspects concerning the development of policies, costs, and funding to fulfill the millennium development goals are also included. the importance of developing innovative solutions that can be sustainable, affordable, and progressively implemented is discussed. emerging chemical pollutants . . . . slow filtration . . . . waste stabilization ponds . . . . wetlands . . . . land treatment . . . . reservoirs and water storage tanks . . . . upflow anaerobic sludge blanket before reading this chapter, it should be considered whether it is justifiable to have a specific section dealing with sanitation for low economic development areas (developing countries). evidently, the editors of this book think so. the reasons include • an increasing evidence that wastewater quality in high and low economic areas is different regarding some parameters that determine treatment options and • differences in economic conditions necessitate alternative solutions not only at the technical level but also in terms of the ways to implement them. to protect health, raise the quality of life, and increase the economic level, a good sanitation service is required in developing countries. while in developed countries, sanitation coverage is almost % as a result of a clear commitment of governments to provide it as part of the public services, in developing ones it is only around % (who-unicef, ). in addition, in the developed countries, the term sanitation applies not only to the installation of sewers but also to the full implementation of systems for the safe disposal and reuse of treated wastewater, sludge, and septage. in contrast, in developing countries, the term sanitation mostly applies to the use of sewers not always ending in treatment plants. in fact, reported sanitation figures frequently do not reveal the disposal of wastewater or excreta uncontrolled into the environment, the existence of malfunctioning wastewater treatment plants, or the use of rudimentary and inefficient basic sanitation facilities sometimes contributing to increased environmental pollution rather than to control it. as a result, waterborne diseases affect millions of people in the developing world, and the water quality of surface and groundwater bodies is increasingly deteriorating. the aim of this chapter is to assist the process of increasing sanitation in low-income regions by contrasting the differences in needs and solutions' options with high-income regions. most technical publications have traditionally grouped developing countries together as low-income societies without considering that in them there are high-and low-income areas and that among the latter ones there are several factors that create differences that need to be taken into consideration to provide suitable solutions, that rarely fall under the logic used in developed countries to provide sanitation. most people lacking sanitation include the millions of poor people ( figure ) living under precarious institutional conditions and under an economical and social situation that avoids the use of conventional solutions. this renders the provision of sanitation in low-income areas a major challenge. the history of sanitation is mainly about three aspects: toilets, sewers, and final disposal. as sanitation is a broken subject in developing countries, the story of these three is also the same. when mankind was nomadic and lived in very small communities, sanitation was not an issue. nature could absorb human wastes. later, when villages grew, there was the need to set up special practices and facilities. in ancient egypt (b bc), each household had the responsibility to dispose of their garbage and excreta at the communal dump, in irrigation canals, or in open fields. irrigation canals were the first drainage and waste disposal systems. at that time, toilets were a luxury that only the wealthier people could afford in cities. toilets were carved of limestone, and the used water was disposed of into pits in the streets (msu, ) . flushing toilets -some of them communal -existed in india since the twenty-sixth century bc. reports on the use of toilets and other safe sanitation practices in ancient civilizations from asia, latin america, and africa were common in places where nowadays lack of sanitation is a problem. the earliest covered sewers reported are from the indus civilization ( ( - where pakistan is located today. cities used sewers to control inundations caused by pluvial water. the cloaca maxima or roman sewer dates from around bc. initially, it was an open drain that was covered and left below the urban level, as the city building space became costly (wikipedia, ) . later, when water began to be supplied in large quantities to households, getting rid of the used water became a problem and water was considered as a waste. it was then when sewers were found to be a useful infrastructure to convey wastewater out of the city in addition to stormwater. concerning disposal, land application of wastewater and excreta has a long tradition in many countries. for centuries, farmers in china used human and animal excreta as fertilizers. the oldest references to the use of excreta in aquaculture come from some asian countries, where it was employed to increase fish production (who, ) . further, even now in china, mexico, peru, egypt, lebanon, morocco, india, and vietnam wastewater is used as a source of crop nutrients (jiménez and asano, ) . according to rusong ( ) , in contrast to the 'mechanical' ideas predominant in industrial societies, human ecological thoughts in ancient china emphasized the use of systems advocating 'man and nature as one' . this principle is considered as equivalent to the sustainability principle and is based on terms describing concepts that are dissociated in modern civilizations, such as • tian -heaven or nature; • di -earth or resources; • ren -people or society; • wuxing -the five fundamental elements and movements within any ecosystem, that need to be in equilibrium by promoting and restraining each other; and • zhong yong -describing that things should never go to their extremes but should be kept at equilibrium. for several centuries, based on these ecological principles, china has developed and supported % of the world's population with only % of the world's arable land and less than % of the world freshwater resources (rusong, ) . once again, similar conceptions can be found in ancient civilizations from asia, africa, and latin america, in the same places where there are environmental crises now. the urban water cycle is a relatively new concept used to analyze water quality problems in cities (jiménez, b) , which is depicted in figure . it is useful in identifying conventional and nonconventional sources of pollution, in particular those that are specific to developing countries. it is important to understand the difference in order to be able to apply proper solutions to sanitation that go beyond the simplistic approach of merely installing wastewater treatment plants. a similar analysis could be made for rural areas. the urban water cycle is important because of the large increase in urban population that is being experienced worldwide. by , the urban proportion of the global population is expected to be around %. over the next years, in developing countries, most of the population growth will occur in urban and periurban areas. furthermore, most of the cities with the most rapid growth are located in chronically water-short regions in the developing world (un-habitat, ) . providing water sources to urban areas from the developing world is a challenge because nearly one-third of the population ( . % compared to a % in developed countries in ) are poor people living in slum areas. the slum growth rate is of . %, a value significantly higher than the average world urban growth rate of . %. traditionally, pollution sources are classified as point and nonpoint sources. municipal and industrial wastewater discharges are considered to be point sources, while agriculture (considered as the surface return flow from irrigation), storm runoff, and a wide variety of others are considered as nonpoint sources (jiménez, a) . municipal discharges are those produced by cities and small towns. they are considered to be point sources of pollution where they are produced and collected in sewers and thus disposed of as a well-identified source. when not treated, the main environmental concerns relate to conventional pollutants, such as biological, biodegradable, and nonbiodegradable organic matter, and heavy metals, in that order of importance. the content of almost all these of pollutants is similar around the world, tending to be more concentrated in arid and semiarid areas because of lack of water. in some cases, higher concentrations of pollutants result from increased industrialization of cities. unfortunately, even when treated, municipal discharges introduce used water containing used compounds, some of which are pollutants, to water bodies. municipal wastewater is never treated to recover its original quality (the one it had at the water source) as the selfcleansing and dilution capability of nature is used to complete the task. this is confirmed by the increasing amount of trace pollutants, such as endocrine disrupters, found in water sources. the presence of these compounds might be considered as an indicator that we have surpassed the natural depollution capability of the environment. despite this, the idea of using water bodies or soil to depollute wastewater is still very common, and it could be reduced in water bodies as the depollution capability is lost as result of the water temperature increase due to climate change. in developing countries, the environment is frequently used to depollute wastewater, included when not treated at all, explaining the low quality of water bodies and the widespread presence of diarrheic diseases. industrial wastewater has very variable quality and volume depending on the type of industry producing it. it may be highly biodegradable or not at all, and may or may not contain compounds recalcitrant to treatment. these include organic synthetic substances or heavy metals whose content in developing countries' wastewater may be considerably different (in quantity and quality) from that of developed ones. the main concern with industrial wastewater is the increasing amount (in quantity and variety) of synthetic compounds contained in and discharged to the environment. a list of the most common pollutants in industrial discharges can be found in jiménez ( a) . due to the difficultly in tracking toxic compounds and their fate, combined with the need to use complex and costly treatment methods to remove them from wastewater, it is advisable and cost effective to consider the implementation of cleaner production methods in industries (such as the replacement of toxic recalcitrant compounds with others that are less harmful or not harmful at all) and, also to raise awareness of society to reduce the use of such types of compounds (jiménez, b) . water pollutants come not only from urban and municipal wastewater discharges, but also from nonpoint sources, some of which are not perceived as such. most of the nonpoint sources have been initially recognized as such by groundwater experts (foster et al., ) who realized that soil (urban or rural) was an important means of transporting pollution to ground and surface water through complex interactions. a list of such pollutants is presented in table and a detailed description of some of the pollution sources can be found in jiménez ( a) . in this section, the types of different pollutants are reviewed, emphasizing those of special interest in developing countries. biological pollutants are the major threat to low-income countries as diseases caused by them are rapidly manifested and have important effects on children and the elderly, sometimes even resulting in fatalities. according to who ( ) , diarrheal diseases accounts for an estimated . % of the total daily global disease burden and is responsible for . million deaths every year. it is estimated that % of that burden is attributable to unsafe water supply, sanitation, and hygiene. biological pollutants cause hydraulic diseases that are frequently divided into three categories: . waterborne diseases that are caused by pathogenic organisms ingested when consuming water polluted with fecal contamination or food irrigated with polluted water. examples of these types of diseases are giardiasis and amebiasis. . water-washed diseases that are caused by the lack of safe water or simply any water for hygiene purposes. disease transmission is linked to skin or eye contact. an example is trachoma, a disease that causes blindness. some million people have been blinded by trachoma. another million need treatment, and an estimated million are at risk. the disease is endemic in countries, with only china and india accounting for million cases. productivity losses caused by trachoma are estimated to be us$ . billion (who, ) . . water-based diseases that are caused when water accumulates and stagnates, promoting the breeding of vectors such as mosquitoes that cause dengue or malaria. there are four groups of organisms that can be found in waste and polluted water: viruses, bacteria, protozoa, and helminths (in the form of eggs, jiménez ( ) ). the general characteristics of these organisms can be found in specialized literature. in the following sections, properties relevant to developing countries will be highlighted for each type of group. a list of pathogens that have been detected in wastewater is presented in annex . the main aspect to highlight is the notable difference in the quantity and variety of pathogens found in wastewater between developed and developing countries ( table ) . viruses are the smallest ( . - . mm) infectious agents. there are more than types of enteric viruses capable of producing infections or illnesses that multiply in the intestine and are expelled in feces. unlike bacteria, pathogenic viruses are found in wastewater and feces when people are infected, independently of whether they display symptoms. in regions where viral diseases are endemic, they are constantly isolated from wastewater. the presence of viruses and their concentration in wastewater is linked to the season of the year and the age distribution of the population. concentrations are usually higher during summer and lower in the autumn months. the composition, type, and especially the content of viruses contained in wastewater are poorly known, particularly in developing countries, as a result of the complex and costly analytical techniques required to identify them (jiménez, ) . the enteric viruses most relevant to man are enteroviruses (polio, echo, and coxsackie viruses), norwalk, rotaviruses, reoviruses, caliciviruses, adenoviruses, and hepatitis a viruses. rotaviruses are responsible for between . and billion cases of diarrhea per year in children under years of age in africa, asia, and latin america and up to . million deaths. usually, between % and % of the cases of children with gastroenteritis that are hospitalized are caused by rotaviruses. reoviruses and adenoviruses are the main causes of respiratory illness, gastroenteritis, and eye infections and have been isolated from wastewater. to date, there is no evidence that the human immunodeficiency virus (hiv) causing the acquired immunodeficiency syndrome (aids) can be transmitted via a waterborne route. it is recognized that low virus levels may cause infection or illness; wastewater contains thousands of them, some of which are much more resistant to chlorine disinfection than bacteria (jiménez, ) . viruses discharged in polluted water can migrate long distances in soil and groundwater. the reported horizontal migration varies between and m, while vertical migration ranges from . to m depending on soil conditions. industrial sources industries located in urban or rural areas, in general variable, mostly synthetic compounds bacteria are single-celled microorganisms ranging from . to m in size with different shapes. they reproduce and grow in an appropriate environment at defined ranges of temperature, salinity, ph, etc. they may or may not be encapsulated. the environmental distribution of bacteria is ubiquitous and has different nutritional requirements. many species of bacteria are not harmful to man. in fact, some even live inside humans forming intestinal colonies. bacteria are expelled in feces at high concentrations (jiménez, ) . table shows some characteristics of pathogenic bacteria that can be found in the feces of infected people. in wastewater, pathogenic bacteria are always present but at a variable concentration, depending on the local health conditions. as shown in table , due to the high rate of diseases caused in developing countries, salmonella, shigella, and helicobacter pylori are bacteria of importance as agents causing endemic diseases. in contrast, vibrio cholerae is present only when an epidemic exists. protozoa are the group of parasites most closely associated with diarrheas. they are single-celled organisms ( - mm in size) that develop in two ways: as trophozoites and as cysts. infections are produced when mature cysts are consumed. cysts are resistant to gastric juices and transform themselves into trophozoites in the small intestine, lodging in the wall where they feed on bacteria and dead cells. in time, table characteristics of some bacteria frequently found in wastewater (with information from jiménez ( ) and lenghton et al. ( ) ) escherichia coli is commonly found in wastewater at high concentrations. different e. coli strains can cause gastroenteritis in both animals and humans and pose a high risk to newborns and children under years of age. e. coli strains implicated with human diseases are: ( ) enteropathogenic e. coli ; ( ) e. coli that is the common cause of traveler's diarrhea, which provokes a liquid and profuse diarrhea with some mucosity, nausea, and dehydration; ( ) enteroinvasive e. coli that invades the intestinal mucus lining like shigella spp., and ( ) e. coli (ehec) that produces a similar toxin to shigella causing hemorrhagic colitis. infective doses are relatively low ( organisms). salmonella spp. is frequently present in wastewater at content always lower than that of fecal coliforms by - log. there is a wide variety of strains capable of infecting humans and animals. the incidence in humans is lower than in animals and has a seasonal variation. the most severe form of salmonellosis is typhoid fever caused by salmonella typhi. typical symptoms are chronic gastroenteritis with diarrhea, stomach cramps, fever, nausea, vomiting, and headache. in severe cases, collapse and death might occur. transmission is through ingestion of polluted water or food, and is very common in developing countries. infective dose is of the order - microorganisms, but for salmonella typhi doses as low as - have been reported. shigella is similar to salmonella spp. but less frequent in wastewater. there are more than strains, but s. sonnei and s. flexeneri represent almost % of total wastewater isolations. it rarely infects animals and lives for a shorter period in the environment. one route of transmission is through swimming in polluted water. shigella spp. produces bacillary dysentery or shigellosis. this is light watery diarrhea that can develop into full-blown dysentery. the symptoms are fever, nausea, vomiting, abdominal pain, migraine, and myalgia. the classic form of dysentery is characterized by the expulsion of feces containing blood with or without mucus. the infective dose is less than microorganisms. helicobacter pylori is found in wastewater. its major habitat is the human gastric mucosa. three species are human pathogens: h. pylori, h. fennelliae, and h. cinaedi. the pathway of transmission is not entirely clear but water could be involved. in developing countries, h. pylori is acquired early in childhood, and up to % of children are infected by the age of . this contrasts with the low infection rate during childhood observed in developed countries ( . - %). campylobacter jejuni usually is a pathogen to animals but it can cause severe gastroenteritis in humans. the main source of infection is nonchlorinated water supplies. mycobacterium tuberculosis along with m. balnei (marinum) and m. boris causes pulmonary diseases and tuberculosis. for m. tuberculosis, contaminated water is the main source of infection. vibrio cholerae is the cause not only of epidemic but also eight pandemics, the last one between and . cholera epidemics are caused by v. cholerae group o and some non-o . symptoms are abundant liquid diarrhea with significant loss of hydro-electrolytes and severe dehydration associated with vomiting. v. cholerae is rare in developed countries but frequent in poor ones. humans are the only known hosts. the most frequent pathway of transmission is water, either through direct consumption or when used to irrigate produce that is consumed uncooked. fish grown in polluted water are another source of transmission. since , there have been outbreaks of cholera in india, iraq, congo, vietnam, and zimbabwe. in , west africa suffered more than cases of cholera, leading to deaths. - - fecal streptococci, no. ml À (u, b, k) - - protozoan cysts, organisms l À (u, m) giardia lamblia, cysts l À (u, e, k) - - cryptosporidium parvum, oocysts l À (u, e) - nd helminth ova, egg l À - - trophozoites become once again cysts that are expelled in feces. infected persons may or not display symptoms. protozoa do not reproduce in the environment, only in their host. however, they are able to survive in the environment and remain active for periods ranging from some months to up to several years, depending on the environmental conditions. most intestinal protozoa are transmitted through polluted water and food contaminated with polluted water or unsanitary handled (jiménez, ) . table shows the characteristics of some protozoa. in the developing world, the more relevant protozoa because of their effects on humans are giardia and amoeba. cryptosporidium is a threat to developed countries, as was unfortunately demonstrated in milwaukee, us, when people became ill and more than died after an infection was transmitted through the drinking water supply (hrudey and hrudey, ). helminths are worms some of which are parasites in humans. where helminths are the origin of waterborne diseases, they are mainly transmitted through the consumption of contaminated food (crops, meat, or fish). helminths can also be transmitted through the oral-fecal route and, therefore, hygiene is important as a factor in their control. as helminths are associated with turbid water, they normally are not a concern in drinking water. helminths are pluri-cellular worms and because of this they are poorly addressed in environmental microbiology books. the eggs -their infective form -are microscopic and travel along with wastewater. helminths occur in different types and sizes (from mm to several m in length), and have diverse and complex life cycles compared to most of the microorganisms known in the sanitary field (jiménez, a) . before infecting humans, in some cases, they may have an intermediary host as is the case for schistosoma spp. that temporarily lives in snails. there are three different types of helminths: ( ) plathelminths or flat worms, ( ) nemathelminths, nematodes or round worms, and ( ) annelids. if plathelminths have their body formed by segments, they are called cestodes; if not, they are then called trematodes. only the first two types are of sanitary importance. although common in sanitary engineering literature, it is improper to use the terms nematodes, ascaris, and helminths as synonyms. this misunderstanding comes from the fact that ascaris (a nematode) is the most common helminth egg in wastewater and sludge. a list of helminth eggs found in wastewater and sludge and its classification can be found in jiménez ( a) . helminthiases are diseases of high incidence in developing countries compared with developed ones. globally, there are around - thousand million people suffering of helminthiases but most of them are from developing countries where it affects up to % of the population. the incidence rate may reach % in regions where poverty and poor sanitary conditions prevail. in contrast, in developed countries, helminthiases' incidence is at the most . % and affects mainly poor immigrants (jiménez, a) . helminthiases have different manifestations but, in general, they cause intestinal wall damage, hemorrhages, deficient blood coagulation, and undernourishment. they can degenerate into cancer tumors. helminthiases affect mainly children, the elderly, and poor people . around % of the more than billion cases of diarrhea in the world are caused by helminths (murray and ló pez, ) . there are several kinds of helminths with different local names (annex ). this along with the fact that it is hard to properly identify them clinically unless a costly laboratory analysis is performed, makes it difficult to track the actual incidence of all the table protozoa related to sanitation problems and that are of interest for developing countries (with information from jiménez ( )) entamoeba histolytica is one of the most important parasites detected in municipal wastewater and is commonly known as amoeba. trophozoites measure - mm and t cysts - mm. amoebae usually lodge in the large intestine; occasionally they penetrate the intestinal wall, traveling and lodging in other organs. they are the cause of amoebic and hepatic dysentery. entamoeba histolytica infects % of the world's population -mostly in the developing world -resulting in approximately million infected persons; there are between and million cases of invasive amebiasis per year resulting in up to annual deaths (placing it second after malaria in mortality caused by protozoan parasites). ninety-six percent of these cases occur in poor countries, especially on the indian subcontinent, west africa, the far east, and central america. giardia spp. are common in wastewater as it frequently causes endemic diseases. it especially affects children under suffering from malnutrition. the total number of sick people is of the order . billion, % of whom live in poor countries. giardia spp. is the most common parasite of humans but water is not necessarily the main pathway of transmission. cysts (that are - mm long and - mm wide) can survive in water bodies for long periods, especially in winter. giardia lives in the intestines of a large number of animals as trophozoites. the disease is characterized by very liquid and smelly explosive diarrhea, stomach and intestinal gases, nausea, and loss of appetite. cryptosporidium spp. is a parasite widespread in nature. oocysts are resistant to chlorine and due to their small size ( - mm) are difficult to remove from water, as many other protozoan. cryptosporidium spp. infects a large spectrum of farm animals and pets and was recently recognized as a human pathogen that is why it is considered as an emerging pathogen. cryptosporidium spp. is capable of completing a life cycle within the same host and causing reinfection. once an individual has been infected, the person carries the parasite for life and can be reinfected. the disease rate in developing countries has been poorly studied, in particular due to the higher occurrence of other types of diseases. cryptosporidiasis in developing countries has shown a greater incidence among immune depressed people and in rural areas (snelling et al., ) . the main symptoms of cryptosporidiasis are stomach cramps, nausea, dehydration, and headaches. although it is known that the infectious dose varies between and , outbreaks have always been associated with large concentrations in water. helminthiases. that is why frequently figures are underestimated. technically, helminthiases take their name from their causative agent. for instance, trichuriasis is named after thrichuris. ascariasis, affecting nearly million people, is the most common of the helminthiases and is endemic in africa, latin america, and the far east. even though the mortality rate is low, most of the people infected are children under years of age with problems of faltering growth and/ or decreased physical fitness. around . million of these children will probably never bridge the growth deficit, even if treated (silva et al., ; jiménez, a) . the helminthiases' infective agents are the eggs, not the worms. actually, worms cannot live either in wastewater or in sludge because they need a host. helminth eggs are transmitted through ( ) the ingestion of crops polluted with wastewater or sludge, ( ) direct contact with polluted sludge or fecal material, and ( ) the ingestion of polluted meat or fish (jiménez, a) . each type of helminth has its own pathways of infection. eggs of different helminths generally occur in different shapes, sizes, and resistances ( figure ) . as a result of the higher incidence of ascariasis, in wastewater and sludge, these examples of local names given to helminth and helminthiases diseases are the eggs found in the highest concentrations ( figure ) . the percentage of types of helminths might vary from one region to another following the disease's pattern. due to differences in health conditions in developed and developing countries, their helminth eggs content is very different in wastewater and sludge ( table ) . eggs contained in sludge are not always viable and infectious. to be infectious, the larvae need to develop, and, for that, a certain temperature and moisture are needed. the necessary conditions are frequently met in soil or crops, where eggs are deposited when polluted wastewater, sludge, or excreta is used as fertilizer. under such conditions, the larvae develop in days. according to previous information (that has not been updated using better analytical techniques), ascaris eggs remain viable - months in crops and many months in soil, freshwater, sewage, feces, night soil, and sludge -periods which are much longer than those for microorganisms (jiménez, a, figure ). this high resistance is due to a cover composed of - layers that gives mechanical resistance to eggs and protects them from desiccation, strong acids and bases, oxidants, reducing agents, detergents, and proteolytic compounds (jiménez, a) . the resistance of different helminth eggs genera under environmental conditions has not been reported in literature. to inactivate helminth eggs, it is recommended to raise the temperature above c for - days for ascaris or to reduce moisture levels below %. these conditions are not ease of use during wastewater treatment; thus, helminths are usually removed from wastewater to be subsequently inactivated in sludge. helminth ova of interest in the sanitary field figure continued. measure - mm, have a specific density of . - . , and are very sticky. these properties are used to remove eggs from wastewater (jiménez, a) . helminth ova criteria. as shown in table , not all wastewater and sludge contain significant amounts of helminth ova. for this reason, they are not included in all countries' wastewater, sludge, or fecal sludge norms, as is the case with biochemical oxygen demand (bod) or fecal coliforms, which are universal parameters used to design wastewater treatment (jiménez, a) . based on toxicological and epidemiological studies, the world health organization who ( ) suggested a value of r egg l À in wastewater intended for the irrigation of crops that are eaten uncooked. wastewater used for the culture of fish should contain egg l À , since trematode eggs (schistosoma spp., basically) may multiply in an intermediary host (a snail) before infecting fish and humans. for excreta, the recommended criterion is of egg g À total solids (ts). thermotolerant coliform bacteria (commonly referred as fecal coliforms) are the group most frequently used as indicators of fecal pollution because they behave in a similar way to most pathogenic bacteria in the environment, and, during treatment, they are abundant and easy to determine. hy me no lep is sp p. to xo ca ra sp p. tri ch os om oid es sp p. en ter ob ius sp p. ta en ia sp p. un cin ari a thermotolerant coliforms are less specific indicators of fecal contamination than escherichia coli, since they may sometimes arise from nonfecal sources, especially in tropical climates (who, ) . however, it is becoming increasingly evident that they are not useful to simulate the behavior of all enteric viruses, protozoa -in particular with regard to giardia and amoeba -and helminth eggs that are of concern in low-income regions. despite this, it is frequently, but wrongly, assumed that fecal coliforms are indicators of all kinds of biological pollution. even though they can be useful indicators of fecal pollution in developed countries' drinking water, this is not always the case for water and wastewater from developing ones, owing to the presence of a wider variety and larger quantities of microorganisms (jiménez, ). this does not mean that fecal coliforms are not useful for developing countries; it simply means that care must be taken to select additional indicators for specific purposes, such as for wastewater and sludge reuse in agriculture and aquaculture. in these cases, the helminth egg content (who, ) needs also to be specified. it is worth mentioning that the treatment procedures to inactivate helminth eggs are frequently developed using ascaris eggs as models as they have been informally considered as indicators for all helminth eggs, although this has not been fully proven experimentally. in other cases, taenia saginata or ascaris galli, types of eggs that are rarely present in wastewater, are used to test treatment procedures. some pathogens that are not usually followed during conventional monitoring have been linked to outbreaks in developed countries. these pathogens have been called 'emerging' pathogens. they have led to new regulations as well as to improvements in water and wastewater treatment procedures. some of the microorganisms considered as emerging pathogens are giardia lamblia, cryptosporidium parvum, cyclospora cayetanensis, blastocystis hominis, legionella pnuemophila, e. coli h , campylobacter, mycobacterium, and norovirus (jiménez, b) . in developing countries, some of these pathogens are endemic, while others have either not been studied or not reported as disease-causing agents. assessing the biological quality of water is always a challenge due to the diversity of organisms and the need for different and proper methods to identify and enumerate them, some of which are complex, time consuming, and costly. in the following sections, a short description on the techniques used for different type of organisms is described. viruses. identification and quantification of viruses in wastewater, sludge, or excreta is complicated due to the low level of recovery from wastewater and the need to use complex and costly techniques to analyze them. a laboratory requires days, on average, to determine the presence or absence of a virus in water and another days to identify them, using conventional procedures. polymerase chain reaction (pcr) techniques have considerably speeded up the process, as they can be used to determine viruses online. these techniques are based on the amplification of a single or few copies of a piece of dna allowing the identification of different types of viruses. however, quantification with the precision required in the sanitary field remains a challenge. in addition, the method is sophisticated, and requires highly specialized equipment and highly trained personnel. due to these difficulties, it is sometimes preferred to detect bacteriophages, that is, bacteria infected by viruses. bacteriophages are used as informal indicators of viruses and not been linked to human diseases; therefore, their presence has no health significance (jiménez, ) . bacteria. as mentioned previously, thermotolerant bacteria are the common accepted indicator of bacterial fecal pollution. they are detected by using a selective medium and incubating it after inoculation at or . c and/or or . . c, depending on the medium used. the materials and equipment used for this analysis are very common in most wastewater laboratories. pcr techniques to detect e. coli are useful as well. protozoa. there are enough accessible techniques to determine the presence of the main protozoan pathogens in wastewater and sludge; however, fewer techniques are available to quantify them with the required precision for the sanitation field. the presence of protozoa on samples does not necessarily always imply a risk, since this requires them to be also viable. to determine the viability, several days are required. pcr techniques for protozoa are not as well developed as they are for bacteria and viruses. helminth eggs. helminths eggs require laborious techniques to detect them and even more so to enumerate them. fortunately, the technique is readily available and does not use complex equipment, although it does require well-trained laboratory personnel. currently, there is no standardized method and most of the few laboratories trained to detect them are using either different analytical procedures or similar ones with modifications. moreover, most of the laboratories, instead of reporting the total content of helminth eggs, only report the ascaris content, as is done in developed countries where it is frequently the single type of helminth eggs present (jiménez, a) . analytical techniques for quantifying helminth eggs can be divided into two: direct and indirect techniques (jiménez, a) . the first consists of separating helminth ova from the other particles contained in wastewater or sludge (where there are many) and then identifying and counting different genera using a microscope. some examples of these techniques used the us-epa (united states-environment protection agency), the membrane filter, the leeds i and leeds ii, and the faust techniques. the most widely used technique seems to be the us-epa ( ) . a comparison of the performances of the above-mentioned methods has been made by maya et al. ( ) . the recovery rate among them varies from % to %. sensitivity for each notably varies as well and not all are capable of measuring the criteria values set by who ( ) of egg l À for wastewater and egg g À ts for sludge. the second types of techniques are indirect ones, and these have been applied only for wastewater. they are based on measuring either the total suspended solids (tss) content or the particle size distribution (psd), and then correlating the concentration to the helminth egg content. calibration curves need to be established for each type of wastewater and treatment process. nevertheless, it is a worthwhile method because the helminth egg determination costs us$ - if tss are used, and us$ with the psd, instead of us$ , which is the cost of direct methods. it is important to distinguish between fertile viable and nonfertile eggs as only the viable eggs are infectious. this can be done visually using stains or by incubation at c for - weeks (jiménez, a) . conventional parameters as understood in this text are those commonly used to design or select wastewater and sludge treatment processes worldwide, and they refer mainly to the organic matter content (measured as bod or codbiological or chemical oxygen demand), or suspended solids. in general, they are similar worldwide except for the heavy metals content that in general -and especially for sludge -is notably lower in developing countries than in developed ones (leblanc et al., ) as result of the difference at the industrialization level. however, at a local level, metal content in some industrialized areas of developing countries, notably where metal or tanning industries are placed, may be high. a detailed description of conventional parameters and their significance can be found in jiménez ( a) . the term (chemical) 'emerging pollutant' is used to describe a wide variety of complex organic chemical compounds that are candidates for future regulation and that have not usually been monitored. to detect them, complex and costly analytical equipment is needed, such as gc-ms or gc-ms-ms (gas chromatography coupled with one or two mass spectrometers) as these are the only ones capable to measure the very low concentrations at which the pollutants are present (in the order of micro-or ng l À ) and to identify them. emerging pollutants have been detected in untreated wastewater, treated wastewater, surface water, groundwater, and even in drinking water of both developed and developing countries (some). among the countries that have measured and detect emerging pollutants, the following can be cited: austria, brazil, canada, finland, germany, italy, japan, mexico, the netherlands, spain, switzerland, uk, and usa (jiménez, b) . the sources of emerging pollutants are diverse. they come from nonpoint sources, municipal wastewater (treated or nontreated), and industrial discharges. they are also the result of the improper disposal of solid wastes. two groups of compounds that are considered as emerging pollutants are: endocrine disrupter compounds (box ) and personal care and pharmaceutical products (pcpps). wastewater treatment processes have not been designed to remove them; thus, they are randomly removed during conventional treatment. from the limited literature currently available, emerging pollutants -as other organic compoundsare concentrated in sludge during wastewater treatment. initial risk studies suggest minimal ecological and health effects through biosolids recycling to soils (leblanc et al., ) . as most of these pollutants have only been recently studied, the knowledge of their fate, transport, behavior during treatment, and risks is still poor in the sanitary engineering field. chemical emerging pollutants, in general, are not considered at the moment as a priority for the developing world as there are more pressing health and environmental pollutants of concern. it is important to bear in mind that the simple presence of a pathogen or a toxic chemical in wastewater, sludge, or excreta does not necessarily mean that a negative effect will occur. for that, several other things need to happen. these include ( ) the need for a compound/pathogen to reach a certain concentration; ( ) the existence of a pathway for transmission to human or the environment; ( ) the ingestion or presence of a certain dose to cause long-or short-term effects; ( ) sufficient exposure times to the pollutant; and ( ) sufficient sensitivity of a person or of the environment to pollutants. in addition, it should be remembered that, for humans, water is not the only source of risk, as food and air are also sources of pollutant ingestion and, in some cases, they may be the main ones. in terms of the differences of biological risks to humans in developing and developed countries, there are additional aspects to consider as humans develop immunity to pathogens depending on the type of environment they are exposed to, and thus infectious doses may be higher. genetic history, nutrition, and the combination of social patterns also intervene. for these reasons, data developed for developed countries are not always applicable to developing ones to perform risk analysis. in order to quantitatively assess risks, it is necessary ( ) to establish the type and quantity of given microorganisms in a region, ( ) to know the actual infectious dose, and ( ) to define and evaluate the possible infection route. to box endocrine compounds. from jiménez b ( b) wastewater risks in the urban water cycle. in: jiménez b and rose j (eds.) urban water security: managing risks, p. . paris: unesco leiden: taylor and francis group. endocrine disruptors are chemicals that mimic hormones or have antihormone activity interfering with the functioning of endocrine systems in various living species. they derive from many sources including pesticides, persistent organic pollutants, nonionic detergents, and human pharmaceutical residues. some of them have been identified in municipal wastewater and many of them may persist in the environment for some time. endocrine disruptors have been also found in drinking water. their presence in recycled waters also raises broader questions about the risks and benefits of water recycling and our approaches to anticipating the emergence of new contaminants. human health effects potentially linked to exposure to these chemicals include breast, prostate, and testicular cancer; diminished semen quantity and quality, and impaired behavioral, immune or thyroid functions in children. although direct evidence of adverse health effects in humans is lacking, reproductive abnormalities, altered immune function, and population disruption potentially linked to exposure to these substances has been observed in amphibians, birds, fish, invertebrates, mammals, and reptiles. notably, feminization or masculinization on male or female animals, respectively, has been reported. quantitatively evaluate the risk from a chemical or microbial pollutant, several methodologies are available in literature, but the data needed to apply them may be lacking for special cases in developing countries. sanitation is a term that has a clear meaning in the developed world. however, for the developing one, there is need to have a better definition. traditionally, sanitation has been reported as the percentage of the population having access to the service. in practice, this service in low-income regions ranges from simple access to sewers that are discharging the wastewater just behind households or into the streets to sewers connected to sophisticated wastewater treatment plants coupled with water reuse projects and comprising safe sludge management practices. for basic sanitation -sanitation provided in rural or poor periurban areas, the term sanitation includes a wide variety of on-site sanitation options going from simple pit to highly comfortable package treatment plants, which may or may not be functioning. to overcome this, the joint monitoring programme (jmp) from who-unicef proposed in to introduce the term 'improved sanitation' . improved sanitation is a system in which excreta are disposed of in such a way that the risk of fecal-oral transmission to users and to the environment is reduced (who-unicef, ). table shows which options qualify as improved sanitation and which do not. in , the world summit on sustainable development (wssd) provided a definition for basic sanitation that, besides considering the service itself, considered its impact on human health. this definition comprises the following: • the development and implementation of efficient household sanitation systems; • the improvement of sanitation in public institutions, especially in schools; • the promotion of safe hygiene practices; • the promotion of education and outreach focusing on children, as agents of behavioral change; • the promotion of affordable and socially and culturally acceptable technologies and practices; • the development of innovative financing and partnership mechanisms; and • the integration of sanitation into water resources management strategies in a manner that does not negatively affect the environment (it includes protection of water resources from biological or fecal contamination). as a result, the wssd's focus is not only on the construction of a particular number of toilets but also on the effective improvement of health and hygiene through basic sanitation. however, still new elements are needed to be added as problems caused by lack of sanitation are combined with those arising from the lack of economic resources and frequently also with lack of water in societies lacking even from social, economical, and political rights (box ). the millennium development goals (mdgs) are drawn from the actions and targets contained in the millennium declaration that was adopted by nations and signed by heads of state and governments during the un millennium summit held in new york city on september (who-unicef, ). they comprise eight goals and quantifiable targets. water is part of the th goal under target c: ''reduce by half the proportion of people without sustainable access to safe drinking water and basic sanitation.'' fulfilling this target represents the challenge of providing safe water supply to . million people and safe sanitation to . million people within years. table improved and unimproved sanitation facilities according to who-unicef ( ) connection to public service or bucket latrine sewer or septic tank traditional latrine pour-flush latrine public latrine or shared toilet pit latrine with slab open pit or pit latrine without a slab vip latrine open defecation in bush or field ecological sanitation box what sanitation should include, with some information from lenghton l, wright a, and davis k (eds.) ( ) health, dignity and development: what will it take? millennium development goals. london: earthscan. reporting figures concerning the state of sanitation in the developing world is a difficult task. first, there is a lack of information; second, the information available is generally presented in a heterogenic way; and third, different sources tend to contradict each other despite national and international efforts to produce consensus. the worsening situation with regard to sanitation in developing countries can be described using different indicators (box ). contaminated water and poor sanitation account for the vast majority of the . million child deaths each year from diarrhea -almost every day -making it the second largest cause of child mortality (undp, ) . the expansion of water services is essential to reduce the burden of waterrelated diseases and to improve the well-being of a large part of the world's population. it is also vital for economic development and poverty alleviation (who, ) . according to the figures presented by who-unicef ( ) , despite the efforts made and due to population growth, between and , the population with access to sanitation services has increased from million to million ( %), while the net number of people without improved sanitation decreased by only million. the difference between the level of sanitation in developed and developing countries is high: % versus % (table ) . however, between and , the percentage of people with access to improved sanitation increased from % to % with countries' variations ranging from % to % (who-unicef, ) . the difference observed between rich and poor countries is also observed between urban ( %) and rural ( %) areas from developing countries and as well between rich and poor people living there following the inequities of wealthy distribution. the sanitation coverage as percent of the population with service per country is presented in the map of figure for the year . annex contains a table with countries with less of % of the total, urban, or rural population. sanitation in developing countries is quite a complex issue, because the lack of it is combined with other several problems, some of which are geographically described on the maps - from annex . by analyzing these maps, the following conclusions may be drawn: . several low-income countries are located in arid or semiarid regions; thus, besides sanitation problems, they face the problem of water scarcity. . many of the areas under greatest stress (where people are already overexploiting rivers by tapping water that should be reserved for environmental flows) coincide with areas that are heavily developed for irrigation to provide water for food, that is, mostly in developing countries. . water withdrawal for agriculture is mainly performed in developing countries as a result of low water availability and the high dependence of agriculture. . areas where poverty and hunger are prevalent coincide with areas lacking sanitation. . in the future, it seems that the situation may worsen as water availability will decrease in the countries already experiencing water-related problems, including lack of sanitation. as result of the past and present situations, sanitation has different aspects on developing countries that cannot be described simply using the percent of population-covered index. in the following, some of these aspects will be described. basic sanitation versus sanitation. providing services for excreta management in poor rural or urban areas is frequently known as basic sanitation. thus, it has to do with excreta management rather than with sewerage and wastewater treatment plants (box and figure ). the quality of the service is frequently associated with peoples' economic level, and thus, is box some figures for global sanitation * for each four persons that do not have access even to a simple pit latrine, six have it. * for each one person that does not have access to sanitation, another one has it. * in rural areas, for each two persons, only one person has access to a sanitation service. * for each l of wastewater that is nontreated, l is treated. also a sign of status. another aspect to consider is that the lack of basic sanitation frequently is associated with lack of water. leblanc et al. ( ) highlights that research and experience suggest the following hierarchy of risk to human health: ''living in a dense community without basic sanitation (is more risky thany) irrigation of crops with untreated, pathogencontaminated wastewater use of untreated, pathogen-contaminated excreta or wastewater sludge on soils use of untreated, pathogencontaminated animal manures on soils use of treated manures, wastewater, or biosolids on crops use of these treated materials in accordance with strict modern regulations that address heavy metal and chemical contaminants.'' differences on sanitation services. possibly, one of the aspects that contributes the most to render sanitation in developing countries a challenge is the variety of needs and circumstances arising from social differences. as shown in figure , for instance, poor people not only are less served but also the quality of the services is lower. one of the deepest disparities is between urban and rural areas as for the former the coverage is twice as much than for the latter in developing countries. traceable differences in sanitation services have been reported as well among indigenous and nonindigenous people and minorities such as castes and women (box ). among these differences, the following common challenges can be identified: • the need to provide the service in poor areas with large population increases. • for urban areas, a very fast service demand growth in slums that are spread out in cities, have high population density, and there is no land to place the infrastructure. • for rural areas, the need to assist a population frequently dispersed and hence at higher cost. • the need to fund projects combining liquid and solid waste collection and treatment infrastructure. • the need to develop new or different management structures to provide services in social and political complex areas. • the need to include health education and awareness programs on sanitation projects. • the need to use public funding to provide services that are to be subsided. • the existence of regions having high income where services can be provided in a similar way to developed countries. sanitation versus wastewater treatment. as described previously, sanitation coverage does not necessarily result in wastewater being treated or safely disposed of. to illustrate this, figures for the situation in some developing countries are provided. two comments on this figure are that ( ) it is really difficult to find data on wastewater treatment, notably for the asian and african regions and ( ) although there should not be a full correspondence between the sanitation coverage and the wastewater treatment -as some people are served using basic sanitation facilities -the figures should not be as different as they are for some countries. in latin-america, for instance, although the sanitation coverage was % in , only % figure ). according to lenghton et al. ( ) , the amount of money needed to fulfill the sanitation mdgs ranges from us$ billion to us$ billion representing, in mean conditions, an annual average investment of us$ . billion. to put these figures in perspective, the above-mentioned authors mention that each year europe and the united states spend us$ billion on pet food and europe spends us$ billion on ice cream. the overall cost estimation of the current water and sanitation deficit is of the order of us$ billion, equivalent to . % of developing countries' gross domestic product (gdp). for each us$ invested for sanitation, the economic even if sanitation represents an economic benefit, its cost is still important to societies in which this is not the only requirement. therefore, it is useful to combine options that involve building infrastructure with others that do not (such as washing or cooking produce that has been irrigated with polluted water) in order to improve health conditions while the sanitation services can be gradually provided. such an approach is described in who ( ) . in the next sections, options to build up wastewater management systems are reviewed. a wastewater management system (wwms) is understood in this chapter as the combination of one or several of the following components: ( ) basic sanitation facilities or toilets; ( ) wastewater collection systems (sewers) or box some challenges to provide basic sanitation in low-income countries * open defecation is practiced by % of the population in southern asia and % in sub-saharan africa. * in ouagadougou, the capital of burkina faso, the access to sanitation facilities is % while the figure for the country is . %, a figure that reduces to only % for rural areas (paskalev, ) . * in yaoundé, cameroon's capital with inhabitants, the available facilities for most people ( %) are external and in shared proprieties (figure ). * basic sanitation and sanitation figures reported are not the same. for instance, for cote d'ivoire, a coverage of % is reported for rural areas, but, in fact, % refers to basic facilities and only % to adequate systems (angoua, ) . ( ) wastewater disposal or reuse facilities. before presenting these components in detail, the two options in which they can be managed (centralized or decentralized) are discussed. conventionally, to handle wastewater, sewers connected to wastewater treatment plants have been used. this is known as a centralized system and is a well-mastered and well-managed technology approach applicable to cities, provided funds for its construction and operation are available. in terms of operation, centralized systems are often cheaper and easier to handle than decentralized ones. for isolated slums and dispersed rural areas and even for cities where new sewerage systems is too costly, it is advisable to use decentralized wastewater management systems. in these, sewers of reduced size result in a lower capital cost (around %) due to the smaller diameter and length of the used pipelines. in addition, they offer the following benefits (lenghton et al., ; correlje and schuetze, ) : ( ) they allow investments to be made stepwise, in line with available funds, local development, and population growth; ( ) they are used in smaller areas of service that are easier to manage; ( ) they allow the use of different technologies to provide services to different socioeconomic groups; and ( ) they facilitate the reuse of water on-site. nevertheless, all these advantages need to be assessed in practice, as they cannot be taken for granted universally. as for many water utilities, decentralized systems represent a higher number of systems to manage, which is difficult and complex; to overcome this limitation, centralized management of decentralized systems is recommended. this way it is possible to ensure high performance and reliable operation, reduce costs, and also ensure the need for specialized operators (hughes et al., ) . from a technical point of view, there are four important components to consider when providing a basic sanitation service: ( ) the type of toilet, ( ) the storage facility for feces which frequently are associated to the toilet, ( ) the way in which feces are extracted from the pit, and ( ) their further management. this section deals with the first two components. their main characteristics are discussed here; for design, it is recommended to consult specialized books. a good option to begin with is the united nations environment programme (unep) website (see section titled 'relevant websites'). latrines are the most widespread type of on-site sanitation facility. they are used in rural settings and deprived areas in cities. they consist of a makeshift pit dug in the ground and box women and sanitation (with information from lenghton l, wright a, and davis k (eds.) ( ) health, dignity and development: what will it take? millennium development goals. london: earthscan.) one explanation for the low effective demand for sanitation is gender inequality. women tend to place a higher value on household toilets than do men for a number of reasons, among them privacy, cultural norms, care-giving responsibilities, and the risk of sexual harassment and assault. in addition, the unique sanitation needs of women and girls (e.g., during menstruation and during and after pregnancy) receive little recognition when discussions about sanitation and hygiene occur. yet, the limited political and personal power of women in many developing countries means that some of sanitation's strongest advocates are virtually absent from decision making and priority-setting processes. generally covered with any material (a wooden, plant, or metallic cover, whichever is available). when latrines are full they can be emptied (this is unpleasant and has an associated cost) or closed to build another one (this requires the availability of land). these latrines, instead of having a single vault, are made up of a shallow pit divided into two - m vaults. their major advantage is that they are a permanent facility due to the alternate use of each pit. the name comes from the inclusion of a properly designed pipe allowing ventilation, which also requires a screen to avoid the accumulation of flies. the pit cover is made of precast concrete, wood, palm leaves, or metallic material, and is removable. emptying is performed manually in low-income areas, but can be done mechanically every - years. the ventilated improved pit (vip) latrine with multiple pits can be built for collective use, such as in schools, markets, fueling stations, and administrative buildings (mamadou, ) . the septic tank is commonly used as primary treatment in rural areas, low-income urban settings, isolated households, or on sites where soil is not suitable for the installation of sewers (jiménez and wang, ) . they are built where a constant water supply is available and are used to partially treat domestic wastewater and to digest the settled sludge. they remove around % of the organic matter and suspended solid content in - days. for sludge digestion, . - year is required; during this time, sludge is mineralized and its volume is reduced. septic tanks are made up of a series of communicating chambers. they must be water sealed to avoid underground infiltration and are built using bricks, mortar, or concrete. a variation of the septic tank is the imhoff tank, having the advantage of a shape that allows the removal of suspended solids and the control of foul odors in a better manner. septic tanks need to be periodically cleaned ( - times per year, leaving % of the mature sludge as inoculum for digestion). this represents an additional cost that cannot always be afforded by poor people. septage (the slurry taken out of septic tanks) is sent to wastewater treatment plants or treated separately. to treat septage, lime is frequently added until a ph of is reached, over a period of min (jiménez and wang, ) . effluents from septic tanks are discharged into trenches for subsoil infiltration or diverted to the sewerage system (when available). septic tanks are widespread sanitation systems but are often responsible for environmental pollution due to poor purification effects and leakages notably affecting groundwater. composting toilets are characterized by the separation of urine and feces. for this reason, they are also referred to as urine diversion (ud) toilets. they are constructed with two vaults or chambers. when the first vault is full, the pedestal is moved over to the second vault, and the first hole is closed. when the second vault is full, the first vault is emptied and so on. the urine is diverted to a soakaway. in comparison to vip latrines, they have a lower cost associated with emptying the pits (snyman, ) . urine is collected in small cans ( - l) and can be used to enrich the soil after a stabilization period of days. feces are treated using an aerobic composting process. to control odors and to assist in the mineralization of feces, materials, such as ashes or pieces of wood, are used daily to raise the ph. the pathogens in fecal matter are inactivated over time through the drying process so they can be safely removed by the owner at no cost to the municipality. once the sludge is digested, disinfected, and removed, it is used as fertilizer. ud toilets are seen as a viable option for rural applications. the main reasons are that they are cost-effective and, since the rural community is accustomed to the use of manure, the ud toilet is socially acceptable. however, its use in periurban areas is more problematic. the emptying of the vaults requires large-scale programs for which small businesses can contribute to the emptying of tanks (from ud or vips) either manually, using appropriate safety equipment, or by the use of a tanker. the disposal of the fecal matter in periurban areas is challenging due to the lack of land. if space allows, fecal sludge is buried on-site. where this is not feasible, the sludge is blended into the waterborne system. this frequently leads to the complete overloading of the wastewater treatment plant (snyman, ) . there are several options of composting toilets (see section titled 'relevant websites'). pour-flush toilets have been developed based on traditional flush toilets, which rely upon a water seal to perform cleansing and to control odors and insect infestations. the system works via a manual flush, where - l of water are poured into the toilet. the water, urine, and excreta are collected in an anaerobic chamber, which works similarly to a septic tank. the chamber needs to be periodically emptied and the partially treated wastewater needs to be disposed of, normally to land (hughes et al., ) . in the context of water-scarce areas, a very interesting option is combining graywater reuse with basic sanitation using pour-flush toilets. this concept was developed by united nations international children's emergency fund (unicef) on a system called the wise water management scheme (godfrey et al., ) . this system was conceived to provide both water supply and sanitation services for water-scarce areas and can be used for both rural and lowincome urban areas. it was conceived in madhya pradesh, india, a densely populated and poor area. the wwms uses groundwater as the primary source of water and also includes rainwater harvesting, used to dilute groundwater when polluted with fluoride to reduce its content for human consumption ( figure ) . first-use water is employed for cooking, handwashing, and bathing. water from these two activities is recovered and properly treated in a sand filter to be used for toilet flushing and kitchen garden irrigation. the graywater reuse system can be installed independently of the rainwater harvesting system. by matching water demands, in quantity and quality, to different conventional and nonconventional water sources, the wwms increases water availability by nearly %. sanitation using low-consumption reused water flush toilets has proven sustainable under the prevailing local conditions and has eradicated open defecation. . . . . additional recommendations to set up basic sanitation facilities one important aspect to keep in mind when selecting the technology is that facilities need to be operational and, to achieve this, there is a need to sustain them under operation from the economical, technical, and cultural perspectives. investment costs are linked to the type of sanitation system selected, the construction materials, and labor. frequently, to reduce costs, cheap materials and the users are employed to build the facilities. however, this may result in failures, as cheap material frequently means low quality and the users are not people experienced enough, even if trained. it is thus preferable to invest in good and durable material and to use experienced workers. in india, for instance, sanitation programs using professional well-trained masons are being implemented in which the same masons for whom sanitation is a source of income become at the same time sanitation promoters. norms and institutional capacity to provide basic sanitation constitute another weak link in the complex chain needed to implement and provide services. how to build institutions, policies, and human resources to provide successful sanitation services is better known in high-income countries than in developing ones. each country/region needs to look for the proper way to solve their problems. finally, concerning basic sanitation, it needs to be considered that in several places, providing basic sanitation means to change open defecation habits and to handle domestic solid wastes (box ). it means as well to properly dispose of the toilet paper. under this section, only the toilets using less water or none at all are described as compared to the others (pour flushing toilets using l of water is a well-known technology widely spread commercially). concerning these toilets, one aspect to highlight is that even if convenient from the point of view of the used water, care must be taken when designing treatment plants as wastewater will be not only lower in volume but also highly concentrated, notably in terms of its organic matter content. these toilets are based on the same working principles as common flush toilets but they are specially designed to fully operate with less water ( - l). in such toilets, it is possible to select either a full flush (with , , or l depending on the model) for solids or a half flush ( - . l) for liquids. box poor people have a globalized attitude towards excreta management as described for senegal by ba ( ) , in most poor areas of the developing world, water from baths and in some cases from showers are routed to septic tanks from which the effluent is sent to infiltration wells or trenches. kitchen and laundry water is generally poured directly into the street, discharge areas in the wild, a well, a nearby river, or riverbed. wastewater and noncollected solids are also frequently mixed creating breeding sites, odor problems, and development of flies. these toilets are also available with separate drainage for urine to reduce the impact of nutrients and pharmaceuticals on the sewage and to facilitate the reuse of urine as a fertilizer. however, most water-saving toilets available on the market are designed to be connected to typical drainage systems. there are several technological options on the market, some of which use a vacuum to transport feces at a much higher cost. the investment cost for low-volume toilets is comparable to high-volume toilets. however, dual flush toilets may cost more than common ones (nearly double). the installation of water-saving toilets must be stimulated by education (e.g., in the form of campaigns to raise awareness concerning watersaving issues), water metering, and pricing. water-saving urinals, using - l, are also available (correlje and schuetze, ) . the idea of dry toilets is not new. they have been used for thousands of years in east asia (china, japan, and korea). dry toilets are available as industrial prefabricated products and can also be constructed in local workshops; however, knowhow for its good operation and to avoid foul odors is required. investment, construction, or installation costs vary significantly and depend on the specific system and design. the cost ranges from low investment for simple dry toilets to comparatively high cost for industrialized composting toilets. due to the large size of the storage and composting chambers, these toilets require a large space underneath; if this is not possible, then they need to be regularly emptied and feces need to be transported to treatment facilities. user acceptance depends on cultural background and awareness. generally, people who are already using flush toilets do not readily switch to dry toilets because the image of dry toilets is less attractive than that of flush toilets. equally important as the type of on-site sanitation system selected is the provision of all the services associated. past experiences (water decade, - ) have shown that massive sanitation infrastructure provision without a proper planning of the whole scheme can be a complete failure (koné, ) . besides the technical aspects that are discussed later, the most worrying aspect is the lack of financial, institutional, and regulatory framework in most of the developing countries to establish the network required. management of on-site sanitation infrastructure comprises on-site sanitation systems emptying, fecal sludge haulage, treatment, and safe reuse or disposal (koné, ) . fecal sludges refer to sludge collected from on-site sanitation systems such as latrines, nonsewered public toilets, or septic tanks. the criteria to select an extraction method -a task that is never pleasant -depend on ( ) the ts content and ( ) the funds available. sludges with less than b % ts, such as those produced in septic tanks, can be pumped; but, for the rest of facilities producing all sludge with % ts, pits need to be emptied using cesspit trucks or manually by laborers (koné, ) . even though when mechanically emptied and water is used for toilet cleansing, - % of the contents in the lower pit part need to be manually emptied to extract the thicker sludge. the use of mechanical equipment allows carrying away the sludge several kilometers for disposal on controlled sites or on treatment facilities, but this is often expensive and needs proper equipment and skilled laborers. in contrast, when sludge is manually emptied, this is deposited in nearby lanes or on open spaces representing a source of risk. according to koné ( ) - % of the on-site sanitation facilities from west african countries are emptied manually. in addition, in almost every developing country, fecal sludge collection and haulage are conducted by private entrepreneurs. however, their important role and responsibilities as key stakeholders are not yet fully recognized and legalized (koné, in many low-income areas, the sanitation problem begins with the lack of sewerage. one option is to build sewers of small extent coupled with on-site sanitation systems. sewers carry the treated effluent to disposal (usually to soil for infiltration, to irrigation canals, or into water receptors), to wastewater treatment plants, and/or to reuse sites located within a short distance. as these sewers frequently convey partially treated wastewater (such as septic tank effluents), they are designed for self-cleaning using a high wastewater velocity and/or a steep slope. this option is applicable for rural areas or urban ones where adequate land is available. another option is to use simplified sewers. these are recommended where an uncertain population increase is occurring, as normally happens in periurban areas or slums. small sewers are built to reduce the infrastructure and maintenance costs, as well to allow high operational flexibility. inspection chambers such as manholes are replaced by inspection cleanout. the life expectancy of such sewers is in the order of years rather than the years quoted for conventional sewers. such sewers are short and shallow (hughes et al., ) . one example of simplified sewers are condominial ones in which pipelines are laid through housing lots instead of on the side street, in a way that allows isolated and stepwise construction (unep, ) . condominial sewers were developed in the s in brazil with the aim of extending sanitation services to low-income communities. this technology has now become a standard sanitation solution for some urban areas in brazil, irrespective of income levels. condominial sewers reduce the per capita costs of service by replacing the traditional model of individual household connections to a public sewer with a model in which household waste is discharged into branch sewers, and eventually into a public sewer through a group (or block) connection (watson, cited in lenghton et al., . these are structures that are bigger and deeper than those previously discussed. details for design can be found in conventional literature on sewers. many developing countries are located within regions subject to tropical storms, or in areas where there are only two seasons per year: wet and dry. therefore, urban hydraulic infrastructure needs to be designed accordingly to have sewers that can handle large peaks of stormwater and the normal wastewater flows (wastewater treatment plants should also be capable of dealing with the varying wastewater characteristics in quantity and quality, at least in large cities). sewers in tropical areas produce a high amount of sediments to be disposed off, which turns out to be a peculiar and difficult-to-solve problem not frequently commented upon in specialized literature but that needs proper methods to extract sludge and handle it. in addition, when conveyed in sewerage systems, stormwater must be treated in treatment plants at the same time as wastewater; but, if transported separately, it can be discharged to surface water or into wells for groundwater infiltration receiving treatment in soil. in this case, it must be kept in mind that stormwater quantity and quality are determined by rainfall, catchment processes, and human activities, which cause its flow and composition to vary in space and time. normally, for the first rains of the year, stormwater has higher suspended solids, heavy metal content, and bacterial numbers than nontreated wastewater, and lower dissolved solids, nutrients, and oxygen demand than secondary-treated sewage effluent. wastewater treatment is the typical method applied for sanitation, and is the predominant option used in developed countries for that purpose. although it cannot be considered a caveat for all the negative impacts produced by wastewater, it is still a very important option, and, in many cases, the only one. there are several steps to treat wastewater. the primary step basically serves to remove easily decantable and floating solids. the secondary one, generally a biological process, is used to remove biodegradable (mostly) dissolved suspended material. the tertiary step is used to refine the quality of the effluent produced by a secondary treatment. it may have different purposes, most commonly being the removal of nutrients (n and p). as the treatment steps were conceived following treatment needs, in practice, they are usually implemented in separate tanks or in well-defined sections of wastewater treatment facilities; however, it is possible to use compact processes eliminating physical separation among steps and thus reducing costs (jiménez, ) . wastewater treatment plants are not common facilities in low-income countries. in contrast to developed countries, in developing ones, the sanitation figure ( % according to who-unicef ( ) ) does not include the treatment of wastewater, which barely reaches % (us-epa, ). moreover, when available, the treatment merely consists of a primary step or including eventually a secondary step that is not always properly functioning. in many developing countries, the main issue concerning treatment is still the proper disposal of feces, particularly in low-income urban or rural areas. this, combined with a high content of pathogens in wastewater, sludge, or fecal sludge, implies the need to properly select the treatment process in order to effectively control disease dissemination. in general, coupling any kind of secondary wastewater treatment process (biological or physico-chemical) with a filtration step before disinfection will considerably reduce the pathogen content. however, this is rarely feasible for economic reasons and therefore it is sensible to consider the use of other technologies alone or combined with other type of intervention methods to build up a multiple barrier system to control wastewater risks (jiménez, b) . in the following sections, guidance will be provided to support the selection for treatment options, based on the type of pollutants. to address problems caused by suspended solids, organic matter, nutrients, and fecal coliforms, there is a wide variety of available technologies supported by literature and practical results. their affordability in economic terms and the suitability of the processes for local conditions are among the important aspects to consider for developing countries. it is beyond the scope of this chapter to provide a full description of treatment technologies for conventional pollutants, which can be found elsewhere in the literature. table shows the removal of pollutants by different processes so that it is possible to identify those acting upon the same type of pollutants. . . . . pathogens treatment table presents organisms' removal or inactivation achieved by different wastewater treatment processes. this table is a guide for selecting a process. however, to design complete treatment schemes, the operating conditions need to be properly selected as well as the pre-and post-treatment. table differs from the one presented by who ( ) in showing the removal efficiency data for helminth eggs in terms of a percentage instead of log removal. this is because helminths eggs' content is by far much lower and log units are meaningless. for developing countries, the removal of protozoa and helminths eggs is the main concern, considering their content and the occurrence of diseases caused by these types of agents. to remove protozoa, filtration is a good treatment option. conditions used to remove cryptosporidium oocyststhe targeted protozoan for developed countries -can be used as well to remove protozoa relevant to developing countries. helminth eggs are not affected by conventional disinfection methods (chlorination, ultraviolet (uv) light, or ozonation); thus, they are first removed from wastewater using sedimentation, coagulation-flocculation, or filtration processes to be subsequently inactivated in sludge (jiménez, a) . removal occurs because eggs are particles - mm in size. it is estimated that for contents of - mg l À of tss in treated wastewater, the concentration of eggs is around - eggs l À , while for values below mg l À it is around egg l À or less (jiménez, a) . however, for a process to be reliable, besides the removal efficiency attained, it is important for it to produce an effluent with constant concentration. the removal efficiency of emerging chemical compounds during conventional treatment can be found in jiménez ( b) . it is recommended that experimental tests be performed under laboratory conditions, prior to treatment selection. in the following, a description of main wastewater treatment processes is made, highlighting aspects that are relevant to developing countries, notably concerning their efficacy to control pathogens. table removal of pollutants by different wastewater treatment process that can be used to buildup a multiple barriers treatment scheme (with information from jiménez ( ) noxious by-products can be formed. if there is no competition with organic matter (bod or cod). doses are several orders of magnitude higher than those used for disinfection. if granular carbon is used. high for nonpolar organic compounds with log k ow > and when there is no competition with organic matter. medium to high depending on the presence of cations and organic matter. high but not for low molecular weight uncharged compounds. effective for several ec but not for carbamazepine, primidone, and iodinated x-ray contrast media. high for some ec, as it depends on the strength of solar irradiation removal will be different for different latitudes, or conditions. can be enhanced with photosensitizers. ? unknown or insufficient information * , can be removed or inactivated. no, not applicable for the pollutant. , . . . . slow filtration slow filtration is recognized in water potabilization as an efficient method to control microbial pollution in rural and low-income communities. the few studies carried out on slow filtration of wastewater have demonstrated a removal range of - % of suspended solids and - e. coli log, with coarse sand (jiménez, ) . in rural areas, it may be coupled with absorption wells, irrigation reuse, or a soil aquifer treatment (sat) system. waste stabilization ponds (wsps) are shallow basins that use natural factors such as biodegradation, sunlight, temperature, sedimentation, predation, and adsorption to treat wastewater (mara, ) . wsps are capable of removing organic matter with efficiencies similar to the activated sludge process and all kind of pathogens. they are easy to design and operate but require long retention times (several weeks). wsp systems comprised several ponds connected in series. lagoons are made through the shallow excavation of around - m, and they are frequently unlined to reduce investment costs. after a period of time, soil percolation and sedimentation form an impermeable barrier. if the water table is very high at the site, ponds need to be impermeable from the beginning. wsps remove up to bacteria log, up to viruses log, and almost all the protozoa and helminth ova. to control cryptosporidium spp., almost days' retention time is needed . in developing countries with wet warm climates, the use of stabilization ponds is recommended if land is available at a reasonable price. for arid and semiarid regions, high evaporation rates limit their application as there is a net loss of water of - % due to evaporation. this, in addition, increases the salinity of the effluent limiting its use for agricultural irrigation . sludge production in ponds is low but if extracted it needs disinfection as helminth ova remain viable in ponds for more than years (nelson et al., ) . wsps can be coupled with aquaculture systems that are shallow ponds or wetlands where fish, duckweed, or aquatic vegetables are produced as is frequently done in indonesia, china, and thailand. ponds can be used to produce only one crop such as duckweed that is used as food for the next pond where grass carp are grown. different species can also be cultured in the same pond, as happens in nature. to operate the system, wastewater is applied to ponds at the required rate (estimated in terms of the organic load applied per hectare of ponds per unit time), and the organic matter and the nutrients contained serve as food for plant and animal production (hughes et al., ) . in order to avoid health problems, wastewater needs to be previously disinfected according to who guidelines ( ) . constructed wetlands are used to naturally remove organic matter, pathogens, and nutrients from wastewater through biodegradation, adsorption, or filtration in a similar way to wsps. nutrients are also removed by plant uptake and pathogens by competition and sun uv-light inactivation (jiménez, ) . wetlands are shallow ponds where aquatic macrophytes are planted in soil, sand, or gravel. there are three main types: surface-flow, horizontal-flow subsurface, and vertical-flow systems. juncus spp. or phragmites are commonly used plants but any local plant can be employed. construction requires expertise and skilled labor. once installed, operation is relatively easy. wetlands remove nitrogen, phosphorus, and heavy metals. up to - % of thermo-tolerant coliforms, - % of ms coliphages, and - % of protozoa are inactivated or removed using hydraulic retention times of - days. in practice, pathogen removal is highly variable and depends on climate, type of wetland, and the kind of plant used. to completely remove helminth ova, it is necessary to couple wetlands with filtration, otherwise effluent with variable content may be produced. breeding of mosquitoes and unpleasant odors can be a problem if wetlands are not operated correctly. subsurface wetlands are used to avoid mosquito breeding (correlje and schuetze, ) . wetlands are a good solution for wastewater treatment in urban or rural areas where space is available; as a rule of thumb, . - . m per person is required for the treatment of graywater and - m per person for domestic wastewater. they are considered environmentally sound technology by unep for the treatment of graywater and stormwater urban runoff. they are used as secondary or tertiary treatment units, in which case, they treat effluents from septic tanks, anaerobic ponds, upflow anaerobic sludge blanket (uasb) reactors, or conventional wastewater treatment plants. treated wastewater can be reused for agricultural irrigation, although its nutrient content is low. wetlands have been used in bangladesh and china to treat wastewater and to cultivate fish and ducks. in addition, they have the advantage of producing a low quantity of sludge. soil can be used to treat wastewater by infiltration. it has a greater depollution capacity than water receptors, as there is no limit for the oxygen transfer needed for biodegradation. land-based treatment is recognized as an environmentally sound technology by unep ( ) that has a low cost when used for primary effluents. among its disadvantages is the high demand for land (jiménez, ) . in the case of land treatment, depollution takes place in the unsaturated zone through biodegradation, adsorption, ion-exchange filtration, and precipitation. for the removal of organisms, in addition to predation and humidity, the temperature also plays a role. heavy metals and trace organic compounds (such as emerging pollutants) are removed mainly by adsorption. to operate, wastewater is to be applied at specific rates; if pretreatment is needed primary sedimentation or sand filtration might be used (brissaud and salgot, ; jiménez, ; bouwer, ) . in developed countries, pre-treatment usually consists of a secondary treatment. wastewater application occurs in cycles at a rate that depends on the soil infiltration characteristics. in a typical situation, the cycle involves week of wastewater flooding where infiltration is reduced by organic buildup, and week of drying where bacteria consume the organic matter and soil drying takes place. there are several types of land treatment options in specialized literature that can be consulted. for efficient functioning, hydraulic loads ( - m m À yr À ) and mass loads should be limited. to avoid aquifer pollution, application of wastewater (preferably partially treated) is restricted to sites where groundwater is a minimum of m in depth. applied as primary or secondary treatment, land treatment produces a consistently high-quality effluent (tss o mg l À , organic carbon mg l À , and total nitrogen mg l À , with a phosphorus removal of almost % with minimal pre-treatment). as tertiary treatment, it removes % of bod, % of cod, % of ts, % of detergents, % of ammoniacal nitrogen, % of total nitrogen, and % of phosphorus. land treatment is effective for the removal and/or inactivation of helminth eggs, protozoa, bacteria, and even viruses (jiménez, ) .treated wastewater can be used for irrigation or any other use and can be collected on the surface or underground. reservoirs or wastewater storage tanks can be used as well to treat wastewater. while wastewater is stored during the wet season to provide water for irrigation during the dry season, pathogens are removed or inactivated via sedimentation, uvsunlight inactivation, predation, and other similar processes, which also occur in wsps. nevertheless, the efficiency is lower. procedures for designing wastewater storage and treatment reservoirs are detailed in juanicó and milstein ( ) and mara ( ) . reservoirs and storage tanks are easy to operate and maintain, and if considered as part of the irrigation system, they result in a low investment cost. however, they facilitate vector breeding if they are not well maintained and operated, and algal development in effluents may interfere with irrigation applications. effluent storage reservoirs remove À -log of viruses, À -log of bacterial pathogens, and À -log units of protozoan (oo)cysts. if treatment reservoirs are operated as batch systems with retention times over days, the complete removal of helminth eggs can be achieved (juanicó and milstein, ) . in addition to large storage reservoirs, small storage ponds can be utilized for pathogen removal when used for urban agriculture irrigation as intermediate water storage reservoirs. such reservoirs reduce the helminth ova content by around % (keraita et al., ) . the uasb is used to remove organic biodegradable matter. a uasb is a kind of attached system where microorganisms adhere to themselves, forming flocs. uasbs are considered as the most successful anaerobic process applied to treat wastewater due to low hydraulic retention time compared to other anaerobic processes thanks to the high density of biomass attained in the blanket (campos, ) . the reactor is designed to not only produce the biological reaction but also to sediment and filter suspended solids from wastewater. in addition, sludge retained in the bottom part of the reactor is anaerobically digested (campos, ) . the uasb produces better results when the wastewater has a high organic matter content. as by-products, it produces methane and partially treated sludge. the gas can be used as a source of energy, while the sludge remaining, after proper treatment to control the pathogen content, can be used to fertilize soil. uasbs remove - % of bod and cod and helminth eggs through filtration in the sludge blanket and through sedimentation. however, their efficiency with regard to the removal of helminth eggs is very variable. from wastewater containing - eggs l À , they produce effluents with - eggs l À ( - % removal). therefore, uasbs are frequently coupled with other treatment process such as stabilization ponds or filtration to completely and reliable remove helminth ova and to inactivate other pathogens. several stand-alone uasb plants or those coupled with wsp are currently under operation in curitiba, brazil. uasb reactors require careful design and operation to avoid bypasses (campos, ). the construction, operation, and maintenance of improved anaerobic technology such as biogas installations require considerable expertise and skilled labor as well as space (correlje and schuetze, ) . uasb reactors have a low capacity for tolerating toxic loads, need several weeks to start up the process, and require a post-treatment step. it is the most common way to treat wastewater in developed countries. compared to other secondary biological processes, activated sludge is effective for pathogen control as it removes % more than trickling filters. both sedimentation and aeration play an important role in this. sedimentation eliminates heavy and large pathogens, while aeration promotes antagonistic reactions between different microorganisms, causing their elimination. as a result of becoming entrapped within the flocs (which are subsequently sedimented), there is fairly good removal of small nonsedimentable microorganisms, such as giardia spp. and cryptosporidium spp., which remain concentrated within the sludge (jiménez, ) . helminths eggs are also removed, but due to continuous difficulties in achieving efficient and reliable sedimentation of suspended solids in secondary decanters, protozoan and helminths eggs may be found in effluents along with flocs. for an initial helminths egg content of - eggs l À , effluents with - eggs l À are produced . other biological secondary treatment options include aerated ponds, oxidation ditches, and trickling filters. much specialized literature exists describing the processes that are used to treat effluents before discharge into water bodies. this is a process that was almost abandoned for the treatment of municipal wastewater in the - s due to the high sludge production, which considerably increased the overall wastewater treatment cost. the introduction of new chemical products, in particular flocculants, combined with the possible reuse of treated effluent for agricultural irrigation and ocean disposal, has been instrumental in its reintroduction. coagulation-flocculation removes helminths eggs while preserving nutrients and organic matter in contents suitable to grow plants. when this process is applied using low coagulant doses combined with a high molecular weight and high charge density flocculants, it is called chemical enhanced primary treatment (cept). if, a high-rate settler is used instead of a conventional settler, it is referred to as advanced primary treatment (apt). as a result, cept has a total hydraulic retention time of - h while, for apt, this is only . - h. among the coagulants that have been used, iron and alum compounds are the most common. apt removes - % of protozoan cysts (giardia, entamoeba coli, and e. histolytica) and - % of helminths eggs. from a content of up to eggs l À , an apt can consistently produce an effluent containing . - eggs l À . this process produces an effluent with a low content of suspended solids or turbidity, which leads to greater disinfection efficiency, either with chlorine or with uv light. likewise, the process allows the use of sprinkler irrigation in high-tech countries or countries where water is scarce. the effluent quality is improved by the soil effect, and aquifers can be used as water supply storage (jiménez, . apt and cept are useful in middle-and high-low-income countries on large urban areas as an economical alternative to an activated sludge process as the treatment cost for apt is one-third of this process when considering sludge treatment and disposal within km. coagulation-flocculation can also be applied as a tertiary treatment after a biological process. this is a very good method to remove enteric viruses (jiménez, ) . rapid filtration (at rates over m m À h À ) is very efficient in removing protozoa and helminth eggs from wastewater, primary effluents, and biological or physicochemical effluents. it removes % of fecal coliforms, salmonella, pseudomonas aeruginosa and enteroviruses, - % of protozoan cysts (giardia, entamoeba coli, and e. histolytica), and - % of helminths eggs. efficiency can be increased to easily reach % if coagulants are added . for helminth ova removal, rapid filtration is performed in silica sand filters with . - . mm media size, a bed depth of at least m and filtration rates of - m m À h À . the helminth ova content in the effluent is constantlyo . ho l À in filtration cycles of - h for primary effluent (jiménez, . the challenge for any disinfection method is that microorganisms respond differently. efficiency depends on the disinfecting agent, the type and content of microorganism, the dosage, and the exposure time. the water matrix has as well a relevant influence, which becomes more important as its concentration and complexity increase. the most common disinfection processes for wastewater are chlorination, ozonation, and uv-light disinfection. . chlorination. it is the most widely used process to control microorganisms. it is effective for the inactivation of bacteria, less so for viruses and protozoa, and not at all for helminth eggs. with regard to virus and bacteria, chlorine has inactivation efficiencies of up to - log. however, chlorine is a very reactive agent and, therefore, before attacking microorganisms, it reacts with many substances contained in wastewater, in particular with organic matter, hydrogen sulfide, manganese, iron, nitrites, and ammonia. as a result, chlorination is a process that, in order to be efficient, needs to be applied at the end of treatment schemes to avoid interferences. if, in treated wastewater, ammoniacal nitrogen and organic matter are still presented, chloramines and organo-chlorinated compounds are formed. these are compounds that increase cancer risks. notwithstanding such risks, it is always preferable to chlorinate wastewater as microbial diseases have faster and often more dramatic health effects (jiménez, ) . . ozonation. ozone is very effective at inactivating viruses and bacteria. it inactivates - log concentration units in a very short time, provided there is a low demand for oxidizing agents by wastewater. there is abundant information in the literature concerning the design and operation of the processes. required ozone doses for several microorganisms are also available in the literature but, frequently, they are not affordable. as happens with chlorine, by-products generated during ozonation are a source of concern as many of them have been reported in the literature as toxic (jiménez, ) . . uv light. nowadays, uv-light disinfection closely competes with chlorination because it does not generate by-products that are too costly to remove from wastewater. besides, compared to chlorination, uv light does not need storage facilities, does not imply the handling of hazardous chemicals, and uses very small-size treatment tanks as disinfection contact times are very small (in the range of seconds or minutes). furthermore, due its simplicity of operation and high adaptive potential, it is suitable for rural and isolated communities. . . . sanitation and wastewater treatment costs figure presents estimated cost for different sanitation options, including from basic sanitation system to wastewater treatment plants. simple services certainly are much cheaper to provide, but they do not necessarily represent what the society wishes to have due to the comfort level. as cost is an important barrier to spread sanitation services, one would expect that these data is a well-known parameter. despite this, in many developing countries there are no reference costs, as exist in developed ones. as result of this situation, in many bids, costs are established using international data that do not necessarily reflect the local conditions (table ) . differences are due not only to build the sanitation facilities but also for the use of fuel and electricity, two important inputs to operate wastewater treatment plants. sludge management and disposal ( figure ) is another source of different affecting costs ( figure ). table also shows that the cost of emptying onsite sanitation systems is not negligible. the selection criteria for wastewater treatment processes are presented in table , emphasizing the needs of developing countries. after treating wastewater, the next step is its disposal. recently, some researchers have suggested (asano, ) to use the term 'dispersion' instead of 'disposal' in order to change the perception of getting rid of used water, but this term has to an extent the connotation of wanting to dilute a problem. in this chapter, the term 'reintegration' is introduced in order to emphasize that water needs to be returned to the environment or used once again (reuse). by reintegrating the water to the environment, the responsibility of using it and then restoring it back to the environment in a proper way may be realized. as, well water can be reintegrated into the hydraulic cycles in which is been used by the society, thus reducing the negative impact of extracting water from the environment beyond the amount needed for ecological use (environmental flow). water can be reintegrated to the environment by discharging it to the soil or into water bodies. in the following, different ways to reintegrate used water are discussed. this is followed by discussing the reintegration of water through reuse. soil reintegration (disposal) consists of discharging treated or nontreated water into land. as discussed in the section . . . the soil may act as a treatment step if a proper management is provided. the options to reintegrate treated wastewater into the environment are presented below. after discharging used water to soil, it will be evaporated, infiltrated, or will percolate to reach surface or groundwater bodies. the extent of each of these will depend on the soil and local conditions. they are used mostly for on-site sanitation effluents. they consist of a trench in which partially treated wastewater is discharged to allow its infiltration to the subsoil. the seepage in the trench allows uniform disposal of the wastewater over a given area. the leach drain is often filled with gravel or highly permeable material and a perforated pipe -from which used water is distributed -is placed in the centre at about . m beneath the soil surface. the perforated pipe is typically around . m in diameter (hughes et al., ) . the size of the trench depends on the wastewater load and the soil type, groundwater depth, and precipitation. leach drains are not recommended disposal options if the groundwater table is close to the surface (e.g.,o . m depth) or the soil has low permeability (e.g.,o mm d À ). they are convenient where soil is highly impermeable (e.g., clay) but can also be used in permeable soil from where water is both evaporated and infiltrated. in each case, plants are positioned to increase evapotranspiration and to remove nutrients from wastewater. if a limited area is available, evapotranspiration beds can be used in conjunction with a seepage trench. to increase dispersal of the wastewater throughout the whole bed, perforated pipes surrounded by gravel are used. the design of the bed should ensure it is large enough to hold wastewater loading and pluvial precipitation while, at the same time, providing sufficient water and nutrients to plants (hughes et al., ) . soil disposal can be coupled with soil treatment in the soil aquifer treatment-aquifer storage recovery system (sat-asr). an aquifer storage recovery system (asr) consists of holding water in an appropriate underground formation, where it remains available in such a way that it can be recycled by extraction when needed. an asr can have several objectives, some of which are (dillon and jiménez, ; jiménez, ) temporary or long-term storage; decrease of disinfection by-products; reestablishment of underground water levels; maintenance or improvement of underground water quality; prevention of saline intrusion; deferment of expansion of water supply systems; aggressive water stabilization; hydraulic control of contaminant plumes; and compensation of soil salinity lixiviation. the major advantages of underground storage is that evaporation losses are considerably lower than dams (b %) and do not have the eco-environmental problems associated with them (dillon and jiménez, ) . aquifers can be an economical option to reintegrate water to the environment in arid and semi-arid countries where it remains available for future use. they are also convenient in densely populated urban areas where, besides storing treated water, aquifiers can store stormwater runoff. effluents from treatment plants can be used for the augmentation of surface water bodies, in which the effluent is diluted with freshwater and reused as a source for water. the water quality of receiving water should be preserved to facilitate a safe water supply. for this, it is important to control pollutant content in the effluent, notably pathogens, organic matter, and nutrients (especially for surface water bodies with slow flow). two aspects need to be monitored: oxygen depletion in rivers and eutrophication in dams and lakes. to avoid oxygen depletion, biodegradable organic matter needs to be removed before introducing the wastewater. there is considerable literature available concerning this aspect as it has been the main target for most wastewater treatment processes. control of eutrophication is achieved by removing n and/or p from effluents; this is an operation costly to perform in wastewater treatment plants for most developing countries. as an alternative, land treatment can be used or treated wastewater used first for agricultural irrigation recovering it from the agricultural drainage before sending it to on lakes. eutrophication of dams and lakes is a frequent problem in developing countries; alternatives for its control are discussed in box . reuse is another option to reintegrate water to the environment but through its use. due to the increase in the human population and the increased use of water for almost all human activities, water is becoming scarce and new tools are needed to use it better. such tools are ( ) the efficient use of water (using less water for the same activity -this is beyond the scope of this chapter) and ( ) water reuse. water reuse is a key component to alleviate the mismatch between water supply and water demand. at the global level, water availability is of around m inhab À yr À but with important variations at a regional, national, and local level. for instance, it is estimated that around million people ( % of the total population) in countries live in areas with less than m inhab À yr À . by the year , % of the total world population will live under such water stress, increasing to % (in countries) by the year (undp, ) . as shown in maps , , and (annex ), most of the affected people live in developing countries. for these countries, three aspects can be highlighted concerning water stress and water demand. first, water is needed for economic development and a better quality of life (even if industrialized countries are not completely making an efficient use of water; they use - times more water than developing ones (un/wwap, ) ). second, agriculture is the dominant user of water worldwide, but, in addition, for developing countries, agriculture is usually the criteria for selecting wastewater treatment operation and processes must be evaluated based on past experience, data from full-scale plants, published data, and from pilot and full-scale plant studies. if few data or unusual conditions are encountered (atypical wastewater characteristics) pilot plant studies are essential. for developing countries: -since much less experience is available, a good wastewater characterization is needed as well as a request during bids that the applicability of the processes should be demonstrated before construction. -bids should encourage operating at lower costs at the same pace the process is optimized. -technology complexity need to be in agreement with the type of community being served: rural areas, rural isolated areas, small urban towns, large towns, and megacities (low-, middle-, and high-income urban and periurban areas densely or dispersed populated). -possibility to combine treatment technologies with soft intervention methods (management). performance needs to be expressed not only in terms of the effluent quality but also on its allowed variability, and both must be consistent with the effluent discharge requirements and the possible use of treated wastewater. performance needs also to be considered in terms of its reliability, as it may vary according to the process type. reliability is very important when the effluent is to be reused or treated water is to be discharged into sensitive aquatic environments. performance should be verified in terms of the disinfection needs locally required. consider wastewater characteristic variations in probabilistic terms. consider wastewater variability in terms of climate change impacts and climate variability. for developing countries: -it is important to have a statistically representative wastewater characterization considering parameters not only defined in norms but also those that might interfere with the treatment processes or the future use of treated water. -design data should not be based on bibliography data, especially that coming from other countries. -since segregation and pretreatment of industrial discharge is not common, there are high chances that the wastewater to be treated will contain inhibiting constituents. an evaluation of these is important but not as intensive as the one required for the characterization of the targeted treatment parameters. -consider wastewater quantity and quality possible variation if programmes to reduce water consumption (such as the use of water less toilets) are to be implemented. achievable performance needs to be expressed in statistical terms and in short and long terms, taking into account water flow and wastewater quality variations. for developing countries: -unusual situations and emergencies are common. selecting robust albeit more expensive processes might be cheaper long term, both economically as well as in terms of the negative effects that malfunctioning can produce. reactor sizing is based on the governing reaction and kinetic coefficients. if kinetic data are not available, process loading criteria are used, but not always with good results, even in developed countries. -most of the available information used in the design of biological process comes from the developed world, where wastewater and climatic conditions, among others, are different, and so bibliographic kinetic data and load criteria use should be avoided as much as possible. -for coagulation-flocculation process doses and mixing conditions determine at laboratory conditions are essential to minimize cost and sludge production. -for disinfection processes conditions need to be determined or checked up using laboratory data -if experimental data are not available, the adjustment of published data to local conditions, such as pressure and temperature, should always be checked in bids. the process should be matched to the expected ranges of flow rates. moreover, whenever possible, considering the presence of stormwater, notably considering impacts of climate change. for developing countries: -for those located in regions with high pluvial precipitation concentrated in short periods of time, treatment processes must be able to deal with flow and major variations in quality. -alternatively, the use of flow equalization tanks and their cost should be considered. -processes that can be operated as modules than can be easy to start should be preferred to match variable influents in terms of quantity and quality. the types and amounts of solid, liquid, and gaseous residuals produced must be estimated. use pilot plant studies to identify and quantify residuals. continued for developing countries: -by-products and wastewater treatment residues are often disregarded in proposals in order to offer a lower operating cost. to avoid this, it is important to clearly state in bids that any residues must be quantified and the management options considered within costs. design, operation, and maintenance must have the same degree of investment and complexity of its management as that of the wastewater treatment. for developing countries: revalorization of sludge as biosolids (treated sludge) for soil fertilization, erosion control, or land remediation are to be considered as a priority. for urban areas, use of biosolids to cover landfill cells can be an interesting disposal option. temperature affects the reaction rate of most chemicals and biological processes; therefore, local water temperature should be taken into account when selecting a processes. for developing countries: -in most developing countries temperature is relatively high, so problems arise due to high temperatures not low ones. high temperature may accelerate odor generation and also limit solubilization of gases such as oxygen. in densely populated urban areas, temperatures may rise even more than expected due to the 'heat islands' phenomena. environmental factors, such as prevailing winds, may restrict or affect the use of certain processes, especially where odors are produced near residential areas. a wastewater treatment plant may have negative impact on the environment if not properly designed. the disposal site restrictions of the treated wastewater need to be considered regardless of the norms to be met. water reuse can be a way of making wastewater treatment more attractive in economic terms. for countries located in water-stressed areas, besides being ecologically sound to reintegrate water to the environment as disposal option, reuse serves to alleviate water scarcity. for developing countries -land degradation is costing - % of their agricultural production (young, ) and fertilizers have often a prohibitive cost for farmers; in both cases, biosolids can be used to remedy these problems. wastewater treatment plants are often accompanied by ancillary (complementary) processes that do not necessarily directly relate to the wastewater treatment process, such as power plants, special storing facilities for reagents, etc. it is important therefore to know, before selecting a process, what are those needs, their cost and viability to obtain them from the local market. the type and amount of chemicals to be used need to be considered as well as their cost and market availability, both now and in the future. if chemicals are added during the treatment of wastewater or sludge and these are to be reused, their selection needs to be compatible. for developing countries: -although the use of chemicals is often prohibited, an economic comparison is worth making, especially if chemicals are locally available. the present and future cost of the energy used is something to consider. in selecting and designing wastewater treatment plants, the location, efficient use of energy, and the possibility of recovering/producing energy for in-plant use must form part of the selection criteria that in the long term will contribute to properly closing the urban water cycle. the energy foot print of the wastewater and sludge treatment plant should be minimized to contribute to the reduction of ghg (greenhouse gases). the amount of people as well as their skill levels need to be well defined. for developing countries -the most common situation is a high availability of low-skilled personnel working for low salaries. thus, selected processes may have a high labor demand but cannot be very sophisticated. alternatively, intense training programs should be considered; nevertheless, high indexes of personal rotation are frequently experienced in developing countries when personnel are trained. define operational needs under routine and emergency conditions. define the type and need for repairs. it is important that the items selected be compatible for efficient operation. for developing countries: -it should be considered that cheap or obsolete equipment may become costly if frequent repair is needed. -equipment and spare parts must be available within an appropriate period of time. obsolete equipment is very difficult to repair. main source of income and the main mean to feed a growing population. third, the increasing demand for water by municipalities and industries is increasing the competition for its use with farmers. it is estimated that, in developing countries, water withdrawals will increase more ( %) than in developed ones (undp, ) . among the uses demanding water, sanitation needs to be considered and, in that respect, water reuse may be a component in some areas to promote it through the alleviation of water demand, saving water for sanitation facilities or through coupling projects to treat wastewater with reclamation ones. two types of water reuse can be distinguished: nonintentional and intentional or planned. as, in several developing countries, lack of sanitation is generating nonintentional reuse, national policy will need to encourage controlled options -normally, few items are produced or available locally, therefore overall equipment selection needs to consider compatibility between different equipment traders. many treatment plants will need to adapt to future conditions and not all systems have the same capability to be adapted. cost evaluation must consider initial capital cost and long-term operating and maintenance costs. the plant with lowest initial capital investment may not be the most effective with respect to operating and maintenance costs. the nature of the available funding will affect the choice of the process. it is important to consider the size of the selected treatment process with respect to available land, including buffering zones for future expansions. for developing countries: -there is not always land or cheap land available, as frequently believed. -considering the fast growth of cities in the developing world and the possibility of building plants in modules, it is very useful to consider buffering zones to increase treatment capacity, complete the treatment process or even to avoid building human settlements near to the facilities. communities reject systems producing foul odors or vector breeding. communities also tend to more readily accept natural process that are integrated with the landscape. low-income communities accept better technologies that are a source of jobs for local people than rich ones. eutrophication is a process in which plants (such as water lilies or hyacinths (eichornia crassipes), hydrilla (hydrilla verticillata), cattail -(thypa sp.), and duckweed (lemna sp.)) proliferate in surface water bodies due to the presence of high concentrations of phosphorus and/or nitrogen that may come from wastewater, treated effluents, or agricultural runoff. it is commonly observed in polluted lakes or dams, but problems in low flow rivers and agricultural canals have also been observed. aquatic plants cover the water surface preventing sunlight and oxygen from entering the water. other negative effects that are provoked are ( ) oxygen depletion in the hypolimnion; ( ) release of fe, mn, nh , and heavy metals from the sediments; ( ) vector breeding, such as schistosomas and mosquitoes; ( ) loss of biodiversity, especially in higher trophic levels; ( ) displacement of native species, ( ) obstruction of hydroelectric plants and irrigation canals and drains; and ( ) restrictions on tourist, recreational, and fishing activities. to reduce aquatic weed density (plants m À ), five methods are available: * biological control. it consists of using living organisms to control weeds. in theory, it is a cheap option as no equipment or chemicals are required but it has an associated labor cost in order to perform maintenance. to be completely effective, the rate of grazing needs to be higher than the plant growth rate, which is very difficult to match in practice. a wide variety of fish, arthropod, fungi, and bacteria have been used for this purpose. * mechanical control. these methods remove or cut weeds into pieces using mechanically or manually operated equipment. it is an expensive option that can play a role in quickly reducing the extent of infested areas prior to the application of another control method. * chemical control. pesticides are also used to control weeds. some substances that have been used are terbutryn, diquat, , -d, glyphosphate, paraquat, and simazine. however, due to their toxicity, they can only be applied under controlled conditions and for a limited period of time. * water level control. in this method, the water level is decreased so the weeds located close to the edges of the water body dry out. the applicability of this method is limited to dams where water levels can be controlled, and to the dry season in which rain would not convey plants once again to the water. * nutrient control. weed growth is caused by high n or p content in water, and so, lowering their concentration through wastewater treatment is another alternative. unfortunately, the cost remains high. due to their low efficiency or cost implications, in practice, two or more methods are often used to control weeds. instead of promoting practices to start up water reuse. this is the biggest difference with developed countries, where reuse is being promoted once wastewater is treated. in literature, water reuse is considered merely as an activity where wastewater is intentionally treated to be used once again. therefore, water reuse is understood as an artificial man-made practice. however, unintentional reuse also exists as part of the natural hydrological cycle, but this is frequently not acknowledged. (jiménez, a) . 'nonintentional', 'nonplanned' or 'incidental' water reuse describe situations where used water is mixed with (or becomes part of) the water supply. in most cases, this unplanned reuse is difficult to identify, although it would be important to acknowledge it in order to properly control it. the nonplanned use of water is at the origin of the presence of emerging chemical pollutants in water sources and the reason why drinking water standards are becoming increasingly comprehensive and stringent and more sophisticated technologies to treat water are needed (jiménez, b) . nonplanned reuse of wastewater is happening for agricultural irrigation, aquifer recharge, and human consumption. . nonplanned reuse for agriculture. three-quarters of the total irrigated area worldwide is located in developing countries, and, as a consequence, there is a high dependence on water for food production. frequently, due to lack of sanitation in these countries, wastewater is used to irrigate land. this is a practice that happens almost naturally because of the combination of the high demand for water for irrigation ( % of total use compared to only % in developed countries, figure ), the availability of wastewater, the productivity boost that the added nutrients and organic matter provide, and the possibility to sow crops all year round (jiménez, ) . it is estimated that at least million hectares in countries (around % of irrigated land) are irrigated with raw or partially treated wastewater (who, ) . approximately one-tenth of the world's population consumes crops irrigated with wastewater, diluted or not. as an example, in hanoi, vietnam, wastewater is used in the production of % of the vegetables consumed locally (ensink et al., ) . the use of nontreated wastewater is also common for urban agriculture, which is practiced in urban and periurban areas of arid or wet countries where there is local demand for fresh food products, and people live on the verge of poverty with no job opportunities (jiménez, b) . for urban agriculture, wastewater flowing in open channels is used to irrigate very small urban plots of land where trees, fodder, or any other product that can be introduced to the market in small quantities (flowers and vegetables) or be used as part of the family diet are grown (ensink et al., ) . in terms of volume, reuse of nontreated wastewater is at least times higher than of treated wastewater (jiménez, ; jiménez and asano, ) . as a consequence, any sanitation project in localities using wastewater should consider its actual use. . unintentional reuse for water recharge. since groundwater is not water that can be observed as in lakes or dams, very often its pollution and nonintentional recharge is not perceived. infiltration may result from agricultural irrigation, leakages from wastewater and water urban networks, unlined dams, tanks or reservoirs, and on-site sanitation systems. little information on the extent of this problem is reported in literature, but some cases (a summary is presented in table ) have been described highlighting the importance of this phenomenon as a source of water supply. for the one referring to the tula valley, it has been the best documented (jiménez, b ) that recharge with wastewater amounts to at least m s À , and the aquifer is used to supply people. infiltration and pollution of groundwater supplies varies from negligible to severe, and the recognition of unplanned reuse is needed in order to advance understanding of how to manage the risks. this may involve continuing groundwater recharge with water of improved quality and/or separating the recharge areas further from points of water abstraction. appropriate monitoring information will allow the most cost-effective investments to be identified (dillon and jiménez, ) . . nonintentional reuse for human consumption. nonintentional reuse for human consumption occurs as described previously, not only through aquifer recharge but also through surface water sources when effluents, treated or nontreated, are discharged into them. this has been documented in developed countries. for instance, in the river thames in england, during dry periods, % of the water used as supply downstream comes from treated effluent. in california's santa ana river, a large part of the supply consists of treated wastewater (gray and sedlak, ) and in berlin, - % of the city's water supply comes from an advanced treated effluent that is discharged to a nearby water supply (jekel and gruenheid, ) . the increasing evidence of the presence of emerging contaminants in water sources is an indication of the nonintentional reuse of water. information on this subject for developing countries is very poor, and possibly only reported as pollution cases. recognizing the nonintentional reuse of water for human consumption will help society to acknowledge that water reuse is unavoidable in the future and also to understand that, to properly reintegrate used water to the environment is needed. for this, tools other than wastewater treatment plants will be needed. according to asano ( ) , wastewater reclamation involves the treatment or processing of wastewater to make it reusable; and wastewater reuse or water reuse is the beneficial use of treated water. planned reuse may be performed for agricultural irrigation, industrial purposes, environment restoration, and municipal uses. . reintegrating water for irrigation. most of the world's poorest people, million to billion rural people, live in arid areas and depend directly on natural resources, including water, for their livelihoods (dobie, ) . in such a context, safe wastewater reuse can be a sanitation option that could also be coupled with food security and economic development goals. under prevailing land and water management practices, a balanced diet represents a depleting water use of m inhab À yr À , which is times more than the l inhab À d À required for basic household water needs (siwi-imwi, ) . for several middle-and low-income countries, agriculture is currently, and will continue to be, a key sector representing % of export earnings. limited and unreliable access to water is a determining factor in agricultural productivity in many regions, a problem rooted in rainfall variability that is likely to increase with climate change (lenghton et al., ) . to feed this sector, water reuse can be one option. planned reuse of water for agricultural irrigation in developing countries is a convenient strategy for many reasons (jiménez and garduñ o, ; jiménez, jiménez, , a who, ; keraita et al., ) , such as • it is an easy option to increase controlled reuse when nontreated wastewater is already in use as it allows more profitable and safe products. • it can be a low-cost option to manage wastewater and to reintegrate water into the environment. • it allows the reclamation of nutrients (n and p, to increase soil fertility) and organic matter (to improve soil characteristics) at no cost. • particularly in (but not limited to) arid and semi-arid areas, it permits higher crop yields, as it allows crops to be sown year-round due to higher water availability. • due to the availability and reliability of water, crops with better profitability can be selected. • it avoids discharging pollutants to surface water bodies (which have a considerably lower treatment capability than soils). • it is possible to recharge certain type of aquifers through infiltration. • it can be part of a strategy to secure food and increase poor people's income in water-scarce areas. to obtain all the advantages from reusing wastewater for agriculture in planned projects, it is important ( ) to control possible negative effects (jiménez, ; who, ) such as those related to health; ( ) to keep in mind that in many cases nontreated wastewater is being reused at low or even no cost by poor farmers and, hence, they will be unable to afford reuse costs; and ( ) from the legal aspect, the historical use of nontreated wastewater by farmers confers riparian rights. . reintegrating water for industrial reuse. industrial reuse (reclamation of wastewater from a different use, i.e., reuse of a municipal effluent for industrial cooling) differs from municipal and agriculture reuse as it involves the private sector that has its own rules and well-defined needs driven by economic factors (jiménez and asano, ) . before reusing water, industries always prefer to implement watersaving projects as these immediately reflect on their budgets; for reusing water, investments to provide proper treatment and monitoring programs are needed. to promote industrial reuse, the best government strategy is to provide incentives rather than setting compulsory regulations (jiménez and asano, ) . among the different industrial reuse options, cooling is the most popular due to its high water demand, and the possibility of using secondary-treated municipal effluents, sometimes coupled with filtration or softening processes. as a consequence, power plants located near urban areas are potential sites of industrial water reuse. . reintegrating water to the environment. more than . billion people live in river basins where the intense use of water threatens freshwater ecosystems (smakhtin et al., ) . reintegrating water to the environment is a practice that is gaining momentum, as it is being recognized that ( ) the environment needs water and ( ) the environment has the same entitlement to water as other uses. unfortunately, these two aspects are better recognized by developed countries than developing ones. overuse of water tends to occur in regions heavily dependent on irrigated agriculture or where there is rapid growth of densely populated areas (undp, ) , two characteristics common in developing countries. among the more prominent examples (undp, ) of water overuse, the exploitation of the yellow river basin, in northern china, can be cited: human withdrawal currently leaves less than % of the flow remaining in the river. the river ran dry km inland for a record days in . the drying up of the river caused a drop in agricultural production averaging . - . million tons a year, with losses estimated at us$ . billion for . the purified effluent from sewage treatment plants can be used for the augmentation of river flows, to raise the level of wetlands or lakes, to recover dried lakes, or even to create new lakes or wetlands. in doing so, biodiversity may recover. care must be taken when restoring water into water bodies to preserve or improve the actual quality of water. used water reclamation can be combined with rainwater reclamation. water reuse with environmental restoration can be coupled with projects of urban image improvement or programs to provide better facilities at recreational areas. . restoring water to aquifers. aquifer recharge is not, itself, a use of reclaimed water but is often part of the pathway to reuse. it is a convenient way to reintegrate water into the environment but can be used only under certain circumstances related, in particular, to the type of soil and groundwater. aquifer recharge can be performed to recover groundwater levels, to control saline intrusion, to augment drinking water sources, to protect and, in some cases, to improve underground water quality, to protect surface water bodies from contamination by effluents, to increase water availability for any use, and simply to store water for the future (dillon and jiménez, ; corrleje et al., ) . intentional recharge with reclaimed water can play a role in providing balanced storage and supplemental treatment for water (bouwer, ; dillon and toze, ) . it also provides low-cost storage that occupies a minimum of valuable urban land, while stored water is protected from pollution and evaporation. there are two methods to recharge aquifers. the first is known as land-spread infiltration where treated wastewater infiltrates through soil by gravity. this option has relatively low operating and maintenance costs. the second method for recharge is direct well injection. in this option, wells are used to convey a highly treated effluent directly to aquifers. regulation to recharge aquifers are very different from one country to another; some are set at a national level while others are defined using a case-by-case approach (jiménez, ) . most of the projects to recharge aquifers are found in developed countries. in developing ones, some examples are found in atlantis, south africa (for drinking and agricultural purposes, using pond infiltration), in windhoek, namibia (for drinking purposes and using injection wells), in new delhi, india (for irrigation using infiltration ponds for treated urban wastewater and stormwater), in beijing, china (for drinking purposes using wells and recharge basins), and in mexico city, mexico (for drinking purposes on a limited scale and using infiltration ponds; dillon and jiménez, ) . in all these cases, wastewater is treated to at least at a secondary level (see section titled 'relevant websites'). . reintegrating water for municipal use. in years, % of the world's population will be living in cities (un, ) . this being the case, more water will be needed for municipal use and, at the same time, more municipal wastewater will be produced. this situation, therefore, represents an opportunity to increase municipal wastewater reuse. water reuse in cities represents an opportunity to conveniently treat wastewater, with environmental and even economic advantages. opportunities to reuse wastewater in cities are classified into two groups: ( ) those demanding relatively low-quality water and involving low health risks, and ( ) those demanding high-quality water where health risks are high. in the first group, there are several types of uses, such as: (a) the filling of recreational lakes or the operation of fountains; (b) car, truck, or street washing; and (c) green area irrigation. options demanding high water quality include reuse for drinking supply. around the world, there are successful examples of both types of reuse, low risk options being the most common. water reuse for human consumption, although less common, is no less important. moreover, the only two examples of the reuse of water for human consumption in the world are notably from two countries from the developing world: namibia and singapore (box ). graywater (i.e., domestic wastewater not containing toilet wastewater) is more accessible for reuse as it is less contaminated than wastewater, notably in terms of (but not limited to) pathogens. typical sources of graywater are bathing, laundry, dishwashing, and food preparation. due to its comparably low and easily degradable contamination, it can be relatively easily treated for reuse. graywater reclamation entails the production of less wastewater to be treated in centralized plants. graywater reuse is performed at the same facilities where it is produced and, as a result, a short storage time is needed ( day retention time). graywater reuse can be performed individually (for a single home) or collectively (several groups of houses or larger buildings). treated graywater may be used for watering plants, kitchen gardens, and for the safe augmentation of ground-or surface water. treatment can be very simple or highly sophisticated, ranging from simple manually operated sand filters to biomembrane reactors, hence, covering the needs for rural areas or buildings located in upmarket areas in megacities. further details on design and operation can be found in correlje and schuetze ( ) . graywater reuse can be as well an important component for basic sanitation, as described in section . . . . as the quantum of wastewater treatment is still low in developing countries, little information is available concerning the actual situation. leblanc et al. ( ) performed a survey in some countries showing that the tendencies are the following: . for middle-income countries. from information coming from middle-income countries, including africa (namibia and south africa), the middle east (iran, jordan and turkey), asia (china and russian federation), and latin america (brazil, colombia and mexico), it is shown that wastewater treatment facilities serve mostly urban areas using preliminary, primary, and, in some cases, secondary processes. for rural or poor periurban areas, basic sanitation facilities are provided. although sludge is produced in these facilities, this is not always managed as part of the sanitation service. the disposal options for the sludge from wastewater treatment plants produced are landfill dumping, dumping into sewers, storage at wastewater treatment plants, land application, and agricultural reclamation. land application and agricultural reclamation are options limited by space problems, while the use of landfills is restricted in densely populated urban areas, where solid wastes compete for space with sludge. as sludge production is still low in the few wastewater treatment plants available, sludge management policies are novel, and are still in a maturation phase. some of these policies offer new approaches different to those used in developed countries (leblanc et al., ) . with regard to fecal sludge, the main constraint for their management is the cost to empty on-site sanitation systems as these are often located in inaccessible areas, are large in number, and are frequently highly dispersed. it is noted that the high cost of latrine emptying is not sustainable, even for large municipalities. extracted fecal sludge is often buried on-site, dumped into landfills or sewers or sent to uncontrolled discharge sites. discharge of sludge and fecal sludge in sewers often lead to surpass the wastewater treatment plants' capacity when available. . for low-income countries. data from different african countries (burkina faso, cameroon, cô te d'ivoire, ethiopia, mali, mozambique, namibia, nigeria, senegal, and south africa) demonstrated a similar situation focused on the need to provide basic sanitation services either in rural or urban areas. few cities have complete sewerage systems and, when available, sewers frequently feed into partially functioning wastewater treatment plants. in these countries, the use of on-site sanitation systems, such as septic tanks, bucket latrines, pit latrines, and dry latrines, produces fecal sludge, which is often 'contaminated' with domestic waste. in dense informal settlements, the challenges to properly handle fecal sludge are significant as besides the technical constraints other factors related to the social, political, and cultural aspects come into play. fecal sludge handling includes the need to provide reliable and low-cost options to emptying the facilities, to provide proper and affordable treatment and transportation, and to have suitable sites for safe disposal. literature exists concerning the alleviation of sludge and fecal sludge disposal and revalorization problems, not all of which is relevant for developing countries. common issues in box reuse of wastewater for human consumption in namibia and singapore windhoek, namibia, has been reusing wastewater for human consumption for more than years (van der merwe et al., ) as result of an original idea in . since its operation, no measurable health risk has been observed and neither have people drinking reused water displayed associated health problems. the reclamation plant has undergone several modifications to improve the technology used. the quality of the water supplied can be consulted every day in the local newspaper. the amount of water reused is around ls À , which is distributed after dilution by a factor of - with first-use water. the monitoring program for the facility represents % of the operating costs, and is performed by the wastewater treatment plant and also by three independent laboratories. the system is operated using a multiple barrier concept that goes beyond the wastewater treatment plant. the astute words ''water should be judged by its quality; not its history'' are attributed to dr. lucas van vuuren (van der merwe et al., ) , one of the pioneers of the windhoek reclamation system. this refers to the fact that fear of reused water should be based on rational aspects. the other example of direct reuse of wastewater for human consumption comes from singapore (funamizu et al., ) and is known as the newater project. it started in and uses a secondary effluent that is further treated with a membrane system (microfiltration (mf) and reverse osmosis (ro)) and uv-light disinfection. the water produced is cleaner than tap water as it fulfills all the requirements set by us-epa and who for drinking purposes. treated water is channeled to a reservoir, from which it is taken as supply after dilution with first-use water. water is distributed through the network for use for domestic and industrial purposes. when the newater project was launched, it operated at a rate of l s À . this will be progressively increased to reach l s À by (b . % and . % of total water consumption, respectively). in both cases, namibia and singapore, before the implementation of the reuse programs, stringent industrial pre-treatment programs and segregation of industrial effluent from the sewer were put in place. properly managing sludge and excreta in developing countries are as follows (leblanc et al., ; jiménez, • conventional sludge and excreta treatment options used in industrialized countries do not necessarily achieve the levels of pathogen inactivation required for its safe reuse. • nutrients, organic matter, and energy are resources available in fecal and wastewater sludge that should be utilized as best as possible. there are examples around the world showing the feasibility and convenience of reclaiming them. • applying properly treated excreta and biosolids to soils in a safe way can contribute to soil fertility and with it to food security; it can also raise income for poor farmers. • proper management of excreta and wastewater sludge can significantly reduce releases to the atmosphere of potent greenhouse gases such as methane and contribute to carbon sequestration in soils. the mdg target stating ''reduce by half the proportion of people without sustainable access to safe drinking water and basic sanitation is considered under goal : ensuring environmental sustainability'' (box ). therefore, sanitation is to be provided in a sustainable framework which, in practice, means to provide a service comprising much more than was expected in the past. to implement it, a proper policy is needed. in order to consistently provide sustainable water services, it is recommended that an integrated water resources management (iwrm) approach is used. this approach is useful to analyze situations such as when • multiple barrier system comprising solutions that go beyond the construction of wastewater treatment plants need to be implemented to protect health and the environment; • sanitation needs to be provided as a tool (sometimes indispensable) to have clean water supplies and to provide a safe water supply (box ); • sanitation is coupled with projects contributing to food security, job opportunities, increases in exportation, soil erosion control, efficient use of water, etc.; • sanitation needs to be provided over a wide area rather than to a single section of it to effectively control negative environmental impacts; • sanitation needs to be part of a three r concept system (reduce, reuse, and recycle); • sanitation is considered as part of a cycle in which wastewater is properly reintegrated to the environment; • sanitation needs to consider the impacts caused by climate change; • projects need to be designed, operated, and/or managed by different institutions, sectors, basin agencies, or even countries; box what does sustainability mean? ''a process that promotes the coordinated development and management of water, land and related resources, in order to maximize the resultant economic and social welfare in an equitable manner without compromising the sustainability of vital ecosystems'', un-water, according to leblanc et al., , elements defining sustainability are * dealing transparently and systemically with risk, uncertainty, and irreversibility; * ensuring appropriate valuation, appreciation, and restoration of nature; * integrating environmental, social, human, and economic goals in policies and activities; * providing equal opportunities and community participation; * conservation of biodiversity and ecological integrity; * ensuring inter-generational equity; * recognizing the global integration of localities; * a commitment to best practice; * avoiding net losses of human or natural capital; * implementing principles for continuous improvement; and * providing good governance. bissau, guinea, in west africa is a city attracting huge numbers of people from the surrounding countryside. most of them have settled in squatter new areas around the old colonial center. during a study performed in the s, it was found that the newly piped water taps ran dry several times per day. as a result, many people returned to the old wells. these were often more contaminated than before because the new pit latrines installed close to the wells polluted the groundwater. groundwater quality was also impacted by solid waste thrown into the pits dug for the production of adobe blocks to build new houses. moreover, the new network of gutters was now efficiently removing most of the clean rainwater that used to recharge the groundwater. the gutters caused an extra problem. on the edge of the settlements, where the gutters ended, storm water peaks caused serious soil erosion. this created problems for a newly developed scheme of vegetable gardens on the urban fringe, and even threatened houses.the original problem -the lack of water in piped water taps -was related to electrical power failures causing water pumps to stop. similar situations can be encountered in many developing countries and they cannot be easily solved as long as their roots are not properly and integrally tackled. • good technical solutions needing proper social, economic, and political policies are to be put in place; and • wastewater, treated or not, is being nonintentionally reused. developed countries, through experience, research, and technological innovations have progressively improved their sanitation services and have developed systems that are what they need. however, as described in this chapter, the problems they have faced and the problems they are now facing, although similar, are not the same as those confronted by developing countries. thus, there is a need for low-income nations to develop their own processes using part of the developed countries' experience. to contribute to this process, a definition of the issues to address and the challenges to face is provided in the following. the issues that need to be addressed are as follows: • low sanitation coverage lagging behind population growth, needing an intense effort in order to be tackled. • need/importance to couple sanitation programs with others addressing problems such as food security, low income, and soil erosion control. in practice, this requires increased efforts of coordination. • lack of sanitation as a component of poverty, and therefore, as a problem that cannot be completely solved if its roots are not properly addressed (box ). • lack of sanitation, particularly in vulnerable groups that, due to their own characteristics, are often more difficult to provide services for. • a growing population, notably in urban areas and, within them, in slums. • higher vulnerability to the negative impacts of economic and climatic change on sanitation needs. • for low-income countries, lack of economic capacity to deal with the cost of covering the sanitation mdg targets and, for middle-income countries, the need to mobilize funding required to put sanitation above other needs. • the proper management of sludge and excreta, two byproducts often not considered as part of sanitation targets of funding programs. the challenges to be encountered are listed below: . the lack of political will and commitment at the highest level (who/unicef, ) is a barrier that is greater than, for instance, the lack of economic resources, the capacity for building, or the acquisition of appropriate technology, since all these may be overcome by a strong political support. in order to develop political will, politicians and society need to appreciate the value of sanitation. an understanding that it is through the provision of water supply and sanitation that industrialized countries build up strong societies with good health and good economic conditions is needed (box ). . the second challenge is to put in place accountability mechanisms to ensure that resources provided to fulfill in cameroon, some houses are equipped with a m-deep hole for a latrine, surrounded by pieces of timber. when the hole is full, it is covered with earth and medicinal or aromatic plants, and another facility is built. if the family has no land to dig another hole (as frequently happens), they call the tanker to empty it at a cost of us$ . sometimes, while the family saves up the money, excreta overflows and pollutes the nearby area where wells and boreholes are located, threatening drinking water quality. when feces are removed by tanker trucks, they are often dumped into rivers or the forest, because there are no treatment facilities. houses in modern residential areas have septic tanks, and their effluents are directed into wells for filtration. often, this does not happen in the correct way because builders have not mastered the technology. some collective residential areas, universities, and hospitals are connected to sewers that convey wastewater to a treatment plant, from where treated water is directed to a river. but still, there are people without access to any of the facilities described above who go into the bush to relieve themselves on the spot. villagers continue to use this practice because they have no choice. box clean meansy yy y healthy? mexico city produces % of mexico's gross domestic product (gpd) (us$ per capita). after the swine flu (h n flu) outbreak in may , a loss of us$ million was experienced solely due to the shutting down of restaurants, and us$ . million were lost due to the closure of public transport for just days. to allow the city to return to normal conditions, health experts advised constant handwashing and the disinfection of school toilets. at this point, politicians realized that public schools had no water at all, had malfunctioning toilets and more had no facilities at all. before the swine flu epidemic, politicians had not understood the link between water, sanitation, and health and had not addressed this problem, although on many occasions parents' associations had requested the services. the president of one parents' association commented on the news that, in contrast to most mexicans, he believed that the swine flu had been a blessing as it was the only way to ensure proper sanitation facilities at schools. the mexico city government invested us$ million on the school program 'clean means healthy'. the mdgs (public and private from donors) will be used wisely and for what they were originally intended for. . the third challenge involves a broader aspect. even if sanitation programs are put in place, if poverty is not properly addressed, most of the solutions provided will be unsustainable. this will possibly lead in the future to adding addressing poverty to the already lengthy list of reasons why sanitation has failed in developing countries (this list already comprises financing, institutions, education, the need for decentralization, and the need for private participation). although there is no recipe for success, strategies that can be considered when developing plans for sanitation include the following (jiménez and garduñ o, ; jiménez, jiménez, , lenghton et al., ; undp, ; who, ; leblanc et al., ; correlje and schuetze, ) : to develop policies: • take time to perform proper planning in order to identify the resources (human and economic) needed to design, build, operate, and maintain facilities, and to develop policies and institutions. do not initiate projects for which this has not been previously defined, otherwise there is a risk of losing any investments made (a case in point is the existence of many facilities installed around the world, which have been subsequently abandoned). • take time to define how much money is needed, supported by experts with no commercial interest, specifically not those from companies that are potential participants in bids. • define needs and priorities using the best available information even if it does not come from the water sector. priorities can be set by using the methodology proposed by lenghton et al. ( ) , which considers actual water service coverage, and mortality due to gastrointestinal diseases and density of settlements, considering urban and rural areas. evaluate risks using quantitative methodologies to properly identify and prioritize problems, and select solutions accordingly (in terms of size, and economic and human resource investments). • as much as possible during the planning stage, involve sectors related to the solutions other than the water sector (e.g., the federal, regional, and local governments, ministers of the environment, urbanism, agriculture, land use, transport, economic development, social development, finance, etc.). • couple sanitation programs with programs related to food security, soil remediation, and economic development. • produce efficient, affordable, and enforceable norms and set goals for them that are easy to understand. • promote innovation at all levels (institutional -box -, financial, regulatory, and technological). • combine different intervention methods to control problems; consider not only of sewers, latrines, and wastewater treatment plants. • consider water reuse and the safe reintegration of sludge and fecal excreta as an important part of the overall sanitation program. • promote the management of the environment in an integrated way, even considering climate change effects. • design monitoring programs that wisely use resources by including information that will be used. use the new information obtained to evaluate and improve the program. • review the program to ensure it covers the specific targeted population sectors (women, the poor, rural areas, etc.) and meet the defined goals. for funding: • be creative in finding solutions to funding needs; • extend financial support to the poorest households to ensure that sanitation is an affordable option; • discern whether there is an absolute lack of resources for expanding water supply and sanitation coverage, or if there is a need to redistribute potentially sufficient existing resources; and • develop and put into practice transparent mechanisms to easily and rapidly transfer monetary resources from central to local institutions. for institutional design: • develop national and local political institutions that reflect the importance of sanitation in terms of social and economic progress. • promote institutions throughout government that use or at least understand concepts of integrated management, not only for water. • develop institutions where innovation and solidarity are considered as a virtue. water and sanitation service agencies are typically modeled after utilities in industrial countries, and as such are organized around the goals of maximizing operational efficiency for public sanitation components (trunk sewers and treatment plants) rather than providing services to poor people, slums, disadvantaged groups, etc. as result, in, in developing countries, experience and institutional structures to provide the type of services needed is deficient. as a result, services are being provided by other means. data from india indicate that as much as % of rural households across the country invest their own money and use small private providers to construct latrines. self-provision accounts for about million privately installed septic tanks in manila and in jakarta. research in africa confirms that the role of the small-scale private sector in sanitation provision is significant. these findings are further supported by data from the jmp (who-unicef joint monitoring programme): between and , the increase in the number of people served by sanitation reported by the jmp was much larger than the expected impacts of the public investment that occurred during this period. the reorientation of public programs to either modify their structures or to promote and assist the provision of sanitation services by small private and even familiar companies is needed. this does not currently occur in developed countries. • consider the need to have as part of the institutions welltrained and highly professional personnel. • identify which problems should be addressed by using norms (compulsory), criteria (recommendations), or other type of tools (such as incentives and education). • set appropriate and affordable sanitation risk-based standards, designed to contribute to solving local problems that can be reviewed over time to integrate experience. these should be able to be adapted to new and better conditions in order to move progressively to an ideal situation. • allow the development of norms that are adapted to local needs and capabilities (table ) . sanitation systems are often adopted from other developed countries without sufficient adaptation and users tend to put in place an idealized solution in which a uniformly high level of service is provided and the technology to be used is already set. • set up regulations that combine different intervention methods to control risks that are not based only on wastewater treatment plants. • keep in mind that parameters selected are to be enforced and they will demand economic and human resources for. • review the whole legal framework related to the standard so they can fit in and be implementable. • set up standards using a participatory approach, which includes stakeholders and expert participation, notably coming from local universities. • where noncontrolled reuse is already in place, regulations need to maintain the benefits already obtained while progressively controlling drawbacks; this can be done by promoting controlled reuse rather than adopting vanishing current practices. • incorporate reuse as part of the sanitation standards. to set up programs: • perform a national inventory of the actual needs and solutions to be implemented to manage wastewater, excreta, and sludge, include a survey on water reuse possibilities to couple them with sanitation solutions when feasible. • implement policies by promoting incentives rather than imposing rules and fines; but when rules are to be observed, be firm on decisions, and inform society in order for it to be perceived that jeopardizing the health of others is important. • as there is no universal solution, support a wide range of sanitation technologies and service levels that are technically, socially, environmentally, and financially appropriate. • promote innovation to have both technically and economically feasible technologies to deal with local pollutants, notably for the high and varied pathogen content. • implement pilot plant programs to test policies and use the information obtained to retrofit your program before scaling it up (box ; spaliviero and carimo, ). • empower local authorities and communities with the authority, resources, and professional capacity required. • in order to fund the maintenance and expansion of services, local governments and utilities should ensure that users who can pay, do so. • carry out training programs addressing all stakeholders needs, from plumbers to politicians. some aspects to consider when setting regulations definition of fixed treatment option(s) to use and inclusion of predefined treatment design and operating criteria. -reduces the need for monitoring and surveillance. -limits innovation -renders project implementation easier. -encourages bias in regulators who will be responsible for both selecting the method of control and meeting objectives. -may lead to nonviable schemes from an economic point of view. selection and use of the best indicators as parameters. reduces monitoring and surveillance cost. -introduces the idea that indicators are the best and ideal parameters to define pollution. -most of the current best indicators have been proven effective for developed countries but have not been tested for all conditions in developing countries. -may give a false impression of safety. selection of normal monitoring parameters and establishment of limits for each one. -facilitates surveillance. -cannot be universal or static over time. -increases supervision costs. use of epidemiological local data. -introduce protection for local problems. -information not always available for all of the diseases currently present. use of toxicological tests. -data available internationally. -often render norms too stringent. -helps to establish cause-effect relationship. -for diseases originating from microbial pollution do not correspond to local conditions when diseases are endemic. use of risk evaluation models. -help governments to make rational decisions. -difficult to explain their meaning to the population. • implement programs to segregate and/or pre-treat industrial discharges to sewers to render municipal wastewater treatment more affordable and to avoid the presence of noxious compounds in treated wastewater and sludge that will limit their revalorization options. • as wastewater, sludge, and excreta management regulation compliance often depend on the work of different ministries, coordinate the work of such institutions taking care that the objectives of each are compatible. • develop public indicators to follow up progress globally and also consider the implementation of indicators to follow specific targets such as wastewater treatment coverage, safe reintegration of treated water to the environment, and sludge and fecal excreta management. attention should also be provided to deprived sectors (women, poor people, slums, dispersed rural areas, etc.) • seek to validate your indicators by a third independent party such as a university or a non-governmental organization (ngo). • verify that the same information is provided international, nationally, and locally. to raise support for the program: • make it understandable to all that lack of sanitation means a barrier for economic development is an unsustainable way to manage the environment, is at the origin of local pollution problems, contributes to water scarcity as it reduces water availability, and increases vulnerability and reduces the capacity to adapt to climate change. all of these issues have broad support among society and different groups, not all of which are concerned by sanitation for the poor. • build community-level initiatives through government interventions aimed at scaling up best practice. • create awareness of the nonplanned reuse of wastewater and the importance of investing in it as an option to make clean water accessible for any use. figure shows the investments made for water supply and sanitation from to ; it can be observed that, in the past, most efforts were orientated to water supply and cities, leaving sanitation (only about one-fourth of investments made for water supply) and rural areas far behind. figure shows the origin of investments. in the case of asia and latin-america, almost all the finances have come from governments, while, for africa, it represented nearly a half. from the previous analysis, it is evident that there is need to invest money to catch up with the level of services needed. before calling for funding, it is convenient to analyze (preferably only within each country, without the input of donors or enterprises) what the money should be used for. to sustainably increase sanitation coverage, economic resources are needed not only to build sanitation infrastructure, but also for planning according to local needs and possibilities, developing research and technology, and developing institutional capacity in a local context. unfortunately, most of the time, funding is provided only for some of these activities (mostly for infrastructure); one major reason being that, often, this is the only type of funding that is sought. there are two funding options: public or private, each of which has different modalities. for public funding, the money comes from federal or local governments either directly from tax revenues or user charges, or, indirectly through crosssubsidies from users who can afford to pay, private-sector investment, or international and national loans. private sector box development of a stepwise program in mozambique (with information from spaliviero m and carimo d ( ) mozambique. in: leblanc rj, matthews p, and richard rp (eds.) global atlas of excreta, wastewater sludge, and biosolids management: moving forward the sustainable and welcome uses of a global resource: unhsp, pp. - . vienna: un.) following mozambique' s independence in , the government identified sanitation as one of the key components to improve health conditions. as such, in , the ministry of health launched an intensive national campaign for the self-help construction of latrines. many thousands of latrines were constructed during a relatively short period. however, there were numerous problems, including insufficient awareness about environmental conditions, a lack of technical guidance in latrine design and construction, and shortages of critical building materials. consequently, many of the latrines became structurally unsafe and unusable. in response, a research project was initiated in to ''identify and develop a suitable technology and method for large-scale implementation of improved sanitation in periurban areas.'' the result was the development and successful pilot testing of an appropriate and cost-effective technology. from to , around improved latrines were produced. in addition, an awareness campaign was carried out on the use of the latrine, hygiene promotion, and capacity building. in , the program was extended to the rural areas. prior to , more than latrines were constructed and installed. in december , the program was formally transferred to the national directorate of water affairs. overall, it has been a long and steady scaling-up process over more than years that ended by ensuring a progressive withdrawal of the government from latrine production. the emphasis now is given to decentralization and privatization for the services, although the responsibility for the program remains with the government. from this experience, some lessons learned, are * although technology must be simple, it is important for massive use to ensure its local production and commercialization. there must be several types of sanitation facilities with different prices in order to commercialize. * a good network needs to be established between users (periurban communities, the government, nongovernmental organizations (ngos), small private companies, and donors) to ensure that the program progressively developed its own dynamism. * latrines need to be emptied and the service needs to be provided. investments and national and international loans are to be paid from taxes, the difference is only that payments differ in time and are used simply because it is very difficult to finance sanitation projects directly from users. as a result, people who pay for the services are not always the same who will be using them. private aid is made available by private enterprises or ngos. private funding is used simply because developing countries have greater needs than economic resources. the participation of private enterprise cannot be taken for granted as there are several factors that actually inhibit their participation. these include low accessibility to loans from towns and municipalities, the need to organize projects that have payback periods of years, and the need to recover costs through water tariffs (lenghton et al., ) . private funding includes not only international or national firms, but also self-provision schemes provided by nonconventional private enterprise. these nonconventional private enterprises have been called by some 'informal' although for several developing countries, they have in many cases proven to be more formal, useful, and to provide more reliable services than formal ones. for example, in india, an ngo named sulabh has installed pour-flush toilets that are operated on a fee-paying basis and are maintained by attendants who live at the facilities. through providing good reliable service, sulabh's facilities have become a model for sustainable public sanitation services. this shows that there is growing knowledge and capacity provided by small and even family-run companies that are capable of producing significant and innovative improvements in access to sanitation. financing strategies are specific for each country and situation and depend on the political will, the compatibility with existing institutional arrangements, the degree of community involvement in decision making, the available economic and financial resources, and the prevailing social and cultural preferences, among other aspects. when either private or public funding is used, some key elements to make a good use of it according to lenghton et al. ( ) are • maximum scalability. the selected financing strategy needs to be one that can be scaled up quickly and in a straightforward manner to allow for rapid increases in the population served. • minimal transaction costs. • full financial accountability. • closed revenue cycle, that is, financially viable in the sense that all capital and operating costs are fully covered -either through user fees, government subsidies, or external finance. sanitation is of public interest (box ) and hence is a public process. in order to implement what needs to be provided is, for the governments, to identify the main requirements, the areas of responsibility, the risks associated, who is responsible for what, the different options to address needs, and the associated costs. once this is performed, it is required to review, set up or adapt the legal and institutional framework, and to educate all the persons involved (from society to politicians, experts, regulators, private companies and functionaries, besides children and women). sanitation management (basic sanitation facilities management, wastewater collection, treatment and reintegration, by-product management, and risk control) requires the coordination of different public institutions, society, academia, private enterprises, and in some cases, even different countries. therefore, the government is needed to set up the programs. today, around the world, it is still mostly government agencies that construct and operate wastewater collection and treatment systems. however, private companies are contracted to conduct operations in many places, and all countries have significant commercial enterprises built around collecting excreta and septage and managing wastewater sludge and biosolids, mostly in cities. theoretically, private companies, if well used by the government, could be useful to increase sanitation coverage if the level of society is raised and private companies are not used to increase the already-considerable differences existing between economic social classes. nevertheless, private participation is not increasing in sanitation. after steadily increasing at a global level between and , it began to decrease (lenghton et al., ) . there are many reasons for this, one of which is that it is not easy to build up successful schemes combining private and public interests. box how industrialized governments approached funding for sanitation (with information from lenghton l, wright a, and davis k (eds.) ( ) health, dignity and development: what will it take? millennium development goals. london: earthscan.) in general, in developed countries, public water infrastructure components have been highly subsidized by governments, reflecting an understanding that the public health benefits of sanitation generate substantial positive external gains that merit public investment. in britain, for example, urban authorities borrowed more than d . million for sewerage work during the period - . eventually, the public provision of sanitation became an uncontroversial and indeed, an expected part of life. similarly, for many municipalities in the united states, public financing of sanitation infrastructure was seen as the only option for ensuring investment adequate to protect public health. in the nineteenth century, boston, for example, had lower-than-expected connection rates among households to the city's new water and sewer network; this prompted the city to cover the cost of service pipes for all unconnected households. in , an influential state sanitary survey concluded that governments must accept responsibility for financing public sanitation infrastructure because, left to their own devices, a large proportion of massachusetts residents would be unable or unwilling to take on personal responsibility to conduct their lives in accord with recommended sanitary principles. until recently, grants of up to % or more were provided for innovative sanitation technologies in the united states. one aspect to keep in mind concerning public and private participation is that for the sanitation field, these funding options combine better with certain type of sanitation systems, characterized in terms of their size and used technology (table ) . low-income countries need to invest - % of their gdp to fulfill their mdgs (lenghton et al., ) . for some, these are figures difficult to reach even if the use of loans is considered. for them, external donors can play an important role. middleincome countries have fewer needs and more economical capacity to meet their mdgs. for some, it is estimated that they could use up to % of their gdp, and hence it is considered that no external finance is needed (lenghton et al., ) . moreover, this situation, from the point of view of some authors, offers to inform the private sector of great opportunities to conduct a business and, as a result, in several middle-income countries private funding is being promoted. one possible risk, which needs to be considered by local government and known by society in general, is that through private participation and international loans, technology and sanitation schemes from other countries are promoted, which do not always effectively solve local problems in the cheapest and most efficient way. another risk is the use of the money for additional purposes. to deal with this, it is important, on the one hand, for the government to be accountable and, on the other hand, for society to demand transparency. in any case, it is certain that developing countries need to be creative to raise funds for sanitation. one option is to raise them as part of other projects in which sanitation can be a component; these include those considering goals for food security, health, land remediation, environmental problems control, and adaptation to climate change, for which several donors may be available. as an example, carbon credits could be used to fund projects to manage sludge and fecal sludge. in developed countries, a complex and complete system of public agencies, private companies, equipment vendors, consultants, scientists, engineers, operators, and supporting professional and educational organizations makes sanitation possible. promoting this organizational and human capacity in developing countries is one of the challenges on the path to increasing adequate sanitation, wastewater reuse, and proper fecal sludge and wastewater sludge management. science and innovation are needed in developing countries to reduce their intense dependence on developed countries. unfortunately, in many situations, technology originating in high-income countries is still preferred and implemented. however, this may not match the actual needs or promote local the brazilian sanitation research programme (prosab) is a public program that has received financial support for different projects since . its goal is to develop and optimize existing technologies for water supply, wastewater treatment, and solid residues management. for that, its objectives are * to establish the state of the art of technology; * to adapt or develop technology to provide sanitation services in local and regional conditions, and to meet the different needs of all population sectors, preserving and restoring the environment; * to make technology and knowledge part of the public domain; and * to support participatory processes, creating cooperative research networks to discuss subjects. the total investment for the three phases listed is around us$ million distributed as shown in table , in which investments made for salaries and scholarships are not considered. both, research papers and technological innovation, were produced from this program. economic development. in some other cases, developing countries are even used as laboratory testing grounds for new magic solutions. in low-and middle-income countries, examples can be found where a significant part of the investment made for wastewater treatment plants is used to pay for the intellectual property rights of the processes, as happens with many other activities. in figure , it is shown that royalties received because of patents in developing countries are nonexistent or low while those for developed countries are high; sanitation could be in the future another source of this dependency and inequity. on the top of this, some of these processes do not solve actual problems and, as a result, around the world, several places can be found where new solutions for providing sanitation to poor people have been installed in series unsuccessfully. this situation has two negative effects: first, it discourages donors from making further investments and, second, it makes local people wary of possible solutions. the only way to prudently overcome this is to promote the development of technology by people immersed in local problems. for this purpose, investment in education and local research is important (box and table ). as presented here, the solution to sanitation problems can be combined with the solutions to other problems. the possibility therefore exists to develop new and individual technologies, to adapt the existing ones, and even to rediscover ancient local solutions. in parallel, the same can be done with policies to manage water. at an international level, there is current mobilization to support and improve sanitation conditions in developing countries. this mobilization is being expressed in terms of donors, private participation, and international aid agencies support. from this chapter, it is concluded that there are many reasons explaining why providing sanitation in developing countries is different to the solutions implemented in developed ones; therefore, care must be taken to not to use the aid to implement projects, which may prove not successful. for this reason, it is important to promote that each country defines first its needs and works defining programs. as the challenges to provide sanitation are many and very complex (policy definition, technologies to be used, education and awareness programs implementation, development of adequate institutional capacity, finding new financing options, etc.) it is important for developing countries to share among them their knowledge and experiences in the framework of the so-called south-south cooperation. sanitation is an important pillar to develop wealthy societies (in terms of health and economic capacity) and, for this reason, governments should promote investments in this field that are to be properly and responsible managed. the only way to assure this is to promote, allow, or to demand a participatory approach. finally, the water situation in developing countries has some bright sides. the first consists in the fact that the wide divisions observed in developed countries within the water sector (water supply and wastewater experts) does not exist or is not so pronounced. this allows easier understanding and promotes the integrated management of the problem. the second has to do with the high degree of solidarity existing among the population, which may play an important role in speeding up a sanitation program proven successful and contributing to raising the quality of life. global atlas of excreta, wastewater sludge, and biosolids management: moving forward the sustainable and welcome uses of a global resource: unhsp global atlas of excreta, wastewater sludge, and biosolids management: moving forward the sustainable and welcome uses of a global resource: unhsp wastewater reclamation and reuse the role of wastewater reuse in water resources management senegal water reuse: an international survey of current practice, issues and needs artificial recharge of groundwater: hydrogeology and engineering infiltration percolation as a tertiary treatment tratamento de esgostos sanitarios por processo anaeróbio e disposicao controlad no solo, st edn regional document for the americas prepared for the th world water forum every drop counts: environmentally sound technologies for urban and domestic water use efficiency. division of technology, industry and economics water reuse via aquifer recharge: intentional and unintentional practices water quality improvements during aquifer storage and recovery poverty and the drylands. nairobi: united nations development programme a nationwide assessment of wastewater use in pakistan: an obscure activity or a vitally important one? sanitation and disease: health urban wastewater as groundwater recharge evaluating and managing the risks and benefits water reuse: an international survey of current practice, issues, and needs water safety plans for grey water in tribal schools removal of -b-estradiol and -a-ethinyl estradiol in engineered treatment wetlands safe drinking water: lessons from recent outbreaks in affluent nations conventional small and decentralized wastewater systems in developing countries indirect water reuse for human consumption in germany -the case of berlin state of the art report health risk in aquifer recharge using reclaimed water irrigation in developing countries using wastewater water reuse new paradigm towards integrated water resources management unplanned reuse of wastewater for human consumption: the tula valley coming to terms with nature: water reuse new paradigm towards integrated water resources management encyclopedia of biological, physiological and health sciences wastewater risks in the urban water cycle water reclamation and reuse around the world. in: water reuse: an international survey of current practice using ecosan sludge for crop production navigating rough waters: ethical issues in the water industry. american water works association jiménez b and wang l ( ) sludge treatment and management semi-intensive treatment plants for wastewater reuse in irrigation extent and implications of agricultural reuse of untreated, partly treated and diluted wastewater in developing countries. cab reviews: perspectives in agriculture, veterinary science making urban excreta and wastewater management contribute to cities' economic development: a paradigm shift water policy global atlas of excreta, wastewater sludge, and biosolids management: moving forward the sustainable and welcome uses of a global resource un-habitat dignity and development: what will it take? millennium development goals global atlas of excreta, wastewater sludge, and biosolids management: moving forward the 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water requirements in global-scale water resources assessments. comprehensive assessment of water management in agriculture cryptosporidiosis in developing countries south africa. faecal sludge management global atlas of excreta, wastewater sludge, and biosolids management: moving forward the sustainable and welcome uses of a global resource: unhsp water for people, water for life. the united nations world water development report united nations development programme human development report beyond scarcity: power, poverty and the global water crisis international source book on environmental sound technologies for wastewater and stormwater management the state of the world's cities report / ; the millennium development goals and urban sustainability: years of shaping the habitat agenda united nations/world water assessment programme guidelines for water reuse targeting sanitation water reuse in windhoek, namibia: years and still the only case of direct water reuse for human consumption guidelines of the safe use of wastewater and excreta in agriculture and aquaculture guidelines for drinking-water quality: recommendations guidelines for the safe use of wastewater global water supply and sanitation assessment report, joint monitoring programme for water supply and sanitation meeting the mdg drinking water and sanitation target: a mid-term assessment of progress meeting the mdg drinking water and sanitation target: the urban and rural challenge of the decade progress on drinking water and sanitation: special focus on sanitation. geneva: who and unicef earth trends: environmental information key: cord- -vz rsy authors: wodarz, dominik; komarova, natalia l. title: patterns of the covid epidemic spread around the world: exponential vs power laws date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: vz rsy we have analyzed the covid epidemic data of more than countries (excluding china) in the period between january and march , . we found that some countries (such as the us, the uk, and canada) follow an exponential epidemic growth, while others (like italy and several other european countries) show a power law like growth. at the same time, regardless of the best fitting law, most countries can be shown to follow a trajectory similar to that of italy, but with varying degrees of delay. we found that countries with ``younger" epidemics tend to exhibit more exponential like behavior, while countries that are closer behind italy tend to follow a power law growth. we hypothesize that there is a universal growth pattern of this infection that starts off as exponential and subsequently becomes more power law like. although it cannot be excluded that this growth pattern is a consequence of social distancing measures, an alternative explanation is that it is an intrinsic epidemic growth law, dictated by a spatially distributed community structure, where the growth in individual highly mixed communities is exponential but the longer term, local geographical spread (in the absence of global mixing) results in a power-law. this is supported by computer simulations of a metapopulation model that gives rise to predictions about the growth dynamics that are consistent with correlations found in the epidemiological data. therefore, seeing a deviation from straight exponential growth may not be a consequence of working non-pharmaceutical interventions (except for, perhaps, restricting the air travel). instead, this is a normal course of raging infection spread. on the practical side, this cautions us against overly optimistic interpretations of the countries epidemic development and emphasizes the need to continue improving the compliance with social distancing behavior recommendations. to some extent in younger segments of the population. the overall mortality rate further depends on the prevalence of the infection in the population: once the number of infected individuals has reached sufficiently large sizes, health care systems become overwhelmed and lose the capacity to treat all patients in need [ ] . in particular, the number of respirator units poses an important limitation, which has resulted in difficult triaging policies in some countries, most notably italy and spain. non-pharmaceutical intervention methods, such as social distancing, have become an important tool in the fight against coronavirus spread [ ] . the idea is to slow down the rate at which the virus spreads through human populations, and thus to maintain the number of infected individuals that require treatment below a threshold level, thus avoiding a situation in which hospitals become overwhelmed. hence, wide-spread closures of schools and businesses, and stay-home orders, have been implemented across asia, america, europe, and other affected regions. a number of studies have been performed that investigated the kinetics of coronavirus spread through human populations. the pattern of virus spread was found to be approximately exponential, at least during the early stages of virus spread [ , ] , and importantly, the basic reproductive ratio of the virus has been estimated [ , , , ] . the implementation of social distancing measures are expected to have a significant impact on the virus spread kinetics [ ] , which has been observed in some asian countries, such as china [ ] . while the effect of containment efforts have been very pronounced in these countries, they might be more subtle in other countries across the globe, especially during the initial phase following their implementation. to better assess observed virus spread trajectories following the implementation of social distancing measures, a more detailed understanding of the basic kinetics of virus spread in different countries is required. while the virus spread pattern is often quoted to be exponential [ , ] , power law patterns have been reported in data from china [ ] . in this study, we compare the per capita virus spread kinetics observed for many countries around the globe, in order to obtain a better understanding of similarities and differences. interestingly, we find that as per capita infections grow towards larger numbers, the growth pattern deviates from exponential and is better described by a power law. this can be hypothesized to be due to social distancing measures [ ] , or potentially to the build-up of immunity in the population [ ] . we show, however, that the longer term per capita infection levels over time across a wide array of countries can be remarkably similar, and follow the same power law trajectory as seen in countries that are most strongly affected, such as italy. this indicates that the long-term dynamics of covid spread might be intrinsically governed by a power law, even in the absence of non-pharmaceutical interventions. we interpret these findings with computer simulations of a metapopulation model, which can account for an initial exponential spread phase, followed by a longer-term power law behavior, by assuming that the infection spreads in a well-mixed manner inside local demes, while also spreading spatially across different demes. we relate model predictions to epidemiological correlations found in the data. these insights into the spread kinetics of covid might be useful for assessing the impact of non-pharmaceutical intervention methods in different countries. the data of confirmed covid cases over time have been obtained from the data repository maintained by johns hopkins university center for systems science and engineering (csse) (https://datahub.io/core/covid- #data-cli). as of march , countries were represented in the database, as well as the cases on "diamond princess" (which were not used in the analysis). we only included the total counts for each country, even though information on the different provinces was available for several countries. the number of confirmed cases has been recorded since january , , and has been updated daily. to compare the time course of covid cases across different locations, the per capita incidence was calculated, normalizing the numbers by the total population size of the country. the information on the population size and the area of different countries was taken from wolfram mathematica's database, "countrydata". here, we present the comparison of the kinetics according to which cumulative covid cases grow over time in different countries around the world. figure (a) presents the raw data showing total case counts for a select number of key countries. figure (b) shows the corresponding per million case counts. a complication for comparing the growth dynamics is that the timing of the onset of community spread varies across locations. the growth curve of confirmed cases was therefore shifted in time to make them comparable, according to the following procedure. the cumulative confirmed covid case counts in italy were chosen to be the example against which the growth curves in all other countries were compared, due to italy being a current epicenter of the outbreak. the (normalized, cases per million) infection growth curves of the other locations were shifted in time such that the difference between all data points of the country under consideration and italy was minimized. the shift that minimized this euclidean distance between the curves was assumed to indicate the number of days that the country lags behind italy. some examples of such results are presented in figure . we note that this assumes that all the countries test for covid at comparable levels, which is an over-simplification. if a country tests less than italy, it will lag behind italy to a lesser extent. conversely, if a country tests more than italy, . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . it is predicted to be further behind italy. reliable data on the total number of tests in different countries are currently not available to our knowledge. in this way, we obtained a time course of confirmed covid cases that are temporally synchronized with italy, which allows for a more straightforward comparison of the kinetics. heterogeneity in growth laws across the different countries are observed. while some countries appear to show exponential growth of confirmed covid cases, other countries appear to exhibit growth laws that deviate from exponential. previous work [ ] has suggested that a power law might be a better description of the cumulative covid cases over time in china during the earlier stages of the epidemic (before it was controlled). therefore, we hypothesized that for a subset of the countries that were analyzed, a power law is an appropriate description. to test this hypothesis, we fit both exponential and power law curves to the data for each country and determined the goodness of fit. this data fitting was performed as follows: only the data points were considered where the number of covid cases had risen above a threshold, which we set at case per million people (see appendix for variations of this threshold). we fit both a power function and an exponential function to the data to determine which model fits the data better. for the power law function, a complication arose because fitting requires knowledge of the "zero" point, that is, the moment of time when the growth (according to the power law) began. the fits to the data change if the time scale is changed. hence, we started by assuming the first data point to be the day when the infection frequency first exceeded case per million, and fitted the power law, a x b , for some constants a and figure : the same data as in figure (bottom), presented by shifting individuals lines to match the italy curve. the table shows the lag, that is, by how many days each country is behind italy. b . then we shifted the time series incrementally by one day, and for each shift the power law was fitted. for each fitting frame, a different value of the power law exponent, b , was obtained. subsequently, we fit an exponential function to the same data (a e b x ). the estimated exponent does not depend on the time shift, so fitting the exponential function was straightforward and yields a unique value b for all the fitting frames. for both the exponential and the power law fits, we determined the sum squared error between observed and expected, and compared them. for more details of the fitting procedure, see appendix a. figure shows the fitting errors calculated for countries; we included a country if the number of cases reached per million, and excluded china and south korea, since their epidemics clearly deviate from an exponential or a power law. the yellow horizontal lines represent the exponential fitting and the blue lines the power law fitting. we observe that there are several different configurations that are repeatedly encountered. • for some countries (like the us, see also figure (a)), the power fitting error is always above the exponential fitting error. such countries are clearly showing an exponential epidemic growth. • there is another group of countries (such as italy, see also figure (b)), where the power law fitting error is always below the exponential error; here we clearly have a power law growth. • there are some other countries that we can classify as power law-like and exponential- . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . like. suppose a power law error curve crosses the exponential error line (see greece, figure (c)), at a given frame shift. in this case, we will classify the growth as power law-like if the value of the exponent b that corresponds to this frame shift satisfies b < . otherwise, we will classify the growth law as exponential-like. for the examples mentioned here, figure shows the best fits obtained by this method. for (b) and (c) it is clear that the power law provides more satisfactory fits. more details are provided in appendix. since in smaller countries (such as for example luxembourg) the laws may be harder to determine and the data are subject to a higher degree of noise, for classification purposes we restricted the pool of countries to those with over a million inhabitants. then the following country's epidemics were classified as exponential and as a power law, see also figure : in the lists above, the countries that are classified as power law-like and exponentiallike are printed in gray. there are countries in the exponential law class, with of them being truly exponential and the rest exponential-like. there are countries in the power law class, with of them being truly power law and the rest power law like. it is interesting that the countries showing a power law (or power law-like behavior) are different with respect to some characteristics compared to the countries showing exponential or exponential-like behavior. figure (a) shows a numerical probability distribution for the day when the infection in each country reached the level of case per million. blue represents the power law set and yellow the exponential set (grey means an overlap of the two colors). the average date of reaching case per million (counting from jan ) is about days for the power law and days for the exponential set (p = . by t test). in other words, the countries that are demonstrating a power law infection spread have had the relative infection level slightly longer than the exponentially developing countries. this points us towards a hypothesis that perhaps it is typical to observe a transition between an early, exponential stage of growth, and a later, power-like stage of growth. figure (b) shows the difference between the two classes of countries in terms of . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint their area. we find that the exponentially growing infection class is associated with larger countries (mean area of about . × km ) compared to the power law class (mean area about . × km , p = . by t test). similarly, exponential epidemic spread tends to correlate with lower density countries (figure (c)). it is possible that it takes longer for a larger country of a lower density to transition to a power law growth. we provide a possible explanation of this correlation in the context of metapopulation modeling. it is important to understand the dynamics with which the cumulative case counts increase over time, such that we have a better ability to judge whether non-pharmaceutical . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . interventions (e.g. social distancing) have an impact on the course of the epidemic. the covid epidemic is often thought to grow exponentially. if this is the case, a deviation from exponential growth following the introduction of non-pharmaceutical interventions can indicate success of those interventions. in contrast, if the infection grows according to a power law while growth is incorrectly assumed to be exponential, a slow down of the cumulative covid cases over time on a log scale can result in the false conclusion that the non-pharmaceutical intervention methods are working. if the cumulative cases grow like a power law, successful intervention would result in the growth deviating from the power law, and not from exponential growth. one interpretation of our analysis could be that in the absence of non-pharmaceutical interventions, the disease burden grows exponentially, but that over time, the nonpharmaceutical interventions slow down the spread. hence, overall, the disease dynamics are described better by a power law than by an exponential function, because the power law is characterized by a slow-down of the growth rate over time. italy, where one of the most pronounced power laws was observed, implemented some degrees of social distancing relatively early, although the more strict measures were implemented only recently. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . while this cannot be excluded, the comparative plots in figure might argue against this hypothesis. these graphs shows the spread dynamics for a few countries, whose epidemics are relatively advanced, and they have all been shifted to be temporally synchronized with italy. as the infection spreads to higher levels, the curves for the different countries converge towards a common trajectory of the per capita cases of covid . in other words, as the infection spreads, the per capita number of cases converge and follow the same power law. if this deviation from exponential growth was due to nonpharmaceutical interventions, then it is surprising that those countries follow the same trajectory because they implemented those interventions at different times and to different degrees. the percentage of countries with a given delay that belong to the power law group and to the exponential law group. the trend that the percentage of exponential growth increases with the time lag (that is, decreases with the epidemic "age") is significant (p < − by linear fitting). alternatively, it is possible that the local epidemics characterized by power laws demonstrate an intrinsic power law spread that is independent of interventions. computational models suggest that infection spread across networks or in spatially structured populations can lead to dynamics that follow a power law rather than an exponential trajectory, see below. if some countries truly show infection spread that is governed by a power law, the question arises why other countries show clear exponential spread, and why yet other countries are more difficult to classify. we hypothesize that different countries are at different stages of epidemic development, but they all roughly follow the same trajectory, where an initial exponential growth is gradually replaced by a more power like behavior. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint tries until, for each country, the best match with the italian curve was obtained. as we can see in figure (a) , there are only a few countries that are just behind italy, and as the number of lag days increases, the number of countries grows. this corresponds to the world wide spread of the pandemic: more and more countries become affected as time goes by. figure (b) calculates, for each lag time, the percentage of countries that were classified as following power law or exponential dynamics. we can see that for the countries that are just a few days behind italy, % of them belong to the power law group. as the lag time increases, indicating an earlier stage of the epidemic, more and more countries exhibit exponential growth (p < − ). the same trend is also corroborated by figure (a) that shows that the epidemics in the exponential group are "younger". how can we explain the existence, to different extents, of power law like behavior in different countries? one possible reason could be non-pharmaceutical interventions that are only partially effective, see a schematic in figure . it is possible that in early stages of the infection, exponential virus spread occurs because people have not yet altered their behavior and continue to travel and socially mix with each other. mass-action dynamics are expected to yield exponential growth. as a result of non-pharmaceutical interventions that are only partially effective, people might stop traveling and thus slow down large scale mixing. however, they would still be interacting locally within their social network, which would lead to a transition to power law dynamics. it is possible that a number of countries are difficult to classify because they exhibit early mass action dynamics (exponential), followed by network interactions that lead to a transition to a power law. this would indicate that stronger non-pharmaceutical intervention methods need to be implemented. more generally, the results can be interpreted in the context of a minimally parameterized metapopulation model, see figure . assume that within a local deme (such as a local community), people interact with each other, resulting in mass action dynamics. for the infection to spread further, however, people have to enter other demes, and seed the infection there. we have performed computer simulations of such a model to explore outcomes. the model is a two-dimensional metapopulation consisting of n × n patches. in each patch, i, the infection dynamics are given by a set of ordinary differential equations (odes) that take into account the population of susceptible (s i ), infected (i i ), recovered (r i ), and dead (d i ) individuals: . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . here, infection is described by a frequency-dependent infection term [ ] , characterized but the rate constant β and a saturation constant . infected individuals die with a rate ga and recover with a rate g( − a). the migration terms include the outward migration to n neighbors and an inward migration from all the n neighboring demes that belong to neighborhood b n i of deme i. the migration rate is denoted by f and we assume that each patch has eight direct neighbors, i.e. n = . the boundary demes are characterize by fewer inward/outward migrations (that is, they have smaller neighborhood sets). using this model, we track the predicted dynamics for i + r + d over time, which represents the cumulative infection case counts. in a first scenario, we start the computer simulations with a small amount of infected individuals in a single patch, located in the center of the grid. all other patches contain only susceptible individuals. the resulting dynamics are shown in figure . we observe an initial exponential phase of infection spread, followed by a transition to a power-law spread. the spread is initially exponential, because within a single patch (the first patch), the dynamics are governed by well mixed populations. as the infection spreads to other patches by migration, the overall infection spread starts to be governed by spatial dynamics, which explains the . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint next we assumed that instead of starting with infecteds only being present in a single patch, a small amount of infected individuals are initially present in more than one patch around the same time. this could correspond to larger countries, in which the infection is simultaneously seeded in multiple areas (e.g. due to travel from other places). now, we observe overall growth dynamics that are are more exponential-like. the length of the predicted exponential phase becomes longer the more patches are initially seeded. the reason is that with more initial seeding events, the importance of spatial spread is de-emphasized. the metapopulation model can therefore predict an array of growth patterns where an exponential phase of varying length is followed by a transition to power law, depending on the initial conditions of the simulation. in this paper, we analyzed data that document the cumulative covid case counts over time in a large number of countries around the world, and examined the laws according to which the infection spreads. this suggests that although the initial phase of the spread may be exponential, the longer term dynamics tend to be governed by a power law. the analysis indicates that the countries that display clear evidence for exponential growth are currently in a relatively early phase of the epidemic. the data further suggest that countries that are further along in the epidemic converge to a common power law . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . behavior, and cumulative per capita case counts appear to converge over time. these observations were interpreted by computer simulations of a metapopulation model that takes into account both local spread and spread across geographical space. this model predicts an initial exponential phase (due to local transmission events driving the dynamics), followed by a transition to a power law (once spatial dynamics significantly drive spread). the duration of the exponential phase is determined by the number of patches that are initially seeded with the infection. if the infection originates in a single location (patch), the exponential phase is likely not very pronounced, and most of the growth curve is predicted to follow a power law. if the infection is seeded simultaneously or nearly simultaneously in multiple locations, the duration of the exponential phase becomes longer. the larger the number of initially seeded locations, the more pronounced the exponential phase of the infection spread. these predictions are further in agreement with the correlations that we found between the growth law of the infection and country size. exponential growth was associated with countries that are characterized by a larger area. more pronounced power laws tend to occur in counties with a smaller area. if a country has a larger area, it is more likely that multiple locations are seeded with the infection around a similar time, for example due to travelers returning from a country with a larger disease incidence. for this scenario, the metapopulation model predicts more pronounced exponential growth. if the country has a smaller area, it is more likely that the infection is seeded within one geographical area and spreads outward from there. in this case, the metapopulation predicts an infection spread pattern that mostly follows a power law. beyond scientific interest, a better understanding of the laws according to which covid spreads through populations is also of practical importance. currently, emphasis is placed on non-pharmaceutical intervention measures to slow down the spread of the infection such that the ability of the health care system to cope with the number of incoming patients is preserved. the success of these intervention measures should be reflected in slowed infection spread. an understanding of the infection spread laws is crucial to interpret such data. if we assume that infection growth is exponential and if we plot the cumulative number of covid cases on a log scale, a deviation and slow-down from exponential growth would lead to the conclusions that the non-pharmaceutical intervention measures are successful [ ] . if, however, the true spread dynamics are characterized by a power law, we expect deviation and slow-down compared to exponential growth over time, even if the infection continues to spread at full force. in this case, a deviation from exponential spread cannot be interpreted to mean that non-pharmaceutical intervention measures are sufficient. to come to that conclusion, we would need to observe a deviation and slow-down of the infection spread compared to a power law null model. as with any data and modeling studies, it is important to note that results can depend on assumptions and methodologies. these are clearly spelt our here. one of the larger challenges we faced in the data analysis is the lack of knowledge at what time the infection was initiated in the individual countries. this information is not available. the time frame in turn influences the fit of the power law to the data, which we have addressed with our time shifting methodology. if further information becomes available about the time when infections are estimated to have originated in the individual countries, the methodology can be updated. genetic studies could provide valuable data in this respect. another limitation of the data interpretation is the degree, to which different countries test for the coronavirus. if some countries test less than others, they will appear to be further behind italy, while in reality the lag could be shorter. this type of uncertainty however does not change the central finding that the long term dynamics of covid cases in different countries follow a power law, after an initial stage of exponential growth. here we present the details of the fitting procedure used to determine the growth laws for different countries. it is illustrated with the example of italy in figure . the full data for the number of cases per million in italy are presented in figure (b) , orange curve. in figure , the subset of same data starting from case per million, is plotted on the log-log scale (panel (a)) and on a linear scale (panel (b)), with varying horizontal shift, which corresponds to changing the position of time zero. this is what we refer to as a "fitting frame". the fitting frame number one is when the first data point in the selected subset corresponds to day . the ith fitting frame shifts this point to day i. for each fitting frame, we obtained the best fit with function a x b , by using a built-in mathematica routine "findfit". note that the natural logarithm of the data was fitted for the figures presented here. clearly, some fits are better than others, see figure (a,b) . the fitting error for each fitting frame, i, was calculated as the distance between the data and the fit, normalized by the number of points: where y exponential fits of the same data from italy are shown in figure (a,b) . in panel (a) we used a log scale, such that the exponential fits look like straight lines. it is clear that, first of all, these fits are all parallel lines and thus the error is exactly the same (thus the exponential fitting errors as functions of the fitting frame are horizontal lines, see figures and ). second, we note that these fits are not very good for italy, that's why the power fit errors is always below the exponential error, see figure (b). for comparison, panels (c) and (d) of figure show the exponential fits for the us data. we can see that the quality of the fits is better, see also figure (b). in the main text and in this appendix so far, we describe a fitting procedure where the "confirmed cases" data for each country were used only if the numbers exceeded case per million. here we demonstrate how this changes if a different choice is made and a minimum of cases per million is required for each data point to be included. in figure we demonstrate the difference for countries. the choice of countries for this graphics was somewhat arbitrary: we included the countries out of the subset used in figure that had the largest infection (cases per million). . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . figure : examples of exponential fits for italy (a,b) and the us (c,d), where the log scale is used in (a,c) and the linear scale in (b,d). the yellow lines show exponential fits for different frames from to , as in figure (a,b) . here we present plots of the best fits for different classes of countries. figure shows the countries that were classified as a power law countries. the plots are presented on a log-log scale, such that the power law fits are straight lines. we can see that the best power law fit (blue) is a visibly better match than the exponential fit (yellow). note that for all of these countries the power law fitting error for any frame shift is smaller than that obtained by the exponential fitting. the rest of the power law countries (those that were classified as power law like) are shown in figure . this list contains countries. for convenience, we present both a log log plot (such that the power law fits, blue, appear as straight lines) and a log plot (such that the exponential fits, yellow, appear as straight lines). figure shows the countries that are characterized by a straight exponential growth. for these data, we used a log scale, such that the exponential fits are straight lines. for all of these countries the power law fitting error for any frame shift is larger than that obtained by the exponential fitting. note however that power fits that are almost as good as exponential fits can always be found, if we we shift the frame far enough. these fits correspond to very large values of the power coefficient b in the power law, see for example figure (a) which presents the example of the us. as the fitting frame index increases, the power law fitting error (top, blue line) approaches the exponential fitting error (horizontal yellow line). this, however, is meaningless, and does not indicate the presence of a power law. figure presents the rest of the countries from the exponential class, that is, those that were classified as exponential-like. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint figure : comparison of two different choices of the fitting procedure, for countries. each panel represents a country, with the hrizontal axes being the fitting frame, and the vertical the fitting error. red symbols correspond to the case per million threshold, and blue circles to the cases per million threshold. circles represent the error of the power law fitting; they form non-constant functions. squares represent the error of the exponential fitting and form horizontal lines, because these errors do not depend on the fitting frame. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint figure : the countries that were classified as those following a power law. for each country, two panels are presented. one is the full data (cases per million) plotted on a log log scale. the other is the subset of data (with or more cases per mission) plotted on a log-log scale (black circles) together with the best power law (blue line) and exponential (yellow line) fits. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint figure : the countries that were classified as power law like. for each country, three panels are presented: ( ) is the full data (cases per million) plotted on a log log scale. ( ) is the subset of data (with or more cases per mission) plotted on a log-log scale (black circles) together with the best power law (blue line) and exponential (yellow line) fits. ( ) is the same as ( ) except on a log scale. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint figure : the countries that were classified as those following an exponential law. for each country, two panels are presented. one is the full data (cases per million) plotted on a log log scale. the other is the subset of data (with or more cases per mission) plotted on a log scale (black circles) together with the exponential fit (yellow line). note that for these countries, the power law fits correspond to very high values of the exponent and are therefore not significantly different from the exponential fits. figure : the countries that were classified as exponential-like. panels are as in figure . . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint the covid- epidemic the epidemiology and pathogenesis of coronavirus disease (covid- ) outbreak clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study. the lancet fair allocation of scarce medical resources in the time of covid- impact of non-pharmaceutical interventions (npis) to reduce covid- mortality and healthcare demand covid- and italy: what next? the lancet covid- epidemic outside china: founders and exponential growth. medrxiv estimation of country-level basic reproductive ratios for novel coronavirus (covid- ) using synthetic contact matrices. medrxiv the reproductive number of covid- is higher compared to sars coronavirus estimating the reproductive number and the outbreak size of novel coronavirus disease (covid- ) using mathematical model in republic of korea the reproductive number r of covid- based on estimate of a statistical time delay dynamical system. medrxiv covid- containment: china provides important lessons for global response scaling features in the spreading of covid- coronavirus may have infected half of uk population how should pathogen transmission be modelled? trends in ecology & evolution effective containment explains sub-exponential growth in confirmed cases of recent covid- outbreak in mainland china acknowledgements. support of grant nsf dms / is gratefully acknowledged. key: cord- -mbg e j authors: hardstaff, jo l; häsler, barbara; rushton, jonathan r title: livestock trade networks for guiding animal health surveillance date: - - journal: bmc vet res doi: . /s - - - sha: doc_id: cord_uid: mbg e j background: trade in live animals can contribute to the introduction of exotic diseases, the maintenance and spread endemic diseases. annually millions of animals are moved across europe for the purposes of breeding, fattening and slaughter. data on the number of animals moved were obtained from the directorate general sanco (dg sanco) for . these were converted to livestock units to enable direct comparison across species and their movements were mapped, used to calculate the indegrees and outdegrees of european countries and the density and transitivity of movements within europe. this provided the opportunity to discuss surveillance of european livestock movement taking into account stopping points en-route. results: high density and transitivity of movement for registered equines, breeding and fattening cattle, breeding poultry and pigs for breeding, fattening and slaughter indicates that hazards have the potential to spread quickly within these populations. this is of concern to highly connected countries particularly those where imported animals constitute a large proportion of their national livestock populations, and have a high indegree. the transport of poultry (older than hours) and unweaned animals would require more rest breaks than the movement of weaned animals, which may provide more opportunities for disease transmission. transitivity is greatest for animals transported for breeding purposes with cattle, pigs and poultry having values of over %. conclusions: this paper demonstrated that some species (pigs and poultry) are traded much more frequently and at a larger scale than species such as goats. some countries are more vulnerable than others due to importing animals from many countries, having imported animals requiring rest-breaks and importing large proportions of their national herd or flock. such knowledge about the vulnerability of different livestock systems related to trade movements can be used to inform the design of animal health surveillance systems to facilitate the trade in animals between european member states. electronic supplementary material: the online version of this article (doi: . /s - - - ) contains supplementary material, which is available to authorized users. animal trade is an effective way of introducing, maintaining and spreading animal diseases, as observed with the spread of different strains of foot and mouth disease (fmd) in africa, the middle-east and asia [ ] and the spread of bovine spongiform encephalopathy (bse), for example into oman and canada through the importation of infected cattle [ , ] . within a year, millions of live animals of many different species are transported between countries within europe for breeding, fattening, sports, companionship, conservation and slaughter. this creates opportunities for communicable diseases to be spread across the european union (eu), which is the focus of this study, even though animals must be in a fit state to be transported i.e. healthy animals without clinical signs of illness [ ] . however, animals with sub-clinical infections may go unnoticed, providing an opportunity to transport disease to different regions. live animal trade complicates tracing the origin of any disease outbreak that may occur due to an infected animal being displaced. for this reason, the eu has established a trade control and expert system (traces) to monitor imports, exports and trade in animals and animal products across the eu and to ensure traceability within the food chain [ ] , in addition to livestock movements recorded by the food and agricultural organisation of the united nations (fao). traces records the number of animals and consignments entering and leaving eu countries. despite the availability of this comprehensive database, animal health surveillance systems are rarely based on international live animal movements. to understand better livestock trade within europe with a view to inform disease surveillance we analysed trade networks across the eu for all major livestock species and purposes of movements. animal health surveillance includes the systematic, continuous or repeated, measurement, collection, collation, analysis, interpretation and timely dissemination of animal health and welfare related data from defined populations, essential for describing health hazard occurrence and to contribute to the planning, implementation and evaluation of risk mitigation measures [ ] . recent outbreaks and spread of exotic or emerging diseases such as avian influenza (ai), schmallenberg virus (sbv) and bluetongue virus (btv) in previously unaffected territories of the eu have emphasised the need for well-developed and adequately resourced health systems, including surveillance, to ensure early detection and rapid containment, the complexities of which are highlighted by braks et al. ( ) [ ] . at the same time investment is being constrained due to significant financial budget reductions in many european countries. livestock disease is important economically with regards to a loss of productivity, its potential impact on human and animal health, and the mitigation activities implemented when disease occurs (for example trade or movement bans, testing and culling). for example, the economic cost of bse in the uk accrued from the value loss in infected carcasses, disposal costs, and, most importantly, the sharp drop in domestic beef demand due to consumer scares (sales of beef products declined by % once the possible link between bse and new variant creutzfeldt-jakob disease (cjd) was announced, but the costs were partly offset by an increase in consumption of substitute meat), and a complete loss in export markets [ ] . further costs accrued from operating various public schemes, establishment and enforcement of new legislation and the adjustment of the industry to the new structure and markets [ ] . livestock disease can be spread directly for example the introduction of fmd from irish calves imported to the netherlands that were also held responsible for the infection of a farm near to the port of introduction to mainland europe [ ] . it can be spread by infected equipment, crates or transporter vehicles which can be contaminated by microbes. for example escherichia coli (e. coli) bacteria were detected on the sides and floors of lorries [ ] and contaminated transporters were found to be responsible for spreading classical swine fever to different farms in lithuania [ ] . by moving animals with latent or asymptomatic infections this enables disease to spread to wherever the animal travels or where the necessary vectors may be present. particularly in the case of epidemic diseases where the reduction of time from introduction of a hazard to its detection can enable early response and thereby lead to a reduction in intervention costs to contain an outbreak [ ] , effective surveillance is critical. few surveillance systems however, are designed based on international livestock movement data, even though such data can provide information on the quantity and seasonality of livestock movements, the types of movement (for example flows from production of point of lay birds to laying units), the route the animals take and associated stopover or resting points. surveillance for many livestock species occurs at the farm where it is the responsibility of the farmer (and veterinarian) to report notifiable diseases or at the abattoir where it is the role of the official veterinarian to inspect livestock according to council regulation (ec) / [ ] and report notifiable diseases to the national authorities, which in the uk is the department of the environment, food and rural affairs (defra), which in turn must inform the european food safety authority (efsa) as stated in council regulation (ec) / [ ] . network analyses are useful ways of visualising the countries that are importing animals from a great number of other countries (high level of indegree) and countries that are exporting to a high number of countries (outdegree), these are values that can change temporally. they have been used to find out movement between farms of different species, for example, fish movement between farms in scotland [ ] and a study of pig and cattle movement between farms in sweden [ ] . countries with a high indegree, which for the purposes of this study has a maximum number of (the number of countries, i.e. (nodes, within this study and the eu as of ) that could be used to rank countries, can be more vulnerable to introducing disease due to importing animals from a greater number of countries than those with a low indegree whilst countries with a high outdegree may have a great ability to be able to transmit a disease to many countries; this highlights the importance of understanding levels of disease within trading countries. information about the indegree and outdegree of farms was used by frössling et al. ( ) [ ] to investigate whether it could be used to target the surveillance of two cattle diseases in sweden, based on a threshold of in-and out-degrees. they found a positive association between a positive test result and the purchase of animals and proposed approaches to design risk-based surveillance based on cattle movement data. networks can also be used to quantify the proportion of international partners trading with each other (dyadic contacts) compared with the maximum number of national trading partners available for trade within an area allowing a comparison to be made between species and production systems [ ] . the higher the density the more connected countries are with respect to the animal being traded and the more countries that may be at risk from contracting a disease from buying in infected livestock. a measure of mixing within a network is to look at its transitivity which indicates whether countries that a country is trading animals to are also trading animals with each other (a triad) [ ] . the greater the level of transitivity the faster a disease can spread between countries and potentially infect many countries within the european area [ ] . transitivity and density for different communities of wild and domestic ungulates were investigated for the propensity to transmit e. coli by vanderwaal et al. ( ) [ ] . however, the network may only consider the point of origin and destination and not necessarily consider the route itself that may involve briefly stopping in other countries where a disease transmission event may occur, for example fmd in france [ ] . we hypothesise that the description of trade networks can inform the design of more efficient animal health surveillance systems that may enable a more rapid investigation or response to be implemented. different species being transported for different purposes will have networks of different densities and different countries with the greatest indegree or outdegree. the aim of this project was to map live animal trade networks in eu countries and assess potential differences between species and purposes of transport. this was done by illustrating the number of live animal imports and exports between eu countries including the number of country contacts and numbers of livestock units (lsu, a unit that takes into account the age, sex, purpose of animals with dairy cows having a reference number of ) moved determining the density of networks and similarities of networks between species. table illustrates the median livestock intra-community movements (expressed in livestock units) and the densities of the transport networks. by far the most heavily moved animal species within europe in were poultry for slaughter and breeding, followed by poultry for 'other' purposes, pigs for fattening, pigs for slaughter and cattle for fattening; goats were the least traded species. generally more lsus were transported for fattening than for slaughter. the density of movement (table ) shows that there was greater connectivity for cattle than for the heavily traded poultry. breeding networks were found to be denser than those for other purposes. this may be due to the number of consignments needed to move the relative units of animals. the geographical trade flows are shown in figures , , , , and . the transitivity indicates that disease would spread more slowly for 'other' purposes of animal movement than for breeding, fattening or slaughter with the exception of poultry and equines. figures , , , , and show the in-and outdegrees of livestock unit movements in the eu on the left and the geographical trade flows in the right, which are separated by species and by purpose of trade. the axes of the graphs of the in-and outdegrees reflect the numbers of trading partners. the countries in the top right received and exported animals with the greatest number of countries, whilst the bottom left indicates those that have little or no export or import trade with other countries. some countries are found in the top right corner with regards to many different animal movements e.g. germany, whilst others rarely buy or sell to the other countries considered in this study e.g. cyprus, finland and sweden, whilst other countries import from many countries and export to few e.g. italy. very few shipments of weaned cattle, sheep and goats require a rest period of hours (additional file ), whereas many unweaned animals would require a hour break in their journey from their point of origin to their figure the outdegree is shown against the indegree for the trade of cattle for different purposes on the left column of the table and the geographical movement across europe is shown on the right column of the table. the arrows between the countries indicate trade between the countries. the numbers in the figures refer to the corresponding countries: [ ] austria, [ ] belgium, [ ] bulgaria, [ ] cyprus, [ ] czech republic, [ ] denmark, [ ] estonia, [ ] finland, [ ] france, [ ] germany, [ ] greece, [ ] hungary, [ ] ireland, [ ] italy, [ ] lithuania, [ ] latvia, [ ] luxembourg, [ ] malta, [ ] netherlands, [ ] poland, [ ] portugal, [ ] romania, [ ] slovakia, [ ] slovenia, [ ] spain, [ ] sweden and [ ] uk. and exporting high proportions of their national population, the officially recorded number of animals of that species in the particular country. the poultry and pig sectors had the greatest number of lsu movements, which are being used to indicate breeding fattening slaughter other figure the outdegree is shown against the indegree for the trade of pigs for different purposes on the left column of the table and the geographical movement across europe is shown on the right column of the table. the arrows between the countries indicate trade between the countries. the numbers in the figures refer to the corresponding countries: [ ] austria, [ ] belgium, [ ] bulgaria, [ ] cyprus, [ ] czech republic, [ ] denmark, [ ] estonia, [ ] finland, [ ] france, [ ] germany, [ ] greece, [ ] hungary, [ ] ireland, [ ] italy, [ ] lithuania, [ ] latvia, [ ] luxembourg, [ ] malta, [ ] netherlands, [ ] poland, [ ] portugal, [ ] romania, [ ] slovakia, [ ] slovenia, [ ] spain, [ ] sweden and [ ] uk. the potential opportunities of pathogen introduction and spread, implying that they require more attention in terms of disease prevention and management, while the equine and goat sectors had the greatest and lowest densities of movements respectively. in addition to lsu movements larger proportions of national pig populations are imported breeding fattening slaughter other figure the outdegree is shown against the indegree for the trade of sheep for different purposes on the left column of the table and the geographical movement across europe is shown on the right column of the table. the arrows between the countries indicate trade between the countries. the numbers in the figures refer to the corresponding countries: [ ] austria, [ ] belgium, [ ] bulgaria, [ ] cyprus, [ ] czech republic, [ ] denmark, [ ] estonia, [ ] finland, [ ] france, [ ] germany, [ ] greece, [ ] hungary, [ ] ireland, [ ] italy, [ ] lithuania, [ ] latvia, [ ] luxembourg, [ ] malta, [ ] netherlands, [ ] poland, [ ] portugal, [ ] romania, [ ] slovakia, [ ] slovenia, [ ] spain, [ ] sweden and [ ] uk. compared with species such as goats increasing the possibility for the introduction of infected animals to an existing population. for poultry, the highest numbers of lsus moved were for slaughter, which may present less of a risk of introducing disease to an existing population, as the animals are likely to be transported from the production site directly to the slaughter point. however, many poultry journeys would require a break in transit emphasising the breeding fattening slaughter other figure the outdegree is shown against the indegree for the trade of goats for different purposes on the left column of the table and the geographical movement across europe is shown on the right column of the table. the arrows between the countries indicate trade between the countries. the numbers in the figures refer to the corresponding countries: [ ] austria, [ ] belgium, [ ] bulgaria, [ ] cyprus, [ ] czech republic, [ ] denmark, [ ] estonia, [ ] finland, [ ] france, [ ] germany, [ ] greece, [ ] hungary, [ ] ireland, [ ] italy, [ ] lithuania, [ ] latvia, [ ] luxembourg, [ ] malta, [ ] netherlands, [ ] poland, [ ] portugal, [ ] romania, [ ] slovakia, [ ] slovenia, [ ] spain, [ ] sweden and [ ] uk. vulnerability of the chain and need for adequate surveillance. poultry for breeding had the second highest lsu movements overall, which likely reflects the current structure of commercial poultry production. pure line grandparent and parent stock for breeding are produced by only a limited number of breeding organisations worldwide. for example, the two companies aviagen and cobb, have a market share of more than % of the commercial broilers produced in the eu and use their global network of distributors to serve almost all european countries [ ] . the breeder farms supplied with young breeding stock have links to hatcheries that produce day old chicks, broiler or layer farms, and slaughterhouses. this system leads to transport of young breeders, hatching eggs and day old chicks. in pigs, heavy movements were recorded for fattening, which reflects ongoing changes in production centres in the eu. in fact, more than two thirds of breeding pigs are produced in denmark, germany, spain, france, the netherlands and poland with half of the breeding pigs at regional level being concentrated in eleven regions in these six countries [ ] . germany is the main importer of fattening pigs, with an indegree of and denmark is the main exporter with an outdegree of . moreover, pigs for breeding and fattening as well as poultry for breeding were shown to have among the highest transitivities, indicating that disease spread in these networks would be fast if uncontained. hence, solely taking into breeding slaughter other figure the outdegree is shown against the indegree for the trade of poultry for different purposes on the left column of the table and the geographical movement across europe is shown on the right column of the table. the arrows between the countries indicate trade between the countries. the numbers in the figures refer to the corresponding countries: [ ] austria, [ ] belgium, [ ] bulgaria, [ ] cyprus, [ ] czech republic, [ ] denmark, [ ] estonia, [ ] finland, [ ] france, [ ] germany, [ ] greece, [ ] hungary, [ ] ireland, [ ] italy, [ ] lithuania, [ ] latvia, [ ] luxembourg, [ ] malta, [ ] netherlands, [ ] poland, [ ] portugal, [ ] romania, [ ] slovakia, [ ] slovenia, [ ] spain, [ ] sweden and [ ] uk. account trade data, surveillance efforts would need to focus on poultry for breeding and pigs for breeding and fattening. however, a mapping of surveillance in seven european countries showed that the highest proportion of surveillance components in place were for cattle [ ] . similarly, a recent literature review on animal health issues (including zoonoses) researched in the eu showed that cattle and buffalo were the species most breeding slaughter other registered figure the outdegree is shown against the indegree for the trade of equines for different purposes on the left column of the table and the geographical movement across europe is shown on the right column of the table. the arrows between the countries indicate trade between the countries. the numbers in the figures refer to the corresponding countries: [ ] austria, [ ] belgium, [ ] bulgaria, [ ] cyprus, [ ] czech republic, [ ] denmark, [ ] estonia, [ ] finland, [ ] france, [ ] germany, [ ] greece, [ ] hungary, [ ] ireland, [ ] italy, [ ] lithuania, [ ] latvia, [ ] luxembourg, [ ] malta, [ ] netherlands, [ ] poland, [ ] portugal, [ ] romania, [ ] slovakia, [ ] slovenia, [ ] spain, [ ] sweden and [ ] uk. frequently studied in the eu [ ] ; this may reflect differences in resource allocation for surveillance and disease mitigation. the reasons for this may be that cattle harbour or are perceived to harbour more pathogens than other species, that outbreaks in cattle systems have higher impact, that cattle receives more attention than other species for cultural or historical reasons, or that disease prevention and management in cattle systems are of lower quality. currently, there are no multipathogen, multi-species systematic risk assessments available at eu level that would allow a comparison of these factors. breeding networks were found to be more highly connected with more trade between countries indicating disease may spread more easily through them. this is of concern as these animals are not intended to be slaughtered on arrival and will produce new animals, therefore stringent precautions are needed to protect these populations, particularly if they are diseases not covered by eu legislation, for example the diseases listed in council regulation (ec) / [ ] . the density of international agri-trade calculated by ercsey-ravasz et al. ( ) [ ] was . which was comparable with density of many networks in this study. however, in national networks the densities and transitivities are smaller, which are due to the greater number of farms involved in national animal production compared with the number of countries involved in this study. the cattle trade network in france had a very low annual level of transitivity indicating that disease spread would be slower than that between european countries [ ] . the pig and cattle networks in sweden had lower transitivities than international networks of these species [ ] as did the transitivity of pig movements in denmark [ ] and the uk [ ] . the location of countries in figures , , , , and gave an indication of where surveillance could be targeted with countries in the upper right quadrant both importing and exporting high numbers of lsu, which means that they need to monitor both production to export healthy animals and import processes to avoid introduction of disease. countries in the lower right quadrant may need to consider strengthening surveillance related to import processes. many national studies have found that the majority of animal movements are between premises with lower indegrees and outdegrees as shown in a study by smith et al. [ ] , this reduces the likelihood of disease transmission to many different areas, reducing the level of surveillance needed. many countries trading cattle were found to have an in or out degree equal or greater than five. this was the threshold that was calculated to require enhanced surveillance for bovine coronavirus in a study on trade and cattle in sweden by frössling et al. [ ] . consequently, there seems to be ample opportunity to take advantage of trade network data to enhance surveillance. the evolution of trade networks over time at the eu level could be monitored using indegrees, outdegrees, and transitivity. such monitoring would provide information at the systems level and allow observations of changes in networks over time and where consequent surveillance efforts should be focused. higher-level surveillance capturing trends or changes in trade patterns could complement existing surveillance systems that are commonly disease centered. the differences across countries in terms of indegrees and outdegrees also bring up the question of who has the responsibility for disease control, including surveillance the buyer, the seller or relevant food business operator depending on the stage of livestock production [ ] . while the draft new eu animal health law [ ] refers to listed diseases and pre-dominantly supports disease centered surveillance, it also creates a framework for the better use of the synergies between surveillance undertaken by the different actors in the field to ensure the most effective and cost efficient use of surveillance resources as well as promotion of data availability and facilitation of data exchange. transportation itself is stressful for animals as indicated in many studies in many species for example cortisol in pigs [ ] ; heart rate and cortisol in cattle [ ] ; cortisol in lambs [ ] ; cortisol in horses [ ] ; increasing susceptibility to disease and may enhance the likelihood of shedding pathogenic agents in transit or in the receiving country, which may lead to infection in other animals. it is common to refer to malaise post-transportation as shipping illness [ ] . however, pathogens may be introduced or spread from transporters and not just from the animals that they transport. studies have demonstrated that transporters need to be thoroughly cleaned to prevent them from acting as a source of pathogens to subsequently carried animals, for example to prevent transmission of porcine reproductive and respiratory syndrome virus, that can survive in transporters, being transferred to pigs [ ] . rest stops are infrequent for some species, however, if animals from more than one origin are rested in the same place it may allow for disease spread. this is most likely to impact animals traded for breeding and fattening purposes that have more lsus and are more highly connected than animals already at slaughter weight. these are animals that will live in the receiving country for a period of time that may enable pathogen transfer. many of the highly connected countries (with high in and out degrees in the top right of figures , , , , and ) for example germany are geographically located in an area (central europe) that minimises the distances and therefore time that animals have to travel reducing the need for rest breaks and the consequent potential for pathogen transfer. many of the long distances are from countries that rarely trade with mainland europe for example cyprus. many animals undergo long journeys between countries. the time in transit is a concern with regards of the potential for disease to spread along trade routes [ ] . this has implications for policy around the planning of livestock production and slaughter. ideally, large production facilities would not be placed adjacent to well-known and used trade routes and or resting points. however, such information is only of use to policy makers if it is captured in a systematic and continuous way allowing to monitor trends, change and modify policies accordingly if deemed necessary. the analyses have only considered the spatial aspect of trade and not taken into account temporal variations that may occur altering the relationships between the countries (nodes) and the respective network, and affect the likelihood of an animal being infectious with a disease. animal populations fluctuate within a year and the population recorded in december was used to calculate the proportion of animals being imported or exported into a country, therefore it may have under or overestimated the actual population at the time of movement. for example the majority of lambs are born between january and april increasing the sheep population until they reach slaughter weight and are culled, which occurs before december. networks are highly dynamic and these changes in movements between countries will need to be considered by surveillance programs using this approach. one method that may address this is to use exponential random graph models that can incorporate a range of different distributions of connectivity between the nodes to create many different networks, which can be compared with the data to find a model that best fits the current trade pattern [ ] . the distances that animals are transported between countries may be shorter or longer than the distances between centroids. in addition, there are many different routes across europe that may be used and this may be worth investigating in future analyses with regards to distance, time and mixing between countries. this means that our calculations for whether particular species need a rest break for movement between particular countries are generalised so that there may be fewer or greater numbers of animals being rested en-route to their destination country altering the potential for pathogen exposure. the analyses did not take into account the numbers of convoys or animals and the mixing of animals: from different farms per convoy, at resting places, at borders, when received by individuals and at markets in the country of destination. these factors will have an impact on contact between potentially naïve and infectious animals, pathogen exposure and susceptibility. the analyses could not take into animals being bought and sold on to more than one country i.e. the chain of infection [ ] and assumed that an animal moved once between countries in its lifetime. creating networks has enabled us to visualise the countries that have a higher level of involvement in animal trade. using network analysis we were able to determine the extent to which a disease may spread, the production systems where disease spread may be more rapid, for example registered horses and breeding cattle, pigs and poultry, and facilitates comparisons with networks in other areas. similarities between countries, species and production purposes has the potential to inform international surveillance policies that take into account trade patterns. the study has highlighted the vulnerability of the pig network to disease, which is of increasing concern due to the proximity of african swine fever to the eu and the potential for wildlife to introduce the disease [ ] . this information could complement the national movement recording systems that are mandatory for cattle throughout the eu [ ] that will soon be implemented in sheep and goats now that their form of identification tags have been decided upon [ ] , and being planned for porcines [ ] to produce a more robust surveillance plan. data on numbers of live cattle, goats, horses, pigs, poultry and sheep movements in eu countries were obtained from directorate general sanco animal health dg sanco unit g activity report for the year obtained from http://ec.europa.eu/food/animal/resources/publications_en. htm. the data obtained related to the production purpose of the animals, which fell into five categories: breeding, fattening, slaughter, registered and other (e.g. pets, show animals). these categories were analysed separately and combined for each species. the numbers of animals were converted into livestock units to enable comparison between species using the following conversion factors derived from the eurostat glossary on statistics ( ) [ ] : pigs . (breeding), pigs . (other), goats . , sheep . , horses . and poultry . . all data were obtained at a national level from publically accessible databases and no animal experimentation occurred nor consultation with animal owners therefore ethical approval was not needed. all the analyses and associated network figures were created and carried out using r . . . [ ] . networks were created from adjacency matrices and their densities were calculated using network function found in r package network [ ] . the in and out degrees were calculated and respective graphs were produced using the degree and network.layout.degree functions in r package network [ ] . the transitivity of each network was calculated using the gtrans function in the sna package [ ] . trade maps in the figures , , , , and were produced by merging shapefiles of all the countries of europe downloaded from maplibrary.org (www.gadm.org/, , gadm version ) into one polygon (europe) using arcgis . [ ] . the map of europe was then read into r using the function readshapepoly found in the maptools package [ ] . centroids (the co-ordinates for the centre of a country) were calculated for each country and linked with respective importing and exporting countries were calculated using the calccentroid function in r package pbsmapping [ ] . curved lines and arrows were drawn between the centroids for each movement using the gcintermediate function found in the geosphere package [ ] . to be able to relate the numbers of animals being traded with the animal populations of the countries, the numbers of animals of each species were obtained for from the eurostat database. the data used was for december as this was the only calendar month available for all species. a movement:standing population ratio was calculated for both animal imports and exports through adding the total number of breeding, fattening, slaughter, registered and other animals being moved and dividing by the total population of animals of that species in the exporting or importing country. to illustrate the number of animal journeys that require hour rest periods during transit, distances that animals would have to travel were approximated by estimating arc distances from one capital city to the other using www.timeanddate.com. the time in transit before animals are required to have a hour rest period were obtained from council regulation ec / [ ] . the regulation states that unweaned cattle, goats, sheep, pigs and horses require a hour rest period after hours of travel. weaned cattle, goats and sheep can be in transit for hours without a rest, whereas weaned pigs and domestic horses need to be rested after hours of transportation. any animal being transported by boat should be rested for hours at the port after being unloaded. the law for poultry and rabbits states that they can travel for up to hours without food or water and whereas chicks within hours of hatching can travel for up to hours without food or water. to gauge whether a journey between two rest points would need a break the following equation was used given the assumption that a vehicle would be travelling at an average kilometres an hour. hour rest period ¼ distance between cities duration of travel before hours rest period à km=h combining livestock trade patterns with phylogenetics to help understand the spread of foot and mouth disease in sub-saharan africa, the middle east and southeast asia bovine spongiform encephalopathy identified in a cow imported to canada from the united kingdom-a case report european union council regulation (ec) / . the protection of animals during transport and related operations and amending directives / / eec and / /ec and regulation (ec) no / l european union council regulation (ec) / . commision decision of august concerning the development of an integrated computerised veterinary system known as traces proposed terms and concepts for describing and evaluating animal-health surveillance systems towards an integrated approach in surveillance of vector-borne diseases in europe the economic impact of bse on the uk beef industry the foot-and-mouth disease epidemic in the netherlands in the effects of transport and lairage on counts of escherichia coli o in the feces and on the hides of individual cattle international disease monitoring economic principles for resource allocation decisions at national level to mitigate the effects of disease in farm animal populations european union council regulation (ec) / . the laying down specific rules for the organisation of official controls on products of animal origin intended for human consumption council regulation (ec) / . laying down the general principles and requirements of food law, establishing the european food safety authority and laying down procedures in matters of food safety small-and large-scale network structure of live fish movements in scotland network analysis of cattle and pig movements in sweden: measures relevant for disease control and risk based surveillance application of network analysis parameters in risk-based surveillance -examples based on cattle trade data and bovine infections in sweden collective dynamics of "small-world" networks disease evolution on networks: the role of contact structure quantifying microbe transmission networks for wild and domestic ungulates in kenya chapter production and consumption of poultry meat and eggs in the european union pig farming in the eu, a changing sector mapping of surveillance and livestock systems, infrastructure, trade flows and decision-making processes to explore the potential of surveillance at a systems level review of the emerging animal health and food security issues council regulation (ec) / approving annumal and multiannual programmes and the financial contribution from the union for the eradication, control and monitoring of certain animal diseases and zoonoses presented by the member states for and the following years complexity of the international agro-food trade network and its impact on food safety vulnerability of animal trade networks to the spread of infectious diseases: a methodological approach applied to evaluation and emergency control strategies in cattle relationship of trade patterns of the danish swine industry animal movements network to potential disease spread descriptive and social network analysis of pig transport data recorded by quality assured pig farms in the uk european union council regulation (ec) / . laying down of specific hygiene rules on the hygiene of foodstuffs council regulation (ec) / . approving annual and multiannual programmes and the financial contribution from the union for the eradication, control and monitoring of certain animal diseases and zoonoses presented by the member states for and the following years shipping stress and social status effects on pig performance, plasma cortisol, natural killer cell activity, and leukocyte numbers a comparison of the welfare and meat quality of veal calves slaughtered on the farm with those subjected to transportation and lairage effects of weaning and h transport by road and ferry on some blood indicators of welfare in lambs effects of transport, lairage and stunning on the concentrations of some blood constituents in horses destined for slaughter isolation of respiratory bovine coronavirus, other cytocidal viruses, and pasteurella spp of shipping fever an evaluation of disinfectants for the sanitation of porcine reproductive and respiratory syndrome virus-contaminated transport vehicles at cold temperatures an introduction to exponential random graph (p*) models for social networks council regulation (ec) / : implementing regulation (ec) no / of the european parliament and of the council as regards eartags, passports and holding registers report from the commission to the council on the implementation of electronic identification in sheep and goats council regulation (ec) / : the identification and registration of pigs eurostat glossary: livestock unit (lsu) -statistics explained r core team: r. a language environment for statistical programming package network package sna desktop: release . environmental systems research institute maptools: tools for reading and handling spatial objects pbsmapping: mapping fisheries data and spatial analysis tools submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution acknowledgements bh acknowledges financial support from the leverhulme centre for integrative research on agriculture and health (lcirah). additional file : journeys that would require rest breaks due to being over hours long or over hours long. these data are displayed in tables.additional file : journeys that would require rest breaks for unweaned animals. the data are displayed in a table.additional file : journeys that would require rest breaks for poultry other than chicks < hours old. the data are displayed in a table.additional file : the proportions of national animal imports and exports compared with the national population. these data are displayed in separate tables for each species. the authors declare that they have no competing interests.authors' contributions jh obtained the data and undertook the analyses. jh, bh and jr interpreted the results and had an equal contribution to the manuscript. all authors have read and approved the final manuscript. key: cord- -dc oyftd authors: koehlmoos, tracey pérez; anwar, shahela; cravioto, alejandro title: global health: chronic diseases and other emergent issues in global health date: - - journal: infectious disease clinics of north america doi: . /j.idc. . . sha: doc_id: cord_uid: dc oyftd infectious diseases have had a decisive and rapid impact on shaping and changing health policy. noncommunicable diseases, while not garnering as much interest or importance over the past years, have been affecting public health around the world in a steady and critical way, becoming the leading cause of death in developed and developing countries. this article discusses emergent issues in global health related to noncommunicable diseases and conditions, with focus on defining the unique epidemiologic features and relevant programmatic, health systems, and policy responses concerning noncommunicable chronic diseases, mental health, accidents and injuries, urbanization, climate change, and disaster preparedness. prevailing concerns and expected future trends, as seen clearly in the reemergence of tuberculosis and malaria as key health problems that have become global and individual country health priorities. infectious diseases have always had a decisive and rapid impact on shaping and changing health policy with global pandemics such as severe acute respiratory syndrome (sars) and h n , emerging without warning and challenging approved priorities within days if not hours. however, it is important not to lose sight of other areas of health and to maintain a close and watchful eye on trends and developments in those diseases that do not generate the immediate impact that some infectious diseases have been able to do. noncommunicable diseases fall into this group; they may not have garnered as much interest or importance over the past or years, but in fact have been affecting public health around the world in a very steady and critical way, becoming the leading cause of death in both developed and developing countries. this article discusses emergent issues in global health related to noncommunicable diseases and conditions. trying to offer an in-depth discussion on such a wide range of issues in just one article is clearly not possible, and therefore focus and emphasis is given to defining the unique epidemiologic features and relevant programmatic, health systems, and policy responses concerning noncommunicable chronic diseases (ncds), mental health, accidents and injuries, urbanization, climate change, and disaster preparedness. in the shadow of global efforts to achieve the millennium development goals (mdgs), by far the largest killer on the planet has continued to advance in low-income and middle-income countries. ncds cause % of all global deaths but receive just . % of international development assistance for health. approximately % of deaths caused by ncds occur in developing countries, generally in a younger population than those in high-income countries. , over the next years, the world health organization (who) predicts that ncd deaths will increase by % globally with the greatest increases in the african ( %) and the eastern mediterranean ( %) regions. in terms of the highest absolute number of deaths, the western pacific and south-east asia are projected to lead the field. noncommunicable diseases are a group of illnesses and include those conditions that have been identified as the leading causes of death around the world: heart disease, stroke, cancer, chronic respiratory diseases, and diabetes. these diseases are characterized by their long latency period often influenced by exposure to risk factors for extended periods over a patient's lifetime. the situation becomes more acute with the addition of the word "chronic," indicating that these diseases are mostly incurable and the duration of treatment may cover decades of a person's life. cardiovascular disease (mainly heart disease and stroke) is the biggest killer worldwide, contributing to % of global deaths each year. the importance of such a high figure can be seen in the countries that make up latin america and the caribbean, where cardiovascular disease alone accounts for % of the total mortality burden while aids, tuberculosis, malaria, and all other infectious diseases combined are responsible for only % of that burden. globally, chronic disease deaths have been predicted to increase by % between and . although research on multimorbidity has been based primarily on high-income countries, experts estimate that around % of the population living with chronic disease may actually be living with multiple chronic conditions. sometimes erroneously referred to as "lifestyle diseases," ncds are affected by a variety of risk factors that are often outside the control of the individual. there is very little that can be done about some risk factors, such as age and genetic inheritance, and increasing evidence suggests that what happens before a person is born and during early childhood plays a key role in the onset of adult chronic disease, demonstrated by the proven association between low birth weight and increased rates of high blood pressure, heart disease, stroke, and diabetes. however, the most common chronic diseases share some of the same highly preventable or avoidable risk factors including physical inactivity, tobacco use, and obesity, leading researchers to study mortality for ncds by risk factor. the who estimates that each year approximately . million people die from tobacco use, . million from being overweight or obese, . million as a result of raised cholesterol levels, and . million as a result of raised blood pressure. raised cholesterol and raised blood pressure (hypertension) are particularly dangerous risk factors because they can exist in an individual for a long time without presenting any obvious symptoms. in its seminal book preventing chronic disease: a vital investment, the who presents what it defines as effective and feasible interventions to reduce the threat of ncds, with low-income and middle-income countries being specifically targeted. the who seeks ideally to reduce the burden of ncd mortality by % per year through the implementation of the who framework convention on tobacco control (fctc), which was the first global treaty negotiated by the who in . as of it had been signed by nations, although stages of ratification vary. the fctc contains guidelines for implementing demand-reducing policies toward tobacco including health policies aimed at protecting the public with respect to commercial and other vested interests of the tobacco industry, protection from exposure to tobacco smoke, packaging and labeling of tobacco products; and limits or bans on tobacco advertising, promotion, and sponsorship. tax increases for tobacco control are considered to be clinically effective and very cost-effective relative to other health interventions, while the implementation of smoking bans in public areas appears to reduce the risk of heart attacks significantly, particularly among younger individuals and nonsmokers, according to a study published in the journal of the american college of cardiology (september , issue). researchers reported that smoking bans can reduce the number of heart attacks by as much as % per year. , policy level programs are also being discussed for reducing salt and sugared beverages , in the diet, consumer products, and food outlets. the who report also encourages screening for which there are clear public health benefits and cost benefit, and in situations in which the ability to treat the condition (such as raised blood pressure and cervical cancer) exists. however, at present the quality and quantity of research investigating the actual benefits of different intervention programs to prevent noncommunicable diseases in developing countries is sparse and exists primarily as case studies. , low-income and middle-income countries have developed their health provision and policies according to a primary care or alma ata model, focused on meeting the needs of pregnant women and children younger than years, and developing services for a variety of high-impact communicable diseases such as human immunodeficiency virus (hiv)/aids, tuberculosis, and malaria. the health systems in these countries are unprepared to deal with risk-factor education and behavior modification for the prevention, diagnosis, and treatment of ncds, or the long-term management of these conditions. despite growing interest among the population and health system leadership, one high-ranking health official pointed out that currently, donor countries are operating a policy ban on funding ncds, thereby starving low-income governments of the financial and technical assistance needed to turn around the ncd epidemic. this policy has to change, with overseas development assistance aligned to the priorities of recipient countries. this situation continues to be an issue for developing countries despite numerous calls for action in the area of ncds and funding. , , [ ] [ ] [ ] furthermore, there is a clear inequity inherent in noncommunicable diseases, as the poor and less educated are more likely to be exposed to several preventable risk factors including tobacco use, high-fat and energy-dense food consumption, physical inactivity, and obesity. there is no denying that noncommunicable diseases are linked to economic loss, and the who highlighted this in , predicting that national income loss due to heart disease, stroke, and diabetes for china, india, and the united kingdom are expected to be $ billion, $ billion, and $ billion, respectively, with part of the losses being the result of reduced economic productivity. the global burden of disease (gbd) project began in and since then chronic diseases have exceeded the burden of infectious diseases. despite this, the international community has yet to display a sense of urgency toward reducing ncds or supporting ncd-focused interventions in developing countries, even though they are threatening development and economic progress. perhaps the situation will change in the near future with the participation of united nations (un) member states in a highlevel summit on noncommunicable diseases scheduled to take place in new york in september . although nothing can be guaranteed, similar un summits have provided the catalyst for change, as seen following the summit on hiv/aids in that resulted in significant funding and political commitment to a coordinated action plan. since , the who has defined health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." however, mental illness and related conditions have never received the same importance or consideration as other areas of health despite their enormous burden on the population. this fact is exemplified by the routine exclusion of mental health services from primary health care (phc) and the absence of any mental health-related objectives in the mdgs. , mental illnesses, including behavioral, neurologic, and substance use disorders, affect a significant number of the world's population. in , the who estimated that globally million people suffered from depression, million from schizophrenia, and million from substance use disorders, with around , people committing suicide every year. in the same year, unipolar depressive disorders were ranked as fourth in terms of burden of disease, well on the way to prove the prediction of the gbd analysis that estimated mental illness, specifically unipolar major depression, would become the second leading cause of burden of disease by , second only to ischemic heart disease. studies in phc settings in turkey, the united arab emirates, france, vietnam, and zimbabwe revealed that the prevalence of mental illness ranges between % and % among adults, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] with depression being the most common ranging from % to %, followed by generalized anxiety disorders ( %- %) and dependency on addictive substances ( %- %). [ ] [ ] [ ] children are not immune to mental health problems, with those aged between and years exhibiting a prevalence of mental illness of between % and %, , the most common diagnoses being anxiety disorders, major depression, behavioral disorders, and attention-deficit/hyperactivity disorder. , mental illness has an effect on other family members, which is seen clearly in a study looking at growth rates of children with mothers suffering from mental illness. the study showed that % of these children suffered from stunted growth, which could have been averted if interventions to treat the maternal depression had been performed. , individuals suffering from severe form of depression are at increased risk of attempting suicide, as are women who experience abuse. meanwhile, the prevalence of mental health problems among elderly people is %, the majority of whom suffer from depression. , cost-effective treatment for most mental illnesses exists and, if correctly applied, most patients become functioning members of society, leading normal lives even in low-resource areas, and suicide risk is reduced. of interest, poverty indicators are related to mental disorders - with low education level being the most influential determinant. extrapolating these data, it is feasible to suggest that developing countries with low education levels will tend to have a higher proportion of the population suffering from mental health problems. despite this, however, most low-income and middle-income countries spend less than % of their health expenditure on mental health. explicit mental health policy, legislation, mental health treatment facilities, and community care are all lacking. injuries as a global health issue include many types that are routinely reported to and published by the who, such as poisoning, falls, drowning, burns, and intentional injuries including interpersonal violence such as elderly, partner, or child abuse, and collective violence such as war. however, two of the most important injuries that contribute to high global death rates are road traffic accidents and occupational injuries. in , an estimated % of all global deaths were the result of an injury. injuries not only affect morbidity and mortality rates but also have a tremendous effect on the individual, the family, and the community. box presents the scope of injuries and their importance as a national health issue. it is predicted that by , road traffic injuries will be the fifth leading cause of death. already, approximately . million people die due to road traffic accidents each year, and an additional to million are injured or disabled. despite being home to fewer than % of the world's motor vehicles, low-income and middleincome countries have % of the mortality burden for road traffic accidents. one injuries prove to be the largest killer of children between and years of age, accounting for % of all classifiable deaths. this means that children per day die of injuries or children per hour. the leading cause of injury-related deaths among children is drowning ( . %) followed by road traffic accidents ( . %), animal bites ( . %), and suicide ( . %). it is estimated that injuries permanently disable around , children per year in bangladesh. nonfatal injuries occur in approximately million children per year or per minute (institute of child and mother health, ). when injury-related deaths are broken down by type and by age group, children aged - and - years are most likely to die from drowning with a mortality rate of per , and per , child deaths, respectively. in the - year age group, road traffic accidents account for per , child deaths, and in the - year age group, suicide accounts for per , child deaths. of the most important reasons for this apparent discrepancy is the high number of vulnerable road users in developing countries. vulnerable road users include pedestrians, cyclists, and both the rider and passenger of motorcycles and scooters. vulnerable road users account for % of deaths, and in low-income countries pedestrians account for nearly half of all road accident-related deaths. there are proven interventions that can lead to a reduction in the amount of road traffic deaths and injuries. such measures include controlling or reducing the speed of traffic with speed bumps or low-speed zones in urban areas, establishing and enforcing blood alcohol concentration limits, enforcing the use of helmets for both riders and passengers on motorcycles, and enforcing the use of seat belts, infant seats, and child booster seats. the wearing of seatbelts in automobiles can reduce front-seat passenger deaths by % to % and rear-seat passenger deaths by % to %; however, only % of countries require the wearing of seat belts by all passengers. the problem is that because of the high numbers of both people and different types of vehicles in developing countries and the lack of resources to police traffic effectively, traffic laws are not easily enforced, despite evidence showing the benefit of specific interventions in the reduction of traffic-related morbidity and mortality. occupational injuries are a significant problem in global public health, contributing to between , and , deaths worldwide each year. with great shifts in industrialization from the developed to the developing countries, it is logical that the highest number of occupational injuries is shifting in the same way toward the developing world. however, it is very likely that published figures are underestimated, with numbers probably being % below the actual figure for the united states and as much as % for some locations such as rural africa. , although several factors come into play when analyzing the causes of underreporting in developing countries, one of the main reasons is the lack of adequate data. determining the actual prevalence of occupational injury is critical for several reasons: ( ) to provide accurate data to health providers, policy makers, nongovernmental organizations (ngos), and the public; ( ) to provide baseline data against which to measure interventions; ( ) to aid priority setting and targeting for policy change and interventions; and ( ) to estimate societal costs of rising occupational injuries. tools to capture occupational injury have been designed and widely circulated by the un's specialized agency, the international labour organization. however, field testing of the tools has been limited to small-scale surveys in diverse settings such as vietnam, ghana, and bangladesh, - and larger, nationally representative studies are needed. in many developing countries, there is a lack of policy for or enforcement of safe working environments, which naturally means that wood cutting, mining, agriculture, construction, and manufacturing are more hazardous than in developed countries. the developed world has accepted that poor working conditions and practices are unacceptable and has legislated against them, leading to a reduction in occupational injuries over the past century. however, it seems that globally the same care has not been forthcoming, and developing countries have taken on the burden of heavy industry and poor working conditions that generate increases in occupational injuries. this trend is perfectly exemplified by the phrase "export of hazard" to describe when an outdated and dangerous technology is relocated from a high-income country to a developing country, despite the knowledge that the risk of injury with this technology is high. cost of production plays a key role in maintaining poor working conditions, and many industries in developing countries manage cost control through the use of manual labor, which is cheaper than the infrastructure and equipment needed to upgrade a process that produces the same amount of product at a much safer level. manual labor is particularly exploited in the construction industry in developing countries, which have a disproportionate number of deaths from workers falling and injuries from falling objects. working conditions at all levels of commerce are also full of risk factors to health, from the lack of ergonomically designed offices to avoid back injuries and repetitive stress disorders, to building materials used in construction, which may offer a long-term risk of health problems. the latter is of particular concern in many low-income and middle-income countries, with construction still making use of asbestos despite the documented links to lung cancer. , urbanization urbanization is a major public health challenge for the twenty-first century, with significant changes in our living standards, lifestyles, social behavior, and health. previously more of a phenomenon in developed countries; it is now taking hold and being seen at a greater level in developing countries. the united nations population fund (unfpa) predicts that over the next to decades, almost all the world's population growth will be in urban areas in developing countries. who figures for the period to already show an alarming increase in urban population growth, with developing countries' urban areas growing at an average of . million people per week or around , people every day. while urban settings offer many opportunities including access to better health care, they can affect existing health risks and introduce new health hazards. the living and working conditions of those living in rapidly expanding and poorly planned urban areas often experience risks to health in some of the most basic areas such as unsafe drinking water, unsanitary conditions, poor housing, overcrowding, hazardous locations, and exposure to extremes of temperature. these increases in health risks are particularly critical for those most vulnerable: children younger than years, infants, and the elderly. , the rapid growth of urban settlements is often due to poor economic performance of the area in question and lack of urban planning and regulation, which has resulted in an increase in the number and size of informal settlements or slums in many cities. it is estimated that in the developing regions, more than % of urban residents live in slums. the urban health situation the current pattern of urban growth is expected to have a multiplier effect on many dimensions of illness and disease. child mortality is already high in the urban areas of developing regions. in nairobi, where % of the city's population lives in slums, child mortality in these slums is . times greater than in other areas of the city. evidence from various surveys and studies points to a heavier burden of diseases such as diarrheal diseases, acute respiratory diseases, malnutrition among children, hiv/aids, tuberculosis, malaria, diabetes, and obesity on the urban poor. , , migration, increased mobility, changes in the ecology of urban environment, high population density, poor housing, and poor provision of basic services all act as pathways for emerging and reemerging communicable diseases. , the consequence of these changes is evident in the spread of multidrug-resistant strains of tuberculosis that is placing the urban poor of india, indonesia, myanmar, and nepal at a higher global health risk. vector-borne diseases such as dengue and malaria are also increasing in many urban areas, due to migration, climate change, stagnant water, insufficient drainage, flooding, and improper disposal of solid waste. , unhealthy lifestyles characterized by unhealthy nutrition, reduced physical activity, and tobacco consumption due to rapid and unplanned urbanization are associated with common modifiable risk factors for chronic diseases such as hypertension, diabetes mellitus, and obesity. urban environments tend to discourage physical activity and promote unhealthy food consumption. overcrowding, heavy use of motorized transport, poor air quality, and lack of safe public spaces are some urban factors that restrict participation in physical activities. in the larger populated cities of asia obesity is becoming a significant problem, and the rapid transition of diets in developing countries is typified by the coexistence of child malnutrition and maternal obesity in the same household. one of the main factors identified as causing an increase in diabetes worldwide is the change in traditional diets caused by urbanization. urbanization is exacerbating the health risks in terms of traffic accidents, injuries on the street or in the home, and mental health problems. the changes in climate and rising sea levels work toward increasing urbanization, with million people living in the low-elevation coastal zones being at heightened risk of flooding, which will lead to migration to higher elevations and larger cities. adopting preventive measures to control communicable diseases, upgrading the infrastructure of existing health facilities, increasing human resource capacity, and taking appropriate measures for providing equitable health services to all, especially the most vulnerable groups, are vital for improving urban health. recently, the who identified key areas of action for improving urban health: . promote urban planning for healthy behaviors and safety . improve urban living conditions, including access to adequate shelter and sanitation for all . involve communities in local decision making . ensure cities are accessible and age-friendly . make urban areas resilient to emergencies and disasters. however, these actions will only be effective if there is strong collaboration between health authorities, urban planning agencies, environmental agencies, energy providers, and the transportation systems. climate change is an emerging threat to global public health. it is now widely accepted that climate change is occurring as a result of emission of greenhouse gases, especially from fossil-fuel combustion. climate change is predicted to affect many natural systems and habitats, for example, increasing the frequency and intensity of heat waves, increasing the number of floods and droughts, altering the geographic range and seasonality of certain infectious diseases, and disturbing food-producing ecosystems, which in turn will affect human health both directly and indirectly. direct health effects include changes in mortality and morbidity, and changes in respiratory diseases from heat waves. in terms of indirect health effects, these are much more extensive and include changes in the distribution of vector-borne diseases, the nutritional and health consequences of regional changes in agricultural productivity, and the various consequences of rising sea levels, flooding, and droughts. [ ] [ ] [ ] climate change is highly inequitable, and the paradox is that those at greatest risk are the poorest populations in developing countries who have contributed least to koehlmoos et al greenhouse gas emissions. however, the rapid economic development and concurrent pollution means that developing countries are now vulnerable to adverse health effects from climate change and, simultaneously, are becoming an increasing contributor to the problem. , although the effects of climate change affect all levels and ages of any single population, the elderly and those with preexisting medical conditions are seen as being the most vulnerable. conversely, major diseases that are most sensitive to climate change such as diarrhea, malaria, and infection associated with malnutrition are most serious in children living in poverty, making them highly vulnerable to the resulting disease burden. heat waves are expected to increase the occurrence of heat-related illnesses such as heat exhaustion and heat stroke, and aggravate existing conditions related to circulatory, respiratory, and nervous system problems, especially among the elderly. , in , a major heat wave affected most of western europe and caused additional deaths in england and wales. another consequence of high temperatures is that they raise the levels of ozone and other air pollutants, which in turn aggravate respiratory diseases such as asthma. meanwhile, health impacts due to natural disasters, such as floods, droughts, and storms, range from immediate effects that include physical injury, mortality and morbidity, and communicable diseases, to possible long-term effects such as malnutrition and mental health disorders. from to , flooding was the most frequent natural disaster ( %), killing almost , people and affecting over . billion people worldwide. droughts increase the risk of food shortages and malnutrition, and increase the risk of diseases spread by contaminated food and water, because viral load increases in water sources when levels drop dramatically. rising temperatures, irregular rainfall patterns, and increasing humidity affect the transmission of many vector-borne and water-borne diseases such as malaria, dengue, cholera, and other diarrheal diseases. vector-borne diseases currently kill approximately . million people each year while . million die from diarrheal diseases. studies suggest that by , climate change may put million people in africa at risk of malaria, , and by the s the global population at risk of dengue is likely to increase to billion. , recent published data provides evidence of an association between the el niñ o and la niñ a phenomena, which are major determinants of global weather patterns, and some infectious diseases. evidence shows that there is an association between el niñ o and malaria epidemics in parts of south asia and south america, and with cholera in coastal areas of bangladesh. , studies of malaria have already revealed the health impacts of climate variability associated with el niñ o, including large epidemics on the indian subcontinent, colombia, venezuela, and uganda. one of the most immediate problems related to changes in climate and climate patterns is that on food production and availability. each year approximately . million people, mostly children from developing countries, die from malnutrition and related diseases. it is projected that climate change will decrease agricultural production in many tropical developing regions, thus putting tens of millions more people at risk of food insecurity and adverse health consequences of malnutrition. disasters in certain areas of high food production will also affect global prices, thereby affecting not only those people living in the affected region but others around the world who depend on food produced from that region. the who gbd study in indicated that the climatic changes that have occurred since the mid- s would be having an effect by the year , with , deaths ( . % deaths globally each year) and . million lost disability-adjusted life years (dalys) per year ( . % global dalys lost per year). the estimated effects are predicted to be most severe in those regions that already have the greatest disease burden of climate-sensitive health outcomes, such as malnutrition, diarrhea, and malaria. , , many of the projected impacts on health are avoidable, and public health policy makers need to act to reduce or negate the impact caused by climate change through a combination of short-term public health interventions that aim to adapt measures in health-related sectors, such as agriculture and water management, and long-term strategy. the most effective responses are likely to be strengthening of the key functions of environmental management, surveillance and response to protect health from natural disasters and changes in infectious disease patterns, and strengthening of the existing public health systems. , however, countries need to assess their main health vulnerabilities and prioritize adoptive action accordingly, keeping in mind the costs involved. natural disasters know no boundaries, and any nation or population can be subject to a catastrophic disaster at any time. however, some nations and populations are more at risk of disasters than others due to geographic location, poverty, and several sociopolitical factors. this issue of disaster risk reduction (drr) rose to global prominence in the aftermath of the tsunami in the indian ocean in december . following a disaster, some populations suffer more acutely than others. it is worth considering the complex issues of how societies organize themselves in terms of risk and actual prevention and care, for access to clean water and sanitation, and how they communicate and initiate behavioral change among the displaced or fragile populations. at the forefront of most discussions when planning post-disaster management and action is the priority placed on certain elements of disaster relief, such as the building of embankments, the distance to clean water, or the time from incident to response. recent examples of varying responses and outcomes were seen following the two cyclones in south asia. there was a relative success in bangladesh in terms of lives saved and response coordination after cyclone sidr in november , compared with the devastating loss of more than , lives after cyclone nargis in myanmar in may , not to mention the loss of draft animals and dykes, and the flooding of fields during planting season. bangladesh reverted to its welldeveloped program for drr that includes national-level coordination, whereas in myanmar there was no national platform for disaster preparedness, and delays occurred in the coordination of international response to the disaster. in addition to the immediate and obvious impact of natural disasters, conditions often worsen in poorly coordinated settings, as evidenced in when vibrio cholerae emerged in post-flood pakistan, and for the first time since the s in post-earthquake haiti. in general, there are factors that can turn a natural disaster into a complex disaster regardless of the severity or magnitude of the initiating event such as a hurricane, earthquake, or tsunami. according to the un department of humanitarian affairs, the factors are: poverty, ungoverned population growth, rapid urbanization and migration, transitional cultural practices, environmental degradation, lack of awareness and information, and war and civil strife. poverty is by far the single greatest factor that contributes to the vulnerability of a population to complex disasters. in addition to lacking financial resources to prepare for or recover from a disaster, impoverished people are also more likely to have low levels of education and low amounts of political influence to properly deal with a disaster situation. in addition to increases in birth rates, rapid population growth can be the consequence of urbanization or migration. population growth without limits produces a population that is more likely to settle in areas that are unsuitable or at risk for natural disasters, meaning that more people are at risk of disease and, most importantly, are more likely to undergo civil strife while competing for scarce resources. as mentioned previously, rapid urbanization and migration lead to impoverishment. former rural populations make themselves more vulnerable to disaster by settling in less developed or high-risk city environs, often leading to homelessness or living in urban slums that have circumvented any planning controls or regulations. such populations therefore are made more vulnerable to floods, landslides, and the destruction of their dwelling during a hurricane or earthquake. transition of cultural, economic, or government practices such as the increase in migration from rural to urban areas, economic advancements, families moving away from traditional support networks and to unfamiliar surroundings, and the shift from an agrarian to an industrialized society leave certain societies vulnerable to natural disasters. environmental degradation can play a role by either causing or exacerbating a disaster. for example, deforestation can work in two ways: firstly enabling runoff or secondly, making landscapes vulnerable to storms, due to lack of natural wind breaks. everyone is aware of the natural conditions that provoke droughts, but through the construction of dams, unchecked urbanization, implementation of poor cropping patterns, and the depletion of water supplies, man-made droughts are becoming more widespread. it is clearly of upmost importance to ensure that populations are informed about what to do to prepare in advance of a natural disaster such as a hurricane, and also are able to fend for themselves following the event. a lack of awareness and the dissemination of accurate information is a major factor that can turn one disaster into a multiple or complex disaster involving, for example, subsequent outbreaks of cholera, malnutrition, and physical injury. war and civil strife are extreme events that can both produce disasters or be caused by disasters, normally as a result of the preceding factors. the phrase for disasters that specifically strike war-torn populations is complex humanitarian emergencies. global efforts to address and capture the importance of disaster risk and poverty have been hampered by a lack of data, especially from asia, latin america, and the caribbean. empirical evidence linking disaster risk to poverty tends to come from microstudies within one community, making it impossible to generate generalized findings across regions or entire countries. prompted by the devastation that followed the tsunami on december, , there was widespread acceptance that an early-warning system should be installed and other actions taken to prevent loss of life where possible. the world conference on disaster reduction was held in japan in january , and resulted in the creation of the hyogo framework for action - (hfa), which was endorsed by un member states and urges all countries to make major efforts to reduce their disaster risk by . the hfa outlines the need to increase awareness and understanding about drr, the importance of knowing the real and potential risks, and taking action against them. specific recommendations included the need to create or enhance early-warning systems, build drr into education, and reduce risk factors such as deforestation, unstable housing, and the location of communities in risk-prone areas. although different areas of the planet experience different risks, the one common factor is that drr "concerns everyone, from villagers to heads of state, from bankers and lawyers to farmers and foresters, from meteorologists to media chiefs." to support common needs within regions, associations and networks have been established to support drr, such as the south asian saarc disaster management center and the caribbean disaster emergency response agency. types of activities that can feature in a national or regional drr program can include: establishing early-warning systems; using local knowledge of events; building an awareness of risk and risk preparedness through community activities; building flood-resistant buildings and safe homes; developing contingency plans; helping communities and individuals develop alternative sources of income; and establishing insurance or microfinance programs to help transfer the risk of loss and provide additional resources to the community. in addition to chronic diseases, mental health problems, injuries, and complex disasters, communities should consider increasing risks from more than new or reemerging diseases that have appeared since the s: liver disease due to the hepatitis c virus; lyme disease; food-borne illnesses caused by escherichia coli o :h ; cyclospora, a water-borne disease caused by cryptosporidium; hantavirus pulmonary syndrome; and human disease caused by the avian h n influenza virus. the increasing number of new and reemerging diseases is not the only risk factor that should be added to the planning processes for developing a drr program. drug resistance in treating many diseases and illnesses is a major concern, as witnessed in malaria and tuberculosis, and with a highly mobile world population, global pandemics such as sars, h n , and h n , for which treatments either are not available or levels of suitable drug are clearly not sufficient for a worldwide epidemic, are proving to be very challenging. this clear inability to predict and maintain sufficient levels of treatment for potential threats makes health risk reduction extremely difficult, and in developing countries where resources are already stretched to cope with existing health issues, creating effective programs will require intervention from social partners, global support organizations, and aid from the developed world. an ever quickening pace of globalization means that public health-related problems in one area of the world will have an impact on those living in another area and therefore, it is in everyone's interest to ensure that all countries, irrespective of their economic development and available resources, are sufficiently supported to maintain and review strategies that will effectively reduce morbidity and mortality rates in all spheres of public health. preventing chronic diseases: a vital investment a race against time: the challenge of cardiovascular disease in developing economies non-communicable diseases: time to pay attention to the silent killer. press release missing in action: international aid agencies in poor countries to fight chronic disease when people live with multiple chronic diseases: a collaborative approach to an emerging global challenge the developmental origins of chronic adult disease world health organization framework convention on tobacco control [who fctc]. guidelines for implementation 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evolution of complex disasters united nations-international strategy for disaster reduction united nations-international strategy for disaster reduction [un-isdr] living with risk. a global review of disaster reduction initiatives disaster risk management and climate change adaptation in south asia. dhaka: portfolion new and reemerging diseases: the importance of biomedical research key: cord- -v pvlka authors: navajas-romero, virginia; díaz-carrión, rosalía; casas-rosal, josé carlos title: comparing working conditions and job satisfaction in hospitality workers across europe date: - - journal: int j hosp manag doi: . /j.ijhm. . sha: doc_id: cord_uid: v pvlka job satisfaction is important in the tourism sector since workers’ satisfaction is key to providing high-quality service, which is very important in determining organizational success. the working conditions that influence job satisfaction depend to a large extent on the institutional context, which shows similarities in some european countries. this research aims to compare working conditions and job satisfaction among european country blocks that have similar institutional characteristics. unlike previous studies, this research adopts a comprehensive approach by considering institutional and organizational factors in the analysis of employees’ perceptions of job satisfaction. the sample is made up of workers in european countries. the results demonstrate the existence of three different models of working conditions in europe leading to differing levels of job satisfaction in tourism. these models do not correspond to the clusters identified by the previous literature, which adopts an institutional perspective. and internationally (lee and chelladurai, ) in different sectors such as in banking and the public or hospitality sector (ariza-montes et al., ; kong et al., ) . most of these studies were conducted without taking into account the institutional context. economic conditions, unemployment rate, and national level of inequality of a national territory, among other institutional factors, generate similar working conditions among countries in terms of salaries, working hours, job security, and flexibility (posada-kubissa, ; tangian, ) . working conditions are particularly context-sensitive due to their strong linkage to the industrial relations system of a country, unemployment rate, etc. (van dierendonck et al., ) . despite the existence of a supranational government in the eu, the institutional context differs across countries, and therefore working conditions and employee satisfaction are also different across europe. previous studies have classified countries according to their institutional context and identify different models of human resource management in europe (e.g., brewster and tregaskis, ; ignjatović and svetlik, ; nikandrou et al., ) . it is interesting to complement these studies that present an institutional focus with a perspective centered on organizational practices and employees´perceptions. for employment practices to create value for companies and society, they must generate job satisfaction. due to the importance of job satisfaction at individual, organizational, and societal levels, including employeesṕ erception of their job satisfaction, the analysis becomes crucial. a deep understanding of the differences in job satisfaction across europe could set the basis for a deeper discussion and formulation of novel hypotheses regarding the influence of institutional factors on working conditions. this understanding could lead companies and policy-makers to propose policies for improving working conditions in order to enhance job satisfaction and social welfare. although some studies that compare job satisfaction across european countries can be found in the literature (e.g., eskildsen et al., ; millán et al., ; pichler and wallace, ) , comparisons are made across national territories without considering the homogeneity that may exist among european countries. according to the literature, these countries can be grouped by blocks according to the similarities in their approach to the welfare state-which impacts, among its main facets, working conditions. the welfare state model of each country is determined, among other aspects, by public policies, labor regulation, and organizational practices-fundamentally, human resources management practices. hence, the literature establishes blocks of countries based on their similarities in their institutional setting and their prevailing organizational human resources management models (e.g., albareda et al., ; brookes and barfoot, ; filella, ; ronen and shenkar, ; tangian, ) . the underlying premise is that there is some convergence toward homogeneity of these characteristics of countries within the same cluster and differences with respect to the rest of the blocks. studies that analyze whether this convergence leads to homogeneity in workers´perception of labor conditions and job satisfaction across europe are rare. this study tries to contribute to this end by exploring working condition models in europe from an organizational perspective and considering workers´perceptions. this might allow identification of possible deviations between the institutionally established regulations at the national or supranational level and the patterns of interaction of the workers and organizations in the labor market. this can help us understand which models lead to higher levels of job satisfaction and whether there is convergence in this aspect in the european context. the research seeks: (i) to analyze the different models of working conditions-what likely leads to differences in perceived job satisfaction-that exist in europe; and (ii) to explore whether these models differ among the clusters of countries based on institutional characteristics identified in the previous literature. from these objectives, the following research question is derived: does the clustering of european countries according to institutional characteristics correctly reflect the differences in labor conditions and subsequently job satisfaction across europe? this article is divided into six sections. first, a review of the relevant literature is presented in the second section. next, the methodology of the research and the results are explained in the third and fourth sections. finally, a discussion of the results and the conclusions, which includes the limitations and suggestions for future research, are detailed in the fifth and sixth sections. job satisfaction is an essential aspect for firms to gain a competitive advantage in all sectors, given the central role that employees play in business success (kramar, ) . however, despite the importance of job satisfaction, there is no general agreement regarding its definition. different authors have contributed to its clarification. among the mostcited definitions is the one given by spector ( ) , who emphasizes that job satisfaction refers to the way employees feel about their job and depends on different factors. mahdieh and sotoudehnama ( ) affirm that job satisfaction depends on factors such as personal, organizational, managerial, academic, professional, and economic variables. goetz et al. ( ) underline four factors as determinants of job satisfaction: professional development, interpersonal relations, economic expectations, and working conditions. there are principally two methodologies for assessing job satisfaction: the integral measurement of a single factor and the comprehensive multidimensional measurement. the difference between the two methods lies in the fact that while the former relies on a single item to measure job satisfaction, the latter employs several factors. most research on job satisfaction at the national level adopts a multidimensional measurement approach. for instance, the descriptive work index (jdi) developed by locke et al. ( ) includes different dimensions of the job such as promotion, payment, and relationships with managers and colleagues. spector ( ) created a job satisfaction survey (jss) that contains nine dimensions: salary, promotions, additional benefits, incentives, superiors, colleagues, operating environment, intrinsic work characteristics, and communication. parent-thirion et al. ( ) developed their job quality index (jqi) from seven variables (earnings, prospect, social environment, physical environment, work intensity, skills and discretion, and work time quality) that are related to the multidimensional nature of work. the jqi has been considered for the present investigation because it is comprehensive in coverage, transparent in method, and widely employed in the research on job satisfaction and the quality of work in the european context (e.g., erro-garcés and ferreira, ; punzo et al., ; soriano et al., ) . it is the basis for the development of the sixth european working conditions survey (ewcs) which, according to grimshaw et al. ( ) , yields solid and reliable information. in , the eu launched the european employment strategy with the aim of creating more (quantity) and better (quality) jobs (ariza-montes et al., ) . ewcs asks workers about the intrinsic characteristics of their jobs: salary, hours, participation, organization, and security, among others. the ewcs has been used in previous studies in which the impact of working conditions on satisfaction is analyzed, but using different perspectives such as new technologies (castellacci and viñas-bardolet, ) , gender issues (brinck et al., ; gómez-baya et al., ) , and workers' age (berde and rigó, ; okay-somerville et al., ) . the tourism sector is characterized by high levels of seasonality, which leads to labor practices that do not favor workers' commitment and permanence in the company in the long term (hofmann and stokburger-sauer, ) . the characteristics of the job positions in the tourism sector are related to higher levels of job dissatisfaction compared to other industries, which explains why more than half of the workers in the tourism sector are dissatisfied and consider moving to other sectors (stamolampros et al., ) . factors explaining the low levels of job satisfaction observed in the tourism sector are related to characteristics of job positions and to the lack of professionalization of the human resources management in this industry (jovanović et al., ; lillo-bañuls et al., ; zopiatis et al., ) . on the one hand, the characteristics that make this sector present low levels of job satisfaction compared to other sectors are related to low salaries (earnings), long working hours (work intensity), low job security, and the scarcity of promotional possibilities (prospects) (zopiatis et al., ) . the low work time quality of the jobs in the tourism sector is associated with the continuous relationship with customers, shift work, unsocial hours, and night work (lillo-bañuls et al., ) . this, together with the scarcity of occupational health and safety practices that favor an adequate physical environment, make employees working in this sector experience difficulties maintaining a work-life balance and a healthy lifestyle that would prevent stress and not lead to low levels of job satisfaction (hofmann and stokburger-sauer, ) . this stress is increased by the lack of perceived organizational support and autonomy that characterize jobs in the tourism industry (loi et al., ; tongchaiprasit and ariyabuddhiphongs, ) . the low levels of employee recognition, centralization in decision-making, and presentism that characterize this industry are associated with a lack of professionalization of human resources in the tourism industry (nickson, ) . the degree to which employees perceive social support from their superiors (the quality of the social environment at work) and are provided with autonomy to perform their job (skills and discretion) highly determine employees' level of satisfaction and work engagement since the social support of managers and supervisors influence workers´perception of justice at the workplace (jovanović et al., ) . to obtain a comprehensive view of job satisfaction and its antecedents in the tourism sector, different dimensions must be considered. this study combines different factors that determine the quality of work (earnings, prospect, social environment, physical environment, work intensity, skills and discretion, and work time quality) to provide a holistic view of working condition that allows the comparison of the quality of work and the level of job satisfaction across europe by relying on the employee's own perspective. the eu´s regulations favor workers' mobility within europe. labor mobility is the result of different levels of national unemployment rates, salary level, flexibility, etc. (fahri and werning, ) . taking into account that the quality of employment varies across european countries, factors that strongly explain workerśmobility and differences in job satisfaction depending on the country can be observed, as indicated in the literature (e.g., leineweber et al., ; salpigktidis et al., ; thite et al., ) . these differences can be explained by the distinct institutional settings of each territory (salvatori, ) . as derived from the premises of institutional theory, coercive pressures-especially national regulations-highly determine human resource management practices, so they might lead to differences in working conditions across countries (western, ) . the different labor legislations across european territories, despite european countries sharing a supranational government, influence working conditions and job satisfaction (brewster and hegewisch, ) . according to institutional theory, in addition to the coercive pressures exerted by legislation in a country, there are normative pressures, which are related to the appropriate and desirable norms of behavior for both organizations and individuals that predominate in a country (acemoglu and johnson, ; dimaggio and powell, ; scott, ) . these pressures also vary across territories and can be determinant in working conditions. countries that present similar institutional contexts-that show similar coercive and normative pressures-might present differences in terms of employee job satisfaction. this could be the case in countries such as denmark and norway, which present both institutional and cultural similarities but significantly differ in their working conditions (bech et al., ) . reviewing the literature, it can be observed that previous research has made efforts to identify blocks of european countries according to their institutional context (e.g., albareda et al., ; brookes and barfoot, ; filella, ; ronen and shenkar, ; tangian, ) . one of the most commonly used classifications identifies four clusters of countries in europe: anglo-saxon (ireland and the united kingdom), central european (austria, belgium, germany, the netherlands, and switzerland), latin (france, greece, italy, portugal and spain) and nordic (denmark, finland, norway and sweden) (filella, ; ronen and shenkar, ) . numerous aspects of institutional context determine working conditions. pichler and wallace ( ) emphasize the key role played by four institutional factors in working conditions: economic conditions, unemployment rate, the national level of inequality, and the degree of unionization. economic conditions of a territory highly impact the labor market in terms of job rewards in both extrinsic (average wage level, working hours, etc.) and intrinsic terms (meaningful, high-skilled jobs, etc.). the national unemployment rate and the national level of inequality also influence working conditions and job satisfaction. high levels of unemployment hinder job mobility regardless of a workers' level of satisfaction. employees, even those who are dissatisfied, will remain in their jobs because of the lack of opportunities in the labor market. the scarcity of job opportunities and the excess of job demand might lead employers to offer poorer conditions in terms of salary, working hours, etc. socio-economic inequality is also a determinant of job dissatisfaction if employees perceive that similar jobs lead to great differences in economic outcomes. the degree of unionization in a country seems to be highly determinant of the average wage level and other conditions of work that influence the welfare of employees. in highly unionized countries, employees are more likely to find better jobs in terms of salary, working hours, etc. accordingly, working conditions are generally better in countries that present a solid economic situation, a low unemployment rate, and a high level of unionization. this is the case for companies in the nordic cluster, which have good working conditions in comparison with the rest of european companies (eskildsen et al., ) . this can be explained by the high level of trade union intervention in those countries, where labor reforms encourage workers' representatives to negotiate working conditions with trade unions. as indicated in the literature, another institutional characteristic that determines working conditions is the country level of regulation (gialis et al., ; keune and jepsen, ) . the level of regulation is closely related to the level of flexibility in the labor market and to the degree of job security (posada-kubissa, ). labor flexibility is negatively associated with job satisfaction and employees´physical and psychological health since flexibility is associated with low levels of job security (carr and chung, ; probst et al., ) . flexibilization comes from deregulation; job security pursues the maintenance of social advantages through a compensatory system. both depend on the country and are not only affected by economic conditions, but by collective agreements, and by the agents involved: governments, employers, and trade unions (tangian, ) . in this line, sapir et al. ( ) identified four different social systems within europe according to the level of flexibility of each country. gil-alana et al. ( ) affirm that a robust social security system is associated with low levels of inequality. from the aforementioned two premises are derived: (i) that the institutional context strongly influences working conditions and that these become a determinant factor in job satisfaction (williams and hall, ) ; and (ii) that since institutional pressures are similar in each country block-anglo-saxon, central european, latin, and nordic-similar working conditions within each cluster (intra-group similarities) and differences across clusters are expected (inter-groups differences). this is because, among other aspects, government regulations determine an organization's freedom of action regarding employees' minimum wages, training and development investments, working hours, etc. (vaiman and brewster, ) . although the influence of the institutional context on working conditions is expected, companies' freedom of action within the framework of labor regulations is also expected to determine working conditions. in this way, workers in the tourism sector of countries with similar institutional settings could present discrepancies in their working conditions and, subsequently, in their job satisfaction. providing evidence about this would justify the need to group countries according to their working conditions model, a categorization that would more accurately show the reality of the labor market from an employee's perspective. in order to address the research objectives, the methodology used to develop the empirical analysis is presented below. to investigate differences in job satisfaction and in the quality of work among countries that show significant institutional differences, we have focused on the tourism sector due to the relevant role it plays in the european economy. the data used for the research were extracted from the sixth ewcs (the most recent available). this survey contains data on , working individuals years old or older residing in private homes in one of the european countries studied ( countries of the eu; albania; the former yugoslav republic countries of macedonia, montenegro, and serbia; and turkey). this survey was developed by the european foundation for the improvement of living and working conditions ( ) (dependent on the european commission) to obtain information on the quality of work and employment in europe. to perform the analysis, countries that present significant institutional and organizational differences were selected (filella, ; ronen and shenkar, ) . the sample includes the following countries and country clusters: the united kingdom and ireland (anglo-saxon); austria, belgium, germany, the netherlands and switzerland (central european); france, greece, italy, portugal, and spain (latin); and denmark, finland, norway and sweden (nordic). the sample used in this study is formed of employees of european countries that work in the tourism sector. table shows the number of observations for each country cluster. to select workers from the tourism sector, the statistical classification of economic activities in the european community, nace codes were used. according to eurostat, the following codes were included as part of the tourism sector: (passenger rail transport and interurban); (other passenger land transport); (sea and coastal passenger water transport); (inland passenger water transport); (passenger air transport); (hotels and similar accommodation); (holiday and other short-stay accommodation); (campgrounds recreational vehicle parks and trailer parks); (restaurants and mobile food service activities); (beverage serving activities); (rental and leasing of personal and household goods); (travel agency and tour operator activities); and (other reservation service and related activities). filtering by these criteria, employees ( . % of , ) made up the sample. we based our research on the sixth edition of the ewcs, which includes the dimensions of the european jqi developed by parent-thirion et al. ( ) . this index is formed of seven dimensions that determine working conditions: earnings, prospects, social environment, physical environment, work intensity, skills and discretion, and work time quality. all the constructs used in the analysis except salary (expressed in euros) and job satisfaction (expressed on a four-point likert scale) are numerical variables expressed on a scale of values between and . according to parent-thirion et al. ( ) , the constructs were defined as follows: earnings: the importance of earnings as a motivational factor has been widely studied in the literature (suzuki et al., ) . this construct is defined as the net hourly earnings of workers. prospects: this refers to the job characteristics that contribute to a person's material and psychological needs, encompassing the need for income and for employment continuity. de witte et al. ( ) point to these factors as determinants of job satisfaction. skill and discretion: this dimension refer to the skills required for the job and the level of job autonomy. both are pointed to in the literature as relevant factors influencing job satisfaction since they enhance job identification and commitment (fregin et al., ; mateos-romero and del mar salinas-jiménez, ) . social environment: this dimension measures the social support perceived by employees (good social relations with line managers and fellow workers) and the absence of abuse in the company, which becomes especially important for workers' welfare as it moderates the negative impact of stressors (wisse et al., ) . this construct includes two constructs: adverse social behavior and social support. physical environment: this dimension refers to environmental hazards and to factors related to posture-related risks, which become relevant factors in the health of employees, a fundamental aspect of job hygiene and satisfaction (devonish, ; koh et al., ) . work intensity: this dimension refers to the intensity of work demands. high work intensity is associated with a risk of suffering high levels of occupational stress, which in turn is associated with low levels of job satisfaction (iranmanesh et al., ; rushton et al., ) . work time quality: this dimension refers to the organization and length of working time. the number of working hours, shift work, night work, etc., are determinant for the achievement of a good work/life balance, subsequently playing a significant role in job satisfaction (eagan et al., ; roy, ) . job satisfaction: the level of satisfaction is a variable included in the sixth ewcs survey and is measured as a four-point likert scale. the question is: "in general, are you very satisfied, satisfied, not very satisfied or not at all satisfied with your working conditions?". all the items used for the construction of the variables are included in the sixth ewcs and are shown in the appendix, together with the results of the reliability tests obtained with the cronbach alpha coefficient for the tourism industry. the main objective of the empirical analysis is to determine whether the classification of countries based on the institutional context adequately reflects the different models of working conditions-and subsequently differing levels of job satisfaction-existing in europe in the tourism sector, and if not, to propose a more appropriate classification of countries. to do this, based on the classifications of filella ( ) and ronen and shenkar ( ) , a comparison of working conditions among countries of the same clusters (intra-group comparison) is made. the existence of a high heterogeneity among countries of the same block would indicate an inappropriate grouping of countries located within the same institutional block. this analysis will be completed with an inter-group comparison, in which a high homogeneity in the working conditions of countries of different blocks would indicate a reduced discriminatory capacity among the blocks. therefore, a high intra-group heterogeneity and a reduced inter-group heterogeneity would allow us to conclude that the classification made by previous studies does not correctly classify countries according to the labor conditions perceived by workers. next, through a two-step cluster analysis, a new classification is proposed that improves intra-group homogeneity and inter-group heterogeneity. the suitability of this new group of countries will be evaluated using the methods previously described. the normality of these variables was previously checked for the selection of the method of analysis. to address the research objectives, both inter-group and intra-group differences have been analyzed for both job satisfaction and working conditions. first, the analysis of intergroup differences-among country blocks-has been performed using the mann-whitney test. this technique allowed a comparison of the level of job satisfaction among country clusters (anglo-saxon, central european, latin and nordic). second, the existence of significant intragroup differences among countries within the same cluster in the level of job satisfaction have been studied using the mann-whitney and kruskal-wallis tests due to the ordinal nature of this variable. as the mann-whitney test can only be used to make comparisons between two groups, it has been employed to test the intra-group differences in the level of satisfaction within the anglo-saxon cluster (between ireland and the united kingdom). since the kruskal-wallis test allows comparing more than two groups, it was used to analyze the existence of intra-group differences for the central european, latin, and nordic clusters. working conditions have also been compared among country blocks (inter-groups) and among countries within the same block (intragroups). first, the analysis of inter-group differences in working conditions has been performed using the t-student test. this technique allowed the comparison of the working conditions among all the country blocks. second, as working conditions (earnings, prospects, social environment, physical environment, work intensity, skills and discretion, and work time quality) are numeric variables and normally distributed, t-student and analysis of variance (anova) have been used to analyze the intra-group differences. as the t-student test can only be used to compare two groups, it was employed to analyze the intragroup differences of working conditions within the anglo-saxon cluster. as anova allows comparisons among more than two groups, it was used to assess the existence of intra-group differences among the central european, latin, and nordic blocks. the effect sizes have been estimated with the statistic proposed by rosenthal ( ) for the mann-whitney contrasts ( . , . , and . are used to indicate small, medium, and large effect sizes); cohen's d statistic for t-student contrast ( . , . , and . are used to indicate small, medium, and large effect sizes), and η statistic for the anova test ( . , . , and . are used to indicate small, medium, and large effect sizes) proposed by cohen ( ) . a statistic is used for the kruskal-wallis test ( . , . , and . are used to indicate small, medium, and large effect sizes) (tomczak and tomczak, ) . the existence of significant intra-group differences and limited differences among blocks of countries that present different institutional settings justifies the need for a new classification of european countries. to create this new grouping, a two-step cluster analysis has been developed. to confirm the validity of the proposed clusters, the intra-group and inter-group differences in the level of job satisfaction and in working conditions have been analyzed using the same statistical techniques previously explained. the descriptive analysis of the data shows that the average age of employees of the sample is heterogeneous, standing at just over years, with a standard deviation of . years. the male gender is slightly predominant; they represent . %, compared to . % of women, which contrasts with the existing proportion in this sector at the european level, where these proportions are inverse. secondary education is the predominant level of education among workers in the sample ( . %), followed by university studies ( . %), and primary education ( . %). the most represented sub-sectors in the sample are "beverage serving activities," which represent the majority group ( . %), "passenger rail transport and interurban" and "other passenger land transport" ( . %), and accommodation ("hotels and similar accommodation," "holiday and other short-stay accommodation," and "campgrounds recreational vehicle parks and trailer parks") ( . %). following the international standard classification of occupations (isco- ) based on oecd ( ), . % of the workers in the sample are "white collar" employees, of which less than a quarter are highly qualified. within the "blue collar" employees-who represent . % of the total sample-only . % are considered highly qualified. presuming that the institutional environment is a factor that could significantly affect the degree of satisfaction of workers, in particular those who work in the tourism sector, we have explored the levels of job satisfaction across country blocks that present institutional differences. using the mann-whitney test, we analyzed the differences among working conditions in country blocks with different institutional contexts. the results show that there are mainly significant differences in the level of satisfaction in the latin countries with respect to the rest of the blocks, while the differences among the rest of the blocks are not significant. in addition, the effect size is very small, even in the case where the differences are significant (table ) . hence, there is a high homogeneity in job satisfaction across country blocks that present different institutional settings. when analyzing the intra-block differences, within the nordic cluster, denmark and finland do not present any unsatisfied employees. about % of employees present high and medium-high levels of satisfaction in austria and switzerland (within the central european cluster), the latter not presenting any unsatisfied employees (see table ). the analysis of intra-group differences shows that these differences are significant; therefore, a lack of homogeneity in job satisfaction among countries in the same block is observed, mainly in the central european and nordic blocks, in which the effect size is medium. inter-groups differences in job satisfaction. mann-whitney test. p-value (effect size). accordingly, differences in the degree of job satisfaction among countries within the same block are found, indicating high intra-group heterogeneity. the differences in working conditions among the blocks of countries identified in the literature-based on their institutional characteristics-were also studied. the results show that the latin cluster presents significant differences with respect to the rest of the blocks in all the analyzed variables (except the social environment variable), with some effects of medium size. the results show the absence of significant differences between the anglo-saxon cluster and the central european block in all the variables studied. the same is observed when comparing the former with the nordic group, except in the labor expectations and the physical environment variables, although with a small effect. the differences between the nordic and the central european blocks are reduced since, in addition to finding differences in the previous variables, significant differences are also observed in the skills needed to develop the work, although with a small effect (see table ). hence, there is a high homogeneity in the working conditions across country blocks that present different institutional settings. comparing the working conditions of the countries within each cluster, ireland and the united kingdom (anglo-saxon block) show a great homogeneity in all variables except salaries-workers in the tourism sector in the united kingdom receive higher salaries than in ireland. however, differences among countries of the same block are significant if we analyze the rest of the blocks, as can be extracted from the results of the intra-group anova test (see table ). among the nordic countries, significant differences are observed in the prospects, physical environment, work intensity, and skills and discretion variables. the differences found among the countries of central europe are also significant. a high disparity in wages across countries within this block can be observed, motivated by the high average salary in switzerland, followed by the significant differences in job prospects, in the social environment, and in the skills required for the jobs. hence, the results indicate the existence of a high degree of heterogeneity in the working conditions of countries within the same block. based on the previous results which show differences in working conditions among the countries of the same block and scarce differences among blocks established according to their institutional characteristics (with the exception of the latin cluster), we propose the creation of a classification of countries according to the similarity in their working conditions in the tourism sector, specifically from the seven jqi dimensions (earnings, prospects, social environment, physical environment, work intensity, skill and discretion, and work time quality). to create this new clustering, a two-step cluster analysis was performed (see table ). the results of the cluster analysis show that, on the one hand, there are countries such as greece and spain (group ) that show worse working conditions and, consequently, lower levels of job satisfaction in comparison with the rest of the countries. at the other extreme are denmark, finland, france, and sweden (group ), which present the most advantageous working conditions and the highest degree of job to confirm the validity of these results (average silhouette value is greater than . ), the working conditions of the groups created and the job satisfaction among blocks and within blocks are analyzed. regarding the latter, significant differences between clusters in terms of working conditions and job satisfaction are observed (see table ). comparing job satisfaction among blocks, significant differences are observed. likewise, analyzing the working conditions among blocks, differences among all of them exist, with the exception of clusters and , which show similarity in their work time quality; and between clusters and , which show similarity in physical environment and work intensity. there is a high heterogeneity in the variables related to working conditions in the three groups identified, endorsed by mediumhigh effect sizes in many of the comparisons that are also higher than the effects found in the original blocks identified in the literature. regarding the differences across countries within each cluster, it can be observed that there are no significant differences in job satisfaction among the countries that are part of the same block (see table ). regarding working conditions, a high degree of homogeneity is observed. countries in groups and show the greatest homogeneity in working conditions. although there are significant differences, especially in group , the effect sizes are small. this is observed in the anova test (except in earnings and, to a lesser extent, in prospects in group ), and in the rest of the tests performed, as shown in table . the workers in the three defined blocks are homogeneous in terms of characteristics such as age, gender, seniority in the company, and the percentage of self-employed people, as shown in table . studying the working conditions of each block, a great disparity between the salaries of groups and is observed. the group composed of greece and spain presents lower values in all variables except social environment and work intensity. groups and show similar results, but working conditions are slightly more favorable in group . this group presents better results with respect to the rest in skills and discretion, intensity, and prospects, while group shows more favorable conditions in the social environment and physical environment dimensions with respect to the rest. this research identifies a novel grouping of european countries according to the working conditions prevailing in the tourism sector. the differences among country clusters are manifested in different levels of employee satisfaction since the institutional context greatly influences working conditions, which in turn determines job satisfaction (salvatori, ; western, ) . despite the relevant role of the table proposed country blocks according to their working conditions in the tourism sector. group austria -belgium -germany -italy -ireland-netherlands -norway -portugal -switzerland -united kingdom group denmark -finland -france -sweden group greece -spain variables group group group work intensity physical environment work time quality prospects skills and discretion social environment earnings institutional context-where planning and policymaking occur-in shaping working conditions, this issue has received little attention in the literature on tourism. studies focused on institutional context and working conditions and job satisfaction in the tourism industry are rare. according to western ( ) , working conditions are highly influenced by national regulations-and especially by labor regulations-and therefore by the institutional context. the strength of unionization becomes an important factor influencing job satisfaction because employees' wellbeing is highly determined by salary and work intensity, among other working conditions, which are especially influenced by the levels of unionization (pichler and wallace, ) . since strong unionization in a country can lead to better working conditions, the relevance of the institutional context as an antecedent of working conditions and job satisfaction must be highlighted. classifying european countries according to their working conditions can set the basis for a deeper understanding of the factors that determine job satisfaction in the tourism industry in different territories. as has been concluded from the analysis, a classification of countries based on their institutional characteristics as proposed by the previous literature (e.g., albareda et al., ; brookes and barfoot, ; filella, ; ronen and shenkar, ; tangian, ) does not group countries correctly according to working conditions and job satisfaction perceived by workers. few differences in worker satisfaction among countries that have different institutional settings and large differences among countries of the same institutional context have been found. similarly, countries of different institutional environments have similar working conditions, while countries of the same context present large differences in working conditions. these results point to the need to propose a new classification or clustering of european countries according to their prevailing working conditions and job satisfaction levels. although the comparison of job satisfaction across european countries has been studied by academics, previous studies have analyzed individual countries without considering the existence of homogeneity among countries and the existence of differentiated blocks in terms of their institutional setting. this research proposes a novel classification of countries according to prevailing labor conditions in each territory-what marks differences in job satisfaction across country clusters. one of the key aspects that determines working conditions is labor flexibility, and this depends to a large extent on institutional context (posada-kubissa, ) . tangian ( ) affirms that policies that enhance flexible employment are incompatible with achieving employment security. carr and chung ( ) propose that in countries where the levels of labor flexibility are high, employment security policies should be implemented to increase employees' security. therefore, different levels of employment protection and labor flexibility determine different social systems. despite the eús supranational government, there are differences in social systems across countries (brewster and hegewisch, ) . sapir et al. ( ) identified four social models in europe, each emphasizing security versus flexibility to a different extent: flex-insecure, inflex-secure, inflex-insecure, and flexsecure. according to our analysis, group corresponds to two groups of inflexible countries according to sapir's classification: the continental cluster (inflexible and secure: austria, belgium, germany, italy, norway, the netherlands, and switzerland) and the countries included in the anglo-saxon block (inflexible and insecure: ireland, portugal, and the united kingdom). the former are countries characterized by high income inequality, low-wage jobs, high levels of employment protection, low job security, and by early retirement pensions (sapir et al., ) . according to the previous characteristics and inspired by sapir et al. ( ) , we propose to call group as inflexible group. according to probst et al. ( ) , this model was considered to be effective in reducing poverty but ineffective in job creation in the long term. on the contrary, the anglo-saxon model is characterized by low-wage jobs, low job security, and high levels of income inequality. this model was effective in creating employment opportunities but ineffective in reducing poverty. group resulting from our analysis corresponds to the scandinavian model (denmark, finland, france, and sweden) . this country cluster is characterized by a robust social security system. although job protection is low, employment security is high in comparison to the rest of the blocks. this model enhances job creation and a high standard of living. the countries grouped in this cluster present similar levels of employment protection and low levels of inequality (gil-alana et al., ) . therefore, following sapir et al. ( ) , we propose to call this country block as flex-secure. group resulting from our analysis, the so-called mediterranean working conditions and demographic characteristics in the proposed blocks. model (greece and spain), emphasizes employment protection and early retirement pensions (probst et al., ) . inspired by sapir et al. ( ) , this cluster could be called flex-insecure because both countries in this group show high levels of flexibility and insecurity. according to our results, greece and spain show homogeneity in their working conditions. these countries experienced a deep recession after , leading to an economically inferior position within europe. they are characterized by their weak institutions and the fiscal balance programs that have been implemented by their governments following the recession. both countries have been highly affected by prolonged austerity policies and present the highest levels of unemployment in comparison to other european countries ( . % in greece and . % in spain), according to eurostat ( ) . this can be an important factor that determines the differences found in this research in comparison with the blocks identified by the literature, which groups these two countries according to the institutional and organizational characteristics. while filella grouped italy, france, and spain within the mediterranean cluster in , the socioeconomic development of each country has been different in the past decades. while france and italy have improved their working conditions, spain has remained among the countries with low job security and high flexibility in its labor market, which is reflected in the lowest levels of job satisfaction, showing more similarities to greece in terms of working conditions and job satisfaction than to italy and france. two main motivations led us to focus our analysis on the tourism sector: its high weight in the economy of european countries (world tourism organization, ) and its characteristics that entail high levels of precariousness (jovanović et al., ) . the results of the empirical analysis show that classifying countries according to their institutional setting does not properly reflect the differences in working conditions and job satisfaction across europe. this study proposes a novel classification of european countries according to working conditions in order to understand the differences in job satisfaction in different european countries from an employee perspective. the results point to differences among countries that present similarities in their institutional context. this is observed in the higher levels of satisfaction that countries such as france, italy, and portugal present in comparison with spain and greece (all of them belonging to the same block according to previous studies). the great differences among countries that belong to the same block and the small differences in working conditions among the countries of different blocks (with the exception of the latin cluster) lead us to posit the need to propose a novel classification of countries according to their working conditions. our research results show the existence of different models of working conditions in europe that go beyond the national borders of each country. the existence of three differing working conditions models-and subsequent differences in the levels of job satisfaction-are determined not only by institutional factors, which are similar among some european countries, but by other factors that need to be further analyzed such as companies' freedom of action in labor policies and workers' perceptions. this follows from the results of our study, which show that the grouping of countries according to their institutional context does not correspond to the grouping of countries according to their working conditions. therefore, it can be inferred that working conditions are not only a reflection of the institutional characteristics of the territories, but that other factors must be explored to understand the differences in working conditions and job satisfaction across europe. although previous classifications of european countries according to their institutional context and the model of managing employees exist (e.g., brewster and tregaskis, ; filella, ; ignjatović and svetlik, ; nikandrou et al., ) that take into account different aspects such as regulatory framework, economic and legal characteristics, and the type of educational system prevailing in each country, our research highlights the need to complement these studies with the employee's perspective. human resources policies are instruments that seek to ensure the proper functioning of organizations, but this will not be achieved if these policies do not generate job satisfaction. hence, the relevance of complementing studies that adopt an organizational perspective with the employee's perception of their working conditions and level of job satisfaction. the research makes several contributions to the literature. first, studies on the relationship between the institutional framework and working conditions in the tourism sector are rare. previous research does not explore the differences between the framework in which the working conditions are developed (which is highly influenced by the institutional context where the company operates) and the labor conditions developed at the organizational level, both determining job satisfaction. previous works that classify countries according to their institutional characteristics have only considered the framework in which working conditions are developed, ignoring that organizational management highly determines working conditions. in this vein, this study complements existing literature by proposing a novel classification of european countries based on the working conditions developed at the company level and by considering workers´perceptions about these conditions and their job satisfaction. on a practical level, the research shows how european countries are grouped according to workers' perceptions of their working conditions in the tourism sector. the results show that, although the institutional context is decisive in working conditions, these conditions are not determined entirely by these factors since there are territories with similar institutional settings but with substantially different working conditions. grouping european countries according to their homogeneity in working conditions is particularly interesting for understanding international differences in job satisfaction since work satisfaction is a direct reflection of organizational policies and practices and the extent and character of institutionalized labor norms and regulations. these results have implications for organizations and policy-makers. for organizations, assuming the freedom of movement of workers in europe, companies can attract talented employees from different european countries if they improve their working conditions by assimilating them to the territories with higher levels of job satisfaction. for european policy-makers, interesting conclusions might be drawn from this research. to advance the eu convergence, it is necessary to homogenize the working conditions of the european countries, aiming to reach those conditions that achieve the highest degrees of job satisfaction. this will have benefits not only at the individual level, but also at the organizational and social levels. this need is especially emphasized in the uncertain context in which the tourism sector finds itself due to the covid- pandemic. it is difficult to predict the structural changes that the economic crisis expected after the pandemic will generate in the tourism sector, but it is expected that demand could contract in the near future due to the economic crisis predicted by international organizations such as the international monetary fund ( ). the expected contraction in demand could be seen as an opportunity to create a more sustainable tourism model that prioritizes quality over quantity, a more balanced tourism model that distributes its value more equitably and fairly among the different stakeholders. considering the fundamental role played by employees in the quality offered in the tourist service and their important contribution to business success in this sector, a model based on quality must be accompanied by better working conditions that result in greater employee wellbeing. despite the usefulness of this study, the results should be taken with caution due to the following methodological limitations. in the first place, job satisfaction is measured through self-perception, which can generate some bias in terms of the use of variables with an objective nature. second, the problem of comparing countries involves the bias that is introduced regarding different variables such as salary, which cannot be compared in absolute terms without considering the cost of living, and the expectations of employees in each country. future research could include perception variables about satisfaction with a salary instead of the salary in absolute terms to make the data comparable across countries. the classification of countries proposed by this study sets the basis for a deeper discussion on the factors-beyond the regulatory pressures that shape the institutional context-that influence working conditions. therefore, future research could explore factors such as the culture that might be similar in each of the clusters identified and that can be determinants of job satisfaction. finally, exploring job satisfaction in sectors different from tourism might lead to different groupings due to the specific characteristics of each sector. therefore, future research could replicate this study in other industries. unbundling institutions public policies on corporate social responsibility: the role of governments in europe the price of success: a study on chefs' subjective well-being, job satisfaction, and human values decent work as a necessary condition for sustainable well-being. a tale of pi (i) gs and farmers a 'civic turn' in scandinavian family migration policies? comparing denmark, norway and sweden job satisfaction at older ages: a comparative analysis of hungarian and german data institutional pressures and 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collective turnover: an empirical exploration institutions and the labor market tourism and migration: new relationships between production and consumption catering to the needs of an aging workforce: the role of employee age in the relationship between corporate social responsibility and employee satisfaction european union tourism trends job involvement, commitment, satisfaction and turnover: evidence from hotel employees in cyprus key: cord- - ci irxl authors: chien, lung-chang; lin, ro-ting title: covid- outbreak, mitigation, and governance in high prevalent countries date: - - journal: annals of global health doi: . /aogh. sha: doc_id: cord_uid: ci irxl background: disease control involves multiple actions overtime to halt the spread of covid- . the role of a country’s governance in slowing the spread of covid- has not yet been well investigated. objective: this study aims to investigate the association between governance and the trend of covid- incidence in countries with the highest prevalence. we hypothesized that countries with better governance are more likely to mitigate the spread of covid- than countries with worse governance. methods: we analyzed most prevalent countries with at least , accumulative confirmed cases from january to june , . countries were further grouped into three different levels of governance ( better governance, fair governance, and worse governance), identified outbreak and mitigation periods using the joinpoint regression model, and compared the number of days and average daily percent change in incidence in two periods by governance level using the one-way analysis of variance. findings: the average outbreak period in the countries lasted . days. sixty percent of countries (n = ) had experienced outbreak periods, followed by a mitigation period. in contrast, the rest forty percent of countries (n = ) still had a rising trend. in the outbreak period, better governance countries had a more rapid increase but a shorter outbreak period ( . days) than countries with fair ( . days) and worse ( . days) governance. most countries with better governance ( . %) revealed a declining trend in covid- incidence, while such a trend was less than half of fair and worse governance countries ( . %– . %). conclusions: countries with better governance are more resilient during the covid- crisis. while the mitigation of covid- is observed in most better governance countries, the incidence of covid- is still surging in most fair and worse governance countries, and the possibility of a recurring epidemic of covid- in countries cannot be ignored. in those with high regulatory quality across countries [ ] , and countries with lower scores of political stability and absence of violence were associated with higher inequality in the coverage of health interventions in the study of low-and middle-income countries [ ] . using this data set of governance indicators, we found that governance is just as important as disease control measures (e.g., immunization and hygiene) in reducing a country's child mortality [ ] . despite the critical role of governance in controlling the spread of disease, it has not yet been well investigated in the context of covid- . different countries involve mixed aspects of governance. the question is: would different models of governance that drive collective actions in response to the covid- epidemic lead to different consequences? preventive actions proposed by country governments have determined the speed and duration of the spread of the epidemic [ ] . proposing preventive measures is one thing, but implementing them is more critical in determining whether these preventive actions can be successfully carried out, especially when excessive use of force and restrictive measures impose human rights concerns. as covid- cases surged during the early stages of the epidemic, some countries adopted extreme measures to curb the spread of the disease, raising human rights concerns [ , ] . the united nations office of the high commissioner for human rights urges countries to pay attention to respecting human rights and protecting vulnerable people, as these are fundamental factors to the success of the public health response and recovery from the covid- pandemic in the long run [ , ] . responsible governance represents a responsive government [ ] , especially in more democratic countries where citizens are empowered to voice their needs, participate in public affairs, and request the government's responsiveness. elucidating covid- outbreak information and trends requires the consideration of transparency and corruption, particularly in the context of international politics. most countries have suffered during the current covid- pandemic, and we hypothesized that countries with better governance are more likely to mitigate the spread of covid- than countries with worse governance. this study applied a time series model to analyze the trend of covid- incidence in countries with the highest prevalence from january , to june , . countries were further grouped into three different levels of governance, and we compared the time to mitigate the outbreak among these three groups. we adopted six governance indicators in for each country from the worldwide governance indicator published by the world bank [ ] . the six indicators represent the following dimensions of a country's governance: (i) voice and accountability, (ii) political stability and absence of violence/terrorism, (iii) government effectiveness, (iv) regulatory quality, (v) the rule of law, and (vi) control of corruption [ ] . supplementary table s defines each of these indicators. for cross-country comparison, scores of each indicator have been transferred to the normal distribution (mean = and standard deviation = ), ranging approximately from - . to . . higher scores represent better governance. we obtained the daily accumulative confirmed cases of covid- between january , , and june , at the country level from the johns hopkins coronavirus resource center [ ] , and then calculated the daily new cases accordingly. we further calculated the -day moving average of daily new confirmed cases in each country. the estimated population data of by country were also derived from the worldometer database to calculate the incidence rate per million people [ ] . notice that only countries with at least , accumulative confirmed cases through june were included in our samples for further analyses. to assess the level of governance, we first applied a cluster analysis to group countries according to a similarity measure derived from the mean absolute deviation of the six governance indicators. the criterion in determining the number of clusters was the r [ ] of . , resulting in three clusters, with . % (n = ), . % (n = ), and . % (n = ) countries in each cluster (see supplementary figure s ). we used the joinpoint regression model to analyze the trend of covid- incidence and to detect whether an apparent downward trend had happened in each selected country [ ] . unlike the nonlinear model, which can address the detailed variation of a trend, we alternatively aim to fit the trend by combining several straight lines to explain the daily change as the general linear model. that is the rationale of choosing the joinpoint regression model because it can efficiently evaluate a trend by connecting several lines with joinpoints, which depict time points significantly changing from downward to upward and vice versa. because all lines are based on the log-linear model, the joinpoint regression model is free from complex spline selections and sensitivity concerns. this modeling approach first used a grid method to scan the whole trend to find out possible joinpoints where significant changes occurred over time. we considered at most five joinpoints in each country. a model selection was used to choose how many joinpoints were most appropriate, according to the smallest bayesian information criteria. when j (j ≤ ) joinpoints were determined, the whole trend was partitioned into (j + ) segments, and the change during each time segment was estimated by the following equation: where t is a calendar time variable from the date of the first confirmed case (t = ) until june . if a country has a peak joinpoint with the highest modeled incidence rate, the identified peak joinpoint was defined as a threshold to split the entire trend into an outbreak period from t = to the time of the identified peak joinpoint and a mitigation period from the time of the identified peak joinpoint to june . the number of days and the average daily percent change (adpc) in each period were calculated [ ] . the two metrics were further compared among the three governance clusters by using the one-way analysis of variance and the post-hoc test with tukey's adjustment, respectively. data cleaning and management were done by sas v . (sas institute inc., cary, nc). data analyses were implemented by joinpoint regression software v. . . . (national cancer institute, bethesda, md). the significance level was set to . . by june , the number of cases in the high prevalent countries was . million, accounting for . % of the total confirmed cases in the world. among the countries, sixty of countries (n = ) had experienced outbreak periods, followed by a mitigation period. in contrast, the rest forty percent of countries (n = ) still had a rising trend through june . table shows the number of days and adpc at the country level during the outbreak period (i.e., before the identified peak joinpoint) and the mitigation period (i.e., after the identified peak joinpoint). the average outbreak period in the countries lasted . days, with an adpc of . %. among countries with the mitigation period, the average mitigation period has lasted . days, with an adpc of - . %. figure displays the least square means of three clusters of countries by the six governance dimensions. the one-way analysis of variance shows that all governance indicators were significantly different among the three clusters (all p-values < . ). cluster had the highest least square means for all governance indicators, indicating that countries in this group had better governance. cluster had the lowest least square means for all governance indicators, indicating worse governance. we defined the countries in cluster as fair governance countries. among the selected countries, . % of countries (n = ) are in cluster (better governance), . % (n = ) in cluster (fair governance), and . % (n = ) in cluster (worse governance). significant differences in the number of days and adpc during the two periods were found among the three governance clusters (figure ) . in the outbreak period, better governance countries averagely spent . days to reach the peak, which was . - . days shorter than fair and worse governance countries. in the mitigation period, better governance countries have been lasting for . days, longer than fair and worse governance countries by . - . days. by comparing with the adpc of fair and worse governance countries, the better governance countries experienced a more rapid increase in the outbreak period (adpc = . %; . %- . % faster than in fair and worse governance countries) and decreased in the mitigation period (adpc = - . %; . %- . % faster than in fair and worse governance countries). among countries with a rising trend through june , . % (n = ) of them were fair governance countries, and . % (n = ) of them were worse governance countries. only four countries (chile, sweden, poland, and oman) were in better governance. the average of adpc was . %, . %, and . % in better, fair, and worse governance countries, respectively. no significant difference was identified among the three clusters. national governance plays a critical role in determining how a country copes with the fast-paced dynamic of covid- [ ] . our findings indicate that countries with better governance are more resilient. although better governance countries experience rapid surges in the number of cases during the covid- crisis, the incidence decreases steadily. because covid- has spread rapidly since february , a country's first step is to identify sources of the virus and diagnose infected cases. understanding the routes and timing of transmission helps governments shape and implement effective prevention measures [ ] . governments need sufficient medical capacity for screening and may need to ask employers to give workers sufficient leave time for disease prevention and to relieve the public's worries. if more people are willing to disclose their illness to public health authorities, the increasing number of confirmed cases should be no surprise when a country's disease surveillance system works. for instance, the rapid and large-scale screening strategy in south korea demonstrates its capability to diagnose covid- , including sufficient laboratory and medical resources, government policies, and the capacity to mobilize and authorize resources to both public and private hospitals and laboratories across the country. for instance, the korean food and drug administration shortened the process for the approval of new test kits [ ] . to engender public trust and avoid unreasonable public panic and confusion during the covid- crisis, governments should also be timely and transparent in disclosing information, such as the number of cases, suspected sources of exposure, and what actions have been performed [ ] . overall, a better capacity in capturing and reporting disease outbreaks can be expected in countries with better governance. our results show the outbreak period in better governance countries was . - . days shorter than those in fair and worse governance countries. given the necessity for a rapid response to this once-in-a-century global pandemic, the government's next step should be solving the problem and mitigating the disease burden. relative to countries with worse governance, we found stronger evidence of steady declines in the incidence of covid- among countries with better governance. we hypothesized that the control of covid- is faster in countries characterized as having better governance. rapid and intensive public health measures, from personal protective measures (e.g., hand hygiene and masks) to large-scale restrictive public health measures (e.g., lockdown and quarantining contacts), should be implemented to slow the spread of covid- and stop transmission [ ] . these collective measures to fight against covid- for the sake of public health are regarded as public goods [ ] . harsh steps may be options, but without good governance, covid- may turn back and even lead to governments violating human rights. efforts to detect, prevent, and treat covid- must be sustained, including after therapeutics and vaccines are successfully developed and manufactured [ ] . good governance is the foundation needed to link existing systems and ensure collective measures are implemented and equally distributed, as well as return to normal life in the long term [ , ] . austria is another good example of a country with better governance and controlled the outbreak. the number of days in the outbreak period was days in austria. on march , , immediately after covid- struck europe, the austrian government introduced short-term restrictive measures (e.g., banned gatherings, border controls, social distancing and self-isolation, compulsory face masks in public areas), and a month later, it announced a step-by-step timetable to ease the lockdown and revive the economy [ ] . the country has sustained a low incidence of almost three months. eventually, different governance models should be associated with covid- epidemic trends. continuous regulation and provision of resources to support society, industry, and research can improve disease control and keep the number of cases low, ameliorate the disease burden, and prevent future outbreaks. the authors acknowledge the following limitations to this study. first, the case definition of covid- varies among countries. a recent study revealed that china has had several versions of the case definition for covid- , and if the fifth version of the definition-a new category of cases for hubei province named "clinically diagnosed case," which was defined as a suspected case with pneumonia indicated by chest radiograph but didn't require a virological confirmation of infection-had been applied throughout the whole outbreak, the total number of cases would increase over % [ ] . we are unable to know whether other countries have experienced the same situation. second, our findings have a strong assumption that all confirmed cases were infected on the same day; nonetheless, there might be a lagged effect between the true infected date and the diagnosed date. reasons for lagged diagnoses could include insufficient sieving reagents at the beginning of outbreaks or asymptomatic cases [ , ] . third, we included only those countries with at least , accumulative confirmed cases in our analysis. estimates should be cautiously interpreted and may not be guaranteed in countries not included. however, that should not preclude us from sharing the experience of some good governance countries. a recent study highlighted high transmissibility of covid- even before symptom onset [ ] . while asymptomatic transmission will become a more important source, wearing masks may have played a substantial protective role [ , ] . the immediate question is how the government takes this preventive action to ensure universal coverage and equal access. one example of a country that demonstrated rapid collaboration between ministries and public-private partnerships is taiwan, which is geographically and culturally similar to china but still managed to keep the number of covid- cases low [ , ] . three days after the first imported case on january , , taiwan implemented an export ban on medical and n masks to secure domestic use and established a national team to boost mask production. more importantly, the government initiated a name-based rationing system for mask purchases to ensure equal access to quality-assured masks for everyone and to cope with the general public's fears. the case of taiwan demonstrates that good governance is linked to sound disease prevention policies, responsiveness to people's needs, and protection of the health of the total population [ ] . the impact of covid- on the health of a country's population reflects the status quo and resilience of its governance. we found that countries with better governance had a more rapid increase but a shorter outbreak period than countries with fair or worse governance by . - . days. most countries with better governance ( . %) revealed a declining trend in covid- incidence, while such a trend was less than half of fair and worse governance countries ( . %- . %). while the mitigation of covid- is observed in most countries with better governance, a hidden worry, however, may affect the pandemic in the near future: the incidence of covid- is still surging in most countries with fair and worse governance, and the possibility of a recurring epidemic of covid- in countries cannot be ignored. the additional files for this article can be found as follows: • supplementary table s world health organization. coronavirus disease (covid- ) situation reports. www.who.int/ emergencies/diseases/novel-coronavirus- / situation-reports features, evaluation and treatment coronavirus (covid- ) the sars-cov- vaccine pipeline: an overview sars-cov- vaccines: status report the covid- vaccine development landscape governance matters viii: aggregate and individual governance indicators lenses and levels: the why, what and how of measuring health system drivers of women's, children's and adolescents' health with a governance focus government, politics and health policy: a quantitative analysis of european countries governance commitment to reduce maternal mortality. a political determinant beyond the wealth of the countries is governance, gross domestic product, inequality, population size or country surface area associated with coverage and equity of health interventions? ecological analyses of cross-sectional surveys from countries governance matters: an ecological association between governance and child chien and lin: covid- and governance art. , page of mortality responding to covid- -a once-in-a-century pandemic? eastern europe and central asia confronted with covid- : responses and responsibilities the effect of human mobility and control measures on the covid- epidemic in china the office of the high commissioner for human rights (un human rights) can china's covid- strategy work elsewhere? responsiveness, support, and responsibility: how democratic responsiveness facilitates responsible government the worldwide governance indicators an interactive web-based dashboard to track covid- in real time permutation tests for joinpoint regression with applications to cancer rates average annual percent change (aapc) and confidence interval governance of the covid- response: a call for more inclusive and transparent decision-making national response to covid- in the republic of korea and lessons learned for other countries transparency and information sharing could help abate the covid- pandemic world health organization. strengthening and adjusting public health measures throughout the covid- transition phases global public goods and health: taking the agenda forward the equitable distribution of covid- therapeutics and vaccines the covid- crisis and the austrian response effect of changing case definitions for covid- on the epidemic curve and transmission parameters in mainland china: a modelling study why widespread coronavirus testing isn't coming anytime soon the covid- epidemic contact tracing assessment of covid- transmission dynamics in taiwan and risk at different exposure periods before and after symptom onset response to covid- in taiwan: big data analytics, new technology, and proactive testing to mask or not to mask children to overcome covid- taiwan's response to covid- is a lesson in managing risk initial rapid and proactive response for the covid- outbreak -taiwan's experience governance indicators: where are we, where should we be going? the world bank research observer this work was supported by the ministry of science and technology, taiwan, and china medical university. we thank the editors at tandem editing l.l.c. for their careful copyediting. all authors had access to the data and a role in writing the manuscript. l.c.c. and r.t.l. developed the ideas and research aims. l.c.c. collected data on covid- inci-dence and population; r.t.l. collected data on governance indicators. l.c.c. conducted the statistical analysis. r.t.l. acquired financial support for the project leading to this publication. l.c.c. and r.t.l. wrote the initial draft and edited the final version of the manuscript. all authors approved the final manuscript and agreed to submit for publication.publisher's note this paper underwent peer review using the cross-publisher covid- rapid review initiative. the authors have no competing interests to declare. key: cord- -mqcgqwrb authors: leroy, gregoire; boettcher, paul; besbes, badi; peña, carlos raúl; jaffrezic, florence; baumung, roswitha title: food securers or invasive aliens? trends and consequences of non-native livestock introgression in developing countries date: - - journal: glob food sec doi: . /j.gfs. . sha: doc_id: cord_uid: mqcgqwrb importation of livestock genetic resources from industrialized countries for introgression of specific traits and other forms of crossbreeding is often indicative of a shift in production systems toward greater intensification and specialization. in developing countries, imported genetic resources are regarded as both a solution to improve the performance of local livestock and as one of the main threats to local populations. using international databases, censuses and technical reports, we investigate ongoing trends and consequences of these two phenomena in countries from africa, asia and latin america. in these countries, the share of locally adapted breeds within species has decreased by an average of . % per year over the last years. the corresponding increase has been distributed between pure exotic breeds and crossbred animals, with differences across regions. in several countries, increased utilization of exotic cattle breeds and crossbreeding has been accompanied by a trend in increased milk yield per cow. the shift from local genetic resources to crossbred and exotic animals must be considered in the context of challenges such as food security, erosion of agrobiodiversity, interactions with other agricultural production, reduction of poverty and provision of ecosystem services, as well as resilience to and mitigation of climate change. global production of livestock is expected to increase substantially, driven by increasing demand from developing regions. by , global milk and meat production are expected to be and percent, respectively, above current levels (fao, ) . in this context, and considering limited availability of land, water and other natural resources, livestock farmers from those developing regions need to increase the production and productivity of their animals (mayberry et al., ) . genetic improvement is an important lever for improvement of livestock production traits (miglior et al., ; tallentire et al., ) . livestock in industrialized countries have undergone generations of intense selection and their genetic merit for production in their usual production environment usually is superior to local breeds in developing countries. therefore, crossbreeding and replacement of local livestock by exotic breeds are often seen as attractive solutions to close yield gaps. crossbreeding strategies usually require less investment in capital, infrastructure and technical know-how than within-breed genetic improvement (leroy et al., a) . as a consequence, national livestock authorities in developing countries frequently integrate the extensive use of exotic livestock in their development strategies aiming at increasing the productivity of their livestock production systems (see for instance daph, ; goi, ; shapiro et al., shapiro et al., , . abundant literature documents the theoretical and practical impacts of crossbreeding and breed replacement at the local level (galukande et al., ; getachew et al., ; roschinsky et al., ; wilkes et al., ) . various studies have shown that in appropriate production environments, milk yield of crossbred cattle can be to . times greater than of pure indigenous breeds, with associated increases in farmers' income (galukande et al., ; hegde, ) . on the other hand, outcomes of the many initiatives to replace and/ or crossbreed local livestock breeds have been variable (madalena et al., ; marshall, ) . failures generally relate to limited adaptedness of exotic livestock breeds, poor infrastructure and technical capacity, lack of long-term commitment of institutional partners, and limited preparatory involvement of the small-scale livestock keepers (lemke et al., ; leroy et al., a) . murray et al. ( ) showed that exotic breeds of cattle and their crossbreeds with zebu cattle show reduced resistance to endemic diseases. the use of exotic breeds and indiscriminate crossbreeding have been reported as the two main factors causing erosion of local genetic resources (fao et al., ) . animal genetic resources are an essential component of sustainable food systems. therefore, monitoring and maintaining locally adapted livestock are essential. the putative importance of local breeds is reflected in the un sustainable development goals (sdg), for which target . addresses maintenance of the genetic diversity of domesticated animals (https://unstats.un. org/sdgs/metadata?text=&goal= &target= . , fao, ). despite the abundance of literature on individual projects, little is known on the trends and consequences of crossbreeding and breed replacement on a larger scale. using data from international databases, agricultural censuses and technical reports, we investigate the recent trend in the global share of locally adapted, crossbred and exotic livestock in countries. we also investigate the relationship between those proportions and estimates of average milk yield per cow for countries, as well as the trends of national breed populations considered as locally adapted, and discuss issues regarding sustainability. to obtain data on the relative importance of locally adapted, crossbred and exotic livestock populations, information from agricultural censuses and technical reports from the years between and were used. these data originated from african, asian, and latin american countries and the five main livestock species (cattle, chicken, goat, pig, sheep) (see supplementary table ). in two countries (senegal and niger), the domestic animal diversity information system (dad-is) was used as the source of information, because the dad-is breed population data corresponded closely to the total species population reported in faostat (http://www.fao.org/faostat) for ruminants (± %), this decision was made following discussion with corresponding national coordinators officially nominated by these countries as focal points for animal genetic resources. from those different sources, country/species/year combinations were formed, representing country/species combinations (see supplementary table ). the classification system differed according to countries and species and the three following categories were used in our analysis (see box for terminologies): in some cases, only one category was differentiated from the other two (i.e. locally adapted versus non-locally adapted or exotic versus non-exotic). for this reason, the three categories were analyzed independently from each other. average milk yields (number of l per cow and per year) for cattle were extracted from faostat or provided by national coordinators to compute linear regressions on either the proportion of exotic breeds or the proportion of exotic + crossbred (according to data available) for countries that had provided either information on populations described as dairy cattle (algeria, chile, egypt, ethiopia, iran, morocco, tunisia) or on general cattle populations oriented toward milk (bhutan, india, nepal, and jordan) (see supplementary table ) . to analyze demographic trends at breed level, a third data set was extracted from dad-is, containing information on the population size of national breed populations reported at different points in time during the period - . only data from local breeds or regional transboundary breeds were included as proxies for locally adapted breeds, as in dad-is information regarding geographical adaptation is provided for fewer than % of national breed populations from africa, asia, and box terminologies used for breeds and populations. breed: either a sub-specific group of domestic livestock with definable and identifiable external characteristics that enable it to be separated by visual appraisal from other similarly defined groups within the same species, or a group for which geographical and/or cultural separation from phenotypically similar groups has led to acceptance of its separate identity. crossbred: animals produced through the mating of individuals from different breeds, either following a specific strategy (such as terminal crossing, rotational crossing or synthetic breed creation) or through an indiscriminate process. synthetic breeds are excluded from this definition once the population has reached an equilibrium state at which all animals have the same proportion of genetics from the original breeds. in this study, the crossbred category is restricted to the cross between locally adapted and exotic breeds. exotic: animals originating from breeds that have not been continuously present in a country for sufficient time to be adapted to the prevailing environmental conditions. exotic breeds comprise both recently introduced breeds and continually imported breeds. in this study, exotic breeds correspond essentially to highly productive breeds originating from developed countries. local: breeds that occur only in one country. locally adapted: breeds which have been in the country for a sufficient time to be genetically adapted to one or more of traditional production systems or environments in the country. indigenous breeds, also termed autochthonous or native breeds and originating from, adapted to and utilized in a particular geographical region, form a sub-set of the locally adapted breeds. national breed population: a subpopulation of a breed found in a given country. international transboundary: breeds that occur in more than one country in more than one region. regional transboundary: breeds that occur in more than one country in one region. source: adapted from fao ( ). latin america. national breed populations with at least two population size estimates (as the average of minimal and maximal population sizes provided in dad-is) were extracted from countries of those three regions ( in africa, in asia, in latin america), for a total of population size estimates (to be confirmed). the proportions of the species populations belonging to each of the three categories were analyzed independently for each category, considering a linear mixed-effect model (r lme function). the three regions and five species were included as explanatory factors. year, as well as interactions of year x region and year x species were considered as covariables. species/country combination was added as a random effect, as well as an autocorrelation structure component of order with the year covariate (corcar ). explanatory variables were removed stepwise until minimizing the bayesian information criterion (bic), but keeping region, year and species/country random effects as explanatory variables. a linear mixed model was also utilized for the second data set containing milk yield per cow per year as the dependent variable (r lme function). in absence of information on animal husbandry (e.g. diet and veterinary care) and production environment, year was used as a proxy and considered in the model as a covariable. the proportion of exotic/ crossbred animals was used also as a covariable, while an explanatory factor indicating whether animals were % exotics or a combination of exotics and crossbreds was also included. country was included as a random effect, as well an autocorrelation structure component of order with year covariate (corcar ). explanatory variables were removed stepwise until minimizing the bic, keeping year, proportion of exotic/ crossbred animals and country random effects in the model as explanatory variables. considering the large differences in population sizes among dad-is national breed populations, the third data set was simplified by computing the linear regression coefficient of population size over years for each national breed population, then comparing the number of populations with a positive trend (i.e. positive regression coefficient) to the numbers of populations with null or negative trends, according to regions. the country x species cases studied here covered the past years and originated from africa ( countries), asia ( countries) and latin america ( countries) (see fig. ) , and from the five main livestock species, with cases for cattle, for chicken, for goat, for pig, leroy et al. global food security ( ) and for sheep. the different cases represented a wide range of situations and contexts, with shares of national species populations ranging from to % for locally adapted breeds, from to % for crossbreds, and from to % for exotic breeds, according to years, species and countries (fig. ) . according to the models utilized, the trends observed revealed that the average share of locally adapted breeds has decreased by . % per year, compared to yearly increases of . % for crossbreds and . % for exotic breeds (table ). the estimates for the respective proportions of locally adapted, crossbred and exotic breeds were . , . and . % for africa; . , . and . % for asia; and . , . and . % for latin america. the three estimates within a region do not correspond to the exact same combinations of countries and species, so they do not sum to %. proportions of locally adapted (exotic) breeds were significantly greater (smaller) in africa than in asia and latin america (p < . ). at the national level, our results on impacts of proportions of nonlocal genetics on milk yield from countries suggest very different outcomes depending on the country, as illustrated by fig. . in ethiopia for instance, the share of exotic and crossbred dairy cows has remained very small, increasing from . to % between and , with average milk yield remaining low at around l per cow per year. in contrast, data from jordan show the results of efforts to intensify the dairy industry that initiated in the s (alqaisi et al., ) . the share of exotic and crossbred cattle (almost entirely purebred holstein) was already % in and increased to % by . annual milk yield per cow passed above l during this period, i.e. values comparable to some european countries. our analyses demonstrate a positive relationship between the relative proportion of crossbred and exotic breeds among all dairy cattle and average milk yield. both time and the percentage of exotic/crossbred livestock were found to have a significant relationship with average milk yield, which increased by . l per year (p = . ) and . l per % of increase in improved/crossbred livestock (p = . ). to assess more precisely the consequences for local livestock, we estimated the proportion of local and regional transboundary breeds with positive demographic trends, using national breed populations extracted from dad-is. a large majority ( . %) of local national breed populations from africa showed positive trends in population size (table ) , which was ***p < . . small letters represent non-significantly differentiated regions at p = . . the same letters represent non-significantly differentiated regions at p = . . significantly higher (p < . ) than in asia ( . %) and latin america ( . %). between and , the absolute number of livestock, measured in terms of tropical livestock units (tlu) to account for species differences, increased at a much higher rate in africa (+ %) than in asia (+ %) and latin america (+ %). in the case of africa, the absolute increase in tlus compensated for the relative decrease in the proportion of locally adapted breeds such that populations of most local breeds did not decrease in size. by contrast, in latin america, a majority of local and regional breeds decreased in population size despite increases in the overall livestock population. in the last hundred years, multiple initiatives to improve food security in developing countries have aimed to cross or replace local livestock populations with more productive ones (madalena et al., ; marshall, ; leroy et al., a) . our results show that this trend is still ongoing and that locally adapted livestock still represent the largest share of livestock populations in africa and asia, while exotic breeds have become the majority in latin america. various factors may be responsible for these regional differences. for example, many african countries lack the logistic capacity to allow the diffusion, use and maintenance of exotic germplasm. in latin america, the locally adapted criollo breeds are themselves the products of crosses among various populations imported over the last centuries, so continued importation and crossing may be more culturally and scientifically accepted than in other regions. the regression model that optimised the bic did not include a species effect, although it's plausible that species-based economic, technological and logistic differences across production systems (such as artificial insemination in cattle, or provision of fertilised chicken eggs) could allow crossbreeding and breed replacement to occur more quickly for some species. heterogeneity in the yield gaps between industrialized and developing countries may also play a role in species differences, as selection programmes for chickens, pigs and dairy cattle tend to be more advanced in industrialized countries relative to those for sheep, goats and beef cattle. interpretations of the definitions of exotic, crossbred and locally adapted animals and knowledge of genetic composition may vary among countries and among people within countries and even evolve through time, impacting the classification of breeds into the different categories and thus perhaps affecting our results. genomics may offer a solution to inconsistencies in definition of breed type, which could consequently improve the inferences if our study were to be repeated in the future. depending on species, breeds and locations, extent of influence from exotic (generally of european descent) breeds due to recent admixture has been found to range from negligible to predominant in local populations (leroy et al., ; murray et al., ; buzanskas et al., ; selepe et al., ; ben jemaa et al., ; zhang et al., ) . although incomparably more precise to assess genetic origins of individuals than other sources of information, molecular approaches are currently limited in their coverage of livestock populations. nevertheless, both molecular and census studies describe a wide diversity of situations according to species and countries. the aim of the various crossbreeding, introgression and breed replacement projects has generally been to improve the production and productivity of local livestock (i.e. milk and egg production, growth, or prolificacy for instance) and in turn to increase both livestock production at the national level and income of farmers. this strategy is supported by the results of a wide number of studies showing positive impacts of crossbreeding on productive traits at local level, both in research stations and on farms (galukande et al., ; getachew et al., ) . within countries, our results showed a positive association between average milk yield per cow and the proportion of exotic or crossbred genetics the national herd. those results must be considered with caution, however, and cannot be entirely attributed to genetic differences, given the fact that the model did not directly account for factors such as changes in production systems and environment/inputs (e.g. quality and quantity of feed, health care and housing), which are likely to have occurred and contributed positively to the average milk yield of animals. in absence of information about possible changes in inputs and the costs related to such changes, conclusions on the impact of these trends in terms of costs and benefits and more generally in terms of the overall economic efficiency of the system (acosta and de los santos-montero, ) cannot be drawn. karugia et al. ( ) concluded that crossbreeding of cattle had a positive effect on the kenyan economy and social welfare, although they speculated that the introduction of exotic genes may have not been beneficial at farm level, because improved animal productivity also involved accrued input costs. by contrast, hegde ( ) reported positive economic impacts of crossbreeding for indian cattle farmers, with the number of above-poverty-line families increasing by % over a ten-year period. in senegal, marshall et al. ( ) found that under good management, % indigenous zebu by bos taurus crossbreds for dairy production provided greater net economic benefits to households than did alternative options involving pure indigenous, highly introgressed (with bos taurus) or alternative crosses. most studies concur with the notion that the success or failure of crossbreeding is associated with financial and logistic conditions enabling access to inputs and extension services. overall, marshall ( ) concluded that the socio-economic benefits to households of keeping a specific breed type depend largely on the production systemsand also vary according to the type of livestock keepers within a system. a related factor to consider is that exotic livestock and their crosses require greater nutritional inputs to achieve their genetic potential for milk or meat production. above a certain level of genetic potential for production, ruminant-livestock producers in mixed crop-livestock systems may have difficulty to produce the sufficient high quality forage and may need to purchase feed (mcdermott et al., ) . on a larger scale, this may have consequences on the dependency of countries on importation of nitrogen and other nutrients, which constitutes a growing issue for many regions with developing or emerging economies (lassaletta et al., ) . our results suggest that in africa, and to a lesser extent in asia, the general increase in the overall livestock population over the past years has compensated for the decreasing proportion of locally adapted animals within species, allowing sizes of local populations to remain relatively stable. on the other hand, the population sizes of a majority of local and regional breeds have decreased in latin america, while the overall livestock population has increased less in size than in africa. the increased presence of exotic and crossbred animals does not necessarily mean replacement of local populations, especially if the new animals are not raised in the same production environments (for instance, if new, peri-urban farms are developed). however, even if the importation of exotic animals is not intended to directly replace locally adapted breeds, they may nevertheless remain a threat as they enter in competition with traditional breeds and herds for resources and market share. erosion of the diversity of local animal genetic resources is especially problematic given the phenotypes of interest that are possessed by those breeds (leroy et al., b) and the ecosystem services they and their production systems provide (leroy et al., ) . in relation to their capacity to withstand endemic diseases and harsh climate conditions, survive on low-quality diets and walk long distances to access food and water, locally adapted ruminant breeds are especially well suited for the valorization and maintenance of pastoral rangelands, which constitute a large share of the global agricultural area ( billion ha, of which . billion ha is not convertible to cropland according to mottet et al., ) and therefore of critical importance for food security and livelihoods. more generally, the increased number of crossbred and exotic animals is indicative of a shift in production systems toward greater intensification and specialization. this process may impact negatively on landscapes and use of resources, as illustrated by magnani et al. ( a) . they showed that the sedentarisation of pastoralists and promotion of exotic breeds over local ones resulted in land fragmentation of the middle valley of the senegal river. also, considering the specific adaptive potential and robustness of locally adapted breeds, breed replacement may reduce the resilience of livestock production systems. the use of mixed herds and modifying herd composition to favour more resistant species or breeds are components of a classical strategy of herders facing long-term droughts (blench and marriage, ) and the use of locally adapted breeds has been suggested as an option to cope with constraints (drought, feed shortage, disease) induced by climate change (musemwa et al. ; bettridge et al., ) . considering the short and long term impact that the covid pandemic will have on food and agriculture in general and livestock in particular (e.g. shortage of labor and animal feed, zhang, ) , both the adaptedness of locally adapted breeds to less-intensive and/or short supply chains, and their general resistance to zoonotic diseases (marshall et al., ) give them potential competitive advantages relative to exotic ones. considering the specific issue of mitigation of climate change, locally adapted breeds tend to perform poorly relative to exotic breeds with regard to intensity of ghg emissions, due to their inferior production. however, standard measures of intensity are somewhat biased, as they typically consider only the ratio of ghg emissions to yield of a single commodity, ignoring other ecosystem services usually associated with locally adapted breeds and their production systems. single-commodity measures of ghg intensity also fail to account for the differences among breeds in their ability to survive while consuming poor quality forage and converting it into human-edible food (hoffmann, ) . in the second report on the state of the world's animal genetic resources for food and agriculture (fao et al., ) , countries, especially those of developing regions, reported indiscriminate crossbreeding and introduction or increased use of exotic breeds as the two main causes of genetic erosion. our results provide for the first time an objective assessment of the situation and the rate at which the relative proportion of locally adapted genetic resources is decreasing in those regions. we also discuss how this phenomenon connects to various challenges on the national scale, such as food production and security as well as agrobiodiversity. these discussions are far from exhaustive, however, inasmuch as locally adapted livestock breeds and their production systems are also associated with various aspects of sustainability, including poverty reduction, resilience to climate change and landscape management. our analyses are also limited to the national scale, whereas local-level heterogeneity in constraints associated with environmental conditions and access to markets influence the fit of a given genetic resource to a certain locale. for instance, herold et al. ( ) proposed a stratified organizational scheme for pig production in vietnam, with farmers close to markets raising crossbreds of exotic males and locally adapted sows, the latter of which would be provided by farmers from more remote areas, for whom crossbred genotypes would be of limited interest due to environmental constraints and lack of access to inputs such as high-energy feeds and veterinary care. strategic planning is required to ensure the conservation of the unique alleles possessed by the local breeds, either by complementary in situ or ex situ conservation of the breeds themselves or by breeding programmes to ensure conservation of these alleles in the gene pools of new synthetic breeds. moreover, because of the influence that context has on the success of using exotic breeds, a livestock development policy involving these genetic resources requires strategic thinking that goes beyond the simple technical dimension of breed improvement or conservation (magnani et al., b) 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heterozygosity and exotic introgression the impact of climate change on livestock production amongst the resource-poor farmers of third world countries: a review smallholder experiences with dairy cattle crossbreeding in the tropics: from introduction to impact genetic structure of south african nguni (zulu) sheep populations reveals admixture with exotic breeds ethiopia livestock master plan breeding for efficiency in the broiler chicken: a review is crossbreeding with indigenous sheep breeds an option for climate-smart agriculture? widespread introgression in chinese indigenous chicken breeds from commercial broiler chinese livestock farms struggle under covid- restrictions the authors would like to thank the french government for providing for the secondment of dr gregoire leroy to fao, national coordinators of countries for information provided, and veronique ancey and alejandro acosta for their useful comments. supplementary data to this article can be found online at https://doi. org/ . /j.gfs. . . the views expressed in this information product are those of the authors and do not necessarily reflect the views or policies of fao. g.l., p⋅b., b⋅b., and r.w. designed the study. g.l., c.r.p. collected the data. g.l. and f.j. conducted the statistical analysis. p.b., b⋅b., and r.w. assisted with data preparation and interpretation. g.l. wrote the manuscript, which was edited and approved by all authors. key: cord- -s tyeis authors: norden, m. j.; avery, d. h.; norden, j. g.; haynor, d. r. title: national smoking rates correlate inversely with covid- mortality date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: s tyeis abstract introduction: recent studies show cigarette smokers are markedly under-represented among patients hospitalized for covid- in over a dozen countries. it is unclear if this may be related to confounding factors such as age distribution, access to care, and inaccurate records. we hypothesized that these concerns could be avoided by studying smoking prevalence in relation to covid- mortality. since climate has been identified as a factor in covid- , we studied groups of countries with relatively comparable temperatures. methods: the hottest and coldest countries in the johns hopkins mortality analysis database with a minimum mortality rate of . deaths/ , were selected on the basis of the average temperatures of their largest city. mortality rates were determined as of may , and correlated with national smoking rate adjusting for sex ratio, obesity, temperature, and elderly population. results: a highly significant inverse correlation between current daily smoking prevalence and covid- mortality rate was noted for the group of hot countries (r=-. , p = . ), cold countries (r=-. , p=. ), and the combined group (r=-. , p=. ). however, after adjustments only the regression for hot countries and the combined group remained significant. in hot countries, for each percentage point increase in smoking rate mortality decreased by . per , population ( % ci . - , p=. ). this resulted in mortality rates several-fold elevated in the countries with the lowest smoking rates relative to the highest smoking rates. in the combined group, mortality decreased by . per , population ( % ci . -. , p=. ). discussion: these findings add support to the finding of an inverse relationship between current smoking and seriously symptomatic covid- . however, we conclude that the difference in mortality between the highest and lowest smoking countries appears too large to be due primarily to the effects of smoking per se. a potentially beneficial effect of smoking is surprising, but compatible with a number of hypothetical mechanisms which deserve exploration: ) studies show smoking alters ace expression which may affect covid- infection or its progression to serious lung pathology. ) nicotine has anti-inflammatory activity and also appears to alter ace expression. ) nitric oxide in cigarette smoke is known to be effective in treating pulmonary hypertension and has shown in vitro antiviral effects including against sars-cov- . ) smoking has complicated effects on the immune system involving both up and down regulation, any of which might alone or in concert antagonize progression of covid- . ) smokers are exposed to hot vapors which may stimulate immunity in the respiratory tract by various heat-related mechanisms (e.g. heat shock proteins). studies of steam and sauna treatments have shown efficacy in other viral respiratory conditions. at this time there is no clear evidence that smoking is protective against covid- , so the established recommendations to avoid smoking should be emphasized. the interaction of smoking and covid- will only be reliably determined by carefully designed prospective study, and there is reason to believe that there are unknown confounds that may be spuriously suggesting a protective effect of smoking. however, the magnitude of the apparent inverse association of covid- and smoking and its myriad clinical implications suggest the importance of further investigation. discussion: these findings add support to the finding of an inverse relationship between current smoking and seriously symptomatic covid- . however, we conclude that the difference in mortality between the highest and lowest smoking countries appears too large to be due primarily to the effects of smoking per se. a potentially beneficial effect of smoking is surprising, but compatible with a number of hypothetical mechanisms which deserve exploration: ) studies show smoking alters ace expression which may affect covid- infection or its progression to serious lung pathology. ) nicotine has anti-inflammatory activity and also appears to alter ace expression. smokers are markedly under-represented among hospitalized patients testing positive for covid- . , this is surprising as smoking is generally associated with greatly exacerbating respiratory infections. a systematic review of chinese studies totalling inpatients showed the pooled prevalence of current smokers was . %, approximately a quarter of the population smoking prevalence. researchers in france noting the chinese data and a u.s. report showing a roughly ten-fold under-representation of smokers among covid inpatients and outpatients, were motivated to conduct a cross-sectional study in france. among a group of inpatients they found a smoking rate of . %, and among outpatients a rate of . %, each more than four-fold below community rates adjusted for age and sex. a recent review of smoking and covid- by simons, et al. found that a similar underrepresentation was apparent in seven other countries: italy, israel, kuwait, mexico, spain, switzerland, and the u.k. they found only marginal under-representation in south korea and a reversed pattern in iran. using sex-adjusted rates of smoking prevalence there was moderate under-representation of smokers in south korea -- . % of hospitalized patients vs a sexadjusted national rate of . %, and in iran -- % of hospitalized covid- patients vs. a sex-adjusted national rate of . %. additionally, a small study from germany found a smoking rate of % of hospitalized patients vs. a sex adjusted national rate of . %. however, with the exception of the french study and our adjustments for sex-ratio, all of the preceding community rates are not adjusted for demographics. the most critical adjustment is likely age, as covid- inpatients are heavily skewed toward the elderly and smoking prevalence drops precipitously in this age group, falling to an average of . % among those over years old across european countries. the smoking prevalence among people over age in new york city (nyc) is % among men and % among women. these smoking prevalences allow a good comparison to covid- admissions for two new york city hospitals. current smokers accounted for only . % of the hospitalized with covid- at mt. sinai and only . % of deaths. similarly, in the first patients hospitalized at new york-presbyterian co in nyc current smokers accounted for only . % of patients hospitalized for covid- and . % covid- patients treated in the icu. other us data from , covid inpatients across states showed % current smokers. thus, compared to earlier reports, these more recent us data continue to show less striking but still substantial under-representation of smokers among covid- inpatients. the most extensive study of covid- in the u.k. based on , inpatients in the initial fully adjusted model found a small under-representation of smokers (or . , % ci . -. ). in a post-hoc analysis, however, when further individual factors were added, the or dropped to . and was no longer significant. the mortality figures were more compelling, of deaths recorded, only ( . %) were in current smokers, whereas current smokers constituted % of the cohort. data sets that include non-hospitalised patients present more mixed results. a prospective study using the uk biobank identified patients testing positive for covid, a slight underrepresentation of smokers in that group relative to those testing negative. however, after . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . controlling for other variables they found a non-significant over-representation. similarly, an online survey of , found smokers slightly over-represented among those reporting positive tests or probable cases or . ( % ci . - . ), but only for those having less than years of education. the study also showed smokers to be more worried about contracting covid- , but also less compliant with social distancing recommendations. in mexico of people testing positive for covid- only . % were current smokers, vs. a sex adjusted national rate of . %. finally, among veterans aged - years, out of tested covid- +. smokers were less likely to test positive (or . , % ci . -. ), but there was no significant difference in hospitalization. the apparent substantial under-representation of smokers among covid- inpatients consistently across thirteen countries is remarkable, but variations in results highlight the importance of considering potential confounds. for the most part, reports are not corrected for age or comorbidity, and moreover the records may be incomplete with regard to smoking status. it is also possible that the patient samples were for some reason non-representative (e.g. including many long-term care patients who are not allowed to smoke, higher socioeconomic classes with better access to healthcare, numerous health-care workers, etc), that patients concealed their smoking habit or were too sick to inform, that they failed to seek help because of misinterpretation of symptoms ("smokers cough"), that changes in their bodies from years of smoking somehow produced false negative covid- test results, or that those smokers most at risk for hospitalization had already died or had quit smoking because of their infirmity (reverse causality). we therefore sought to test the association in a way that was not subject to any of these confounds. our hypothesis was that if smoking actually was associated with a several-fold reduction of the risk of being hospitalized for covid- , there should be some reduction in covid- mortality rates in communities with more smokers --assuming other confounds are controlled. however, many countries of western europe had not only high smoking prevalence but some of the highest covid- mortality, so any comparisons with these countries would be unlikely to show such a relationship. analyses from mit and the university of maryland showed most cases of covid- developed within a narrow temperature range. , consistent with this we observed that a group of countries stood out in terms of their mortality rates --all had rates % or more above the others. all but two of these countries fell within a relatively narrow band of temperatures (over the january to april period) -bounded by the temperatures of austria on the low end ( . degrees c) and portugal on the high end ( degrees c). we hypothesized that if there was a protective effect of smoking it might be possible to detect it outside of this moderate temperature band where temperature appeared to be a dominant factor and mortality rates were extreme. to investigate the relationship between national smoking prevalence and covid- mortality we chose two cohorts: "hot countries" and "cold countries." all countries available in the johns hopkins mortality analysis as of / / with mortality rates of at least . deaths/ k population were included in the analysis. a minimum mortality threshold was required because extremely low mortality rates may reflect inadequate testing -furthermore, this limits the impact of floor effects in the analysis. mortality rates were chosen as the main outcome measure, as this reflects not only covid- deaths but the preceding hospitalizations, both of which could potentially be decreased in smokers. all countries colder than austria were included in the cold countries cohort. an equal size group was formed for the hottest countries. mortality data: national mortality figures, deaths/ , population, were obtained for each country in the study from the johns hopkins mortality analysis on may , . temperature data: the months january through april were chosen for temperature comparisons as they are the months preceding our mortality statistics and include the period when the virus was known to be spreading outside of china. monthly temperature averages for the largest city in each country/state were obtained from the website timeanddate.com. the largest city was selected as the reference to establish a rough approximation of the temperature experienced by the whole of the country/state population. obesity prevalence: national obesity rates, defined as a body mass index (bmi) over , were obtained from worldpopulationreviews.com. . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint percentage of elderly in the population: national data was obtained for percentage of the population over years of age from worldbank.org. male and female percentages were obtained for each country from tobaccoatlas.org and sex ratio was used to calculate overall percentages. note that daily smoking prevalence will be lower than overall smoking prevalence which is more often cited. daily smoking was chosen because there might be a dose effect and daily smokers would be the most affected. statistical analyses were performed using the r programming language version . . . for each of the groups, and for the combination, a linear correlation analysis was performed evaluating the relationship between daily smoking rates and covid- mortality. second, for each of the groups multiple regression was performed to adjust for known risk factors for covid- mortality. the independent variables in the regression were daily smoking prevalence, population percentage over , sex ratio, obesity prevalance, and average ambient temperature from january-april, . post hoc analyses were run with and without inclusion of korea and sweden, because of their unique covid- policies and procedures. correlations and scatterplots between national smoking prevalence and covid- mortality rates in each of the three groups of countries can be seen below in figure to test whether any outliers may be driving the results we performed post-hoc analyses removing sweden and korea both individually and together. sweden's policy of minimal mandatory closures of schools and business appeared to result in greatly elevated mortality rates. in contrast, south korea's aggressive testing, contact-tracing, and utilization of masks appeared to result in an exceptionally low mortality rate. removing either or both increased the inverse correlation in each subgroup and the combined groups. removing both countries from . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint discussion a significant inverse correlation of smoking prevalence and covid- mortality rate was found for the subgroups of hot and cold countries, and for the combined subgroups. after adjustments were made for age (% of the population > y.o.), sex ratio, temperature (january -april average), and obesity percentage, the effect of smoking prevalence remained significant for the hot countries, and the combined subgroups, but not for the cold countries. the association was stronger in the post hoc analysis for the combined groups excluding the outliers korea and sweden. it must always be kept in mind that correlation does not imply causation, and although we found the surprising hypothesized correlations supporting a protective role of smoking in covid- , we now question if this association might instead reflect an unknown confound. the correlation found, especially in the hot countries, appears too strong to be based primarily upon an effect of smoking. post hoc, it is apparent by inspection of the scatterplots that countries with the lowest smoking prevalence have several-fold higher mortality rates relative to the lowest smoking countries. this cannot be the result of smoking per se. the reason is that even if we assume every smoker is % protected from developing covid- , there are too few smokers in the population to produce such a large effect, and it is reasonable to assume that there is a confounding influence. for this reason, although the current study reinforces a strong inverse association, at the national level, of smoking and seriously symptomatic covid- , these data suggest that this association is, at least in large part, based on something other than smoking itself. this same interpretation may apply to a study by gonzalez-marron and martinez-sanchez, which appeared in preprint form while we were preparing this manuscript. similarly, they found a significant inverse association of smoking with national per capita rates of covid- cases in the countries of the european union (eu). they found no significant association with the national case fatality rate, but they did not look at the national mortality rate. since most of the countries in the eu have a temperate climate, this suggests that an inverse association of smoking and covid- is not limited to extreme climates. however, when we calculated from their data the case rates in their seven highest smoking and seven lowest smoking eu countries (approximately quartiles), we similarly saw a nearly three-fold difference in median rates ( . vs. . ) . again, such a large difference does not appear compatible an effect of smoking itself, and implicates a powerful confounding influence. . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . what this confound or confounds might be is unclear. countries with high smoking prevalence may generally have weaker health care systems with less access to treatment and, importantly, less testing. more generally, smoking prevalence may be linked to myriad national differences in political structures, economics, or behavioral tendencies (e.g. international travel) that impact the acquisition, diagnosis, treatment, or reporting of covid- . additionally, patients or physicians may assume that the smokers' pulmonary symptoms are a result of smoking and not test for covid- . this may be especially true when testing capabilities are limited. finally, in our study one confound could be that covid- deaths occurring in smokers may frequently not be counted because of smokers dying in the community undiagnosed with covid- -something which would happen more often in a country with a poor healthcare system and limited testing. the inverse correlation may, of course, have both physiologic and nonphysiologic underpinnings. the strongest case for physiology appears to be the substantial underrepresentation of smokers among hospitalized patients that has been consistently observed across thirteen countries. if smoking acts in some way to reduce covid- mortality, it seems that this must be occurring prior to hospitalization, as data show hospitalized smokers are much more likely to experience serious progression of illness relative to non-smokers. , however, it is hard to reconcile this consistent pattern with the results of the simon's review showing little evidence of under-representation of smokers among those testing covid- positive in the community, or evidence that smokers testing positive are less likely to be hospitalized --though here results were mixed. so the under-representation of smokers among those hospitalized remains puzzling. to our knowledge, the only other respiratory virus for which smoking has been suggested to have a protective effect is the closely related sars-cov. a case-study was conducted in to investigate this possibility. while it was found that smokers were more than four-fold underrepresented in this group of sars patients, when confounds were considered this dropped to only . -fold --and the effect was not significant. this under-powered study concluded that "smoking is shown to provide no protection," yet intriguingly there was clearly some suggestion of association in a closely related virus. if smoking actually confers some protection from seriously symptomatic covid- , what are some possible mechanisms of action? there is evidence that smoking affects the ace- . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . receptors used by the virus for cell entry, but studies are mixed whether it upregulates or down regulates this receptor. [ ] [ ] [ ] while down regulation can easily be understood to potentially be protective from infection, up-regulation might be protective from development of severe lung disease. in the case of sars-cov, a study showed it down-regulates the ace and that this was directly implicated in the development of severe lung disease. a group in france proposed a potential role of nicotine as the agent responsible for smoking's action on the ace receptor, potentially providing a protective mechanism for smoking in covid- . nicotine is also of interest because it could help in covid- by mitigating a host of destructive inflammatory reactions , that often are associated with deterioration in the later stages of covid- . , another mechanism of interest is nitric oxide (no) which is one of the many chemicals found in cigarette smoke, and also relevant to nicotine. smokers are exposed to high levels of no in the inhaled smoke as well as endogenously released no after uptake of nicotine in the brain. nitric oxide has antiviral activity, and has been shown to reduce infectivity of h n in vitro. , in colds, some of which are caused by coronaviruses, increased nitric oxide is associated with more rapid viral clearance. evidence also points to antiviral activity with sars-cov. there has been an anecdotal report of successful administration of gaseous no in covid- . two multicenter randomized controlled trials are planned, organized by investigators at massachusetts general hospital in boston. these trials are aimed primarily at treating acute respiratory distress in covid- patients. smoking is associated with inflammation in the respiratory tract and creates a host of changes to the immune system, and it is possible that some of these changes might make for an inhospitable environment for sars-cov- infection. a comprehensive review of immune changes associated with smoking concluded that these effects were almost always harmful rather than beneficial. as noted, the exceptions may involve sars-cov and sars-cov- , and it could be informative to understand what is so different about how these viruses act, and to develop treatments based on this understanding. lastly, heat could be the basis of a protective mechanism directly to the warm vapors being inhaled. the internal temperature of a cigarette averages around degrees c. smoke in the mouth can reach temperatures of degrees. heat may be therapeutic in a number of ways. . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint fever is an evolutionarily conserved function in all vertebrates, it's generally believed to play a role in the body's defense against viruses, , and enhances a host of immune functions, including productions of heat shock proteins, , importantly, covid- patients that are admitted to the hospital without fever have been found to have greatly elevated risk of poor outcomes. , , furthermore, we know that coronaviruses are highly temperature sensitiveat least in the lab where virus inactivation was reduced from taking days at degrees c to five minutes at degrees c. aside from the warm smoke vapors inhaled, there is also another way that heat relates to smoking. a recent study showed that smokers have a full one degree c elevated breath temperature compared to non-smokers. furthermore, in the hour after a cigarette is smoked breath temperature is further increased by an average of . degrees c. smokers are chronically experiencing a localized relative heating of the respiratory tract, believed to be principally related to increased blood flow associated with inflammation. to the extent that temperature is implicated in a smoker's physiology, it is reasonable to consider that there are a host of much more benign ways to warm the respiratory tract than smoking. though the evidence was deemed inconclusive in a cochrane review, several controlled trials - were cited of various heat treatments (e.g. steam) showing successful reduction of symptoms or duration of colds, another illness sometimes caused by a coronavirus. another obvious treatment to investigate is the sauna, as there are similarly promising preliminary evidence of efficacy in colds. furthermore, sauna use has the additional benefit of regular usage being associated with huge reductions of some of the major comorbid risk factors associated with covid- , a % reduction of respiratory illness (including pneumonia) and a % reduction in cardiovascular illness. finally, a study is planned at ut southwestern medical center to treat covid- patients undergoing mechanical ventilation with esophageal heat exchangers. covid- patients at the point of needing ventilation are typically without fever, and the goal of this treatment is to bring their body temperature up to a maximum of about degrees c. the primary strength of the current study is that it shows a strong inverse association between covid- mortality and daily smoking prevalence not subject to the many confounds identified in previous studies reporting under-representation of smokers among covid- patients. it is, of course, still subject to other potential confounds, and the inverse association between smoking and covid- mortality we found did not hold up to full adjustments for one of the two cohorts analyzed individually. the current study has other limitations, while it uses covid- . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . mortality rates that are likely more accurate than case rates, they nonetheless still depend in part on testing availability and accuracy. additionally, all reported national statistics are also subject to political influences, lockdown variability, regional infection rates, timing of initial cases etc. furthermore, this is still an evolving pandemic and mortality rates will change. at this time there is no clear evidence that smoking is protective against covid- , so the established warnings to avoid smoking should be emphasized. the interaction of smoking and covid- will only be reliably determined by carefully designed prospective study, and there is reason to believe that there are unknown confounds that may be spuriously suggesting a protective effect of smoking. however, the magnitude of the apparent inverse association of covid- and smoking and its myriad clinical 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smoking on immune responsiveness: up and down or upside down? measurement of oral and burning zone temperatures during conventional and reverse cigarette smoking studies on smoke temperature during cigarette smoking fever and the thermal regulation of immunity: the immune system feels the heat fever, hyperthermia and the heat shock response fever promotes t lymphocyte trafficking via a thermal sensory pathway involving heat shock protein and alpha integrins risk factors for predicting mortality in elderly patients with covid- : a review of clinical data in china clinical characteristics of refractory covid- pneumonia in wuhan, china stability of sars-cov- in different environmental conditions dynamics of exhaled breath temperature after smoking a cigarette and its association with lung function changes predictive of copd risk in smokers: a crosssectional study is the exhaled breath temperature sensitive to cigarette smoking? heated, humidified air for the common cold local hyperthermia benefits natural and experimental common colds effects of steam inhalation on nasal patency and nasal symptoms in patients with the common cold randomised controlled trial of rhinothermy for treatment of the common cold: a feasibility study what's new with the old coronaviruses? visiting a sauna: does inhaling hot dry air reduce common cold symptoms? a randomised controlled trial frequent sauna bathing may reduce the risk of pneumonia in middle-aged caucasian men: the kihd prospective cohort study joint associations of sauna bathing and cardiorespiratory fitness on cardiovascular and all-cause mortality risk: a long-term prospective cohort study core warming of coronavirus disease (covid- ) patients undergoing mechanical ventilation -a protocol for a randomized controlled pilot study key: cord- -phgfpzbt authors: andrew, jones; nikolay, strigul title: is spread of covid- a chaotic epidemic? date: - - journal: chaos solitons fractals doi: . /j.chaos. . sha: doc_id: cord_uid: phgfpzbt the covid- epidemic challenges humanity in . it has already taken an enormous number of human lives and had a substantial negative economic impact. traditional compartmental epidemiological models demonstrated limited ability to predict the scale and dynamics of covid- epidemic in different countries. in order to gain a deeper understanding of its behavior, we turn to chaotic dynamics, which proved fruitful in analyzing previous diseases such as measles. we hypothesize that the unpredictability of the pandemic could be a fundamental property if the disease spread is a chaotic dynamical system. our mathematical examination of covid- epidemic data in different countries reveals similarity of this dynamic to the chaotic behavior of many dynamics systems, such as logistic maps. we conclude that the data does suggest that the covid- epidemic demonstrates chaotic behavior, which should be taken into account by public policy makers. furthermore, the scale and behavior of the epidemic may be essentially unpredictable due to the properties of chaotic systems, rather than due to the limited data available for model parameterization. the developing covid- pandemic challenges humanity in . according to aggregated worldwide data posted at the international worldometer.info website, more than million were infected by covid- and more than , people died in relation to this disease (as of july , ) . the pandemic has already caused a huge economic loss due to national lock-downs, travel restrictions, and global distractions of trade and manufacturing chains. as the pandemic developed around the globe, severe border control and travel limitations were implemented that led to unprecedented national isolation. different countries, while being isolated, implemented various strategies to limit epidemic spread: many countries implemented extended national-level lock-downs including closure of businesses, schools and stay-at-home orders (for example france, italy, germany, austria, hungary, south korea, and more), some introduced practically no such lock-down measures (for example, sweden, belarus, and brazil). many countries implemented only regional lock-downs (for example, china and the usa). the overall challenge for the development of scientifically-based covid- containment strategy is the apparent unpredictability of this pandemic [ ] . traditional compartmental epidemiological models demonstrated quite limited ability to predict the scale and dynamics of this epidemic in different countries [ , , ] . this apparent unpredictability of the covid- pandemic creates an additional challenge for governments around the globe, who need more accurate predictions to develop a reasonable containment strategies [ , ] . this limitation of traditional modeling approaches can be partially explained by the novelty of the virus and limited relevant epidemiological data necessary for model parameterization [ ] as well as statistical problems in model calibration [ ] . in particular, until recently, we did not know the rate and mechanisms of the transmission of covid- virus as well as its biology and ability to survive and spread outside host organisms [ , ] . in a previous study, [ ] demonstrated that the coronavirus raw data in china's first two months of the disease suggest chaotic growth, similar to other epidemics like h n and measles. mathematical chaos theory originated from studying deterministic systems represented as differential equations where initial conditions dictate their behavior. in these systems sensitivity to the initial conditions was so large that the systems were practically unpredictable. this was originally studied by poincaré in the s in relation to the three-body problem in astronomy, an example of which is the earth-moon-sun celestial system [ ] . as poincaré critically stated, "it may happen that small differences in the initial conditions produce very great ones in the final phenomena" [ ] . in physical systems described by differential equations, systems which experience this effect are described as having "high sensitivity" to initial conditions. one example which demonstrates this concept is a bowling ball; imagine a very small spin on the ball at the beginning of its roll. this small spin in combination with the oiled bowling lane could cause it to move wildly off-course, making it "highly-sensitive" to initial conditions. due to the effect poincaré found, "measurements made on the state of a system at a given time may not allow us to predict the future situation" [ ] . these systems are now termed "chaotic." unpredictability due to highly-sensitive reliance on initial conditions inspired the term "deterministic chaos." after poincaré's studies, the deterministic chaotic behavior was discovered in numerous dynamical systems and confirmed experimentally [ , , , ] . the spread and "fade out" cycle of epidemic diseases often exhibits deterministic chaos. qualitative analysis of that deterministic chaos can offer more information than a "multifactorial stochastic paradigm of causation" [ ] . in the late s, scientists noticed that measles outbreaks exhibited deterministic behavior. by studying this they hoped to quantify conditions for the maintenance of [an] infection in human populations" [ ] . in , grenfell published his study of the chaotic measles outbreaks in the paper "chance and chaos in measles dynamics." that study found that certain parameters in the chaotic disease system created deterministic behavior. for example, applying his model to the city of copenhagen and mapping with poincaré's methods produced drastic results: one example is that doubling the immigration rate into the city could completely eliminate the fade-out of measles [ ] . similar findings in relation to covid- could have wide-ranging societal implications. in this work, we consider the covid- epidemic within the framework of complex dynamic systems [ ] . this framework is broadly applied in modern ecology, social and medical sciences [ , , , , ] . in particular, the covid- pandemic can be considered as a complex phenomena developing simultaneously at multiple temporal and spatial scales varying from individual level to the global scale. within this framework, particular disease dynamics patterns result from major self-organisation mechanisms within the system. the chaotic behavior is a common phenomenon in complex systems, and we hypothesise that the unpredictability of the epidemic scope in different countries is a fundamental property of this dynamic system which demonstrates chaotic behavior. in order to examine this hypothesis we have analysed covid- epidemic data from different countries. in particular, we examine if the covid- epidemic demonstrates a chaotic regime based on the analysis of observed data. we do not aim to derive or validate a correct dynamical system model. instead we consider epidemiological data collected in different isolated countries as an independent observations of the same dynamical system. in order to evaluate whether or not the spread of coronavirus is chaotic, we employ the following criteria, derived from poincaré's definition of chaos [ , ] [ ] . in the study, we find extremely high variation between countries, even when normalizing by patient-zero date and total population of each country. . sensitive -does the growth of the virus experience large regions of activity? are there real reasons for regions of activity, specifically changes in the physical system? this criterion has precedent in the aforementioned university of florida / wuhan university paper [ ] . later in the study, we present multiple examples of high regions of sensitivity in the spread of covid- , as revealed by the derivatives of the system. . numerically unpredictable -can the behavior of the system change unexpectedly from one point to another? this criterion was also introduced in the university of florida / wuhan university paper [ ] . we found numerous examples of sets of countries which exemplified unpredictability by behaving similarly and then suddenly diverging, which we discuss later in the paper. . deterministic -what causes activity in the system? is the system random, or is it determined by some factors of the physical system, as required in order to be chaotic? this is a qualitative criterion derived from poincaré's definition of chaos [ ] . we present cases where real-world changes such as mandated lockdowns had a profound impact on the spread of the disease, suggesting deterministic behavior. the study concluded that the spread of covid- exhibits the major qualitative characteristics of chaotic systems. most countries show a roughly logistic growth curve, but activity in the second derivative revealed great variability in system behavior. when examined under the context that infectious epidemics in the past have exhibited chaotic behavior, the study concluded that the spread of covid- suggests that the epidemic is a chaotic system. johns hopkins university has continuously collected data on the coronavirus epidemic from various sources such as the world health organization, including daily cases per country, which is the data source used for this study [ ] . the data is organized by country and cumulative cases by date. a sample with the first five days of one country is shown in table . we considered the data from the beginning of the global data set, january nd, , to may th, . each data-point tells the number of confirmed covid- cases in that country by that day. in the example shown in table , the united states had five confirmed cases by january th, . with almost , data-points corresponding to countries or territories, the study required a dynamic analysis tool instead of analyzing static charts. in order to investigate deeper, a web-based interface was designed and developed to allow for close inspection of the data through interactive charts. the evolution of the covid- epidemic was mapped over time, in terms of total number of confirmed cases per country per day. data was adjusted to account for country population and date of first-confirmed-case in order to accurately compare the spread behavior between countries. the raw data was extracted as an csv file and analysed using original javascript software [ ] , the graphing utility plotly [ ] was employed to generate all the graphs. figure demonstrated the raw data as percentages of each country's population. since the data only pertains to the total number of confirmed cases, not accounting for decreases like recovery and death, the total number of cases in every country/region increases or remains constant at all times. highlighted in figure , almost all regions show of possible parts of the beginning of a logistic graph: a curved ramp-up (russia), or a curved ramp-up into roughly a line (us), or an upward curve into a line which curves toward horizontal (spain), which is a logistic curve. this is sensible for an infectious disease with a maximum number of infections, that maximum being the population of each country. per capita.png so far, these patterns don't directly suggest chaos: it still seems possible there might be some parameters which control the shape of the curves predictably, potentially population density, weather patterns, etc. figure demonstrates the case data shifted to show the percent of the population that had been infected as a function of the number of days since the first case in each country, instead of the absolute date. this graph is more revealing about the relative behavior of the epidemic in each country. it is clear the virus ran its course faster in some countries, where the growth seems to have flattened in fewer days. for example, only days after the first case in iceland, the country had almost completely stopped the spread. meanwhile, the us at days in was still seeing almost linear positive spread. comparison of iceland and the us these differences confirm that there are a large number of potential solutions or equilibrium and varying behavior between countries over time. another key observation from this graph is that countries which seemed to follow similar growth curves can very rapidly diverge. for example, as shown in figure , in the first days of the epidemic in ireland, the netherlands, and turkey, the percentage of the population that was infected grew almost identically in each country. however, between days and , the three countries' curves diverged greatly, to such an extent that by day , ireland had almost three times the infected population percentage as turkey, and turkey and the netherlands are % apart as well. this example exhibits unpredictability because, by poincaré's definition, the behavior following day cannot be predicted by the state at day , since there are clearly multiple possible behaviors. this is one example confirming unpredictability in the spread of covid- . it is also important to note that these three countries are not alone in displaying unpredictability after formerly-similar spread of covid- . another example is kuwait, france, and sweden, shown in figure . until approximately day , the infected percentage in all three countries had grew with similar shaped curves. however, within days after that point, the infected percentage in kuwait spiked drastically, while it entered linear growth in france and sweden. by days later, even france and sweden diverged, with sweden's infected percent still growing linearly while the spread slowed down in france. by poincaré's definition of unpredictability, knowing the spread behavior in sweden from day to would not provide any accurate prediction of the behavior in kuwait or france, suggesting a chaotic nature.yet another example of unpredictability is cabo verde and new zealand, shown in figure . in cabo verde and new zealand, the disease spread almost identically until day , at which point it continued to grow similarly in each country until day , and then the behaviors sharply diverge: cases grow steeply linearly in cabo verde, but level off almost entirely in new zealand. this example further demonstrate that spread of covid- is unpredictable, because at any given point there are multiple possible behaviors in the time following that point. the observation of unpredictability fulfills one of poincaré's key criteria for choatic systems. we looked at the rate of spread of covid- , the derivative of the number of cases, adjusted similarly to figure . this data, shown in figure shows the spread rate as a function of the number of days since the first patient. negative derivatives represent decreasing numbers of cases, which shows corrections to data, since the data set does not account for real decreases in active cases (by recovery or death). while the raw data shows mostly similar shaped, roughly logistic trajectories with some small bumps and jumps, the daily rate of growth shows a lot of variation in behavior. for example, in the us from day to day , just one week, the daily growth rate decreases by % and increases back to almost the same starting point (shown in figure ). we also see drastically different behavior between different regions, unlike the roughly logistic graphs of the raw data. one example is the comparison of the spread rates of the us and spain. by their respective day s, the spread rate in spain started to decline, while the us spread rate was just starting to increase, as shown in figure . the amount of unpredictable variation within a country and different possible models for each country suggest chaos. however, most countries still follow a very rough pattern of increasing and then leveling-off and decreasing spread rates. the second derivative helps to measure this sensitivity ( figure ) because its behavior shows activity in the system [ ] . the rate of change of the spread rate in each region fluctuates greatly. the us ( figure ) seems to oscillate between roughly two values, spain and italy ( figure ) appear to exhibit a single heart-beat-like pulse surrounded by ramp-up and ramp-down, and russia ( figure ) and germany show clusters of high activity. in summary, the results reveal the following: . large number of solutions -while most countries have a roughly logistic curve of covid- growth, there is a huge amount of variation in: the time it takes to reach the same point in that logistic curve, the highest percent of the population which the logistic curve reaches, and the degree of curvature of the logistic model. . sensitive -the second derivative shows clusters, spikes, and oscillations, revealing that the system is highly sensitive due to the high amount of activity in the system instead of steady or constant behavior. . numerically unpredictable -while the raw data shows roughly predictable shapes, the extreme variation first and second derivatives of different countries reveal a high amount of variability, making the growth of the system unpredictable. furthermore, there are examples of growth curves appearing identical and then suddenly diverging. we may predict that spread in the us will level off logistically, but we cannot tell when that will occur based on the us data or other countries' curves. one important question remaining is what causes the activity: is the system random, or is it determined by some factors of the physical system, as required in order to be chaotic? qualitative investigation is required to answer that, and even then we cannot definitively determine the factors contributing to every change in every country. however, we investigated some of the countries and found good examples suggesting the system is deterministic. new cases take up to days to show symptoms and therefore be reported [ ] . in iceland, lockdown was initiated on march th [ ] , day when shifted. exactly two weeks after that change, there are few new cases reported ( figure ) and almost all activity shown by the second derivative ceases (figure ). this is also the day with the sharpest increase in testing in ireland [ ] , which would explain the jump in the data and higher activity following that day. in bahrain, re-opening efforts began on april th [ ] , which is the likely cause of a the immediately following spikes in number of cases ( figure ) . these examples suggest that real changes in the physical conditions of the system are causing changes in the spread of the virus. the outcome, amount and rate of spread, is determined by these real factors. this suggests the behavior of the system is deterministic, not random, a key qualifier for a chaotic system. complex natural systems often demonstrate chaotic behavior. however, rigorous proof of chaos from empirical data or experimental observations alone is a substantial challenge. in this work, rather than attempt a rigorous mathematical proof, we investigate the hypothesis that the covid- pandemic exhibits chaotic behavior by mapping the disease over time from available epidemiological data. our results suggest that the covid- epidemic exhibits deterministic chaos. the overall predictions of the sir model demonstrate a typical sigmoidal curve. this functional response is characterised by an exponential growth stage, inflection point and slowdown growth phase towards a horizontal asymptote. the first wave of covid- pandemics in different countries demonstrates similar behavior ( figure ). empirical sigmoidal models such as the logistic curve are also broadly employed for modeling of covid- and other epidemics [ , , ] . the discrete counterpart of the logistic curve is a well-known logistic map model that demonstrates a chaotic behavior [ ] . our examination of the epidemic dynamics in different countries reveals amazing similarity to the chaotic behavior known in this and many other dynamics systems. we conclude that the scale of the epidemic is essentially unpredictable due to fundamental reasons rather than due to the limited data available for model parameterization. we find that the chaotic behavior in the spread of covid- suggests that it is a deterministic chaotic system, which should be taken into account by public policy makers. through use of an interactive data map, it was shown that the spread of covid- exhibits the major characteristics of chaotic systems, namely, determinism, high sensitivity, large number of equilibria, and unpredictability. when examined under the context that infectious epidemics in the past have exhibited chaotic behavior, we conclude that spread of covid- is likely a chaotic system. we may be able to gain some insights into its behavior, such as the common logistic pattern, but we cannot assume that it will follow a logistic path in any one country and we cannot numerically predict the behavior of a particular logistic curve. ☒ the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. ☐the authors declare the following financial interests/personal relationships which may be considered as potential competing interests: claration of interest statement coronavirus: bahrain one of first nations to ease lockdown as malls reopen complex population dynamics: nonlinear modeling in ecology deterministic chaos theory: basic concepts first two months of the coronavirus disease (covid- ) epidemic in china: real-time surveillance and evaluation with a second derivative model when will the coronavirus outbreak peak non-linear dynamics for clinicians: chaos theory, fractals, and complexity at the bedside. the lancet chance and chaos in measles dynamics covid- : more deaths, further cases offline: covid- and the nhs-"a national scandal novel coronavirus (covid- ) cases data predictive mathematical models of the covid- pandemic: underlying principles and value of projections original software: covid- graphs: javascript ecosystems and the biosphere as complex adaptive systems complex adaptive systems: exploring the known, the unknown and the unknowable deterministic nonperiodic flow effective containment explains subexponential growth in recent confirmed covid- cases in china simple mathematical models with very complicated dynamics covid- information hub: what you need to know a systematic review of covid- epidemiology based on current evidence complexity, simplicity, and epidemiology chaos, population biology, and epidemiology: some research implications plotly graphing libraries: javascript sur leséquations de la dynamique et le probleme des trois corps estimation of covid- dynamics "on a back-of-envelope": does the simplest sir model provide quantitative parameters and predictions? chaos why is it difficult to accurately predict the covid- epidemic? real-time forecasts of the covid- epidemic in china from february th to february th covid- epidemic in italy: evolution, projections and impact of government measures modeling the epidemic dynamics and control of covid- outbreak in china hert samkomubann: ekki fleiri en mega koma saman key: cord- -jhulvfev authors: blanchflower, david g. title: is happiness u-shaped everywhere? age and subjective well-being in countries date: - - journal: j popul econ doi: . /s - - -z sha: doc_id: cord_uid: jhulvfev a large empirical literature has debated the existence of a u-shaped happiness-age curve. this paper re-examines the relationship between various measures of well-being and age in countries, including developing countries, controlling for education and marital and labor force status, among others, on samples of individuals under the age of . the u-shape of the curve is forcefully confirmed, with an age minimum, or nadir, in midlife around age in separate analyses for developing and advanced countries as well as for the continent of africa. the happiness curve seems to be everywhere. while panel data are largely unavailable for this issue, and the findings using such data largely confirm the cross-section results, the paper discusses insights on why cohort effects do not drive the findings. i find the age of the minima has risen over time in europe and the usa. in this paper, i report on the existence of a midlife nadir in well-being. the analysis is conducted mostly at the country level with happiness and life satisfaction variables, although a number of other measures are used that relate to a household's financial situation and their living standards, satisfaction with local services, and the macro economy. all produce u-shapes in age. using country-level data, i identify u-shapes in age in advanced and developing countries. this includes of the member countries of the united nations. i find this happiness curve (rauch ) for developing and thirty-six advanced countries based on an analysis where i control for gender, education, marital and labor force status, and time. i use data from fourteen different survey series. i use these data to estimate separate country-level estimates that reach a minimum, on average, at age . . there are estimates from developed countries with an average minimum at age . and estimates from developing countries with an average minimum at . . i examine cross-section time series data at the country level rather than examining panel data. longitudinal data files that have a long run of years are restricted to the uk (bhps and ncds), germany (gsoep), and australia (hilda). in part, the concern with these surveys is non-random attrition bias and hence missing values over time with the least happy dropping out or even dying, which may well introduce measurement error. there is a small literature looking at age effects using panel data that i interpret as largely supportive of u-shapes, although there are some technical issues that must be considered. my interest is to see whether there is evidence of a midlife zenith in other countries besides the uk, germany, and australia. i examine the importance of cohort effects to determine if younger and older age cohorts are different from those in the middle and find out that they are not. i examine the data over time and adjust for cohort effects and find remarkable consistency in the findings. i find that introducing cohort effects in the samples where i have a long time series, namely, the eu commission's eurobarometer series pre and post the great recession ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , has little impact on the results. i find the minima in europe have risen over time, from around age in to over in the most recent data. i also address the issue of possible differential response rates among older people, along with the concern that happy people live longer. to minimize that concern, i focus my analysis on people from early adulthood, which is usually age but in some samples is as low as , to under the age of . i exclude older people. it makes sense to look at as many countries as possible given the evidence that in the raw data the usa looks different. in the raw us data, essentially however measured, happiness rises initially to a peak around age and then declines into midlife and then rises again after age . this apparent m-shape disappears once controls are included and a well-defined u-shape appears. it also disappears when the sample is split into separate married and unmarried samples. these patterns are not found elsewhere in the world. this has led to a debate in the usa especially about the importance of including control variables, although less so outside the usa where it matters little. in other countries, the u-shape generally appears whether controls are included or not, although the point at which the function reaches a minimum may differ. it is also worth pursuing the possibility that the u-shape doesn't apply to poorer countries, where residents have shorter life expectancies. blanchflower and oswald ( a) find a u-shape for developing countries in world values survey sweeps - that averages out at a minimum around age when including control variables. in this paper, i find there are u-shapes in age in developing countries with minima similar to those in advanced countries regardless of how well-being is measured. i examine the presence or not of u-shapes with and without controls in the usa and find the evidence is much stronger with controls. i then turn to examining data for the uk and european countries and find there is evidence of a u-shape whether controls are included or not, with very little difference in the age minima. i then proceed to examine a series of multi-country data files. it is striking that the same finding holds across so many countries. the u-shape can be found in multiple data files and does not depend on what question is asked or how the responses are coded. i document clear patterns in the data. this paper is the mirror image of blanchflower ( b) that examined unhappiness data and finds comparable evidence using twenty different measures for an unhappiness curve that maximized with controls at age compared with a zenith of happiness estimated in this paper at age . yes, there is, despite what psychologists say. the background literature is large and there is some disagreement over whether u-shapes exist at all (see, for example, baird et al. ( ) , blanchflower ( ) , blanchflower and oswald ( ) , carstensen et al. ( ) , charles et al. ( ) , easterlin ( easterlin ( , , frey and stutzer ( ) , frijters and beaton ( ) , glenn ( ) , graham and pozuelo ( ) , hellevik ( ) , hudson et al. ( ) , lachman ( ) , leland ( ) , mroczek and kolanz ( ) , mroczek and spiro ( ) , rauch ( ) shields and price ( ) , stone et al. ( ) , steptoe et al. ( ) , wunder et al. ( ) , and schwandt ( )). a recent review by ulloa et al. ( ) goes so far as to draw the conclusion that existing studies show either a u-shaped, inverted u-shaped, or linear relation between aging and subjective well-being. other studies, such as lachman ( ) , come close to arguing that there may be a midlife dip but that it is too small to be significant. many of the studies such claims were based on had very small samples sizes and in fact did show u-shapes despite claims they didn't. an early psychology literature suggested there was no age-happiness relationship (cantril, , and palmore and luikart, ) . myers ( , p. ) argued that no time in life is notably happiest and most satisfying. in contrast, michael argyle concluded that studies of life satisfaction found that it increased with age (argyle, (argyle, , . a survey by diener et al. ( , p. ) concluded that life satisfaction often increases, or at least does not drop, with age. easterlin ( ) examined data from the general social surveys from to and claimed that "happiness is greatest at midlife but not by a great deal. on average it rises somewhat as people progress from age to and declines thereafter" ( , p. ) . a survey by diener et al. ( , p. ) concluded that recent studies converge to show that life satisfaction often increases, or at least does not drop, with age. diener and suh ( ) examined world values survey data for and argued that the raw data on life satisfaction trended up slightly through age. deaton ( ) concluded that the u-shaped relation is present solely in rich, english-speaking countries in which the elderly is relatively satisfied with their lives. (ibid., p. ). more recently, whitbourne ( ) has gone so far as to argue that the u-shape curve is a "myth." blanchflower and graham ( a) examine the evidence that psychologists have cited claiming no u-shape exists over the life span and found that many of the studies cited had very small sample sizes. examples are helson and lohnen ( ) (n = ), freund and baltes ( ) (n = ) , and hamarat et al. (n = ) to name but a few. it is hard to say much of anything about statistical differences in well-being by age with sample sizes that small. psychologists have also cited work by ingelhardt ( ) as not finding any u-shapes in age. for example, diener et al. ( ) citing ingelhardt ( ) argue that "international studies based on representative samples from multiple countries also show that life satisfaction does not decline with age." myers ( ) argued that ingelhardt showed that "age differences in well-being were trivial. does happiness then align itself more with any particular age? do young adults have more fun? surprisingly, and definitely, not" (p. ). ingelhardt ( ) examined well-being across sixteen nations using data from eurobarometers # -# (april -november and the world values survey on the usa, canada, hungary, and japan for - and argued that there was "little variation by age" in well-being (p. ). it turns out the data he used in fact show otherwise. blanchflower and graham ( a) went back to the ingelhardt book and observed he in fact reported u-shapes in the raw data in nine of the sixteen countries studied. blanchflower and graham examined the same data ingelhardt used and estimated a series of happiness equations and found there were u-shapes in age with controls in all the countries and variables ingelhardt examined. in addition, diener and suh ( ) cite work by okma and veenhoven ( ), also used eurobarometers, between and , and argued that the paper showed an almost flat line with age. from around age to , they argued it showed there was almost no change in life satisfaction. it didn't. blanchflower and graham ( a) went back to analyze these same eurobarometer files for the same years which are part of the publicly available mannheim trend file. across these nations, the average score for those under was . , reaching a low point of . at age and then rising to . at age . so, it is true that life satisfaction scores at age are not that different from age but that ignores the midlife drop. without controls in a life satisfaction equation, there is a well-defined nadir in well-being in age controlling for year and nation that minimizes at age and also one with controls-for gender, education, and marital and labor force status-that minimizes at age . i update and extend results in an earlier paper (blanchflower and oswald, a) , where it was shown that a u-shape in age existed in well-being data across a number of countries. using data on , randomly sampled americans and west europeans, the paper found that holding other factors constant, a typical individual's happiness reaches its minimum on both sides of the atlantic for both males and females in middle age. the minimum in age was broadly similar between advanced, east european, and developing nations. the function minimized on average in midlife. for example, in europe, for both men and women, it minimized at around with controls including education and marital and labor force status. for developing countries from the wvs, sweeps - , minima were for men and for women. a maximum in age in unhappiness data for europe was found at around age . some apparent exceptions, particularly in twenty developing nations along with a few western countries, mostly where there are small numbers of observations, to the u-shape were noted. subsequently, glenn ( ) argued that it was inappropriate to include controls and what mattered was the raw data; blanchflower and oswald ( ) disagreed. glenn claimed that the appearance of this u-shaped curve of well-being is the result of the use of inappropriate and questionable control variables and especially marital status. it is worth rehearsing the arguments we used there again. in many countries around the world, and especially in europe, as i illustrate in detail below, the u-shape can be found evidence for a u-shape was found in twenty-two advanced countries (australia, belgium, canada, denmark, finland, france, germany, greece, iceland, ireland, italy, japan, luxembourg, malta, netherlands, norway, portugal, spain, sweden, switzerland, uk, and usa) . second, evidence was provided for the existence of a similar u-shape through the life course in east european, latin american, and asian nations. evidence was found in fourteen ex-soviet republics (albania, bosnia, bulgaria, croatia, czech republic, estonia, hungary, latvia, lithuania, macedonia, poland, romania, serbia, slovakia) and thirty-eight developing countries (argentina, azerbaijan, belarus, brazil, brunei, brazil, brunei, cambodia, chile, china, colombia, costa rica, dominican republic, ecuador, el salvador, iraq, israel, honduras, kyrgyzstan, laos, mexico, myanmar, nicaragua, nigeria, paraguay, peru, puerto rico, philippines, russia, singapore, south africa, south korea, tanzania, turkey, ukraine, uruguay, uzbekistan, and zimbabwe. i find evidence of a u-shape in all of these countries also. that included algeria, armenia, austria, bangladesh, chile, colombia, egypt, greece, india, indonesia, iran, jordan, luxembourg, moldova, morocco, new zealand, pakistan, saudi arabia, singapore, slovenia, taiwan, uganda, venezuela, and vietnam. in this paper, i report u-shapes for all but three of them-bangladesh, pakistan, and saudi arabia. without any control variables, and a major problem with glenn's analysis was that he focused too heavily on the usa. second, we disagreed with glenn's methodological position, which seems to be that social scientists should not hold constant other factors when they study the relationship between well-being and age. ultimately, in social science, the control variables that are included in multiple regression equations we noted have to be chosen with an eye on the intellectual or policy question being answered. the summary of our argument went as follows. if the aim is to describe the data, it is reasonable to leave out most or all control variables. "smokers die at rate z" is an acceptable statement to make. but that is not the same as "smoking changes your risk by z," which requires other confounding variables to be controlled for such as diet, education, income, and exercise. we argued that would be an error to use an equation without controls to tell the public what impact aging has on happiness without separating out the effects of other variables such as, say, education, marriage, or unemployment. if the aim is to understand relationships, we concluded, "it seems, it will rarely be desirable to stop at bivariate patterns." that seems right and i don't stop at bivariate patterns in this paper either. blanchflower and oswald ( ) examined the issue of differences between the well-being and age relationship with and without controls using seven pooled crosscountry data sets, covering countries and . million randomly sampled people; the paper examines the cross-sectional pattern of psychological well-being from approximately age to age . the paper described the two conceptual approaches. one studies raw numbers on well-being and age which we termed the descriptive approach. the second studies the patterns in regression equations for well-being (that is, adjusting for other influences). this we termed the ceteris-paribus analytical approach. the paper applied each and compared the patterns of life satisfaction and happiness. using the first method, evidence of a midlife low was found in five of the seven data sets; the two that didn't were both for the usa. using the second method, all seven data sets produced evidence consistent with a midlife low. deaton ( ) reported only unadjusted estimates in part he argued because of the difficulty in applying consistent controls to the gallup data, not because the questions do not exist, but because their meaning varies so much across the globe, with different patterns of education, work, retirement, and health systems. deaton also suggested that a weightier argument is that many possible and potentially important controls are age dependent, including income and the presence of children but especially health, disability, and marital status. deaton notes that "different authors use different countries and different data sets with different swb questions, so it is possible that the age patterns in the gallup data are different from those that come from other questions and different survey protocols; it would be an important (if daunting) task to make systematic comparisons." this is what i try to do here. some psychologist have even gone as far as to argue that even if there is a u-shape it is broadly irrelevant as any change is "trivial." jebb et al. usa, usa, - and (g) latino barometer, and . in private communications, sir angus deaton suggested that he didn't have quite this in mind. he suggested, more just a look at the questions they ask, their response rates, and whether they are even grossly consistent. that "it is possible that the u-shaped (or other) curve exists but that it is so small that it is not practically meaningful. in other words, just because differences across age are statistically significant, that does not mean that these differences have practical significance. researchers in past studies have generally not taken effect size into account,… at some point, an effect size becomes so small that it is truly trivial and lacks practical significance. for our cantril ladder scale, respondents reported (and probably thought) in terms of the nearest whole scale point from to . therefore, it seemed that differences below . should be considered quite small." as blanchflower and oswald ( ) note the claim that the size of the dip is tiny does not appear to be correct. in the seven data sets, they studied the size of the drop, in well-being to the low point in the late s is equivalent in magnitude to the influence of a major life event like unemployment or marital separation. the size of the fall in wellbeing from youth to midlife is large and likely highly consequential. i should also note that i know of no evidence in any well-being data involving a change anywhere approaching . for any life event. some have argued that no u-shape exists in longitudinal data (frijters and beatton ; kassenboehmer and haisken-denew ) . in contrast, cheng et al. ( ) drawing on four data sets, and only within-person changes in well-being, build on the work of van landeghem ( ) and document powerful support for a u-shape in longitudinal data. three of the data sets are nationally representative household surveys, namely the british household panel survey (bhps, (bhps, - , the household income and labour dynamics in australia (hilda, - ) , and the german socio-economic panel (soep, (soep, - . the fourth data set comprises a relatively more homogenous sample of medical doctors from the medicine in australia balancing employment and life (mabel) longitudinal study. they measure the change in well-being of randomly selected individuals each year and then plot that against individuals' ages. on average, they find people's wellbeing gradually drops until individuals reach midlife. from then on, it picks up smoothly as people go on, in each of three countries and four data sets, to approach the age of . wunder et al. ( ) and ranjbar and sperlich ( ) both use semi-parametric methods on german soep panel data to examine the relation between age and well-being. they both get the same results. ranjbar and sperlich conclude "we find a clear, deep valley between the ages of and , typically interpreted as a midlife crisis." bleischmann ( ) also uses the gsoep and finds "mean life satisfaction is steadily declining between and . after this low, happiness increases strongly until the age of ." de ree and alessi ( ) have examined that the gsoep - found that that "the data is indeed consistent with a u-shape in age over most of the life cycle" (p. ) but have noted that age profiles are not identified without forcing arbitrary restrictions on the cohort/time profiles. there are clear issues though with the data they examine given they have to drop a quarter of households due to missing values. kroh ( ) notes that less than % of the original sample remains after . ferrer-i-carbonelli and frijters ( ) also examine gsoep data find a u-shape with controls for west german workers. the authors find the result is the same whether estimated by ols, ordered logit, or ordered probit and include controls for time, household income, children, a steady partner, and health. when they re-estimate with fixed effect, the u-shape disappears. piper ( ) uses gmm dynamic panel estimation with waves of the british household panel study on youngsters age - and found that happiness declined over that age range, a result found by comparing the coefficients of the age dummies: a result in line with the overall u-shape. furthermore, tests of the individual age group coefficients demonstrate that they are, in many cases, significantly different from each other. additionally, because the preferred model controls for the individual waves in the sample, this decline of life satisfaction with age is a life cycle effect. the life satisfaction of young people between and falls, and this seems to be something that everyone, on average, experiences. overall, his findings, piper argues, "are in line with the common u-shape finding." clark ( ) also finds, using the same data source and panel data methods controlling for fixed effects, that the data "continues to produce a u-shaped relationship between well-being and age." other commentators have expressed skepticism that the curve's trajectory holds true mainly in countries where the median wage is high and people tend to live longer or, alternatively, where the poor feel resentment more keenly during middle age and don't mind saying so. john briley in a recent op-ed argued that "the curve is not universaldata from economically struggling countries, for example, don't show the happiness rebound." arthur krystal , for example, has suggested that there may be a simpler explanation: "perhaps the people who participate in such surveys are those whose lives tend to follow the curve, while people who feel miserable at seventy or eighty, whose ennui is offset only by brooding over unrealized expectations, don't even bother to open such questionnaires." this critique of course could apply to any research based on surveys with a bias having nothing to do with age. there is zero evidence that the u-shape has anything to do with differential response bias by age especially under the age of . i have the u-shape in many data sets with various happiness measures including happiness itself and life satisfaction and cantril's ladder. it makes no difference if the dependent variable is scored, from to say or from to ; the results are essentially the same. the smaller numbers of observations for older age groups are an issue but that simply reflects the overall demographics in the country-there are fewer people age than age and especially so in countries with shorter life expectancy. helliwell ( ) recently argued that "to use a single life satisfaction question in large population-based samples might represent the best use of survey resources." following helliwell's advice, where feasible, i use life satisfaction as my well-being measure, where i can. data i examine the happiness curve using individual micro data from thirteen distinct micro survey series. these were chosen because well-being measures of various types were john briley, "does happiness in your s signal the end of ambition?," the washington post, december , . arthur krystal, "why we can't tell the truth about aging? a long life is a gift. but will we really be grateful for it?," the new yorker, october , . according to the census bureau's international population database in , there were , , individuals age in the us versus , , age . in ldcs, the ratio is smaller-in venezuela, for example, the numbers are , and , respectively, so it is times there versus times in the us. https://www.census.gov/data-tools/demo/idb/region.php?t= &rt= &a=both&y= &c=us&r= available. mostly, the questions examined are on happiness or life satisfaction. the questions used vary a little as do the number of possible responses varying from three to eleven that i call steps. other sweeps (e.g., the brfss from ), for example, did not contain happiness measures although they do contain unhappiness measures (blanchflower, a) . i also examine a broader set of questions on family life, health, trust, financial situations, living standards, and more. in most cases, i have to recode the variables such that a higher number means greater happiness. source: gallup usdt, brfss, brfss, - and gss, - . t-statistics in parentheses. sample size changes when controls are added because of missing values to the control variables *labor force status not available in , hence the smaller sample size ) ten-step happiness using sweeps - of the european social surveys (ess) - (table ) ) ten-step life satisfaction (table ) and -step step happiness from the european quality of life survey: - (table ) ) seven-step happiness from the (table ) and -step life satisfaction from the sweeps of the international social survey program (table ) ) ten-step life satisfaction from waves - of the world values survey (wvs); - (table ) ) five-step happiness from the asia barometers of (table ) ) four-step life satisfaction from the latino barometers of and (table ) ) eleven-step cantril's life satisfaction ladder from the gallup world poll ( - ) (table ) ) three-step financial satisfaction from wave of the wvs (table ) (table ) ) five-step satisfaction with living standards in the afro barometers and (table ) the issp and wvs both contain data from four large non-european englishspeaking advanced nations-australia, canada, new zealand, and the usa-plus japan. they all give u-shapes in happiness with and without controls. i use three methods to identify the u-shape. first, i run an ols regression with the dependent variable a measure of well-being, on a pooled sample of countries across all second, i then re-estimate for individual countries including the gender, education, and marital and labor force status control variables with the age of respondents limited to those under the age of . i do this for simplicity given very different life expectancies across countries and hence much smaller sample sizes for older age groups and likely variability at older ages. sample sizes are often quite small for these individual country regressions, and on average many are only around observations. i find for several advanced countries that there are insignificant results using, for example, issp data, but when using eb or ess when the samples are much larger, the significance of both age terms appears. i assume that there is a significant u-shape if there is a negative sign on the age coefficient and a positive sign on the square with the t-statistic of both above . . finally, i re-estimate the well-being equation and replace the age and age squared term with a complete set of single year of age variables which i then plot in a series of figures. this is to ensure that the quadratic i fitted is not an inappropriate functional form. this way the form is freely estimated and then plotted, with the individual coefficients added to the constant. these figures show u-shapes. the well-being variables are always coded from low to high, so a positive coefficient means happier. sometimes i use happiness data and sometimes life satisfaction and the number of options available varies by survey and year. mostly there are four options that i call -step, or eleven options from to that i call -step, plus i also use -step, -step, -step, and -step. it doesn't seem that this makes much of a difference. sample size does seem to matter although it is surprising how many ushapes are identified even with sample sizes of less than a thousand. i am also able to identify u-shapes in age in both european and african nations using a broader set of attitudinal questions on living standards as well as on an individual's financial conditions as well as the state of the national economy. i focus in particular on questions about financial situations individuals find themselves in as well as on the general state of the economy. these questions are widely used in consumer confidence surveys. respondents are asked such questions in the eurobarometers, as well as in the monthly consumer surveys run by the european commission in every eu country since the s. these surveys have started to move down sharply from march as the covid- shock hit (bell and blanchflower, ) . i also compare results of asking similar questions in europe and africa in relation to satisfaction with living standards. it seems the u-shape in age is more general than just in happiness and life satisfaction equations and applies to other attitudinal economic variables. this suggests the happiness curve has broader applicability to other attitudinal variables about the person and the economy. in this section, i report the results of estimating a series of ols well-being regressions. in each case, i report coefficients and t-statistics for the age and the age squared variables with and without controls for education, gender, marital and labor force status, country, and where appropriate where there are multiple survey years used a set of year dummies. the without controls equations include year and country dummies and in the case of the us and the uk state or region dummies when available. i calculate the minimum of the quadratic in age by differentiating with respect to age and solving which means dividing the age coefficient by the age coefficient multiplied by . hence, on row of table , the age coefficient is − . and the age coefficient is + . so the minimum is - × . /( × . ) = . both are highly statistically significant with t-statistics of and respectively. i turn first to the two countries that have micro data files with many hundreds of thousands of observations-the usa and the uk. in this paper, i report separate estimates each for the two countries, with controls and in both well-being is u-shaped and on average it minimizes in both at age (footnote ). q . "please imagine a ladder, with steps numbered from at the bottom to at the top. the top represents the best possible life for you and the bottom of the ladder represents the worst possible life for you. on which step of the ladder would you say you personally feel you stand at this time?" in the gss, the happiness q is used. q . "taken all together, how would you say things are these days? would you say that you are very happy = , pretty happy = , or not too happy = ?" (my codes). in the brfss, respondents are asked the following -step question: q . "in general, how satisfied are you with your life? very satisfied = ; satisfied = ; dissatisfied = and very dissatisfied = ." (all my codes). in table , i report the results of estimating ols regressions which include an age and an age squared term plus year dummies and state dummies for usdtp and the brfss and region dummies with the gss as that is all that is available. i then repeat including controls for gender, labor force and marital status, and education. in the case of the gusdt, the age term is negative, and the age squared term is positive without and with controls implying a minimum at and respectively. in the case of the brfss, without controls, the age term is negative, and the square term is positive, but the minimum is over . for the gss, the signs are reversed but are both significant suggesting an inverted u-shape. in both cases, when i add controls, there is a significant u-shape with a minimum of and respectively. life satisfaction was included in a subset of the brfss for louisiana, minnesota, mississippi, rhode island, and tennessee in - . i re-estimated the equation in table using these data (n = , ), with controls for age and its square, state, year, education, gender, race, and marital and labor force status and found the quadratic minimized at age . the second part of the table restricts the sample to under years of age. the major change is that the brfss data now gives a u-shape that minimizes at age versus one that minimizes at age with controls. in the case of the gss, with many fewer observations, the age squared term is insignificant and hence i don't report a minimum. it is important in the usa to look at the raw data to determine the appropriateness of fitting a quadratic to the data. fig for the brfss, - , plots the two quadratics with controls from table for all ages and for ages under . it also plots the results of replacing the two age terms with single year of age dummy variables from equations with and without controls. in each case, the individual coefficients are added to the constant. it is clear that without controls, in the raw data, there are two hills: an early dip to the early twenties and a rise to the mid-thirties and then a fall through the mid-fifties and a rise again to the early seventies before the function dips again. adding controls produces a clean and highly significant u-shape which turns over after the age of seventy and remains broadly flat thereafter. the upward slope flattens after around age and then starts turning down around age . it is clear that the quadratic for those age under , with controls, seems to fit the data better, than the one on the full sample. fig does the same with the usgdtp. the quadratic based on data under the age of seems a close approximation. of note though is that there are marked differences in the raw data in the usa between the married and the non-married that is not true elsewhere. below i report step happiness equations for the gss and -step life satisfaction equations in the brfss with only year and region controls included as below with t-statistics in parentheses. in the case of the gss, the positive age and negative age term suggest it also should be noted that there is some evidence that the minimum of the u-shape has risen over time as life expectancy has climbed. in the usa, using data for those age under , it was in versus in . the midpoint using the gss for the years - was and for the years - was . as we show below, there is also evidence of a slightly bigger rise in europe, where life expectancy in many countries grew more. i now turn to examine the data, for people under age , from the other major large cross-section survey of well-being from the most recent sweeps available for - , from the annual population surveys for the uk. earlier sweeps were used in bell and blanchflower ( ) to examine the well-being of the underemployed and the unemployed. these surveys contain data three happiness measures and overall there are about , observations on each variable. the three questions i examine are as follows. q . life satisfaction-"overall, how satisfied are you with your life nowadays, where nought is 'not at all satisfied' and is 'completely satisfied'." q . happiness-"overall, how happy did you feel yesterday, where nought is 'not at all happy' and is "completely happy'?" q . worthwhile-"overall, to what extent do you feel that the things you do in your life are worthwhile, where nought is 'not at all worthwhile' and is 'completely worthwhile?'." table shows that for all three variables, the age coefficient in all six specifications is significant and negative and the age squared term is significant and positive and all minimize in the forties. fig plots the single year of age coefficients for each of the three variables with the full set of controls included in each case. the minima are a little higher at around age . i now move to looking at data files that cover multiple countries. for simplicity, going forward, i use a quadratic in age as a reasonable approximation to the age profiles in well-being and firstly restrict the sample to those age under so that the estimated minima are not impacted by what happens in the older age groups especially as sample sizes can be small at higher ages. to report a minimum, i impose the second rule that both the coefficients on the age and age squared variables must have the right signs and t-statistics of at least . . for each of the data files, i report a pooled regression with year dummies and the full set of controls are for gender; education, and marital and labor force status which are available in broadly the same form in all of the data sets. i also fit age quadratics to each sample pooled across countries with age unrestricted and then replace the quadratic with a more flexible form of single year of age dummies. i then plot the age coefficients, added to the constant, as a check on the quadratic. i start out using data from the eurobarometer surveys (eb). concern has recently been expressed over response rates to these surveys especially in relation to the questions on respondent's views on the eu, with the concern that eurosceptics do not respond to the surveys which then suggest higher levels of support than they should. the eurobarometer surveys differ from other surveys that use the mail or the telephone; the eu commission only conducts interviews with members of the public face-to-face at home. this makes it even more difficult to achieve high response rates. the eu commission on december defended the methods of its public opinion surveys in response to criticism that the low rate of responses could lead to bias towards the eu. in the most recent eurobarometer survey for which response rates have been calculated, and obtained by the danish newspaper, the rate was % in finland, % in germany, % in luxembourg, % in italy, % in the uk, % in denmark, % in greece and france, % in ireland, % in spain, % in latvia, and % in portugal. erik gahner larsen from the university of kent in a blog noted rightly that the response rate is informative but not sufficient or even necessary in order to obtain representative samples. he finds no evidence that countries with lower response rates are much more positive towards the eu in eurobarometer compared to the european social survey. of note is that there seems very little evidence that responses to questions on life satisfaction in the eb have been impacted over time by a rise in non-response rates. table uses data on -step life satisfaction for over . million europeans from forty-two sweeps of the eb for the years - for those age under with only year dummies. the question asked is: q . "on the whole, are you very satisfied, fairly satisfied, not very satisfied or not at all satisfied with the life you lead? not at all satisfied (= ); not very satisfied (= ); fairly satisfied (= ) and very satisfied (= )". it establishes the facts in european countries, by which i mean the eu plus eight other countries (albania, iceland, norway, macedonia, montenegro, serbia, turkey, and turkish cyprus). there are six developing countries including four ex-soviet (albania, macedonia, montenegro, and serbia) that are not eu members plus turkey and turkish cyprus in that group, all of which are so-called candidate countries. "eurobarometer and euroscepticism" https://erikgahner.dk/ /eurobarometer-and-euroscepticism/ information, "new data reveals serious problems with the eu's official public opinion polls", december . https://www.information.dk/udland/ / /new-data-reveals-serious-problems-with-the-eus-officialpublic-opinion-polls and eszter zalan, "eu commission defends eurobarometer methodology," eu observer, december , . first, estimates are provided for pooled samples across all countries without controls. there is a minimum in midlife at age . separate estimates are provided by country and in all thirty-seven cases the age term is significant and negative and the squared term significantly positive. there is some variation with a low of in luxembourg and a high of for bulgaria. the average across the estimates is. table repeats the exercise adding controls and the overall equation now has a minimum of fifty-four, and there are u-shapes for every country. a set of cohort q . the situation in our country? q . the situation of the national economy? q . the employment situation in the country? q . the presence of public services in our country? q . at the present time, would you say that, in general, things are going in the right direction or in the wrong direction, in our country = things are going in the wrong direction = neither the one or the other = things are going in the right direction? i am now going to read out different aspects of everyday life. for each, could you tell me if this aspect of your life is very satisfactory (= ), fairly satisfactory (= ), not very satisfactory (= ) or not at all satisfactory (= )? q . q . in general, how would you describe your own present living conditions? possible responses include: = very bad, = fairly bad, = neither good nor bad, = fairly good, = very good? dummies are added in the second row and the minimum is largely unchanged. there are u-shapes in every country with the minima ranging from for luxembourg to in montenegro. fig uses single year of age plots with and without controls using these eb files from to , and both show u-shapes. it shows an important point that in the eurobarometer files there is always a u-shape whether controls are included or not. there is an issue raised by morgan and o'connor ( ), henceforth mo, over whether there is an m-shape rather than a u-shape in eb data. however, in blanchflower ( b) , i showed that this early bump arose because mo omitted students, who are young, and happy. once students are included, the m-shape disappears and the u-shape returns. table significant u-shapes in every year, but over time the minimum has risen as we noted it did for the usa. the minimum rises from an average of in - to over since . life expectancy for most of these eu countries rises even more rapidly over these years than it does in the usa. for example, based on oecd data between and in both france and italy, life expectancy at birth rose from to and in both germany and the uk it increased from to (see footnote above). it is perhaps surprising that the estimates from developing countries that we examine below that have lower life expectancies have broadly similar minima to advanced countries. table reports a series of happiness equations by country with controls and again restricted to age under , using eight sweeps of the european social surveys. there are over a third of a million observations overall and the question is an -step happiness variable. q . "taking all things together, how happy would you say you are, from to with zero 'extremely unhappy' and 'extremely happy?'" the ess contains our first data on four developing countries-israel, russia, turkey, and ukraine-plus twenty-five eu countries, minus malta, latvia, and romania plus iceland, norway, and switzerland. there is a minimum again in every country equation that are also in the forties and fifties and average . all four of the developing countries have a u-shape and there are eight advanced countries with no ushape (denmark, estonia, finland, iceland, italy and lithuania, poland, and slovenia is happiness u-shaped everywhere? age and subjective well-being in... all six of these countries had significant u-shapes with larger samples with the eb data. the european quality of life surveys (eqls) includes the q happiness question above but also a -step life satisfaction equation. q . all things considered, how satisfied would you say you are with your life these days? please tell me on a scale of to , where means very dissatisfied and means very satisfied. table makes use of -step life satisfaction data from four sweeps ( , , , and ) of the eqls pooled together, with controls. table now turns to look at -step happiness data in five sweeps of the asia barometers of - . the question asked is blanchflower and oswald ( a) q . "all things considered would you say that you are happy these days? -very happy = ; pretty happy = neither happy nor unhappy = ; not too happy = and very unhappy = ?" once again, the numbers refer to my codes. in each case, there is a well-defined ushape with controls and only without controls in two of the five sweeps. significant ushapes are found in fourteen asian developing countries-china, india, laos, maldives, mongolia, myanmar, philippines, singapore, south korea, sri lanka, taiwan, tajikistan, thailand, and uzbekistan. , , , and - and found a u-shape at age for men and age for women with a full set of controls, so this updates that analysis. for both and , there are well-defined u-shapes that minimize in the forties and fifties with controls. there are u-shapes for those under the age of in twelve, for bolivia, brazil, columbia, costa rica, ecuador, honduras, mexico, panama, paraguay, peru, uruguay, and venezuela. multi-country data-issp, wvs, and the gallup world poll . international social survey programme and table now moves to using -step life satisfaction data from the issp which is not limited to europe; the sample size is only , . the question asked is: q . "if you were to consider your life in general, how happy or unhappy would you say you are, on the whole? completely happy = ; very happy = ; fairly happy = ; neither happy nor unhappy = ; fairly unhappy = ; very unhappy = ; completely unhappy = ?" numbers are my coding to ensure a larger coefficient means more happiness. controls are included. all countries have significant u-shapes, mostly in the forties and fifties again. table does the same but with the issp with a -step life satisfaction question and a sample size of n = , . q . "all things considered, how satisfied are you with your life as a whole nowadays? completely satisfied = ; very satisfied = ; fairly satisfied = ; neither satisfied nor dissatisfied = ; fairly dissatisfied = ; very dissatisfied = ; completely dissatisfied = ?" there are u-shapes everywhere once again. table looks in turn at each of the five sweeps - of the world values survey in turn that all use the q -step life satisfaction equation defined above. in each of the five sweeps, there is always a minimum between forty and fifty overall with controls, and only in wave is there no u-shape without controls. in every one of the reported country estimates, for advanced and developing countries, remarkably, given the small sample sizes, there are significant happiness curves. blanchflower and graham ( b) examined data from the gallup world poll from to for fourteen countries. fourteen of those countries have significant and well-defined u-shapes in age and they are not available in any of the other data files, so in table we report results for these developing countries using the q question above for cantril's life satisfaction ladder measure. ) there are well-being u-shapes in advanced and developing countries. ) these answers seem to be similar using happiness or life satisfaction data. ) it doesn't seem to matter how many steps there are in the dependent variable; essentially, the same answer is found with a -step, -step, -step, or an -step measure. ) the answers are broadly the same whichever data file is used. ) adding cohort dummies does not remove the u-shape. ) there is a minimum around age with controls of the happiness curve in both advanced and developing countries, and a little higher than that without controls. satisfaction with financial situation: macro happiness and living standards i now move away from looking at happiness and life satisfaction directly and extend my horizons by looking at other broader measures of well-being. it was already wellknown that there were similarities between happiness data and assessment of someone's financial situation and their living standards, but i find the similarities do not stop there. remarkably, this u-shape pattern emerges when i look at assessments of the national economy as well as the quality of local services. it emerges when respondents are asked about job opportunities and time to do things and the u-shape appears to have broad applicability to a wide class of qualitative measures. , - . financial situation of the household i now turn to other ways of measuring satisfaction, which it turns out also show ushapes. all of the questions used are reported in the appendix. easterlin ( ) found evidence of a u-shape in age in the us general social survey for the years - in answers to q which relates to how an individual is doing financially. he finds that satisfaction with one's financial situation, "declines very slightly through age , but thereafter rises considerably, with the biggest increase late in life." this contrasts with his findings on happiness overall as well as happiness with the family that he found followed an inverted u-shape. i took the data easterlin ( ) used and re-estimated, with and without controls, for a longer time period, from to . t-statistics are in parentheses and i restricted the sample to those under age for simplicity. without controls, year dummies are included, with controls adds controls for gender, marital status, years of education, race, and labor force status. sample size is with controls. i confirm easterlin's findings; both happiness and family situation without controls generate inverted u-shapes in age, whereas financial situation has a u-shape in age even without controls. all three though have u-shapes once controls for education, marital status, and work status are included. the minima are for happiness, for family situation, and for financial situation with controls. it is apparent that a u-shape in these gss data seems more robust using the financial situation data than the other two measures of well-being. i explored the characteristics of this rather intriguing financial circumstance variable further as comparable data is available in wvs sweeps and for both developing and developed countries. in table , i model responses in turn from waves and of the wvs that contains a -step question on how satisfied the respondent is with the financial situation of the household q . we are interested in how people are getting along financially these days. so far as you and your family are concerned, would you say that you are pretty well satisfied (= ) with your present financial situation, more or less satisfied (= ), or not satisfied at all (= )? there are statistically significant u-shapes with controls in both developed and developing countries in both wave and wave . with controls in the country data for satisfaction with family life are only available for the years - hence the sample restriction but in what follows i used data for both happiness and financial situation for the years - . the family situation question was satfam: "for each area of life i am going to name, tell me the number that shows how much satisfaction you get from that area. your family life (my codes) - . a very great deal; . a great deal; . quite a bit; . a fair amount; . some; . a little; . none." equations with the sample restricted to those under years of age, there are u-shapes in thirty-four developing countries from around the world. table uses data from four different european data files. the first part uses eurobarometer # . for june-july . the first question relates to the financial situation examined above and finds a u-shape also that minimizes at age . i then estimate six different attitudinal questions on the individual's views on the situation in the country (q ); the national economy (q ); the respondent's own job if working (q ); the respondent's own financial situation (q ); employment situation in the country (q ); and the presence of public services in their country (q ). in every case, the age term is significant and negative, and the square term is positive. each of the variables have well-defined and statistically significant u-shapes in age and the t-statistics on age and its square are everywhere above five. a -step question is also used on the direction of the country, which is often used in polling. the age minima vary from ages - . a great deal of use is made in economics of survey responses from individuals on the general state of the economy, including in consumer confidence measures such as the michigan and conference board measures in the usa and conducted by the european commission monthly for every eu member state. for example, respondents in the eu commission survey are asked for their views on the "general situation of the economy over the next twelve months" that i have through march . these variables are then collapsed into a score. an equivalent survey from firms is available from his markit in the form of a much-watched composite pmi available monthly from through april . in fig , i plot both series for the eurozone that seem to track each other well. their decline in onwards gave early warnings as did other similar attitudinal variables that few spotted of the oncoming global recession in (blanchflower ). of note is their dramatic collapse in both in march and in april to new lows. for example, the composite pmi hit a record low of . , down from . in march and . in february. the low point in the great recession was . in february . the general economic situation measure had the biggest collapse in the history of the series that runs back to , beating the previous record collapse that occurred in august when iraq invaded kuwait. these macro happiness indicators provide a clear picture of the impact of the covid- shock in march and april that the official statistics do not (bell and blanchflower the final -step question in part of the table relates to living standards which are also ushaped with a minimum at age . the third and fourth sections of table age -step life satisfaction latinobarometers, with controls age -step life satisfaction issp with controls very little analysis has been done on how well-being and age are treated in africa. the afro barometers are a natural place to turn, but unfortunately, they don't contain any questions on happiness or life satisfaction. both the and surveys do though contain a question on living standards. this living standard, measure of wellbeing, has been widely used in the development literature for measuring well-being in africa. it was used by sulemana et al. ( ) for a study of well-being in sub-saharan africa. they justified its use arguing that "the question taps into the individual's evaluations of their life we used this construct as a suitable measure of subjective wellbeing." the authors argued that "many other studies have constructed well-being measures in the same way," which turns out to be correct. deutsch et al. ( ) used this variable from the afro barometer as did pokimica et al. ( ) and sulemana ( b) in their studies of well-being in ghana. sulemana ( a) in a study of the impact of crime on well-being in africa used data from the th sweep of the afro barometer for . sulemana et al. ( ) used this measure with the afro barometer data in their study of the relationship between corruption and well-being in africa. others have been creative in their use of measures of well-being for africa. bookwalter et al. ( ) in a study of south africa use a household level life satisfaction variable. life satisfaction in both surveys was reported at the household level. the head of the household was asked a -step question q on living standards. q . in general, how would you describe your own present living conditions? possible responses include: = very bad, = fairly bad, = neither good nor bad, = fairly good, = very good? table reports the results from estimating an ols equation with this living conditions variable as the dependent variable with and without controls by country. limiting age to less than , there are countries with significant u-shapes in and seventeen in . fig plots the single year of age coefficients added to the constant for with controls and there are obvious u-shapes again, with minima mostly in the mid-fifties. there are u-shapes for thirty african countries using the afro barometer data for those under age . the u-shape appears to have broad applicability to a range of attitudinal questions on the economy and an individual's personal economic situation as well as to their happiness and life satisfaction. there is a happiness curve. no ifs, no buts, well-being is u-shaped in age. the average age at which the u-shaped minimized across the country-level estimates reported here is . . it is in rich and poor countries. or indeed of happiness in africa, for an exception, see helliwell et al. ( ) who found evidence over the years - that happiness in the middle east and north africa had dropped steadily while sub-saharan africa had no overall trend. the authors identify how much happiness has changed over the last decade and how low it is in africa. they note big declines in happiness in rwanda, malawi, tanzania, central african republic, and botswana (their figure . i found evidence of the nadir in happiness in one hundred and forty-five countries, including one hundred and nine developing and thirty-six developed. i found it in europe, asia, north and south america, australasia, and africa. i identified it in all but six of the fifty-one european countries. i have a well-being u-shape for every one of the thirty-five member countries of the oecd. i have it for / member countries of the united nations. i found the well-being u-shape in english-speaking countries and non-englishspeaking countries. a u-shape is revealed in countries ranked highly in the cia world factbook for countries with both high and low life expectancy at birth. i found it in twelve countries ranked in the top twenty for life expectancy of or more. i also found a u-shape in ten countries in the bottom twenty for life expectancy of countries in the world according to the cia. the curve's trajectory holds true in countries where the median wage is high and where it is not and where people tend to live longer and where they don't. i found additional evidence from an array of attitudinal questions that were worded slightly differently. evidence of a u-shape was found across european countries in questions relating to an individual's finances as well as to the state of the economy and democracy and how public services work. in africa, i used a question that development scholars had used relating to living standards and found a u-shape for thirty african countries. this suggests the u-curve in age may have much broader applicability than just in well-being data. given the robustness of these findings, it remains a puzzle why so many psychologists continue to suggest that well-being is unrelated to age. people are struggling. in the usa, deaths of despair are most likely to occur in the middle-aged years, and the patterns are robustly associated with unhappiness and stress. across countries, chronic depression and suicide rates peak in midlife. those in middle age in the years since were most vulnerable to a once-in-a-generation financial shock especially if they were poor and with low levels of education. in the usa, the employment rate in was below that in . in the uk, real wages were below pre-recession levels at the onset of the covid- crash in march . the financial crisis did not suddenly create frailty in downtrodden communities but simply exposed underlying problems with deep roots in the long decades before. it seems it is normal to have a midlife dip in well-being, but for many, especially those with the least skills, with little social support and few if any savings, that was too much to bear when a giant downturn came along in . the finding of a zenith in well-being in midlife likely adds important support to the notion that being in one's forties and fifties exacerbates vulnerability to disadvantages and shocks. that is people with disabilities, less education, broken families, lost jobs, and so on are likely also to get hit hardest by the effects of aging. some might face downward spirals as age and life circumstances interact. many will not be getting the social/emotional support they need, because midlife is the worst time to present vulnerability. they will be dealing with shame and isolation, in addition to the firstorder effects of whatever they are coping with in normal times at a midlife low is tough. it is made much harder when combined with a deep downturn especially when the speed of recovery and the length of lockdown is uncertain. interdisciplinary research is clearly needed into how to stem the worst manifestations of the midlife nadir in well-being, such as depression, lack of sleep, suicide, and higher tendency to drug and alcohol abuse. the fact that the happiness zenith occurs in developed and developing countries and it has even been found in great apes (weiss et al. ) suggests there may be something deeply engrained perhaps in the genes. the pandemic is global. vulnerable individuals and communities around the world will be devastated by the shock, because of both job and income loss but also from bereavement. the prime aged with low levels of happiness already are especially at risk. the happiness curve is found in countries. no myth. i am grateful to jonathan rauch for these suggestions that he says create a "toxic brew." age minimum u-shape -step life satisfaction minima with controls by year, eurobarometers u-shape -step life satisfaction minima with controls by year, eurobarometers v -step happiness with controls -step happiness with controls, ess - is happiness u-shaped everywhere? age and subjective well-being in kazakhstan was the only country i had data for and did not find a u-shape. the remaining five i had no data for were all tiny-andorra malta ( ) eswatini ( ) causes and correlates of happiness life satisfaction across the life span: findings from two nationally representative panel studies us and uk labour markets before and during the covid- crash the well-being of the overemployed and the underemployed and the rise in depression in the uk is happiness u-shaped everywhere? age and subjective well-being in countries blanchflower dg ( b) unhappiness and age international evidence on well-being in measuring the subjective well-being of nations: national accounts of time use and well-being the mid-life dip in well-being: economists (who find it) versus psychologists (who dont)! nber working paper #w fig. living standards with controls is happiness u-shaped everywhere? age and subjective well-being in subjective well-being around the world: trends and predictors 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friends, and faith of happy people is a longer life a better life? happiness of the very old in eu countries health and social factors related to life satisfaction sliding down the u-shape? a dynamic panel investigation of the age-well-being relationship, focusing on young adults religion and subjective well-being in ghana a note on empirical studies of life-satisfaction: unhappy with semiparametrics? unmet aspirations as an explanation for the age u-shape in well-being the relationship between subjective well-being and work-life balance among labourers in pakistan exploring the economic and social determinants of psychological well-being and perceived social support in england subjective wellbeing, health, and ageing a snapshot of the age distribution of psychological wellbeing in the united states the effect of fear of crime and crime victimization on subjective well-being in africa an empirical investigation of the relationship between social capital and subjective wellbeing in ghana international remittances and subjective wellbeing in sub-saharan africa: a micro-level study a micro-level study of the relationship between experienced corruption and subjective wellbeing in africa how does subjective well-being evolve with age? a literature review is happiness u-shaped everywhere? age and subjective well-being in a test for the convexity of human well-being over the life cycle: longitudinal evidence from a -year panel evidence for a midlife crisis in great apes consistent with the u-shape in human well-being well-being over the life span: semi-parametric evidence from british and german longitudinal data publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgments i thank three referees and the editor, angus deaton, dick easterlin, carol graham, robson morgan, kelsey o'connor, andrew oswald, and jonathan rauch for the helpful comments. conflict of interest the author declares that he has no conflicts of interest. key: cord- -xi zy ow authors: allam, zaheer title: the third days: a detailed chronological timeline and extensive review of literature documenting the covid- pandemic from day to day date: - - journal: surveying the covid- pandemic and its implications doi: . /b - - - - . - sha: doc_id: cord_uid: xi zy ow this chapter surveys the global unfolding of events during the third days of the covid- pandemic that originated from china. the third days of the unfolding of the events showcased how city-wide lockdowns were started to be considered globally, the moving of the epicenter from china to europe, and major industries being impacted worldwide. to document this, an extensive review of the literature provides a daily overview of the situation covering health, economic, political, and social perspectives and outlines key events during the unfolding of the pandemic. this chapter surveys, and establishes a chronological timeline of the outbreak from day to day , covering issues appertaining to health policy and dwells into socioeconomic measures and impacts during the unfolding of the pandemic. the past days of the covid- pandemic had been eventful, as the reality of the disease was clear globally, where no single continent had been spared. the next days (day to day ) were marked with major milestones, challenging and most trying in different spheres of life as is demonstrated in succeeding sections. to start with, during this period, the number of confirmed cases increased from slightly above , to a high of million and counting (spotlight, ) , with the number of casualties increasing from deaths to over , deaths across the globe by the end of the days. in addition, the number of affected countries increased from countries to countries and territories (worldometer, ) . another change that was witnessed within the third days is the shifting of the covid- pandemic epicenter from europe to the united states, where the numbers of confirmed cases in the country, beingdby that timedmore than a quarter of the confirmed cases in the rest of the world (kirby and stewart, ). as the impacts of the coronavirus continued to be felt, there was evidence of an economic downturn in different countries, including in developed economies, where the number of people filing for unemployment claims increased. due to the economic hardships, it became apparent that many countries were trying to ease the lockdown restrictions to allow for reopening of economies, but in a gradual and cautious manner to avoid the reemergence of cases. it is within these days that governments were seen to propose economic stimulus packages to bail out their citizens and economies, including companies that were already struggling due to reduced activities. at the same time, due to the economic and social strives, there was evidence of political tension between countries as they trade blame on responsibilities toward containing the coronavirus before it spread, and become global pandemic (business davidson, a; smith, ) . during these days, it also became clear that the world was a long way before a vaccine could be developed and thus, the demand for personal protective equipment (ppes) would continue, and we see countries and regions formulating policies to control the exportation of ppes and medical supplies to other countries. with the increasing scarcity of ppes and other basic, medical essentials, these were seen to rely on the world health organization (who) and well-wishers for the supplies. within these days, there is also evidence of there was no safe-haven against coronavirus, as even those in cruise ships and aircraft carriers were infected and with cases in such places spreading faster (cna, c; gajanan and mansoor, ; kaneko and kim, ; willsher and sabbagh, ) . it also dawned that even those in positions of power and authority are not immune to the virus, where some even succumbed to their injuries. within these days, it also became apparent that every single sector is highly dependent on the health sector, as those like sports and entertainment, religious sectors and others remained "grounded" with some high profile events such as professional football leagues, olympics, and wrestling being canceled, postponed, or suspended indefinitely (bbc sport, ; cacciola and deb, ; schad, ) . during this period also, it becomes apparent that it is possible for technology companies to set aside their competition and come together for the common goal of humanity (apple, ) . therefore, even as events of these third days had been devastating and heartbreaking, there is much that humanity can learn, and have learned, and going forward, even after the covid- is finally phased out, as people, governments, regions, and economies embark on rebuilding, some of the positives that have been learned will need to be kept alive. the following sections document the unfolding of the pandemic. during this month, every effort counted in the fight against the spread of covid- , and this was emphasized by the events of march . on this day, finally, the who conceded that without a doubt, coronavirus amounted to a global pandemic (who, ad) . the build-up to this global pandemic announcement saw a national wide lockdown declared in italy on th following an uncontrollable and astronomic increase in the number of new cases and deaths in the country (bbc, c) . following this, the country was beginning to experience unprecedented abandonment by its neighbors and country members of the eu who had continued to issue a travel advisory to their citizens against traveling into or from italy (gov.uk, a) . unsurprisingly, by th, all eu member states had experienced the outbreak of the covid- disease, and most of the first cases were related to travelers fleeing italy after the situation therein started to worsen (who, ad) . in north america, the situation in the united states was also getting out of hand, with over states including arizona, washington d.c., michigan, colorado, vermont and rhode island, and others declaring states of emergency (razek, ) . here, on march , the united nations headquarters in new york closed its doors to the public for fear of spreading the virus (krisel, ). as the situation escalated, with over confirmed cases in the country, and over deaths from the virus, the national basketball association (nba), one of the most popular and fancied sporting activity in north america abruptly suspended its season, as of march , when a player of the utah jazz tested positive for coronavirus, just before their game with oklahoma city began (cacciola and deb, ) . these unfolding attracted a host of intervention measures in the country to ensure people would observe the health guidelines, especially by staying at home and keeping social distancing. first, on march , vice president pence announced that medical insurance companies had agreed to waive all copayments on covid- testing and also extended their coverage for the treatment of the disease (office of the president, b). similarly, the country, through homeland security, announced a level travel advisory and subsequently temporarily restricting entry to all foreign travelers from china, iran, and certain countries of europe. the restrictions also demanded that all american citizens and legal permanent residents and their immediate families returning from countries already affected by the virus must undergo a self-quarantine for a minimum of days upon arrival (homeland security, ) . this announcement was affirmed by the oval office address by president trump stating that travel advisory applied to all the countries in the schengen area (collinson, ) . the decision by trump was disapproved by the eu leaders (gaouette et al., ) . elsewhere, to control and reduce the spread of the virus, the schooling system in different countries was seen to be disrupted. as of march , a un report indicated that about % of students across the globe were out of school and this included countries like italy, czech republic, part of spain (madrid region), greece, and austria among many others that took the decision of closing the school to protect students and their families, as a mean to comply with who's health guidelines (who, p) . surprisingly, as countries hastened to close down schoolsdhighlighting the worsening of this situation, reports from china indicated that normalcy was returning to a point that some schools were reopening especially in qinghai province (cgtn, ) . in regard to financing efforts against this disease and supporting technological advancement in the development of test kits and vaccine development, on march , the bill & melinda gates foundation, mastercard, and wellcome together committed approximately $ million (bill and melinda gates foundation, ). on the same date, the coalition for epidemic preparedness innovations on its part committed an extra $ . million to render the organization's total investment in vaccine development to $ . million, with the funds expected to help both the company novavax and the university of oxford to research and develop a vaccine for this disease (kff, ). furthermore, on march , the united kingdom announced more funding ($ . million) , this time from its national budget to aid vulnerable countries in their efforts against covid- (gov.uk, b) . two days after declaring the coronavirus a global pandemic, circumstances in the western part of the globe have led the who to make another declaration; this time, the new epicenter of the outbreak of coronavirus was europe (who, ae). this announcement was not surprising as of then, italy was already overwhelmed ( , cases and deaths already) (snuggs, ) , and spain had in the day declared a state of emergency (cnbc, ) . things in other member countries of the union were also worsening, with the region recording over deaths in a span of h from the disease, and over new cases in the same period (who, c) . and surprisingly, from the situation report by the who (who, c), all the cases in each of these countries were of local transmission; thus, warranting the decision different countries were making to restrict movements, and where possible, instituting total lockdowns like the case of italy. on the western side of the globe, more states in the united states were declaring a state of emergencies, restricting the number of people in gatherings, closing all learning institutions, and restricting movements among other things. these happenings were more pronounced on march , and when the worse came to worst, present donald trump, under the robert t. stafford disaster relief and emergency assistance act (stanford act), declared a state of national emergency (office of the president, a). by then, the number of cases in the united states had increased to and those who died from the disease reached deaths, with transmission happening locally (who, j) . in total, the global number of confirmed cases had reached a high of , cases, with of those reported in the past h. of the sum, , had been confirmed from countries, of which were reporting their first cases. the remaining cases were reported in china, where situations were coming back to normal, with only new cases reported in the populous country, and deaths were reported in the -h period. wuhan, the former epicenter only recorded five confirmed cases (reuters, c) . outside china, the deaths increased by , raising the total tally to cases (who, c). following these unprecedented unfolding globally, economies were facing numerous challenges, as most economic activities had stalled or were nonexistent. for instance, in the united states, the stock exchange recorded the lowest point, only reminiscence with situations of (mccabe and ostroff, ). for this reason, different agencies introduced financial packages to offer some support. for instance, the adb announced a $ million package that could be accessed by companies to supply critical essentials for combating covid- (adb, ) . in europe, the european bank for reconstruction and development is reported to have approved a $ . billion financial package to help companies in the region to remain afloat during this period the region was experiencing the most trying moment in the recent history (williams, ) . amid the challenges of covid- and its impacts, some countries like taiwan found some solace in the use of technology to track and instill the mandatory quarantine, especially for those coming from certain areas. with technology, enforcement officers were able to know those who were flaunting rules and their whereabouts, and this helped reduce the spread of the virus, despite it being just kilometers from china where things were worse some days ago (yun, ) . in europe, there was some use of technology, especially mobile apps, that helped in mapping and tracking cases, and to bolster this even further, the european commission (ec) was offering funding to a tune of v m ($ . ) for start-ups or small medium enterprises (smes) developing technologies with capacities to treat, test, monitor, or offer other aspects that could help in the fight against covid- (euroean commission, a). in the past month since the first case was confirmed in africa, the number of countries affected in the continent increased to by march , with seven reporting their first case in a span of h. also, a week prior, the number of cases in the continent was only , but they increased to with six deaths reported to have been imported, except for south africa, algeria, senegal, and cameroon (who, k) . in europe, most countries were receiving unprecedented numbers of new cases, especially in italy, spain, france, and germany, which recorded , , , , and new cases, respectively, and almost all cases in most of these eu countries were locally transmitted (who, k). the number of deaths in the region was also rising with italy losing people in a single day (snuggs, ) , while spain lost , france , and the united kingdom lost lives. in germany, which was reported to have embarked on mass testing as early as the situation warranted so, the number of deaths was relatively low (only two reported by th) (who, k) . following the dire state in the region, the european commission published guidelines (euroean commission, b) on the exportation of ppes out of the region. among such guidelines were the restriction of exportation of the said equipment unless with express green light from the eu member states. however, the eu was categorical that the measures taken were only within a specified period, especially during that period when those ppes were greatly needed locally; and thus, it was not a total ban on export, which would contravene the region's international obligations in matters of trade (euroean commission, b) . in the middle east, the severity of the disease was still present in iran, which until th had a total of , confirmed cases and deaths, with a high of deaths having been reported in a period of h. the situation in other countries within the region was controlled with only deaths reported ( in iraq, in lebanon, and in bahrain). in the american region, only a few confirmed cases were reported, and only deaths were reported in ecuador. however, the government there continued to institute proactive response measures to ensure the spread would be contained. for instance, the cdc announced that no gathering would be allowed in the united states that have more than people, thus putting into disarray functions such as weddings, concerts, and sporting events among others that are known to attract a large crowd (the new york times, a). more states declared a state of emergencies, while more schools in different states (more than states), including new york city with over . students (shapiro, ) calling for the closure of schools. one major news in the united states on that day was the negative test results for the country's president, who a few days ago had some contact with a brazilian official who turns positive after the testdprompting president trump to undergo testing (education week, ) . in other places, country borders were being closed. for instance, after confirming their first covid- cases, kazakhstan and uzbekistan closed their borders (reuters, j) . colombia also closed its border with venezuela, while turkey, with one of the leading airline services globally, suspended flights to nine european countries (liptak, ) . lebanon reported to have called for a -day lockdown in the entire country to curb the spread of the virus, which for the past week had claimed the lives of three people (france , b). the other goods news of the day came from south korea, which had shown a great resolve in bringing down the number of new cases, and this was bearing fruits after it implemented a number of strategies that involved the use of advanced technologies. first, it adopted the use of drive-thru clinics where people could be tested within min and receive their results the following day. this allowed them to test over people per hour, as there were such clinics countrywide, where six people were being tested in an hour per clinic (choon, ) . the strategy also reduced local transmissions as contacts were greatly reduced. the country also implemented the use of mobile apps to enforce quarantines and track the spread of the virus (park, ) . the success of the drive-thru clinics and apps were later adopted by the united states and germany (yamey, on th, the health landscape in different regions changed even further, with the western pacific region having the highest number of confirmed cases, mostly because of china. the european region was on its knees, health-wise, with , confirmed cases, with of these being reported in a single day. the number of deaths in this region had also increased by to take the region's tally to deaths. both north and south american regions had cases, and a total of deaths ( deaths reported in a day). the african and the south-east asia regions were relatively saved until then, with only and confirmed cases, respectively, and total deaths for both regions being (who, l). following the dire need in the european region, the eu closed its borders except for essential travels. russia also closed its borders, only allowing its citizens and legal permanent residents to travel back. spain was also reported to have instituted border restrictions for all noncitizens and residents. in france, besides instituting border restrictions like a majority of its eu counterparts, it also announced a countrywide lockdown, which meant that no gathering of any size would be allowed, with people expected to remain at home with some exceptions (onishi and méheut, ) . similar events of widespread lockdowns and border restrictions were also observed in latin america, with countries such as venezuela and peru leading the cue in countrywide lockdowns. colombia and costa rica also instituted border restrictions and control. however, brazil, which by then (march ) had the most confirmed cases in the region, overlooked all the measures that the rest of the world were implementing, and had a section of its population (supporters of their president; jair bolsonaro) demonstrate against his opponents (harris and schipani, ) . in iran, the government was forced to release over , prisoners as a way of curbing the spread of the virus in the country, which was already at alarming levels (hawkins, ) . as the global social fabric was being dismantled by the disease, its impacts were being felt in the economic sphere. for instance, on th, the airline industry in the united states was seeking government financial assistance of up to $ billion to help them remain afloat (sider and mann, ) . the dow jones industry also recorded its historical low after dropping . points; the worst day crash since the "black monday" crash (millhiser, ) . following those uncertainties and the threat covid- posed to the global fabric, a number of well-wishers and philanthropists were seen to be in the frontline of helping countries win this war. on th, the jack ma foundation donated assorted ppes and testing kits to the united states , which greatly needed these following the increasing demand, and the disruption of supply chain following the slow activities in china. on th, the world bank group committed another $ billion to help in the fight against the diseases (the world bank, b), while on the same day, bloomberg philanthropies gave a financial package of $ million, especially to help low-x and middleincome economies (bloomberg philanthropies, ). as the dark crowd of coronavirus continued to spread in italy, its impacts were becoming evident, as in a month, the number of deaths ( ) in the country surpassed those in china ( ) since the onset of the outbreak to march (quinn, b) . its health sector was completely overwhelmed with images of dejected nurses trending on social media, and while that was happening, china reported no new confirmed cases attributable to local infection, as the new cases that it confirmed were suspected to have been imported from other countries (siobhán o'grady et al., b) , as it had started to ease its border restrictions. the number of new cases in italy also increased by cases, bringing their country total to , , becoming the second most affected country after china. as for the european regions, italy recorded a total of over , cases on both th . the number of deaths for both days totaled , far much more than the rest of the regions combined. in the americas, new cases on th were : almost double of what was recorded the previous day ( new cases on th). the eastern mediterranean region recorded new cases to push their region total to , , and the number of deaths in the region reached after ( died on th), with most of these coming from iran. in total, the global confirmed cases had increased to , cases on th after , more cases were reported. the number of total deaths globally increased by a total of to reach a global tally of cases (who, m). on local scenes, the disease affected some prominent people, celebrities, and sports personalities. for instance, in the us nba teams, denver nuggets (wimbish, ), los angele lakers (whitcomb, b) , philadelphia ers (zagoria, ) , and boston celtics (ward-henninger, ) reported that each had some of their players confirmed positive, but they decline to give the names of those players. on the same land, congress representatives, ben mcadams (d-utah) and mario diaz balart of florida, confirmed that they had also contracted the disease (helsel, ) . in washington, two employees of the world bank group tested positive on the th with fears that more could have been affected. on the th, there were reports that prince albert of monaco also tested positive for covid- (romo, ) . another person is the executive director of the world food program, david beasley, who also tested positive after returning from canada (world food program, ) . to respond to the numerous cases and scenarios prompted by the covid- case, different regions, individual countries, and agencies adopted different and diverse measures. for instance, in india, the government was reported to have banned any export of ppes, ventilators, and certain medications and supplements as such were not enough locally (suneja, ) . in addition to this, to reduce further spread, especially from imported cases, it closed its borders for incoming flights (business today, b). in the united states, the number of interventions was observed, for instance, the two june scheduled party primaries in connecticut were postponed (pramuk and dzhanova, ) . president trump also signed into law the family first coronavirus response act that would see most americans receive a family relief of $ . the act also gave $ billion to be accessed by smes (erica werner et al., ) . the university of hong kong received $ , from the coalition for epidemic preparedness innovations to continue with vaccine testing for covid- (galford, ) . on the th, the rockefeller foundation committed a $ million to assist in response to covid- , especially in cities such as nairobi, new york, washington, bangkok, and bellagio (rockefeller foundation, ). since the onset of the coronavirus, there had been a theory that it was mostly affecting older people, but the who debunked this, by indicating that data on those affected in different countries and regions have shown that a significant proportion of those in hospitals are aged below years; hence, calling the younger generation to be also extra cautious. the organization also launched a health alert messaging services through whatsapp and facebook, demystifying the importance of technology in the fight against covid- , especially in sharing data and information (who, d). the organization also reported that it had reached an agreement with different producers in china who were ready to supply the organization with ppes, so that it could continue supporting countries in need of such across the world (schnirring, ) . while that was going on, they delivered an extra . million laboratory test kits for covid- to different parts of the world (watts and simon, ) . there was also news that first vaccine trials had begun, and the who together with its partners was to organize an international study dubbed solidarity trial in different countries aimed at trying different treatments that could be adopted to win over covid- (who, d) . regarding the reports on the spread and impacts of the coronavirus on this day (march ), the situation reported by world health organization indicated that the world was still in great danger of recording even more cases. for instance, italy reported the single largest number of deaths, where people died, and those confirmed increasing to , cases. in the united states, the cdc indicated that it had confirmed a total of , cases (cdc, ). as that was happening, president trump invoked the defense production act, to force general motors (gm) to produce ventilators to fill the gap after the situation in the hospital become dire (haynes, ) . on this, earlier on the day, gm rejected the move, prompting the president to apply his executive authority on them, and the new york governor equated the ventilators to missiles during world war ii (klein and raju, ) . the controversies in the united states were not over as it was reported that canada, through its prime minister, justin trudeau, would return all asylum seekers to the united states (austen, ). elsewhere, cuba invoked border restrictions for all noncitizens and nonresidents. it had delayed this decision to "keep its key tourism industry alive," but the threat of the coronavirus forced the president to take that crucial and bold decision (france , a). as time passes, the spread of the coronavirus virus took hold across the globe. on march , the who declared the virus outbreak as a global pandemic, and days later (on th), the director-general declared that the "pandemic is accelerating" (chappell, ) . and true to his word, in the past days, the number of new confirmed cases each day were averaging , new cases, to push the global total to , confirmed cases. the number of new deaths in those days was also increasing at an average of almost each day, and by rd, the total number of deaths had reached , globally (who, n). of great concern on those numbers is that most of them were coming from the european region, which by rd had reached a high of , confirmed cases and total deaths. the only regions that had shown a lot of resilience were the african region with only total confirmed cases and total reported deaths. the south-east asia region was also relatively spared having confirmed only cases and total deaths. the region of americas was showing worrisome trends, having reported a high of , new cases in a single day (march ) to push its total tally of confirmed cases to , cases and a total tally of deaths ( deaths) reported in a single day (who, n). while a majority of countries, especially in europe writhed in desperation from the impacts of covid- , china reported a third consecutive day with no local new case of coronavirus (the straits times, c). this meant that they could slowly transition back to their previous economic routine, and it also gave hope to those whose situation was worsening. in the other regions, including africa where confirmed cases were low, they were responding to the spread by escalating lockdowns and border restrictions (aljazeera, b) . other countries followed this trend. for instance, on march e , bolivia (reuters, b) , greece (stamouli, ), cuba (oppmann, ) , and the united kingdom (sparrow et al., ) imposed total lockdown in their countries (aljazeera, b) . egypt on the other hand called off all religious activities in mosques and churches for days (mourad, ) . during this period still, other countries including pakistan (reuters, n), vietnam, singapore (benner, ), uae, panama (aljazeera, b) , india, nigeria (reuters, m), and zimbabwe (the citizen, ) closed their borders to all foreign travels and nonresidents and banned international flights to or from their soils for a minimum of days. germany, on the other hand, banned gatherings of more than two persons, as cases in the country started to soar, while on the same day, spain extended the state of emergency for more days, as the situation internally was getting out of hand, with thousands hospitalized, and cases soaring each day (picheta, ) . the decision taken by each individual country was meant for the good of the citizens, but such also had a far-reaching impact on the economy. for instance, the banning of the international flights in these days, and others that had been instituted earlier mean that sectors such as tourism, hospitality industry, and others are grounded, with millions of workers employed in those sectors uncertain of what the future holds. in such circumstances, governments were forced to rely on external organizationsdlike the jack ma foundation, which on nd delivered a consignment of assorted ppes, and test kits to african countries to fight the covid- (meseret and meldrum, ). on rd, the world bank group's president was also pleading with bilateral creditors to extend debt relief to low-income economies to help them build some capacity that could allow them to fight the disease (bank, ) . while this was going on, african finance ministers were pleading for a $ billion economic stimulus in addition to the suspension of external debt to allow their individual countries to fight the coronavirus pandemic (uneca, ). china's progression toward containing the virus received a boost after the province of hubei was freed from the lockdown after almost months since the lockdown was instituted (associated press, ). it was a relief to the residents who, for such a long period, lived in fear and uncertainty of when they would return to their previous routines. the good news was that wuhan, the first epicenter of coronavirus was to open a month later, as the number of new cases had reduced significantly. in the last h, the entire country of china reported on new cases, of which, cases were reported to have been imported (cna, a). the number of deaths had also increased, with seven reported in the city of wuhan (the star, ) . the other good news came from germany where the chancellor's, angela merkel, the first test came back negative for coronavirus, but would undergo the same process a few days later to confidently confirm this result (mischke, ) . the fear that she would have contracted the disease came after a doctor who had attended her turned positive, forcing the chancellor into a safety procedure of self-isolation (mischke, ) . the day however did not present the good news to everyone, especially to governments, health workers, and security forces implementing lockdowns and other measures in different countries and to the general global population. on this, in the past h alone, the number of newly laboratory-confirmed cases neared , and the deaths on a single day accumulated to globally (cna, a). the most unfortunate report on this is that half of the new cases and deaths reported came from european countries ( , cases and deaths), with the american regions also experiencing a high of , new cases and deaths (who, e). regarding the accumulation of confirmed cases, it took at least months for cases to climb to , confirmed, and only days to reach , cases. from here, it only took days for the global total to surpass , confirmed cases, and even more startling, only days for the total to reach almost , confirmed cases. such trends prompted the international olympics committee and japan's olympic authority, led by prime minister shinzo abe, to postpone the olympics scheduled for summer to as more countries had expressed their fears of the virus (ramsay, ) , while others cited lack of preparation and other technicalities (aarons, ) . they also prompted the prime minister of india, narendra modi, to lock down the country for days, only a day after the later declared an immediate grounding of all flights in or out of india (shroff, ) . new zealand also went into lockdown (bbc, e), as australia announced a ban on all overseas travel (whiteman and sharma, ) . while in the united states, a troop of , us national guards was mobilized in states to help in response to the disease (gresik and altman, ), as it had already infected more than , people countrywide. while those were being mobilized, three of their colleagues in the navy (sailors) contracted the virus, when an aircraft carrier they were boardingdtogether with approximately other peopledset sail from vietnam. by now, the situation of covid- globally reached fever-pitch where the u.n. secretary-general antónio guterres argued that the disease was ravaging the whole of humanity, with approximately one-third of the population experiencing one or more covid- -related restriction (unicef, ). following this, there was shortages in all sectors, with the who warning that already, the world was facing a "significant shortage" of assorted medical supplies. on the social sphere, there was a shortage in the health sector prompting the un to launch a $ billion financial package on march targeting global humanitarian responses, especially to be advanced to vulnerable countries (un secretary-general, ). with the funds, those countries would manage to bolster their laboratory equipment, build and increase available sanitation (handwashing) stations, and increase medical supplies among other things. besides the financial package, the who was calling on developed economies to assist african countries with health machines such as ventilators and respirators as the continent cannot satisfy the demand for such, especially if cases of covid- were to increase (ighobor, ). those calls and interventions come at a time when most countries, especially in europe and america, were experiencing one of the darkest moments of their history. for instance, in spain, as of th, the number of reported deaths ( deaths) surpassed those reported in china ( ). but still, italy was leading in the number of people who had died with a total of , with having died in a span of only h. france had also started to lose a significant number of people as a result of the covid- , with already having succumbed in the past h. the islamic state of iran and the united states were also affected with (total deaths ) and (total deaths ) deaths having died in the past h. in regard to the number of confirmed cases, which were averaging , cases per day in the past days, the global total had increased to , by th according to the who data. africa was still showing some resilience despite reports of weak health system, with only deaths reported coming from confirmed cases across the globe (who, o). the economic situation globally was worsening, but even more in the united states where it was reported that by march , over . million american had filed for their employment benefit (casselman et al., ) ; a figure that is thought to be the highest in the history of the country. this could be attributed to the increasing number of people who were contracting the coronavirus especially in new york, which had become the epicenter of the outbreak in the northern american region, with the united states having more cases than any other country (kirby and stewart, ; the new york times, b). but, fortunately, the trump administration's stimulus plandworth $ trilliondwas unanimously passed the senate (carney, ) , thus allowing the government to offer some financial support, especially to those who continued to lose their livelihoods. elsewhere, more countries were responding to the pandemic by instituting lockdowns or other strict measures that would somehow suppress the local transmission. on this, on march , panama was reported to have suspended any form of domestic flights , days after, it had suspended international flights (aljazeera, b) . in thailand, the government declared a state of emergency forcing more areas within the country to shut down (techakitteranun, ) , while iraq and lebanon extended their curfews by days in each country. in russia, moscow shut down all forms of businesses and activities for a week (march to april ), except for essential businesses such as pharmacies and grocery stores (astapkovich, ) . the highlight of the day was the testing positive for coronavirus of uk prime minister boris johnson, which he announced to the world via a video on twitter (bbc, g). he reported that, henceforth, he would be in self-isolation and will continue working from. but, while this was breaking news, the greatest and most unfortunate news came from italy and spain. in spain, it had earlier been reported that it had recorded the highest number of deaths in a single day ( ) (rtve, ), but later only italy released its official report of the day where it indicated that approximately (who later reported (who, f)) people had died within a span of only h. italy had also confirmed new cases while spain reported new cases bringing the total confirmed cases to , and , cases, respectively. however, the united states reported the highest number of new confirmed cases ( , ), taking its total tally to , according to the data by who (who, f) but according to the us cdc data (cdc, ), the total number of cases reported in the country by th had reached , , thus leading globally. in the middle east, iran was reporting the highest numbers of new cases, with cases reported within h and new deaths during the same period (who, f). other countries in the region were relatively calm with no other reporting more than a cases a day. in africa, algeria reported the highest number of deaths ( ) (who, f) while south africa reported the first death from the virus. this death and the increasing number of confirmed cases in the country prompted the government to announce a -week nationwide lockdown (neuman, b) . elsewhere, china reported new cases and new deaths, in what seemed like a signal to a second wave of infection. following this, the government announced a ban on all foreigners, suspecting that they were the cause of this new trend in rise of cases, as out of those new cases, none were from local transmission (bbc, a; mai, ) . on the same date, the african development bank (afdb) provided aid to the continent with a $ billion social bond targeted to economic and social sectors facing stiff challenges from the impacts of covid- (afdb, ). at the same time, the who announced that the vaccine trial dubbed solidarity trialdthat it had announced about on march dwas to begin shortly, with the first trials administered to patients drawn from norway and spain, but overall, the trials would be extended to more than countries that had agreed to be part of the program (who, af). in the united states, the food and drug administration authorized the use of a -min diagnostic kit for coronavirus intended to speed-up the testing process, but a shortage of necessary equipment for collecting specimens was feared to derail the use of this kit (azad, ) . on the same land, donald trump, president of america, signed the $ trillion stimulus that was passed the previous day by the senate (foran et al., ) . even as the month of march came to an end, the incidences related to covid- continued almost unthwarted. for instance, the number of new confirmed cases for the past days has been increasing at an average of above , each day, and the number of deaths occurring each day likewise increased at an average of deaths. within the days, the total number of confirmed cases globally increased from , das captured by the who on march (who, f)dto , by march . another astonishing occurrencedespecially on march dwas the number of people that died in a single day in both spain and italy, which recorded and new deaths, respectively (who, p) . this happened while the number of patients being admitted to different hospitals in both countries exceeded their bed capacity and human resources allocation (cheng, ) . the united states was also going through thick and thin, as the number of new cases in the country continued to soar at alarming rates. even in africad which had shown some levels of resilience against the spread of this pandemicdthe numbers for the past days seemed to increase at an average of almost daily, with egypt, algeria, and south africa being the most affected (who, q) . in fact, the who's director-general highlighted the plight of the global health system and argued that there was a chronic global shortage of medical supplies such as ppes, ventilators, and other basic amenities required to saving lives (who, af). these unfolding events were happening amidst numerous responses and interventions both at local, regional, and international levels by government, international organizations like the who, the world bank, and others. among the new interventions that countries were implementing include the extension of the social distancing guidelines in the united states by president donald trump until the end of the following month (april ), and perhaps with a possible extension to june (shear, ) . the country had also accelerated the testing of individuals, and by th, the president announced that over one million people had been tested despite earlier hiccups in regard to faulty testing kits (tirrell et al., ) . in africa, on th, nigeria was reported to have directed the cessation of movement in two of its most populous cities, lagos and abuja, to reduce the chances of importation of the coronavirus to rural areas (akwagyiram, a) . in mexico, in a bid to reduce the soaring confirmed cases and growing number of deaths as a result of covid- , the government declared a health emergency (reuters, l) . in portugal, the government had resulted in treating everyone including foreigners with pending applications as permanent residents of the country so they could access public health facilities without encountering hitches (reuters, o) . but despite all those negatives, there was good news from the city of wuhan, which after undergoing a "dark moment" in the past months, saw authorities relaxing some quarantine measures, including rail services in and out of the city, meaning that people could eventually access the rest of the country (beaumont, ) . authorities in the province of hubei also announced that they would allow domestic flights to resume in all airports, except tianhe international airport in wuhan (xinhua, c) . the other goods news is that on , the bill & melinda gates foundation, wellcome, and mastercard together granted three institutions (the university of washington, university of oxford, and la jolla institute for immunology) financial support worth $ million to facilitate clinical trials for immunotherapies they were developing (mastercard, ) . in the wake of the new months, the reality of devastation of the covid- in different countries, regions, and globally was becoming clear. for instance, in spain, by april , the number of those affected reached , . but, by then, italy had more than these cases with , confirmed cases, while the united states, which had become the new epicenter, had , confirmed cases, as per the cdc data (cdc, ), while the who reported , (who, r). regionally, cases in europe reached more than half a million people ( , ), where , of those had succumbed to the virus. the region of the americas was the second most affected with a total of , confirmed cases and deaths. the western pacific region was the third hardest hit, with , infected and deaths. the eastern mediterranean regions had , confirmed cases and recorded deaths, while the african region had confirmed cases and reported deaths from the virus. overall, the global total number of confirmed cases had reached , , and an addition of , from the previous reported numbers. the number of deaths had also reached , , with a high of dying in the past h (who, r). by april , the global total exceeded the , , mark as per the john hopkins data, ncov .live, and other websites, but who reported the total numbers at , confirmed cases (who, g). the reality was reflected in the economic sector with the world bank reporting that the impacts of covid- pandemic would force more than million people into poverty (the world bank, a) . the reality of this statement was affirmed in the happenings in the united states, where it was reported that in a period of just week, . million more people filed for unemployment benefits, taking the number of those who had filed for the benefits to over million people (long and dam, a) . the same trends of unemployment were also being experienced in austria where the unemployment levels jumped to % in the country within the months since the onset of the pandemic (reuters, a) . the said reality prompted several unprecedented actions in different countries and organizations. for instance, on april , the un announced the postponement of the climate conference (cop ) scheduled for november due to covid- (un, ) . in the sporting world, the all england club announced that the wimbledon tennis tournament was canceled due to covid- , and this was the first time since world war ii that the championship was called off. on the same day, the health minister in italy announced that the countrywide lockdown would continue to be in force until the th of the month as the number of confirmed cases, and deaths continued to increase (reuters, i). the announcement was also confirmed by the country's prime minister giuseppe conte said that the situation in the country forced him to sign the decree to extend the measures (orihuela et al., ) . the same measures were taken by germany. on april , more actions continued, with saudi arabia extended its curfew to h on its most visited and the holiest cities in islam: mecca and medina (aljazeera, c) . a similar action was taken in thailand involving the entire country, with exception of medical personnel, and those transporting essential products, and for people moving to quarantine or health facilities (the nation, ). peru and panama establish a different strategy for reducing the number of people outside by imposing a gender divide, where certain days were set aside for only men and the others for men. this way, it would be impossible for those living together leaving their homes together (aquino and moreno, ). in the united states, the white house was encouraging people going out to wear masks (sun and dawsey, ) , and this came while most of the citizens were trying to come to terms with stay-at-home orders that had been declared in almost states in the country (nottingham, ) . the highlight of the day is the worsening health status of the uk prime minister boris johnson, prompting him to be moved into intensive care. he was taken to hospital in london the previous day (april ), after the covid- symptoms persisted, days after he tested positive (bbc, g). on the same day, in the same country, new deaths were reported, taking the country's total death toll to while the total number of confirmed cases increased to , after new cases were reported in a period of h. within the european region, the total number of confirmed cases had increased to , after , more cases were reported in a span of h. the number of deaths also had increased by a total of deaths to take the total tally for the region to , , and these were far much more than the total deaths of all other regions combined. on the same day, the united states reported , new cases to take their country's total to , (who, s) and also reported a high of deaths increasing the total deaths recorded in the country to , while other data showed that deaths had reached , (siobhán o'grady et al., a) . in the previous day (april ), it had reported cases and , new cases; the highest reported data in the region since the onset of the pandemic (who, a). as these occurred, president trump reported that hydroxychloroquine, an antimalaria drug, could be used against covid- (crowley et al., ) . in the middle east, the total number of confirmed cases in iran increased to , after more people tested positive. globally, the total confirmed cases stood at , , and the total deaths reported were , (who, s). in africa, where cases had started to increase significantlydreaching and deaths, it was reported that the former libya prime minister mahmoud jibril died of coronavirus the previous day after fighting the covid- disease for approximately weeks (aljazeera, d). in china, which reported new cases and only deaths, fears were that the country would be experiencing asymptomatic transmissions of the virus; hence, the increase in newly reported cases. these were experienced though the country had already introduced border restrictions with other countries, and following the fear of asymptomatic cases, the government vowed to tighten border control measures even further (zhang and munroe, ) . the most astonishing news reported on april was that of the positive testing for coronavirus of four tigers and three lions in the bronx zoo, bringing the total number of cats reported to have contracted the virus to (daly, ) . this raised alarms as no known research had shown that the virus could be passed from humans to animals. this far, a report by the who indicated that more than % (approximately . billion) of students globally have had to remain at home following the closure of school. to offer some intervention on this, the organization, together with unicef and the international publishers association, launched the "read the world" initiative to allow student access learning materials even during the difficult times (who, a). in the sporting sector, to safeguard the lives of participants and to comply with the health guidelines of social distancing and others, the open golf championship was called off; being the second time, it was canceled since during the ww (the open, ). after days of uncertainties, the chinese authorities finally lifted the lockdown on wuhan as promised, after the city successfully saw a reduction in the number of new confirmed cases for the coronavirus (aljazeera, a) . in fact, the report from the entire country was that the new cases that were being reported were all imported ones, and the government had vowed to take extra measures to control its borders (zhang and munroe, ) . the good news on the country is that on the previous day (april ), despite reporting new confirmed casesdwhich were all imported, the country reported zero death for the first time since it started publishing figures of the death related to covid- (who, b) . even on th, the number of new cases was only : all imported and only two deaths. the situation was, however, totally different in other regions, especially in europe where france, on a single day, reported new deaths to push its total death toll to , , while those whose tests turned positive in the past h increased by to take the country's total to , (who, t) . this total was however smaller compared to germany, italy, and spain whose totals had increased to , , , , and , cases, respectively. belgium and the netherlands also witnessed an increase in the number of deaths with and new recorded deaths, respectively (who, b). on this, despite germany having more confirmed cases, it had managed to keep the death toll relatively low, with reports showing that it is due to the mass testing initiative it had embarked on; thus, cases were getting identified before becoming critical (perrigo, ) . until eighth, it had only lost people, while its european counterparts were worse off (who, t) . the other nation that saw the number of casualty increase was the u.s, which, since a few days ago had started to witness numerous deaths, and confirmed cases. on this day, the country lost lives to the disease, and , were the newly confirmed cases taking the country's total to , , according to who data (who, t), but the uscdc reported the total number as , cases (cdc, ), where the difference could be due to difference in reporting time between who on central european time (cet) and us edt time zones. while this was happening, the country's president, donald trump who had frequently attacked the who for failing in its mandate in detecting the virus earlier threatened to withdraw funding to the agency (sevastopulo and manson, ) . he categorically said that the organization had withheld information about the virus and was wrong about the outbreak in china (davidson, a) . but, in a quick rejoinder, the who's director-general warned that it would be disastrous to politicize the fight against the pandemic (wise, ) . following the health situation in france, authorities announced that they were imposing a ban on daytime outdoor exercise in paris, which had allowed its citizens to enjoy despite the country being on lockdown (bbc, f). on the same day (april ), the egyptian authorities announced that the ban on mosques and churches would still continue even during the ramadan period as the country was still facing the challenge of coronavirus, with new cases increasing and more deaths being witnessed (egypt independent, ) . in the asian region, japan joined the list of many other countries who had declared a state of emergency as the number of cases in the country had started to rise in the month (rich et al., ) . in singapore, to contain the spread of the covid- , the health minister gan kim yong announced that the government was banning any form of social gathering whether at home or in public (zhang, ) . the ban came just a day after a motion to outlaw social gathering in the country was rushed and passed to the law in parliament the previous day. elsewhere, as the impacts of the virus continued to be felt, the wellness trust, on april , started an initiative aimed to raise a minimum of $ billion from the private sector by the end of april to fill the financial gap being experienced in search vaccines, drugs, and tests for covid- (wellcome, ) . a similar initiative dubbed "afrochampions initiative" was launched by african union and africa centres for disease control and prevention to raise over $ million for medical responses, with $ million required urgently for the same purpose (africanews, ) . after spending three nights in the intensive care unit, the uk prime minister boris johnson was finally discharged from the unit and transferred to a normal ward where he recovered. in fact, it was reported that he could manage short walks, though he needed some time to feel better (the sun, ) . while the report of his improvement was encouraging, it was not the case for over families in the country, from england who had lost their loved ones as a result of the disease on that particular day. in italy, a total of people lost their lives on th (who, h), while had died the previous day (who, u) . in total, the number of deaths in italy had reached a high of , by th with of these being doctors who had contracted the virus while in line of duty (aljazeera, g) . in spain, hopes of flattening the curve were high after the country saw a decline in the number of deaths for the third consecutive day (landauro and keeley, ) . however, the number of new cases in the country was increasing and had climbed to , cases after more cases were confirmed on th. the renewed hope was also being experienced in china after it continued to witness a reduced number of deaths in the country, as well as more recoveries, which had reached , (regencia et al., ) . while that was happening, the spread of the virus has gone as far as in deep rural areas where a -yearold boy from the indigenous tribe of yanomami found in brazil, amazon forest was confirmed with the coronavirus on t th, and on th, unfortunately, he passed away (phillips, ) . another rare place where the virus was reported was in the cook county jail in chicago where new cases involving inmates and staff were reported (whitcomb, a) . in america still, the number of death from covid- were increasing at an alarming rate, where new deaths were reported on th (who, h) and more had died the previous day (who, u). following these increases, with most of them coming from new york cities, the state had resulted in burials in mass graves as the numbers kept on increasing (anderson, ) , with its confirmed cases being more than any other country globally (bbc, d) . the situation in the united states prompted the german foreign minister to criticize the us handling of the virus (connor, ) . another rare place that was affected by coronavirus is a french navy airplane carrier, where servicemen tested positive to covid- (aljazeera, e) . as the cases globally increased to over . million people, the economic impact of the virus continued to bite. for instance, in the united states, another . million people filed for unemployment claims bringing the total number of those in the same predicaments into almost million in only weeks (long and dam, b) . in vietnam, it was reported that the country was in dire need of almost $ billion to caution its economy against the budget deficit that continued to widen (reuters, r) . albania was also trending on a tight economic path, prompting it to seek financial support from the imf, which extended a loan of $ . million (imf, ) . in zimbabwe, following the ban on all international flights in or out of the country, air zimbabwe sent its employees on leave, which was, unfortunately, unpaid (the herald, ). on the same continent, senegal adopted a directly opposite approach of protecting its workers against being laid off by companies in excuse of the covid- crisis (france-presse, ). on other news, there were reports that google and apple would cooperate to develop a mobile app that would help in tracking coronavirus spread (apple, ) . although that was good news especially coming from the tech world, in singapore, the use of technology faced concerns when online learning platforms that the government had initiated were suspended after the video conferencing zoom platform was hacked during a learning session, and the hackers displayed explicit images to the students (lee, ) . although the death tolls in at least four countries crossed the , mark, others have witnessed significant declines in the number of new cases being reported daily, and thus planning to ease lockdown stances and other strict measures that had been put in place. until april , countries like the united states ( , deaths), spain ( , deaths), italy ( , deaths), and france ( , deaths) were most affected, with the situation in the united kingdom worsening ( , ) (who, w). indeed, a report by the office for national statistics highlighted that uk numbers were underreported by %, the number in the country would be reading over , cases (bruce, ) . on this, it was highlighted that the number of deaths reported did not reflect the actual number represented in over care homes, where most of the elderly population were (mcintyre and duncan). although those numbers are many, there was hope in spain and italy as the number of deaths kept on decreasing each day, and from the report, these were optimistic that they would ease their stand on lockdowndspain by end of june (bbc, h). on this, other more countries including greece (by may ) (tugwell, ) , portugal (by may ), australia (had already started by then), pakistan, and austria (with already thousands of shops reopened (niesner and murphy, )) were considering this move (dw, ). although those countries were eager to lift lockdown measures, germany was considering reintroducing it after community infection cases over the past few days started to rise after the country had cautiously tried to ease the lockdown (mayberry et al., ) . in moscow, president putin strengthened the lockdown measures until may to counter the rising cases of infections (davidson, b) . similar measures were also being taken in china, in the heilongjiang province bordering russia, where cases were reported on april , where chinese nationals who had fled to russia tried to return home (wu, ) . following this, the cases in the province increased to , and chinese authorities in the province promised to reward locals who would report the "illegal migrants" (the straits times, b). georgia, on its part, was planning to lock down four of its largest cities, including its capital tbilisi for days as local transmission started to increase with the county's total cases reaching (who, w), an addition of more confirmed cases (who, v) . on the economic front, the imf warned that the global economy would shrink by approximately % following unprecedented measures like lockdowns, and ban on transportations, and closing down of manufacturing and other industries (rapperport and smialek, ) . in a way to ease the economic pressure, president donald trump started issuing stimulus checks to americans, amid some delays after he realized that his name did not appear on the checks (rein, ) . the situation of the economy is also pointed by activities in heathrow airports where passenger demands were expected to reduce by almost % this month (april), after having plummeted by % last month and cargo volume reduced by . % (rojas, ) . the economy was worsening also for the who after president trump retaliated that he was halting funds to the agency following its mismanagement of the coronavirus (mayberry et al., ) . on the societal fronts, the racial discrimination of blacks in china continued, with the mcdonald outlets in china forced to apologize after the store displayed posters banning black people from accessing the china store (folley, ) . elsewhere, turkey was planning to temporarily release over , inmates, after getting approval from parliament to ease overcrowding; thus, void the risk of coronavirus infection in the facilities (wilks, ) . as of th, covid- had spread to countries and territories across the globe with over , , confirmed cases and , deaths reported. of those cases and deaths, % were reported in europe, while more than % of the remaining cases ( , confirmed cases and , deaths) reported in regions of the americas. the eastern mediterranean region had , confirmed cases and deaths while the south-east asia region had a count of , confirmed cases and deaths. africa, which had started to experience some significant increase in infections, had , confirmed cases with of those newly reported and deaths of which of those occurred in a span of h (who, aa). still in africa, it was noted that out of the countries that had reported cases of covid- were drawn from the western and central part of the continent, and who officials reported that they had teams on the ground to establish the real reason why this was happening (who, ac) . of the total reported deaths, the highest number occurred in the united states with a high of deaths, while the united kingdom had the second tally of the day with cases. france had cases while italy and spain, two countries that had for past days shown remarkable improvement, had and cases, respectively (who, aa). on th, the french navy reported that an airplane carrier had soldiers affected, and in less than a week, on th, the number of those had increased to a total of (willsher and sabbagh, ). although reports in the health sector showed that the world was still unsafe, as had also been warned by the who, other issues were coming up in other sectors. for instance, in japan, whose total confirmed cases tallied to dwhich included three cabinet officialsd and the number of deaths increasing to , the prime minister shinzo abe declared a nationwide state of emergency (mccurry, ) . he also advanced a handout worth u , to every resident of the country regardless of their economic status to caution them during the period of this emergency (the japan times, a). in the united states, on the same day, . million people filed unemployment claims bringing the total number of those in this situation to more than million people in a period of only weeks (long, ) . following this, president donald trump unveiled guidelines aimed to help some economic activities in the country to resume, but he left the final decision of opening the economy, by easing the restrictions on each individual state, to the individual state governors (white house, ). in germany, after experiencing prior issues after easing lockdown measures resulted to increased number of confirmed cases, the government was planning to reopen the economy as from april by allowing some nonessential stores to open and also allowing schools to resume as from may (morris and beck, ). in brazil, president jair bolsonaro fired the minister for health after the minister insisted on strict social isolation guidelines, a move that the president was against. unfortunately, the president had been seen to have regularly downplayed the outbreak of the virus in his country despite the country having , confirmed cases and deaths by april (quinn, a) . in sports, following the situation in france, the tour de france scheduled for june and july was postponed to a tentative date between th august and th september, as the government banned public gatherings to reduce the spread of the coronavirus (tour de france, ). for world wrestling entertainment, the company was planning to lay off some employees including wrestlers and producers such as kurt angle (russell, ) . the move was to caution the company against the financial decline it was facing following the impacts of the pandemic. after months of extreme pressure, anxiety, and uncertainties, wuhan settled and revised its official data relating to the coronavirus. after the review, the death toll from the covid- pandemics increased by % meaning that its number increased from deaths to deaths, pushing the country total by april to deaths. the errors in reporting were attributed to delays, omissions, and incorrect reporting that are understandable following all the many things that are happening during that period (neuman, a) . the number of reported deaths also increased in the african continent after more deaths were reported, taking the total tally to , while new confirmed cases increased by , pushing the continent's total to , , according to africa centres for disease control and prevention (africa cdc) (xinhua, a) , but data by the who for the same period show a total of , cases and deaths (who, x) . death tolls were rising by higher margins in the european regions and had exceeded , deaths, from , , cases reported in the region. this increase, observed throughout spain and italy, however, continued to experience improvements with death rates reducing each day. the united kingdom, france, and belgium still reported increasing numbers of deaths ( , , and , respectively) . however, the united states still leads in the number of confirmed cases ( , on april ) and death tolls ( on the same day) per day for more than two consecutive weeks (who, x) . globally, the total number of cases had increased to a high of over . million, with the number of deaths exceeding , by april (who, x) . despite the risk of the disease being live, the orthodox churches in georgia were observed to flaunt the state of emergency declaration to hold easter masses, where hundreds of congregants attended (antidze, ) . in the united states, a day after the president had outlined a set of rules for reopening the economy, but left the final say on the hands of the governor, some protesters were observed in states of michigan, minnesota, and ohio and others, calling their governors to lift the restrictions in their states (gabbatt, ) . at the same time, texas governor is said to have signed an executive order to allow a reopening as from may (office of the texas governor, ). this was happening, even as the us secretary of defense extended the travel ban for one more month to void the earlier expiry scheduled for may ; thus, showing that the country was still not ready to ease the restrictions it had set. further south, in chile, the government started issuing "immunity cards" for all those who had infected and recovered from the virus. with the card, these could comfortably return to their work stations (thomson, ) . as this was happening, the number of cases in the country rose to , , taking the country as the third most affected in latin america (who, x) . however, the who, through dr. michael ryan, one of the executive directors, warned that there was no evidence that those who were recovering from covid- were developing any immunity that could prevent them from being reinfected (who, ab) . during the same press conference, the director-general emphasized that as chinese authorities allowed the wet market to reopen, they would ensure conformity to food safety and highest levels of hygiene and that the law banning any trade in wildlife for food was to be implemented strictly to save the world from future pandemics like the coronavirus (who, ab). elsewhere, more countries were slowly and cautious easing restrictions, with france allowing visitors to care homes, albeit some conditions (dodman, ). croatia also eased some restrictions allowing people to travel within their districts. in other countries such as the united kingdom and zimbabwe, the lockdown measures were to remain intact until when the government is confident the situations are controlled (today, b) . in saudi arabia, despite the start of ramadan, the top religious authorities of the country were recommending people to pray at home to reduce the spread of the virus among the faithful (reuters, p) . this was necessary, as already, deaths were not sparing countries' leadership. for instance, in nigeria, president buhari's chief of staff, abba kyari became the latest topranking official to die from covid- (akwagyiram, b) . a similar case was reported in guinea where a top official and ally of the president alpha condé also died (afp, a). within a period of h (april e ), the number of infections globally increased from . million cases to over . million, while the number of deaths increased to above , globally (reuters, g) . in europe, the number of those infected increased over this period to over . million, with a daily average increase of approximately , new cases, while the number of new deaths in the areas also increased by an average of above each daydtaking the total deaths in the region to , according to data by the who (who, y). in the american regions, cases increased by an average of , confirmations pushing the total confirmed cases to , cases (who, y). the number of deaths increased to approximately , by april , with a majority of these reported in the united states, which was the new epicenter for the coronavirus. the eastern mediterranean region had its total confirmed cases increase to , cases with people dying from covid- . the western pacific region had a total of , cases after new cases were confirmed while the number of deaths increased to . the south-east asia region and african regions, though have had their cases increase, have shown remarkable levels of resilience despite having some of the weakest health systems. their total confirmed cases increased to , and , cases, respectively, while the number of people who succumbed to the covid- in the regions increased to and deaths, respectively, (who, y) . following the unprecedented increase of infections in the united states, president donald trump had reported on april that he would be signing an executive order to suspend immigration to the united states for the next days. and, true to his word, on st, he signed the order meaning that green card recipients would be blocked from moving into the country, with only workers holding nonimmigrant visas allowed (nick miroff et al., ) . he supported his decision by arguing that the unprecedented effects on covid- had pushed many americans out of jobs, and he would wish to see them access the available job opportunities without having to compete with migrants (nick miroff et al., ) . and to ensure that job opportunities would be available, on the same day, his office and congressional leaders agreed on a $ billion small business and hospitals stimulus package, that now only awaited approval from the house of representatives (roberts, ) . in africa, south africa took a similar approach of bailing out the economy by unveiling a $ billion relief plan that would also aid the most vulnerable in the society during the period that the country was struggling with increasing cases of coronavirus and the lockdown measures (channelstv, ) . the economic struggles saw iran start to reopen its economy with major shopping centers in the capital tehran being the first (press, ) . similar actions were observed in israel, which eased lockdown restrictions to allow small shops and stores to open and allow people to move around, but on condition mask-wearing in public (haaretz, ) . this came as the number of recoveries in those countries started to increase, while the death toll contained (efrati and rabinowitz, ). in the poorest countries in the world, the world bank supported the pandemic bond, launched in , with an amount of $ . million to assist nations from the impacts of covid- (baker, ) . this came as the un world food programme warned that the impacts of covid- would result in the doubling of world hunger, representing a total of million people (anthem, ) . the economy was however not worsening for individuals only, but on this day, it was seen to have particularly worsened for us oil-producing economies and companies, with the prices per barrel going down to $ , a historical event that has never happened (suleymanova, ). the only sector that was seen to be doing well, especially in the united states is the gaming industry, probably due to the "stay-at-home" orders and also due to the closure of schools. but, while the market increased, there were fewer games produced due to the impacts sparked by the coronavirus (schreier, ) . the other sector that was seen to benefit from the impacts of covid- was the environment, where it was reported that following the reduced activities in the manufacturing and transport sector, less emissions ( % drop) are expected during the year (marchand and faigle, ). as over countries continued to fight the spread, and the impacts of covid- in their countries, the united states was the most hit with over , cases and over , reported deaths as up to april . the new cases in the country had increased at an average number of approximately , (cdc, ). as the number of cases continued to increase, and other more "staying-at-home" measures following the lockdowns in different states, the number of those filing for unemployment claims continued to increase with over . million additional claims reported over the past week, which was the fifth consecutive week since this trend started (lambert, ) . these new numbers raised the total of those who had filed for their employment benefits to over million people (chaney and guilford, ) . outside the united states, there were mixed responses to the virus. some were seen to ease and lift the lockdown and subsequent measures they had implemented, while others were seen to be in haste to institute those measures. for instance, in the netherlands, after experiencing some "relative calm" over the past weeks in respect to infections in the country, its number had started to rise with new deaths averaging over each day and reaching a high of deaths and , confirmed cases by april (who, z). to minimize further infection, a stern decision was taken to ban any form of public gather until september ( months extension) the first of such a ban globally. that means that events such as sports, music festivals, and religious grouping would not be resuming anytime soon (reuters, e) . but, it was not the only one extending such measure as in pakistan, the lockdown was extended by two more weeks until may , as the country was still experiencing increasing numbers of local transmission of the virus, and the lockdown extension would somehow reverse these trends (cherian, ) . indonesia also joined the list of those that were strengthening their measures after the government announced that it would be temporarily suspending nonessential domestic and international air and sea travel until the end of may to curtail the spread of the coronavirus in the country (bangkok post, ) . others that extended their lockdown include liberia (garda, ) , lebanon (reuters, k) , and czech, which sought parliamentary intervention to allow the extension of the state of emergency until may (xinhua, b) . on the same breath, some countries and states in the united states started easing restrictions to allow the reopening of their economy. these include states such as georgia, oklahoma, and others in the united states, which took these decisions despite the disapproval of president trump (smith, ) . belgium was ready to start reopening some businesses and schools as from may, but gradually and cautiously (martens, ) . although countries were reacting to covid- situations in different ways, some unfortunate news besides new cases and deaths were also reported. for instance, in the united kingdom, which had seen the confirmed cases increase significantly and the number of deaths rising to beyond , there were reports that among the dead were national health service personnel who had paid the ultimate price in a bid to save their country from the pandemic (express and star, ) . in bangladesh, it was reported that frontline doctors had tested positive for the coronavirus due to strains that the covid-i had put on the healthcare system, with most of those in the frontline experiencing a shortage of ppes, test kits, and hospital beds, among other basic essentials (mahmud, ) . elsewhere in japan, after a dreadful experience with the diamond princess cruise ship, on st, another fateful incidence involving an italian cruise ship (costa atlantica) happened in nagasaki shipyard (the japan times, b). it started when one of the crew members tested positive for coronavirus, while of his colleagues were also showing signs, especially high fever. the following day, after contact tracing from the first confirmed cases, another cases tested positive (the straits times, a). h later, another people tested positive (kaneko and kim, ) and by th, a total of people; all crew members were confirmed as testing positive (cna, b) . following this, the japanese government stated that it would test people, out of the who were on board the cruise ship and those who turned negative would be repatriated back to their home countries. as the fifth month, since the onset of the coronavirus, is almost over, the number of those confirmed to have contracted the virus increased to over million people globally, and at least , were reported to have succumbed to the disease. over the same period, of the million, over , patients had recovered (spotlight, ). one country where success against covid- have, and continued to be celebrated, was in wuhan, hubei province, china, where healthy officials reported that they had treated all cases and those who recovered were discharged from hospital (o'donnell, ) . in fact, as previously reported, the restrictions and lockdown in the provinces were lifted including in wuhan, on april (aljazeera, a) . following this, on rd, china pledged additional funding, amounting to $ million, to the who (shih, ) , as already, it could manage the few cases emerging, and the funds could help other areas that were experiencing high pressure from the pandemic. in the new cases, between th and th, china was reported to have only recorded a total of new cases and asymptomatic cases, but no death was reported in the days (who, i). as cases in china reduced, those in the european region seemed to have continued increasing reaching a high of , , cases after the addition of , new cases on th, and the number of deaths increased to , . in the american region, the number of cases was , , and , deaths reported, according to data by the who (who, i). the eastern mediterranean, western pacific, and south-east asia regions had , , , , and , confirmed cases, respectively. the african region continued to show high levels of resilience with only , confirmed cases and deaths reported (who, i). but as the number of cases continued to increase, reports of more countries planning to ease up the lockdown also increased. as of th, italy and spain, two of the most affected countries by the covid- pandemic, with cases of death in each exceeding , (italy , deaths, spain , ) unveiled plans of how they would open up their country as from may . in italy, according to prime minister giuseppe conte, the manufacturing industry would gradually open as from may , but schools would remain closed for three more months until september (kayali, ) . in spain, people would be allowed to walk out for physical activities, but social distancing will have to be observed, as infections in the country were still real (reuters, q) . saudi arabia is another country that considered lifting the nationwide curfew, except for mecca, which remained under -h curfew (aljazeera, h). in germany, after easing the restrictions a few days ago, it is reported that volkswagen was gearing to resume production in their wolfsburg factory on april (allan, ) , the same decision was also taken by bmw company and other companies such as mercedes, jaguar land rover, and others reopening in a few days (reuters, f) . this came as some protests were witnessed in berlin as people demanded the easing of lockdown measures to allow them to return to work (reuters, d) . in the united states, as some states started reopening businesses, the airline industry, which was yet to resume, received support funds amounting to $ . billion -taking their bailout total from the us treasury to $ . billion, with the first disbursement received on april (landay and shephardson, ) . although those countries were gearing to resume business, others insisted on strict measures as cases continued to rise. for instance, the united kingdom maintained the lockdown as it was still not safe from the virus infections (bbc, i). sri lanka also extended the lockdown in the country to counter the increasing number of cases (afp, b). honduras was even considering extending the lockdown by at least one more week until may (reuters, h) . in india, prime minister modi urged his citizens to piously adhere to the nationwide lockdown to contain the rising cases that came amid the month-long curfew (the straits times, d). by april , it became official that the number of covid- infection cases had exceeded the million (the who reported . million cases and , deaths) people and caused the death of over , people globally. of the confirmed cases, over million were reported in the united states while a quarter of reported deaths from the virus coming from the united states. the number of deaths in the country ( , ) even surpassed the total of those who died during the vietnam war between and , where nearly , people died (woodward, ) . in new york, it was reported that for every four people, one of them had contracted the coronavirus. this is after almost , cases had been confirmed, and more than , deaths were reported in the city alone. these numbers in the united states eclipse those of other reported regions. for instance, as of th, the total number of reported cases in africa ( , ) was far much less than the total number of deaths ( , ) reported in the united states on the same day. in addition, they were more than the total number of deaths ( , ) in italy and the united kingdom, which were leading in terms of reported deaths in europe (worldometer, ) . to reduce these unprecedented trends, some states in the united states started testing for asymptomatic residents such as delivery drivers, rideshare drivers, and others. this came as most of the states were planning to reopen by easing the lockdown restrictions, amidst opposition from president trump, and the latest, judge clay jenkins of dallas county, who mentioned the solution, for now, was to follow science and people to stay at home (holcombe, ) . besides the united states, other countries that are yet to experience some reductions in a number of cases include russia, where president vladimir putin stated that the country was bracing for a new and grueling phase of the pandemic (llyushina, ) . his statement came at a time when the number of confirmed cases had continued to stabilize, and the country performed significantly well to reduce casualties. italy, though determined to ease its lockdown restrictions, was experiencing some new cases, with its numbers reaching beyond the , mark. according to the who, africa, eastern europe, latin america, and parts of asia were still not yet out of risk; hence, caution was required even as some actions such as easing the restriction were being taken. this came as eu experts warned that the world would have to wait longer for the vaccine, which would not be ready until the end of , especially considering the cost implications, and other processes that have to be accomplished (cullen, ) . in relation to this, in new york city, it was reported that medical personnel had started testing famotidine; an over-thecounter heartburn medication could cure covid- (lentile, ) . this came as human trials had also started in germany where biontech, a pharmaceutical company was testing its vaccine on volunteers, with participants already having received the dose as from april (aljazeera, f) . as solutions for the covid- continued to be sought, some diplomatic disharmony was witnessed when india canceled orders for , rapid test kits from china after claiming that they were "faulty," and also went forth to withdraw some of the kits that were already in use in several states (bbc, b) . china responded harshly and claimed that it was unfair and irresponsible for india to label chinese products as "faulty" (business today, a). in sports, following the unseen end for the pandemic, french authorities stated that there was no hope for "big sporting affairs" to come back until september in the years, thus, throwing the french football season in disarray, thus, causing them to be canceled (aarons and lowe, ) . the cancellation came as other countries like germany had already announced that the football season (bundesliga) would return in a date to be confirmed albeit under closed doors (bassell, ) . regarding the olympics, the olympics international committee stated that it would cancel the event coming in the next year if the pandemic would not have ended (schad, ) . olympics must be delayed to ensure french football season will not resume but la liga has new hope of restart adb to provide $ million to support strained supply chains in fight against covid- african development bank launches record breaking $ billion "fight covid- leading member of guinea government dies from coronavirus sri lanka extends virus lockdown coronavirus e africa: african union and african private sector launch covid- response fund nigeria orders -day cessation of movement in lagos, abuja to fight coronavirus nigerian president's chief of staff dies from coronavirus china's wuhan ends coronavirus lockdown but concerns remain coronavirus: travel restrictions, border shutdowns by country curfew in mecca, medina extended to hours over coronavirus former libya prime minister mahmoud jibril dies from coronavirus france reports covid- cases on board aircraft carrier germany company begins human trials of coronavirus vaccine one hundered italian doctors have died of coronavirus saudi arabia partially lifts curfew except in mecca volkswagen restart production as european car factories reopen burials on new york island are not new, but are increasing during pandemic risk of hunger pandemic as covid- set to almost double acute hunger by end of hundreds of parishioners attend orthodox easter vigil in georgia apple and google partner on covid- contact tracing technology ( ) china to end lockdown of coronavirus-hit hubei province; wuhan to open next month moscow shuts down all non-essential shops & restaurants to stop spread of covid- trudeau says canada will return asylum seekers to fda authorizes -minute coronavirus test poorest countries finally set to get world bank pandemic bond funds indonesia bans air, sea travel until june over virus fears world bank group president malpass: remarks to the development committee bundesliga return in may now looks inveitable but fans far from happy coronavirus travel: china bars foreign visitors as imported cases rise coronavirus: india cancels order for "faulty coronavirus: italy extends emergency measures nationwide coronavirus: new york has more cases than any country bbc. ( e) coronavirus: new zealand announces lockdown coronavirus: paris bans daytime outdoor exercise coronavirus: prime minister boris johnson tests positive coronavirus: spain plans return to 'new normal' by end of coronavirus: uk must find 'new normal' to ease lockdown e raab formula e: china race called off amid coronavirus outbreak wuhan eases quarantine as coronavirus cases in us pass , singapore closes borders to keep virus at bay, but no shutdown bill & melinda gates foundation, wellcome, and mastercard launch initiative to speed development and access to therapies for covid- uk coronavirus death toll could be far higher than previously shown coronavirus crisis: china fumes over icmr clampdown on 'faulty' rapid testing kits, calls it 'unfair business today. ( b) coronavirus outbreak: india bans international flights till suspends season after player tests positive for coronavirus senate unanimously passes $ t coronavirus stimulus package it's a wreck': . million file unemployment claims as economy comes apart coronavirus disease : cases in the us china's first batch of schools reopens in qinghai province available at south africa president ramaphosa unveils $ bn covid- relief plan coronavirus: who head says nations must attack as 'pandemic is accelerating europe's hospitals among the best but can't handle pandemic pakistan extends lockdown for days, until may south korea throws up innovative tech solutions in coronavirus fight. available at: straitstimes. com/asia/east-asia/south-korea-throws-up-innovativetech-solutions china's imported covid- cases spike as fears grow of second wave covid- tally rises to on italian cruise ship in japan cruise ship stranded by covid- fears to dock in cambodia spain impose nationwide lockdown due to virus, closes all stores except groceries and pharmacies trump address sparks chaos as coronavirus crisis deepens germany's maas: trump coronavirus response took 'too long ignoring expert opinion, trump again promotes use of hydroxychloroquine coronavirus vaccine won't be ready until end of under "most optimistic seven more big cats test positive for coronavirus at bronx zoo donald trump stokes fresh coronavirus row as wuhan reopens global covid- cases near million as putin warns russia faces 'extraordinary' crisis devil's dilemma': france lifts ban on nursing home visits as some warn against relaxing rules coronavirus: what are the lockdown measures across europe? available at map: coronavirus and school closures israel reverses the trend: more coronavirus recoveries than new cases mosques to remain closed, charity iftar tables banned in ramadan negotiations intensify on capitol hill over massive stimulus legislation as coronavirus fallout worsens applications welcome from startups and smes with innovative solutions to tackle coronavirus outbreak commission publishes guidance on export requirements for personal protective equipment the nhs workers who have died during the coronavirus pandemic mcdonald's apologizes after store in china displayed sign banning black people trump signs historic $ trillion stimulus after congress passes it friday senegal bans layoffs during coronavirus crisis cuba closes borders to non-residents over virus: president lebanon announces two-week lockdown over coronavirus us anti-lockdown rallies could cause surge in covid- cases, experts warn cruise ship docks in mexico, passengers allowed to disembark after being denied entry in jamaica, cayman islands amied coronavirus fears cepi invests $ , into potential covid- vaccine from university of hong kong european union leaders denounce trumps coronavirus travel restrictions liberia: president extends lockdown measures for two weeks from april /update foreign travel advice: italy uk helps world's poorest countries withstand the economic disruption of coronavirus latest guard update: more than , troops mobilised for covid- response a fine for not wearing a mask: these are israel's new coronavirus regulations bolsonaro defies coronavirus to rally against congress coronavirus: iran release , prisoners in bid to tackle spread of virus trump invokes defense production act to force gm to make ventilators dallas county judge opposes governor's plan to reopen and calls for residents to follow science and stay home fact sheet: dhs notice of arrival restrictions on china, iran and certain countries of europe together we can with the war against covid- ) imf executive board approves us$ . million in emergency support to albania to combat italian cruise ship in japan has coronavirus cases italy and spain announce plans to ease coronavirus lockdowns further cepi approves $ . m in additional funding for coronavirus vaccine research, bringing total to $ how new york became the epicenter of america's coronavirus crisis ventilators are to this war what missiles were to world war ii un headquarters closes to public as coronavirus precaution real unemployment rate soars past %dand the u.s. has now lost . million jobs spain sees slowing coronavirus toll, holds virtual easter parades airlines receive extra $ . billion in payroll support singapore stops zoom for home-schooling after hacking report famotidine trial underway in nyc for covid- treatment trump declares national emergency e and denies responsibility for coronavirus testing failures russia will "face a new and grueling phase of the pandemic now has million unemployed, wiping out a decade of job gains america is in a depression. the challenge now is to make it short-lived america is in a depression. the challenge now is to make it short-lived hundreds of doctors in bangladesh infected with coronavirus coronavirus: beijing's ban on foreign travellers comes into force months after it criticised other countries for 'isolating china will coronavirus reduce emissions long term? available at belgium to gradually ease virus lockdown in first half of may covid- therapeutics accelerator awards $ million in initial grants to fund clinical trials coronavirus crisis 'like no other' as cases near m: live updates stocks plunge % in dow's worst day since japan declares state of emergency over coronavirus care homes and coronavirus: why we don't know the true uk death toll as virus spreads, africa gets medical supplies from chinese billionaire the dow jones had its biggest point drop in history monday angela merkel's first coronavirus test result is negative panama suspends domestic flights to curb the spread of coronavirus: civil aviation authority germany to reopen schools, shops after 'fragile' success egypt shuts mosques and churches over coronavirus fears china raises wuhan death stats by half to account for reporting delays and omissions goes into -week lockdown trump to suspend immigration to u.s. for days, citing coronavirus crisis and jobs shortage austria reopens thousands of shops in first loosening of coronavirus lockdown nearly % of americans have been ordered to stay at home office of the president. ( a) letter from president donald remarks by president trump and vice president pence at a coronavirus briefing with health insurers governor abbott issues executive order establishing strike force to open texas coronavirus-press-conference- apr .pdf?sfvrsn¼ bd c cd_ cuba is going under lockdown over coronavirus concerns italy joins germany in prolonging lockdown to quell outbreak covid- : how a phone app is assisting south korea enforce self-quarantine measures why is germany's coronavirus death rate so low? available at first yanomami covid- death raises fears for brazil's indigenous peoples spain to extend coronavirus state of emergency as deaths soar connecticut becomes latest state to postpone primary as coronavirus spreads iran begins to open its economy despite fears of second wave of infection brazil's populist president ousted his respected health minister while continuing to downplay the coronavirus pandemic italy's coronavirus death toll surpasses china's japanese pm and ioc chief agree to postpone olympics until ) i.m.f. predicts worst downturn since the great depression states have declared a state of emergency due to coronavirus global coronavirus death toll exceeds , : live updates unprecedented move, treasury orders trump's name printed on stimulus checks austrian joblessness hits record despite government bit to avoid layoffs bolivia postpones elections, announces nationwide -day quarantine to stem spread of coronavirus china's coronavirus epicenter reports just five cases, beijing tomb-sweepers urged to stay back dozens of protesters were arrested in berlin on saturday for flouting lockdown rules and staging a demonstration against lockdown measures dutch extend ban on major public events until sept europe restarts car factories amid uncertain demand global coronavirus cases pass . million as u.s. tally surpasses , honduras extends coronavirus curfew by one week to may italy's coronavirus lockdown measures to be extended to april : minister kazakhstan, uzbekistan close borders after first coronavirus cases kazakhstan-uzbekistan-close-borders-after-first-coronaviruscases-iduskbn ex lebanon advised to extend coronavirus lockdown to may mexico declares health emergency as coronavirus death toll rises nigeria closes land borders to fight coronavirus spread pakistan suspends internationa flights for two weeks portugal to treat migrants as residents during coronavirus crisis saudi top religious authority recommends home prayers in ramadan amid coronavirus spain to allow outdoor exercise if coronavirus cases contine to fall vietnam in talks to borrow $ billion as budget deficit seen widening japan declared a coronavirus emergency. is it too late? available at us senate approves $ bn funding for small businesses rockefeller foundation. ( ) the rockefeller foundation commits $ million in covid- assistance coronavirus: heathrow passenger demand to fall by more than % in april prince albert ii of monaco test positive for coronavirus the coronavirus map in spain: , dead and more than , infected wwe announces layoffs two days after florida deems company an 'essential business tokyo olympics will be canceled, not delayed, if coronavirus pandemic still poses threat in as italy covid- cases soar, who tackles ppe, test shortages gaming sales are up, but production is down donald trump threatens to freeze funding for who new york city public schools to close to slow spread of coronavirus trump extends social distancing guidelines through end of april china pledges additional $ million funding for world health organization india extends ban on international flights until airlines seek $ billion coronavirus aid package coronavirus deaths surpass , , hhs watchdog says american hospitals face 'severe' shortages of equipment, staff and tests china reports zero new local coronavirus infections; trump signs bill to ensure paid leave, other financial benefits too soon': trump disagrees with georgia governor's decision to reopen businesses coronavirus deaths in italy up by in a day to , global death toll from coronavirus tops greece to go into coronavirus-induced lockdown crash! us crude futures turn negative for first time in history white house expected to urge americans to wear face coverings in public to slow spread of coronavirus government bans exports of certain masks, ventilators, raw material for masks zimbabwe shuts borders after first coronavirus the herald. ( ) breaking: air zim sends workers on unpaid leave japan to declare nationwide state of emergency as virus spreads the japan times. ( b) one crew member tests positive, feverish on cruise ship in japan. available at the nation. ( ) pm announces pm to am nationwide curfew gives new guidelines, new york to close restaurants and schools and italian deaths rise the new york times. ( b) u.s. now leads the world in confirmed cases. available at statement from the r&a/the open in to be cancelled china reports newly imported covid- cases and one in wuhan cases-on-cruise-ship-docked-fo r-repairs. the straits times. ( b) china tightens russian border checks, approves experimental coronavirus vaccine china's imported coronavirus cases soar, no local transmission for third straight day the straits times. ( d) indian pm modi urges citizens to follow lockdown as coronavirus cases rise boris johnson's move from intensive care to a general ward is the lift britain needed world bank group increases covid- response to $ billion to help sustain economies world's first covid- immunity cards are coming to chile more than million people tested for coronavirus in us, but access varies from state to state georgia proposes -day lockdown of four cities including capital uk not thinking of easing virus lockdown measures yet: minister the tour de france greece to gradually start lifting lockdown measures on may . available at: greece to gradually start lifting lockdown measures on key cop climate summit postponed to 'safeguard lives secretary-general's remarks at launch of global humanitarian response plan for covid- african finance ministers call for coordinated covid- response to mitigate adverse impact on economies and society a global approach is the only way to fight covid- , the un says as it launches humanitarian response plan coronavirus: boston celtics guard marcus smart tests positive for covid- chinese businessman to donate , test kits and million masks to the world health organization has distributed . million coronavirus lab tests around the world global covid-zero initiative launched to fill $ bn shortfall for coronavirus response chicago's largest jail reports inmates, staff positive for coronavirus two los angeles lakers players have tested positive for covid- , team says president donald j. trump is beginning the next phase in our fight against coronavirus: guidelines for opening up america again australia bans overseas travel and extends social restrictions situation report - . available at who. ( b) coronavirus disease (covid- ): situation report - . available at who. ( c) coronavirus disease (covid- ): situation report - . available at who. ( d) coronavirus disease (covid- ): situation report - . available at who. ( e) coronavirus disease (covid- ): situation report - . available at who. ( f) coronavirus disease (covid- ): situation report - . available at who. ( g) coronavirus disease (covid- ): situation report - . available at who. ( h) coronavirus disease (covid- ): situation report - . available at who. ( i) coronavirus disease (covid- ): situation report - . available at who. ( j) coronavirus disease (covid- ): situation report - . available at who. ( k) coronavirus disease (covid- ): situation report - . available at who. ( l) coronavirus disease (covid- ): situation report - . available at who. ( m) coronavirus disease (covid- ): situation report - . available at who. ( n) coronavirus disease (covid- ): situation report - . available at who. ( o) coronavirus disease (covid- ): situation report - . available at who. ( p) coronavirus disease (covid- ): situation report - . available at who. ( q) coronavirus disease (covid- ): situation report - . available at who. ( r) coronavirus disease (covid- ): situation report - . available at who. ( s) coronavirus disease (covid- ): situation report - . available at who. ( t) coronavirus disease (covid- ): situation report - . available at situation report - . available at coronavirus disease (covid- ): situation report - who. ( w) coronavirus disease (covid- ): situation report - . available at who. ( x) coronavirus disease (covid- ): situation report - . available at who. ( y) coronavirus disease (covid- ): situation report - . available at who. ( z) coronavirus disease (covid- ): situation report - . available at who. ( aa) coronavirus disease (covid- ): situation report - . available at who. ( ab) covid- virtual press conference. available at who. ( ac) opening statement who director-general's opening remarks at the media briefing on covid- e who director-general's opening remarks at the media briefing on covid- e who director-general's opening remarks at the media briefing on covid turkey to free one-third of its prisoners to curb coronavirus ebrd unveils v billion emergency coronavirus financing package inquiry after of french aircraft carrier's crew catch coronavirus coronavirus: nuggets report member of organization tested positive for covid- who chief warns against 'politicizing' coronavirus unless 'you want to have more body bags world food programme. ( ) statement from wfp executive director david beasley report coronavirus cases remote chinese city hit by coronavirus after weeks of feeling safe africa's covid- death toll hits , , as confirmed cases rise to czech parliament oks extending state of emergency until except wuhan, china's hubei reopens domestic flights what the u.s. needs to do today to follow south korea's model for fighting coronavirus how taiwan is containing coronavirus despite diplomatic isolation by china three members of the philadelphia ers organization test positive for coronavirus china sees rise in asymptomatic coronavirus cases, to tighten controls at land borders key: cord- - buclszd authors: roussel, yanis; raoult, didier title: hydroxychloroquine recommendations toward the world: first evaluations date: - - journal: new microbes new infect doi: . /j.nmni. . sha: doc_id: cord_uid: buclszd nan author list: yanis roussel , , didier raoult today, now that the epidemic is in a phase of decline in most of the hardest hit countries in terms of mortality ( ), we can issue initial assessments of the treatment strategies adopted in the world according to the mortality of each of the country. we therefore determined which countries recommended hydroxychloroquine using the recommendations issued by the authorities of these countries and the data collected by the website c study.com as source (figure a ). following this work, we established a second map classifying the countries depending on how they were affected by the epidemic (in number of deaths per million inhabitants), using the data gathered by the website worldometers.info (figure b) . a comparison of these two maps shows that developing countries have massively turned to the use of hydroxychloroquine, as well as asian countries which present low mortality by sars-cov , despite the fact that they have been the first to be affected by the epidemic. these countries have in common the early adoption of treatments based on hydroxychloroquine and chloroquine, whether or not combined with other antivirals. the countries having expressed the concerns for its use are combining up to three antivirals ( ). this therefore shows a discrepancy between the strategies of the western world and those of developing countries and the far east, some being much more cautious than others with regard to the use of treatments to fight against the epidemic. the opposite distribution of chloroquine recommendation and fatality rate is striking and may be investigated more deeply. remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus ( -ncov) in vitro breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of covid- associated pneumonia in clinical studies hydroxychloroquine and azithromycin as a treatment of covid- : results of an open-label non-randomized clinical trial maps and trends : new cases of covid in world countries a pilot study of hydroxychloroquine in treatment of patients with common coronavirus disease- (covid- ) key: cord- - n h authors: nawaz, muhammad atif; seshadri, usha; kumar, pranav; aqdas, ramaisa; patwary, ataul karim; riaz, madiha title: nexus between green finance and climate change mitigation in n- and brics countries: empirical estimation through difference in differences (did) approach date: - - journal: environ sci pollut res int doi: . /s - - -y sha: doc_id: cord_uid: n h green finance is inextricably linked to investment risk, particularly in emerging and developing economies (emde). this study uses the difference in differences (did) method to evaluate the mean causal effects of a treatment on an outcome of the determinants of scaling up green financing and climate change mitigation in the n- countries from to . after analyzing with a dummy for the treated countries, it was confirmed that the outcome covariates: rescon (renewable energy sources consumption), population, fdi, co( ), inflation, technical corporation grants, domestic credit to the private sector, and research and development are very significant in promoting green financing and climate change mitigation in the study countries. the probit regression results give a different outcome, as rescon, fid, co( ), human development index (hdi), and investment in the energy sector by the private sector that will likely have an impact on the green financing and climate change mitigation of the study countries. furthermore, after matching the analysis through the nearest neighbor matching, kernel matching, and radius matching, it produced mixed results for both the treated and the untreated countries. either group experienced an improvement in green financing and climate change mitigation or a decrease. overall, the did showed no significant difference among the countries. climate risk is investment risk. green finance is the panacea to dealing with these risks. green finance became popular in the s and continues to attract attention globally. green finance explains the situation whereby business objectives are achieved while considering environmental benefits. contrary to the conventional financial transaction, green finance has to do with environmental activities that protect the environment from degradation (wang and zhi ) . the scientific evidence from climate change is so conspicuous that the world needs to act now to avert disastrous consequences. as a result, green finance is a cornerstone instrument to curb the existential threats of climate change. the central banks have long considered the issue of climate change-associated risks to financial system stability in recent times and financial regulators (gagnon and sack ) . the term green economy gained prominence after the / financial crises, where the world seized the recovery opportunity to bridge the gap brought by the economic recession and to implement policies to address these inequalities and reduce environmental concerns, thus, the term green economy (mohsin et al. a, b) . in revamping their economies after the recession, china, south korea, and the usa called their stimulus packages "the green new deal." the aim was to jumpstart their economies to a sound recovery and putting their economies on a sustainable recovery pathway (georgeson et al. ) . the corona pandemic presents an opportunity for the n- countries to recover sustainably and transition to a sustainable future. according to the iea, the global economy will be reduced by % in , with over million jobs lost (sustainable recovery, ) . but irena ( ) says for the world to recover sustainably and move out of these economic predicaments, the world needs to invest about $ trillion in the post-covid- - recovery phase in green investment projects such as renewables. the investment, coupled with institutional investment and green bonds and dedicated funding, would be crucial for a sustainable recovery (irena ). the n- countries have the opportunity to green their recovery outlook, whether it is w-shape or v-shaped. the covid- has already reduced co emissions but lowered economic growth with its commitment to economic hardships and human suffering. sinha et al. ( ) , in their research, referring to arifin and syahruddin ( ) , revealed that indonesia could increase the growth of their economy, from to , when they increase the consumption of renewables and reduce fossil fuel consumption. furthermore, indonesia targets to go green by generating % of its electricity from geothermal sources; % wind, biomass, hydro, and solar; and % biofuel by (hezri and hofmeister ) . in a significant work to advance the course of indonesia to a low-carbon economy, the country launched the low-carbon development initiative (lcdi), with the high case scenario to deliver a suite of policies and scalable actionable transforming programs in the different sectors of the economy. these interventions will achieve consistent . % economic growth by and . % by . in a high case scenario, about $ . trillion would be added to the gdp by , more than . million decent green additional jobs. as well as a reduction in the poverty rate of . % of the total population of down to . % and saved , lives as a result of improved air quality (brodjonegoro et al. ) . the philippines plans to ramp-up % of its renewable capacity in . the philippines buoyed by a growing economy of . % for the last years; the country plans to install . gw of wind capacity by , out of its theoretical potential of gw (lee and zhao ) . another booming economy is vietnam, with a % gdp growth of about a decade now, which has re targets % in and % in (hezri and hofmeister ) . vietnam currently has an installed wind capacity of mw and plans to install mw by the end of (lee and zhao ) . it has been suggested by yildirim et al. ( ) , the n- countries have quite high energy intensity ratios, which makes it imperative for them to consider investing in energy efficiency and conservation and ultimately greening their economies. while the rest of n- countries have similar traits regarding their economic structures, nigeria is grappling with low energy access and expects to green its energy mix by one fifth in a decade to come (sinha et al. ); turkey has geopolitical issues with the eu; pakistan is undergoing reforms in its financial sector as well as the energy sector. across the world, both the private and public sectors have recognized the urgent need to implement policies aimed at fighting the risks posed by climate change and environmental degradation, and also reaping the economic benefits that come as a result of providing solutions to these risks (kaminker and majowski ) . another source of green finance is through green bonds, where the proceeds are used to finance green projects like renewable energy, other than a carbon pricing system (baker ) . the green bond market had grown significantly since when it was first issued by the european central bank (ecb) (baker ) . another characteristic of the n- countries is that they are grappling with rising energy demand that needs substantial investment as well as heavy industries that are not energy efficient in producing goods, and this has damning environmental consequences (no and padhan ) . green finance and, for that matter, climate change consequences are no longer a niche issue facing the developed world. it has global ramifications . thus, this study seeks to analyze the factor that will determine the catalyzing of green finance by the n- and brics countries and their climate change mitigation strategies. renewable energy consumption is used as a proxy for green finance. in doing this, the difference in differences (did) approach is applied for the n- countries from to . the treatment period starts from to for the treated countries. this model contains two time periods the "before" and "after" and two groups "treatment" and "control." the model analyzes variations between two groups that receive treatment at different times. thus, the n- countries were treated, and the brics countries were controlled. the benefits of using the did far outweigh that of the disadvantages: it is easy to calculate the standard errors, it is easy to include different periods, and we can control for other variables to avoid biased estimates of the coefficients. the contribution of our study is to the best of our knowledge, and it is the only paper that uses the did method to analyze green energy finance and climate change mitigation among n- countries for the period - and the brics. a couple of studies have been done on n- countries such as sinha et al. ( ), padhan et al. ( , yildirim et al. ( ) , and erdoğan, yıldırım, et al. ( ) . all these applied an econometric method in their analysis. however, the difference in our study lies in that we used the difference in differences approach (did) for analyzing both brics countries and n- countries. the findings show that fdi, r&d, technical corporation grants, co , pop, human development index, renewable energy consumption, as the covariates, have significant outcome effects on green financing and climate change mitigation strategies for these countries. the matching method of next neighbor matching, kernel matching, and radius matching produced mixed results for the treated and the untreated countries. on the whole, there were no significant differences among the countries. the rest of the paper is organized as follows: the next section presents an overview of the status of green and climate change mitigation on the n- countries and the brics. the "data and methodology" section is the methodology that is employed in the analysis, the "results and discussion" section is results and discussion, and the "conclusion and policy implication" section concludes the study. green finance includes climate finance but is not limited to it. it also refers to a wider range of other environmental objectives, for example, industrial pollution control, water sanitation, or biodiversity protection. the mitigation and adaptation finance pertain to climate change-related activities: financial mitigation flows refer to investments in projects and programs that contribute to reducing or avoiding greenhouse gas emissions (ghgs) (mohsin et al. a, b) , whereas adaptation financial flows refer to investments that contribute to reducing the vulnerability of goods and persons to the effects of climate change. yildirim et al. ( ) estimated using a bootstrapped autoregressive metric causality approach, a more robust approach for n -countries, detected a correlation between economic growth and energy consumption among these countries. they concluded that pro-energy conservation policies are implemented for bangladesh, egypt, indonesia, iran, korea, mexico, pakistan, and the philippines. gozgor et al. ( ) investigated the economic globalization of oecd countries from to and concluded that as one of their recommendations, the need to increase the knowledge of how economic globalization to spur renewable energy development, not only for oecd countries but also for other developed and developing countries alike (iram et al. ; mohsin et al. a, b) . across the world, countries are enacting policies to mitigate the risks brought by climate change and its environmental impacts. these include a suite of systems such as the issuance of green bonds to raise the needed green financing in fighting the exacerbating effects of climate change. the next n- is not left out. they are made up of eleven countries: egypt, bangladesh, nigeria, iran, indonesia, pakistan, turkey, mexico, south korea, the philippians, and vietnam. godman sachs investment bank chose these as having the economic potential to become the biggest economies in the twenty-first century alongside the brics, in . they exhibited opportunities for investment and growth (bader riyad alonaizi et al. ) . the next emerging countries (n- ) are facing climate change and its attendant problems. these existential challenges make it imperative to green the macroeconomic policies to fight the menace. green finance integrates economic decisions with environmental decisions to arrive at optimally beneficial outcomes (wang and zhi ) . the term green finance has been defined by lindenberg ( ) to refer to "a broad term that can refer to financial investments flowing into sustainable development projects and initiatives, environmental products, and policies that encourage the development of a more sustainable economy" (mohsin et al. a, b) . similarly, a study (paramati et al. ) applying panel data of developed and developing countries globally for the period - discovered that stock market developments have mixed effects on carbon dioxide reduction in these countries. they argued that it has led to the reduction of co emissions in the developed countries, due to the robust systems to curtail emission levels; however, the contrary is said of the developing countries where emission level reduction has not been achieved. this finding is revealing and calls on developing countries to green their stock portfolios by demanding listed companies to institute favorable environmental policies and increase the share of renewables in their energy consumption. a study by xie et al. ( ) concluded that fdi has led to an increase in co emission levels in emerging countries (fig. ) . furthermore, erdoğan et al. ( ) studied the relationship between natural resources exports on economic growth and the level of financial deepening for selected n- for the period - and found that where financial deepening is over %, a unit increase in export brings about a % increase in economic growth. even though this study pertains to fossil fuels, the n- countries stand to benefit if they apply this approach to the consumption of the renewables and green the financial sector. this will bring more than double the economic growth for the economies of these countries. in a study on developing carbon low finance index-based evidence on designing and developing countries, with two n- countries mohsin et al. ( a, b) asserted that developing countries would have to ramp-up efforts to scale up renewables in their respective countries. iran and pakistan as n- countries have the least scores for the financial index for low-carbon finance index. hence, these countries must deepen their financial sectors by instituting mandatory policies to encourage the development of low-carbon financing derisking instruments to attract investments in emerging technologies (no and padhan ) in a novel approach to determine the important factor n- countries face either economic growth or environmental quality, using panel data for the period - . as one of their findings said, n- countries should take steps to curtail an increasing inequalities, by putting in policies like taxes to redistribute wealth to ensure inclusiveness and absorb some expenditures of the poor. these measures will ameliorate the plights of the poor due to the exacerbated inequalities created by economic growth. heine et al. ( ) in their recent paper said, transitioning to a low-carbon economy and therefore, mitigating climate change impacts demand the adoption and utilization of carbon pricing and green bonds. they argued the integration of these approaches would yield desirable outcomes that are political feasibly and environmentally sustainable. more so, in their analysis, tolliver et al. ( ) found that the nationally determined contributions (ndcs) using the difference in difference (did) analysis are statistically crucial to determining the allocation of proceeds of green bonds to renewables between and since they were formally submitted. they said, where there are stiffer ndcs, more proceeds from bonds were allocated to renewable energy assets and projects with a % significance level. realizing the importance of climate finance, multilateral development banks (mdbs) have committed vast amounts of money into fighting this menace. the six mdbs have cumulatively allocated over billion dollars to developing and emerging countries to fight climate change from to . multilateral development banks (mdbs) have seen over % increases in climate finance ratio since , from to % (tanner and horn-phathanothai ) . in , the mdbs committed $ , million to fight climate change, with a whopping us$ , million, representing % for investment loans and another % for policy-based financing with a total value of us$ million. yuan and gallagher ( ) studied green finance in latin america and the caribbean countries, and emphasized the need to bridge the funding gap of $ billion per annum, which is not met by the mdbs. they further contended that the mdbs provided $ billion for green funding, and that of climate change mitigation is $ . billion per annum for these territories. furthermore, it is discovered from their research that countries that have higher human rights records and pro-socialists tend to receive more green funding from the mdbs (yuan and gallagher ) . another groundbreaking study by sinha et al. ( ) concluded the n- countries had faced hurdles to achieve the sdg aims as a result of not being able to maintain environmental quality. and that the n- countries have grown their economics at the expense of the environment. to determine the determinants of green financing for n countries and the mitigation of climate change, the difference in difference (did) approach was applied to analyze the data from through . the treatment period for the treated countries was from to . in conducting the empirical analysis, data from the n- countries (bangladesh, egypt, indonesia, iran, mexico, nigeria, pakistan, the philippines, turkey, south korea, and vietnam) from to was used as well as data from brics countries (brazil, china, india, russia, and south africa). this approach was chosen because the difference in differences methodology is applied in the analysis. the carbon environ sci pollut res dioxide emission levels are measured in kilotons (kt), gdp is (constant, ) us dollars, the population is measured in percentage (%), technical cooperation grants are measured in us dollars, foreign direct investment (fdi) (fig. ) is measured in usd, human development index is measured in percentage, renewable consumption as a proxy for green finance is measured in kilotons (kt), inflation measured in percentage, gdp is measured in usd purchasing power parity (ppp), domestic investment private participation in the energy sector is measured in usd, and local credit to the private sector is measured in dollars as well. all these variables were obtained from the world development indicators. to do the analysis, the widely use did is used as applied by upton and snyder ( ) , abadie ( ), and xu ( ). this approach is used with cross-section data or panel data availability for n- countries and bric countries for different periods. primarily, the theoretical model for the did is given as follows: the rationale for the choice of the did is, it gives unbiased estimates of the coefficient of green finance in africa, thus giving us reliable results. suppose y(i, t), which are the desirable outcomes for country i at time t. the countries are observed in before treatment period t = and after treatment period t = . around these two time periods, if a group of the countries are exposed to the treatment, they are assigned by d =(i, t)= . similarly, if a particular country is exposed to the treatment period prior to t, d =(i, t)= others not. d =(i, t)= refers to countries that are not treated or untreated or controlled countries and d =(i, t)= refers to countries that are treated in the study, the n- countries. the treated countries are the n- eleven countries. as a result, countries can only be exposed to the treatment d =(i, t)= for i (abadie ). the primary did estimator is usually done using a linear parametric model. the estimating of the model is done regarding what is done in card ( ) and abadie ( ). assume that the resultant variable is generated by the variance process in the equation below. from eq. ( ), δ (t) represents a time-specific component, α represents the impact of treatment, η(i) represents a countryspecific component, v(i, t) connotes country-specific shocks that have mean zero within each period, t = , and is directly correlated in time. y(i, t) and d(i, t) are the observable variables. t = , . doing addition and multiplication to e[η(i)|d(i, ) in eq. ( ), it becomes: the limitations put on eq. ( ) that sets t = , signify e[ , the variables in eq. ( ) as well as δ are estimable using an ordinary least squares (ols) approach. the equation makes it possible for selecting treated countries based on dependence, given that d(i, ) = and countryspecific variable η(i). equation ( ) could be further simplified as given below: y it represents outcomes of the rescon, gdp, fdi, pop, r&d, co , human development index, inflation, technical corporation grant, r&d, investment in pp, and domestic credit to the private sector. δ i treat i represents countries that have been exposed to treatment at i, and δ i tpost t explains countries that have been exposed to the treatment after the treatment and β × ttreat i × post t +u it is the interaction term for the treatment dummy of a group country and posttreatment dummy for a group of countries of the regression model. this part integrates the n- countries and bric that have been exposed to the treatment pre and after to find out the determinants of green finance and climate change mitigation. u it is the serial unrelated country transitionary component of green investments in individual countries. this approach is called "difference in differences" (did) and due to the given condition in eq. ( ), we now have eq. ( ) given below: the formulation of the model is necessary when dealing with cross-sections of (y(i, t), d(i, )) where t = , . as a result of the study population using panel data, involving before and after difference among the countries, the outcome of the observation is given as y(i, ) y(i, ) and the δ is estimated by a conventional square method (ols). is an average not depending on d(i, ) and hence without treating of any of the countries, the mean outcomes would have the same variations as the treated countries. according to abadie ( ), the limitation placed on the model maybe limiting if the treated and untreated groups have different unbalanced exploratory variables linked to the dynamics of the outcomes. in making an analogy to the pioneering work by (ashenfelter's dip) ashenfelter ( ) and avoid these variations among the study countries and take care of the heterogeneity among the countries, a model proposed by ashenfelter and card ( ) is proposed to accommodate these: k is a positive integer, y is a constant, u(i) is a random variable. under this scenario modeled above, individual countries that have low green finance and climate mitigation opportunities are likely to increase and adopt policies to spur them to increase their green finance and mitigate mitigation, after the treatment period, as a result of the demands of the paris accord and environmental pressure group concerns. furthermore, the did is applicable on condition that(i, − k). hence, the impact on the treated group is given below: from the ensuing equation, x(i)= (i, − k). as in this article and that of abadie ( ), x(i) is a vector representing observable characteristics of individual countries, already determined at t = . equation ( ) deals with the matching order of the analysis. it compares each treated i group of countries to untreated individual countries. linking to this to the outcome covariate yi of treated yi, a matched outcome by the estimated b y i is weighted to its neighbor in the comparison group. therefore: c (pi) represents a set of treated neighbors i in the group d = , w ij stands for weight on untreated i in making a comparison with treated i, hence.generally, the matching estimator for the att (s ) can be: in analyzing how to determine and how to scale up green finance in n- countries, a normality test was done on the data, using the jaque-bera normality test to ascertain the skewness and kurtosis of the test. the test proved to be generally distributed with significance with a p value of . , indicating the data is normality distributed. we, therefore, conclude that the residual errors are normally distributed. table gives a stata analysis of the jacque-bera normality test. as a result, the difference in difference estimator was applied in analyzing the results. the advantages of using the did approach are as follows: it enables us to compare only the comparable people. that is comparing apples with apples, not apples with mangoes. again, it controls for unobserved and observable different characteristic impacts among the countries, as well as easy to be used in analyzing data and it is nonparametric in its approach. table gives a summary of the descriptive statistics of the covariance and normality test. the gdp per capita mean score of the countries is the highest among the variables. interestingly, research and development represent the number of people undertaking r&d in the countries is negative. this explains that r&d is negative and almost nonexistent in n- countries. fdi mean score is equally high as well as credit given to the domestic sector for the private sector in the energy sector. the r&d figure lends credence to the fact the private sector is very crucial in greening the energy sector and mitigating climate change effects on the planet. expectedly, rescon that is renewable energy consumption in final energy consumption as aproxy of green investment has a lower mean score (fig. ) . the summary statistics for the treated and untreated group of countries is quite similar. but one crucial point worthy of note is that even though the same observations, the means are quite different in terms of numbers; the treated countries showed significant improvement in their green financing and climate change mitigation strategies. this is because the untreated grouped of countries received a mean score of . , and the treatment countries of received a mean score pretty much close of . . the score indicates a significant improvement after the treatment. the mean scores for gdp per capita, foreign direct investment, and domestic credit for private sector participation are equally very high. of course, r&d is having a very low mean. the treated countries, on the other hand, have a higher mean score for the variables but the human development index (hci). table depicts a dummy variable for the countries, as shown in eq. ( ). this is to provide a counterfactual argument to the hypothesis that countries will receive the same level of green funding, whether they are treated or not. the dummy is d = for treated countries and d = for untreated countries. the dummy proves significant with a p value of . . this explains that countries that are exposed to the treatment, as well as those that are not exposed to the treatment, have a high propensity to attract green finances and implement climate change policies aimed at curbing its impact and transition to a sustainable development trajectory. table above shows the regression output with a dummy covariate controlling for x. from the table, rescon, which is a proxy for green investment, has a significant correlation with gdp capita with purchasing power parity of us dollars, level. on the other hand, inflation per consumer price level is ( ) found that r&d is a catalyst for technological progress in that it brings to bear new knowledge that ultimately improves energy production process and consumption ( table shows the t = and t = effect. furthermore, they asserted that r&d is a driver of energy transformation system, making room for the modernization of grids and the integration of renewable resources of the energy matrix. however, the correlation is a negative one. on the heels of this understanding, fdi is equally significant in attracting green finance to the energy sector and therefore helps to mitigate climate change effects. it has a direct correlation and perfectly significant. it is suggesting that as fdi increases, green finance increases. the inflow of foreign direct investors (fdi) is a significant factor in scaling up green finance. according to xie et al. ( ) , before , global fdi cumulatively reached $ . trillion, a chunk of that amount going to emerging countries. several studies have concurred to this assertion from the analysis, such as xie et al. ( ) and sun et al. ( a, b, c, d) . zhou et al. ( ) who said the amount of fdi inflows indicated the flow of fdi at the provincial level in china. xie et al. ( ) confirmed that fdi accentuated co emission levels in emerging countries. again, the technical cooperation grant (tcg) as a balance of payment of the treatment countries is significant. technical cooperation entails any free financial assistance given to increase the technical capacity of a country, without giving specific projects to invest in. in this view, emerging countries need tcg to increase their capacity to invest in green technologies. indeed one crucial initiative note: *** represent the level of significance at % called from "billions to trillions" in official development assistance (oda) from the world bank group seeks to maximize every grant and financing opportunities totaling about $ trillion geared towards development finance (baiocchi et al. ). another covariance that came out significant is the carbon dioxide (co ) variable. this was anticipated. the issue of climate change is caused by co that has made the world look for ways to limit the existential threat to human existence through the formation of the paris agreement that seeks to limit global temperatures rising beyond . °c pre-industrial levels, through the use of market and non-market instruments. it is perfectly significant and has a direct correlation with the green finance variable on the equation. the n- countries cumulatively emitted . % of global emissions and generated above % of income in (sinha et al. ) . one of the ways to mitigating the co emission levels is to through emission trading systems (ets) whereby companies trade for co allowance and as well as a tax system that taxes the externality caused by the co emission. tax is a disincentive because it is a cost and could curb the co emission rates down (l. sun, cao, alharthi, et al., ) . however, a study by shmelev and speck ( ) found taxes alone not to reduce co levels in sweden effectively. the paris agreement has equally placed on countries nationally determined contributions (ndcs) to endeavor to limit their co emission levels voluntarily. a groundbreaking study by kirezci et al. ( ) paints a glooming picture of the adverse effects of climate change on the world by concluding that at a business as usual approach, about % of the world' s land, more than half of the world's population, and % of global asset risk being flooded. and that % of coastal areas will be flooded due to tide and storms and % as a result of regional rise in seal level. a qu essential market-based approach is the china's emission trading scheme that started off in and could significantly lower china's emission levels through its ndcs, as a global number one emitter (china' s emissions trading scheme ). the analysis equally showed that the population is significant in determining how green financing can flow to n- countries. these emerging countries have the most of the world population. as in , the cumulative and nominal gdp was around $ . trillion and had about . billion of the world's population. their population is higher than china but almost has the same gdp size of china. this sizeable population has increased energy demand that culminated in total consumption of % of global share (no and padhan ) . this shows how the spending and consumption power of the n- countries. a study on the n- countries revealed a long-term equilibrium correlation among the population, technological progress, and renewable consumption (sinha et al. ). finally, the human development index and domestic credit to the private sector were not significant in accessing green financing. additionally, regression with a dummy variable controlling x indicates all the outcome variables, except human development, investment in the energy sector by the private sector, are significant in scaling up green finances and climate change mitigation strategies among the treated countries in the study (baloch et al. ) and (sun et al. a, b, c, d) . table gives a description of the treated and the untreated before the probit regression. the countries that were treated are , and the untreated is . these were n- countries and the brics. probit regression models give binary outcomes, and so they aptly describe the did results above. the results indicate that covariates of inflation, gdp per capita, research and development, technical cooperation grants, and population would not likely have any impact on the treated countries regarding green finances and climate change mitigation. on the contrary, investments, co , investment in energy by the private sector, human development index, and domestic credit to the private sector will likely have impact on the treated countries. renewable energy consumption in final energy consumption as a proxy for green finance will likely have impact on the treated countries' green finance and climate change mitigation strategies. xie et al. ( ) found fdi to be directly correlated with economic growth regarding emerging countries and opens a window of opportunities for these countries to access capital, emerging technologies, and knowledge needed for sustainable economic growth. green bond insurance proceeds devoted to renewables energy and energy efficiency increased from $ . billion to $ . billion between and (tolliver et al. ). the analysis confirmed the results obtained during the analysis. in , green bond issuances reached a total of $ billion, and the number was anticipated to increase to $ billion by the end of the year. that growth was modest, given the fact that the green bond market is still a nascent industry. many emerging and developing countries (emde) have embraced the idea and putting policies in place to issue bonds in their financial markets (sustainable banking network ; h. sun, pofoura, et al., ) . from table , the percentiles from the largest group to the smallest are within the % mark, giving us better results. due to the fact, the residual errors are normally distributed; we can confidently rely on the results at % for the smaller percentiles and % for the largest percentiles, as reported by the models. table shows the various matching order for the analysis. the first matching order is the nearest neighbor matching order, with the average treatment effect on the treated value (att) of . . the matching order suggests that countries that are exposed to the treatment have a higher propensity to attract green finances and enforce laws to mitigate the effects the t-value is . , far above . . the nearest neighbor matching order is known to provide estimates of treatment of exposed group effects that is consistent and less susceptible to variability in the estimates. on the other hand, the kernel matching method produced different results, the att value of − . . this explains the fact that countries that are exposed to treatment have experienced adverse effects than those do not receive the treatment. the treatment effect on them is − . . further analysis of the stratification method has an att value of . . average treatment on the treated effect on table , using the radius matching method, is − . . the att effect on the treated countries is negative. this implies countries that are exposed to the treatment have adverse effects on their green finance and climate change mitigation activities. these results were obtained even confirmed after bootstrapping the results. the att came as the same, but with the standard errors reduced. from table , it is apparent that there is no difference between the countries regarding the countries that received the treatment at a different period and the control group of countries. the did value is . . the p value after the treatment was not significant. from fig. , the outcome variable interaction shows that there is a significant difference between the n- countries and brics. the did and the treated outcome covariates are conspicuous from the brcis (brazil, russia federation, china, india, and south africa) countries by showing two lines from the figure. figure gives a positive trajectory of the treated countries. did is the difference in differences estimator for the treated countries. figure box plot of untreated and treated countries. from the box plot, the minimum value for the untreated countries is about . , and the median value is about , and the maximum is about . on the other hand, the box plot of the treated countries is zero. this suggests the group of countries that received the treatment have no significant difference between them. the control group has so many variations among them regarding green financing and climate change mitigation. the treatment of the countries takes care of varying heterogeneity within the treated group. figure shows the untreated and treated trends in each country by period. most of the countries have significant differences before the treatment period. however, after receiving the treatment, the differences have been reduced to zero. countries such as south africa, vietnam, russia, and turkey have wide differences in the treated period and the untreated period. in contrast, bangladesh, brazil, and china did not show so much difference between the treated and untreated periods. the n- countries were chosen based on the following reasons; one, they are the next emerging and developing economies to dominate the global economy in the twenty-first century. second, they are seen as the economies to rival the already established ones, in terms of global trade (except iran, due to sanctions) energy demand and consumption and carbon footprints. however, it must be noted that the brics (brazil, russia, india, china, and south africa) countries were included in the study to evaluate the difference in differences between these major groups of economies cumulatively dominating the global economy currently and the next decade to come. similarly, the bric countries have advanced in almost all aspects of economic development. china is a global leader in installed capacity of renewables like hydropower, solar pv, and wind. china had a share of renewables in its energy mix of . % in and on its way to exceed the % target in and accounted for % investment in renewables in (irena ) (meidan ) . besides, approximately % of green investment needs of china will be allocated to low-carbon technologies, including transport. tackling the issue of climate change in emerging and developing economies (edme) comes with a unique challenge, given the fact that emission reduction is not a short-term priority for most of the developing world. their per capita emission is very negligible and as well as with low-income levels. in this regard, the countries feel the need to continue emitting to deliver sound economic growth and promote inclusive development to their citizenry. as the environmental kuznets theory applies, they should pollute and clean later. however, this argument is not tenable because most of these n- countries are heavy emitters and the most populous countries in the world. the n- countries make up . % of global gdp and emit about . % of global co emission (sinha et al. ) . the issue of burden-sharing demands that the developed world and the developing world alike take proactive steps to avert activities that would increase global temperature beyond the . °c levels as envisaged by the paris accord (sinha et al. ). however, the remaining % will be allocated to water, land remediation, waste treatment, sewerage, etc. between and (oecd ). south africa realizing the importance of climate change passed a bill aimed at mitigating the impacts of climate change and transits the country to lowcarbon generating technologies and diversifies its energy mix to ensure there is energy security (government of south africa ). brazil, as a member country of the brics, has jointly launched the "green bonds brazil " to highlight the importance of working with stakeholders to boost the development of the green bonds market (kaminker and majowski ) . this project was modeled in the same manner as the global bond principles (gbp), which sets out the modalities for promoting transparency and disclosure of green on the other hand, mexico, like the rest of the n- countries, is taking practical steps to move towards sustainable consumption pathways by reducing environmental degradation and improving energy efficiency programs (sinha et al. ) . furthermore, some of the n- countries have advanced in terms of technology and r&d; korea and turkey could compete with the brics countries like brazil and russia in terms of mobile phone usage and other technology. inversely, the less advanced countries exhibit higher economic growth prospects regarding infrastructure uptake, technology, and r&d (sinha et al. ) . meeting the financial requirements of the sustainable development of goals (sdgs), the world needs to move the target from "billions" to "trillions" in official development assistance (oda) (baiocchi et al. ) . at the heart of this, sdg , where sustainable, affordable consumption of energy is central to this goal, about $ trillion is needed from all sources to realize the transformative idea of the sdgs. for the n- countries to scale up finances in the green projects such as renewables, resilient infrastructures, and sustainable water, there is the need for governments to set up an inclusive financial system that integrates technology (fintech) and multiple financial systems to a country-specific condition, as well as deepen financial capital development by making it easy for countries to enlist and offer green financial instruments. furthermore, there is a growing awareness in the corporate world, about environmental concerns like emission standards, social and governance (esg) issues impact on the returns of corporate bodies. investment in energy with private participation is another determinant of access to green financing by n- countries. it is perfectly significant. investments in green technologies cannot be made by the public sector alone. corporate venture capitalists can organize their businesses to invest in a green business on behalf of their parent companies in emerging countries (röhm et al. ). this will boost efforts to creating a public partnership model to catalyze these investments from the private sector. a private and public sector cooperation is needed to unlock the needed funding. robins et al. ( ) suggested adopting an all-encompassing approach by mobilizing investments across the board to ensure a transition to a green future. america's biggest bank, jp morgan, has committed about billion dollars into clean financing through to the . the effort is to increase green financing of energy to its institutional and individual clientele across the globe and in the usa (jp morgan ). an essential aspect of this variable is blended finance, which entails concessional funding from development agents, commercial funding from the international finance cooperation (ifc), development institutions, and the private sector. thus, making room for private sector participation to unlock about $ trillion investment needed annually to achieve sustainable development goals (sgds) (oecd ). this study analyzed the green financing and climate change mitigation of n- countries as well as the brics countries, over the period from to . for us to evaluate whether these countries have any differences in their green financing commitments and climate change strategies between the two time periods, we employed the difference in differences approach by providing a counterfactual hypothesis and then proving it by treating these countries into different periods to ascertain the difference among them. thus, the control group and the treated group were created among these countries. the presence of unobserved time-varying may cause failure in the assumption. we dealt with this situation by considering pretreatment observables by using matching methods such as the kernel, the radius matching, and the nearest neighbor approach to ascertain the impacts of the treatment of the countries. the act of using matching methods would help balance the likely time-varying perplexing between the treatment and the control group. as abadie ( ) authority in the did suggests that, before estimating matching order, it should be done. the approach has revealed that the need for the n- countries and brics to formulate policies to address the systemic risks posed by climate change by catalyzing the necessary financing to mitigate these risks and impacts. the analysis showed mixed results depending on the approach as that there is no significance between the n- countries and the brics countries regarding their green finance and climate risks. the issue of sustainability is very central especially to emerging and developing economies (emde). moreover, certain factors would underpin these countries accessing green financing and climate change strategies. the gdp per capita of these economies are important to these countries fighting the change risks. the economic performance of any of the n- countries is tied to how they can fight climate change and green their macroeconomic policies to mitigate these risks. these risks could come in the form of physical risks to infrastructure and environmental degradation. the probit regression showed co , fdi, rescon, hdi, and investments in the energy sector have a likely impact on the development of green financing and climate change mitigation strategies on these countries. the need to transition to a low-carbon future has a likely impact on emerging markets formulating and implementing policies to deal with externalities caused by co . furthermore, fdi is another driver of green financing; the n- countries and the brics have attracted inflows in the renewables energy sector in particular. furthermore, countries with good human development index are likely to attract green financing, as it has become a yardstick for these countries receiving green funding either from multilateral development banks (mdbs) or blended finance. another outcome variable, rescon, which is the proxy for renewables consumption in final energy demand, is a significant variable for the treated countries to attracting green finances. the n- countries have some of the most energy intensity ratios, culminating in the emission of co , causing global warming. as a result, some of them have launched programs to transition the economies to a low-carbon future. indonesia, for instance, has launched the country's low-carbon development initiative (lcdi). based on the results, it is recommended: . the n- countries should create a conducive atmosphere to attract foreign direct investment (fdi) to scale up green financing. a standard political risk guarantee is vital in this respect. . governments should support regulations and efforts aimed at developing bond markets. . non-corporates bodies, such as pension funds in emerging and developing countries, should issue green bonds. . finally, green bonds must set up according to the green bond principles (gbp). this will ensure transparency, full disclosure, and the allocation of proceeds for climate attributes projects and assets. author contributions muhammad atif nawaz: conceptualization, data curation, methodology, writing-original draft. usha seshadri: data curation, visualization. pranav kumar: visualization, supervision, editing. ramaisa aqdas: review and editing. ataul karim patwary: writingreview and editing and software. madiha riaz: writing-review and editing. data availability the data that support the findings of this study are openly available on request. conflict of interest the authors declare that they have no competing interests. ethical approval and consent to participate we declared that we do not have human participants, human data, or human tissue. we do not have any individual person's data in any form. people's rep semiparametric estimators novel approach of principal component analysis method to assess the national energy performance via the next : emerging investment market causality relationship between renewable and non-renewable energy consumption and gdp in indonesia estimating the effect of training programs on earnings using the longitudinal structure of earnings to estimate the effect of training programs financing the response to climate change 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causal inference with interactive fixed effects models energy consumption and economic growth in the next countries: the bootstrapped autoregressive metric causality approach greening development lending in the americas: trends and determinants how does emission trading reduce china's carbon intensity? an exploration using a decomposition and difference-indifferences approach publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- - v lrlcl authors: pana, t. a.; bhattacharya, s.; gamble, d. t.; pasdar, z.; szlachetka, w. a.; perdomo-lampignano, j. a.; mclernon, d.; myint, p. k. title: number of international arrivals predicts severity of the first global wave of the covid- pandemic date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: v lrlcl background: reported death rates from different countries during the covid- pandemic vary. lack of universal testing and death underreporting make between-country comparisons difficult. the country-level determinants of covid- mortality are unknown. objective: derive a measure of covid-related death rates that is comparable across countries and identify its country-level predictors. methods: an ecological study design of publicly available data was employed. countries reporting > covid-related deaths until may , were included. the outcome was the mean mortality rate from covid- , an estimate of the country-level daily increase in reported deaths during the ascending phase of the epidemic curve. potential predictors assessed were most recently published demographic parameters (population and population density, percentage population living in urban areas, median age, average body mass index, smoking prevalence), economic parameters (gross domestic product per capita; environmental parameters: pollution levels, mean temperature (january-april)), co-morbidities (prevalence of diabetes, hypertension and cancer), health systems parameters (who health index and hospital beds per , population and international arrivals). multivariable linear regression was used to analyse the data. results: thirty-one countries were included. of all country-level predictors included in the multivariable model, only total number of international arrivals was significantly associated with the mean death rate: beta . ( % confidence interval . , . ), p < . . conclusion: international travel was directly associated with the mortality slope and thus potentially the spread of covid- . stopping international travel, particularly from affected areas, may be the most effective strategy to control covid outbreak and prevent related deaths. the atypical pneumonia caused by novel corona virus (sars-cov ) detected in wuhan, hubei province, china at the end of has subsequently spread across five continents at a remarkable speed, with europe and north america being the most affected regions of the world. the world health organisation (who) declared covid- to be a pandemic of proportions similar to the spanish influenza of . as of the st may , there have been over , deaths related to covid- infection worldwide. data collated from across the world suggest that the overall case fatality rate is around %, with country-level estimates ranging between . - %. these figures however are not useful for universal comparison as testing rates also vary by country and there is a lag phase in reported deaths that occur in the community. consequently, there is wide variation in the reported country-specific death rates which may be attributed to variation in testing rates, underreporting or real differences in environmental, sociodemographic and health system parameters. the only previous ecological study to date assessing country-level predictors of the severity of the covid- pandemic including data on countries has found that the cumulative number of infected patients in each country was directly associated with the case fatality rate, whilst testing intensity was inversely associated with case fatality rate. this study found no association between health expenditure and case fatality rate. however, other important country-level predictors were not evaluated and thus their relationship with pandemic severity remains unknown. several risk factors for covid-related mortality have been proposed, including older population, higher population co-morbid burden, smoking, obesity, pollution levels and healthcare system performance. furthermore, countries outside china most severely hit by the pandemic were those with a high income, high gdp per capita and well-established healthcare systems, such as italy, spain, france, the united kingdom and the united states. in contrast, lower-and middle-income countries reported much lower covid- incidence and mortality rates. whilst these differences may be attributable to case underreporting due to inadequate testing facilities in poorer countries, other factors may also be involved. in this study, we aimed to derive a comparable measure of covid related death rates. in addition, we aimed to assess the determinants for this measure by examining the association between potential country level determinants driven by hypothesis based on currently available evidence and this measure using country level publicly available data and an ecological study design. an ecological study design was used. the chosen outcome was the steepness of the ascending curve of country specific daily reports of covid related deaths from january to st may . the following predictors were used: demographic predictors (population and population density, percentage population living in urban areas, median age, average body mass index (bmi), smoking prevalence), economic predictors (gross domestic product (gdp) per capita), environmental predictors (pollution levels, mean temperature (january-april) [ ] [ ] [ ] [ ] [ ] [ ] [ ] ), prevalent co-morbidities (diabetes, hypertension and cancer), health systems predictors (who health index and hospital beds per , population) and international arrivals, as a proxy measure of the globalisation status of each country. given the study design and the use of publicly available data, no ethical approval was necessary. countries reporting at least daily deaths up to the st of may with available data for all chose predictors were included. a total of countries were included in the analysis: algeria, austria, belgium, brazil, canada, the dominican republic, ecuador, egypt, finland, france, germany, hungary, india, indonesia, ireland, italy, japan, mexico, the netherlands, peru, the philippines, poland, portugal, romania, the russian federation, spain, sweden, switzerland, turkey, the united kingdom and the united states. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the data regarding the median population age and population density were the world health organisation health index was extracted from the who global partnership for education (gpe) paper series published in . country-level total hospital beds per , population data were extracted from the world bank dataset "world bank indicators of interest to the covid- outbreak". all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint whilst previous ecological studies of other epidemics have utilised case or death counts as outcome, these variables may be prone to bias due to variations in country level control measures including different testing strategies, variations in population movement controls and differences in secondary attack rates within community cohorts . the mean mortality rate was thus chosen as outcome instead, since it is independent of these highly variable parameters and may thus represent a more reliable indicator of the country-level severity of the covid- pandemic mean mortality rate was defined as the slope of the mean mortality curve (figure ), measured from the first day when more than covid- deaths were reported until either the mortality curve reached a peak value or the st of may , whichever occurred first. before slope calculation, the mortality curve in each country was smoothed using a locally weighted (lowess) regression using a bandwidth of . . in order to ensure a good fit of the lowess regression line, only countries having reported at least daily deaths until the st of may were included. the mean mortality rate thus represents an estimate of the country-level daily increase in reported deaths during the ascending phase of the epidemic curve. data on population density were extracted as the country-level population per square kilometre in . data on ambient air pollution were extracted as the countrylevel mean concentration of fine particulate matter (pm . ) measured in . temperature data were extracted as the mean temperature recorded in each country between january and april between and . data on international arrivals were extracted as the total number of country-level international arrivals in . all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint data on prevalent diabetes were extracted as the percentage of the population aged to years in . data on prevalent cancers were extracted as the age-standardized cancer prevalence among both sexes in , expressed as percentages. data on prevalent hypertension were extracted as the age-standardised percentage of the population over years of age with systolic blood pressure ≥ mmhg or diastolic blood pressure ≥ mmhg in . data on bmi were extracted as the age-standardised mean body mass index trend estimates for both sexes amongst adults (≥ years) in . data on daily cigarette smoking were extracted as the age-standardised rate on both sexes amongst adults (≥ years) in . whilst the definition of "daily cigarette smoking" varies across surveys, it habitually refers to current smoking of cigarettes at least once a day. data on gdp were extracted as gdp per capita by purchasing power parity (ppp) in current international dollars in . the percentage of population living in urban areas was defined as the percentage of de facto population living in areas classified as urban according to the criteria used by each area or country. the world health organisation (who) heath index is a composite index that aims to evaluate a given countries healthcare system performance relative to the maximum it could achieve given its level of resources and non-healthcare system determinants. it was calculated in the year . the index uses five weighted parameters: overall or average disability-adjusted life expectancy ( %), distribution or equality of disability-adjusted life expectancy ( %), overall or average healthcare system responsiveness (including speed of provision and quality of amenities; . %), distribution or equality of healthcare system responsiveness ( . %) and healthcare expenditure ( %). data on hospital beds per , population were defined by the world bank as including "inpatient beds available in public, private, general, and specialized all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint hospitals and rehabilitation centers. the published data for countries included was from to . in most cases beds for both acute and chronic care are included. all analyses were performed in stata . se, stata statistical software. a % threshold of statistical significance was utilised for all analyses (p < . ). linear regression was performed to assess the univariable relationship between each country-level predictor and the calculated mean mortality rate for each country. the following predictors were included in the univariable analyses: population in , median age, pollution levels, mean temperature (january-april), international arrivals, population density, prevalent diabetes, prevalent neoplasms, median bmi, prevalent hypertension, smoking prevalence, hospital beds (per , population), who health index, percentage population living in urban areas and gdp per capita (ppp). predictors reaching a p-value < . at univariable level were then included in a multivariable logistic regression model to predict the mean mortality rate outcome: median age, pollution levels, international arrivals, prevalent neoplasms, median bmi, prevalent hypertension, who health index, percentage of population living in urban areas and gdp per capita. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . table in this ecological study including data from countries which were most severely affected by covid- in the first wave of current global pandemic, we assessed countrylevel socioeconomic, environmental, health and healthcare system, and globalisation parameters as potential predictors of variation in death rates from covid infection. in the multivariable linear regression model, the only predictor that reached statistical significance was international arrivals, a proxy of global connection. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint a recently published ecological study analysed the country-level predictors of the case fatality rate of the covid- pandemic using data from countries. this study found that upon adjustment for epidemic age, health expenditure and world region, the case fatality rate was significantly associated with increasing cumulative number of covid- cases and decreasing testing intensity. nevertheless, no other country-level predictors were included in this study. comorbidities may account for differences in mortality rates across countries. a study among laboratory-confirmed cases of covid- in china showed that patients with any comorbidity, including diabetes, malignancy and hypertension, had poorer clinical outcomes than those without. we thus accounted for country-level data on a selection of key comorbidities in our analysis which included prevalent diabetes mellitus, neoplasms, and hypertension. diabetes mellitus is significantly associated with all-cause and cardiovascular disease mortality globally. bmi ≥ kg/m has been identified as an independent risk factor for severe covid- illness. finally, a recent systematic review on studies from china showed that smoking is likely associated with negative outcomes and progression of covid- . all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . interestingly, during the covid- pandemic, some countries (such as thailand) have adopted aggressive international travel screening and isolation policies, which may have led to lower infection rates. our study suggests that travel restrictions have the potential to influence the impact of the covid- pandemic and should be part of a structured and rapidly instigated pandemic preparedness plan. any policy on the restriction of international all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint travel should be developed taking into account the economic and social impacts of such restrictions. the main strength of this study lies in its use of comparable and relevant outcome data derived from contemporary death reporting from countries affected by covid- . as testing rates for the virus vary across countries, the incidence or prevalence of the disease cannot be compared between countries. while death from the disease is a hard outcome, the denominator information to calculate death rates make between-country comparisons difficult. in addition, the deaths in the community, particularly in the elderly living in care homes, often go untested and thus firm diagnosis remains impossible. therefore, in this study we have adopted an outcome that is comparable in terms of the increase in the rate of death, rather than death rates per se. therefore, this may better represent the spread and seriousness of pandemic in individual countries when comparing countries at different stages of the pandemic. the country-level parameters assessed as potential predictors have all been implicated at some point to be associated with severity and consequently mortality. we however found that the only significant predictor to be total number of international arrivals in the country ( figures), signifying transmission of the infection through travel. although the data was from , there is no reason to believe that international travel figures between countries would be different in early . our model had a reasonably good fit to the data, explaining around % of the between country variation in mean death rates. the main limitation of the study stems from the ecological study design. despite the fact that we did not find any association between comorbidities such as diabetes, cancer all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . out of all the country-level parameters assessed, international travel was the only significant predictor of the severity of the first global wave of the covid- pandemic. given that many of world middle and lower-income countries are showing signs of continued rise in infection rates, international travel restrictions applied early in the pandemic course may be an effective measure to avoid rapidly increasing infection and death rates globally. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . table . observed mean mortality rate and number of international arrivals in (millions) for each country included in the analyses. countries were categorised in groups: high mean mortality rate group (> additional daily deaths), medium mean mortality rate group ( - additional daily deaths) and low mean mortality rate group (< additional daily deaths). (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . japan . . all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . bmi -body mass index; who -world health organisation; gdp -gross domestic product; ppp -purchasing power parity; figure . graphical representation of the smoothed* number of daily deaths of each country (before reaching mortality peak, if applicable) as a function of the number of days passed since the first day when an excess of deaths were reported. countries with higher mortality rates are depicted in blue, while those with lower mortality rates are depicted in red. *smoothed using a local regression (lowess) function with a bandwidth of . all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint figure . predicted (based on the results of the multivariable linear regression) and observed country-level mortality rate (mean daily increase in deaths until the peak in mortality) as a function of the recorded country-level number of international arrivals in (millions). world health organization. coronavirus disease (covid- ) situation report- mortality risk of covid- flattening-the-curve associated with reduced covid- case fatality ratesan ecological analysis of countries demographic science aids in understanding the spread and fatality rates of covid- comorbidity and its impact on patients with covid- in china: a nationwide analysis covid- and smoking: a systematic review of the evidence covid- and obesity-lack of clarity, guidance, and implications for care. the lancet assessing nitrogen dioxide (no ) levels as a contributing factor to coronavirus (covid- ) fatality potential association between covid- mortality and health-care resource availability world health organization. coronavirus disease (covid- ) situation report- european centre for disease prevention and control. european centre for disease prevention and control united nations. department of economic and social affairs population dynamics united nations statistics division. population density and urbanization the world bank group. data bank, world development indicators measuring progress towards the sustainable development goals world health organization. global health observatory indicator views measuring overall health system performance for countries world bank indicators of interest to the covid- an ecological study of the determinants of differences in pandemic influenza mortality rates between countries in europe united nations department of economics and social affairs annual mean concentration of particulate matter of less than . microns of diameter the world bank. international tourism, number of arrivals world health organization. prevalence of raised blood pressure (sbp≥ or dbp≥ world health organization. mean bmi (kg/m²) (age-standardized estimate world health organization. daily smoking of cigarettes (age-standardized rate) we would like to thank dr kathryn martin who provided valuable advice in study design. none. none. key: cord- -arhpqgl authors: gangemi, sebastiano; billeci, lucia; tonacci, alessandro title: rich at risk: socio-economic drivers of covid- pandemic spread date: - - journal: clin mol allergy doi: . /s - - - sha: doc_id: cord_uid: arhpqgl covid- , the novel coronavirus affecting the most part of worldwide countries since early , is fast increasing its prevalence around the world, representing a significant emergency for the population and the health systems at large. while proper treatments are being developed, in-depth studies concerning its way of diffusion are necessary, in order to understand how the virus is actually spreading, through the investigation on some socio-economic indicators for the various countries in the world, retrieved through open-access data publicly available. the correlation analysis displayed significant relationships between covid- incidence with several of such indicators, including the gross domestic product per capita and the number of flights per capita, whereas mortality is mainly related to the main age of the population. all such data displayed an interesting mean to understand the way the virus has diffused worldwide, possibly representing the basis for future preventive measures to effectively challenge a new covid- pandemic wave, but also other, similar pandemics. © the author(s) . this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article' s creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article' s creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/ . /. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/ . /) applies to the data made available in this article, unless otherwise stated in a credit line to the data. covid- , the novel coronavirus spreading worldwide since january , accounts for more than . million cases in the world, with more than , deaths as of may, th, [ ] . however, according to the report, albeit nearly any country in the world reported covid- cases, noteworthy differences are present between continents as well as between single countries, with the largest amount of cases being reported in americas and europe, and a significantly lower prevalence observed in africa, driving one to hypothesize either geographical or socio-economic factors driving such unbalance. indeed, with respect to the previous coronaviruses, including sars-cov and mers-cov, the new sars-cov- is spreading times faster and, as mentioned above, is affecting almost every country worldwide. to explain such different behavior of sars-cov- with respect to previous renowned coronaviruses, manifold reasons can be identified. those include merely virological motivations, but also socio-economic arguments, such as population density, occurrence of social contacts, occupancy of confined spaces, countries' economic statuses, and long-distance transportations [ ] . however, albeit reasonable, and despite already partially hypothesized [ ] , to the best of our knowledge such relationship was not quantitatively assessed worldwide in the scientific literature up to now. as such, in order to fill in this gap, therefore to understand which of these discriminants could represent stronger drivers for the covid- pandemic spread, we retrieved basic data on the open access website wikipedia concerning socio-economic indicators of any country in the world, including their population, density, mean age, gross domestic product (gdp) and nominal gdp (both per capita), the gini coefficient of wealth distribution (an index of overall income inequality, ranging from , where everyone has the same income, to , where inequality is maximal), the human development index (hdi, a composite index of clinical and molecular allergy [ ] . both classes of data were correlated with covid- -related data, including cases and deaths, both per million people, per each country, as retrieved on may, th, from wikipedia [ ] . bivariate correlation was conducted using pearson's correlation index, corrected by bonferroni post hoc analysis for multiple comparison. as displayed in table , the ratio of covid- cases per million people was found to be significantly correlated with several socio-economic indicators, as with transportation-related factors. in particular, for covid- cases, a moderate positive correlation was observed with the gdp per capita, the number of flights per capita, the nominal gdp per capita and the hdi. beyond these findings, weak correlations were also seen with the mean population age of each country and the tfr (inverse relationship). similar results were found when correlating the ratio of covid- deaths per million people with the same socio-economic indicators mentioned above. in this second analysis, more indirect relationships had to be expected, since the number of deaths can be also affected by other factors, including the ratio of elderly people, or the capacity of each national health system to successfully cure a wide number of patients. indeed, this analysis displayed correlation indices that are lower than those presented before, albeit remaining significant in most cases. in particular, for covid- deaths, positive correlations were seen with age, expectedly being the most largely correlated among the indicators studied, the hdi, the gdp nominal per capita, gdp per capita, tfr, gini coefficient (inverse relationship for the latter two), and the overall number of flights, whereas the number of flights per capita were excluded from the significance due to the bonferroni post hoc correction. the negative correlation with gini coefficient could be explained by the fact that in countries with high levels of social disparity, little chances of social integration are present, thus leading to a lower spread of the virus. interestingly, data concerning the overall population and related density were not correlated with the number of covid- cases per million inhabitants in world's countries, nor with the number of deaths per million. taken together, these results lead to the understanding that, aside important clinical studies that should be performed to more clearly understanding the mechanisms of action of spread and the therapies more suitable for effectively tailoring the covid- pandemic, several socioeconomic drivers should be considered when studying the virus spread. indeed, in the era of globalization, with fast worldwide massive passenger transportations and continuous social contacts among people from all around the world, the speed and extensiveness of viruses' propagation is times higher than just a few years ago, and countries with more frequent airplane connections with the rest of the world are more susceptible to this kind of occurrence [ ] . at the same time, socio-economic indicators are also important determinants of pandemic spread, this fact possibly having manifold explanations, among which the higher number of social contacts (i.e., people living in countries with higher economic status are likely to attend a larger number of social events and to spend more time in overcrowded places, possibly paving the way for an easier virus diffusion) [ ] and the higher efficiency of national health systems [ ] , that could affect the number of covid- identified cases. obviously, the aging of the population also makes countries at different risks for pandemic, with those with the older population featuring a higher amount of cases, on average, and the higher occurrence of deaths related to the covid- . however, interestingly, concerning the covid- incidence, it appears that the mean age of the population is not the main factor influencing pandemic data, overtaken by the social and economic ratios mentioned above. on the other hand, higher population age is, otherwise, the first correlated indicator with mortality rate, making countries with the wider ratio of elderly people more at risk for covid- -related fatal occurrences. nonetheless, it is worth mentioning that a correlation itself does not necessarily imply consequentiality between two events that, in turn, should be studied in a more extensive manner and with the support of more complex statistical techniques, including big data analytics and, eventually, taking advantage of artificial intelligence approaches. however, despite such methodological limitations, this kind of correlations can lead to important considerations, potentially useful in a prospective framework. indeed, the knowledge about the different countries' susceptibility to this kind of viruses can allow drawing tailored preventive approaches based on such specificities to avoid, or reduce, future relapse in the covid- pandemic or in future, somewhat similar conditions that might occur. for example, in case of a future, albeit not desirable, new pandemic outbreak or covid- recurrence, measures like social distancing, smartworking or usage of individual protection devices can be promptly adopted to quickly respond to the early emergency phases. such preventive approaches will aim at making the population and the health systems ready to effectively face the related emergency and avoiding, at the same time, considerable loss of lives. in this way, the lesson learned worldwide due to the covid- pandemic could be effectively employed for reducing the burden of future pandemic on economic, sanitary and social point of view. who. coronavirus disease (covid- ) situation report- the sars, mers and novel coronavirus (covid- ) epidemics, the newest and biggest global health threats: what lessons have we learned covid - _pande mic_data accessed low socio-economic position is associated with poor social networks and social support: results from the heinz nixdorf recall study evaluation of the performance of national health systems in - : an analysis of countries not applicable. none. the datasets generated and/or analysed during the current study are available in the repositories mentioned within the references [ , [ ] [ ] [ ] .ethics approval and consent to participate not applicable. not applicable. the authors declare that they have no competing interests.received: may accepted: june springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- - cpybatu authors: varkey, rittu s.; joy, justin; sarmah, gargee; panda, prasant k. title: socioeconomic determinants of covid‐ in asian countries: an empirical analysis date: - - journal: j public aff doi: . /pa. sha: doc_id: cord_uid: cpybatu the spread of coronavirus disease, , has affected several countries in the world including asian countries. the occurrences of covid infections are uneven across countries and the same is determined by socioeconomic situations prevailing in the countries besides the preparedness and management. the paper is an attempt to empirically examine the socioeconomic determinants of the occurrence of covid in asian countries considering the data as of june , , for asian countries. a multiple regression analysis in a cross‐sectional framework is specified and ordinary least square (ols) technique with heteroscedasticity corrected robust standard error is employed to obtain regression coefficients. explanatory variables that are highly collinear have been dropped from the analysis. the findings of the study show a positive significant association of per capita gross national income and net migration with the incidence of total covid‐ cases and daily new cases. the size of net migration emerged to be a potential factor and positive in determining the total and new cases of covid. social capital as measured by voters' turnout ratio (vtr) in order to indicate the people's participation is found to be significant and negative for daily new cases per million population. people's participation has played a very important role in checking the incidence of covid cases and its spread. in alternate models, countries having high incidence of poverty are also having higher cases of covid. though the countries having higher percentage of aged populations are more prone to be affected by the spread of virus, but the sign of the coefficient of this variable for asian country is not in the expected line. previous year health expenditure and diabetic prevalence rate are not significant in the analysis. therefore, people‐centric plan and making people more participatory and responsive in adhering to the social distancing norms in public and workplace and adopting preventive measures need to be focused on covid management strategies. the countries having larger net migration and poverty ratio need to evolve comprehensive and inclusive strategies for testing, tracing, and massive awareness for sanitary practices, social distancing, and following government regulation for management of covid‐ , besides appropriate food security measures and free provision of sanitary kits for vulnerable section. the spread of coronavirus disease, , has affected several countries in the world including asian countries. the occurrences of covid infections are uneven across countries and the same is determined by socioeconomic situations prevailing in the countries besides the preparedness and management. the paper is an attempt to empirically examine the socioeconomic determinants of the occurrence of covid in asian countries considering the data as of june , , for asian countries. a multiple regression analysis in a cross-sectional framework is specified and ordinary least square (ols) technique with heteroscedasticity corrected robust standard error is employed to obtain regression coefficients. explanatory variables that are highly collinear have been dropped from the analysis. the findings of the study show a positive significant association of per capita gross national income and net migration with the incidence of total covid- cases and daily new cases. the size of net migration emerged to be a potential factor and positive in determining the total and new cases of covid. social capital as measured by voters' turnout ratio (vtr) in order to indicate the people's participation is found to be significant and negative for daily new cases per million population. people's participation has played a very important role in checking the incidence of covid cases and its spread. in alternate models, countries having high incidence of poverty are also having higher cases of covid. though the countries having higher percentage of aged populations are more prone to be affected by the spread of virus, but the sign of the coefficient of this variable for asian country is not in the expected line. previous year health expenditure and diabetic prevalence rate are not significant in the analysis. therefore, people-centric plan and making people more participatory and responsive in adhering to the social distancing norms in public and workplace and adopting preventive measures need to be focused on covid management strategies. the countries having larger net migration and poverty ratio need to evolve comprehensive and inclusive strategies for testing, tracing, and massive awareness for sanitary practices, social distancing, and following government regulation for management of covid- , besides appropriate food security measures and free provision of sanitary kits for vulnerable section. the contagious novel corona virus disease was initially identified in wuhan, china in december . since then, the entire world has been transformed into a chaos hub; be it the challenging health problems it brought along with it or an inescapable economic blackout that was experienced all around the globe. the virus being a contagious one has managed to spread insanely to other countries in no time and after leading to the death of at least people in china itself and with almost , cases nationally (bbc news, january , ), the world health organization (who) on march , , declared the novel coronavirus outbreak as a global pandemic. most of the countries were obviously not prepared for the pandemic and hence, death rates skyrocketed due to the lack of hospital beds and the inability to meet the health demands of an overcrowded inflow of covid- positive patients. along with the huge toll that it took on human life, it has also posed a severe threat to the economy worldwide. the economies of some developed nations like the united states, china, united kingdom, germany, italy, and france have undoubtedly been shaken. india being one of the fastest growing market economies is going to face a prolonged period of economic slowdown though it is tough to predict the exact magnitude of economic loss (dev & sengupta, ) . the numbers of the registered positive covid- cases are increasing exponentially and by far show no trend in being stable. over million cases with more than . million deaths are registered due to the covid- pandemic. countries like united states, brazil, russia, spain, uk, india, and italy have the highest number of incidence of cases as well as deaths due to this global threat in the name of the novel coronavirus. the economy of the united states has suffered its most severe contraction in more than a decade in this year. one of the reasons for the major economic breakdown is the inevitable decisions taken by the government following the suggestions of the who to maintain social distancing and people staying at home to reduce the number of cases of covid- . some countries which followed stringent government restrictions in lieu of keeping the contagious disease at bay are south korea, new zealand, germany, and japan. in asia, countries like india, iran, turkey, pakistan, singapore, saudi arabia, and china have reported the highest number of cases pertaining to covid- . a sharp recession in the economies of all the asean countries has been seen lately. a number of international agencies like world bank, international monetary fund, and the asian development bank have all forecasted a decline in regional growth due to the pandemic. the sudden drop in energy consumption all over the world due to nationwide lockdowns and travel ban has reduced the price of oil. countries that have been dependent on the exports of fuel namely indonesia and malaysia have had a severe impact. the lack of effective demand has had multiplier effect on economies since consumption accounts to around % of gdp in major asean countries (searight, ) . asia being the largest and most populous ( . billion as of ) continent has relatively more incidence of the cases due to covid- . india shows the highest number of cases among the asian countries and as it is the second-largest populous country in the world. the country's figures relating to the incidence of covid- cases are increasing every day. iran, turkey, pakistan, and saudi arabia are some of the other asian countries that have also been showing increasing trends of covid- registered cases and deaths. china on the other hand, although was facing tremendous increase in the number of covid- positive cases during the onset of the hazardous disease, after a while has shown almost a stable and decreasing trend. the present scenario of asia in terms of the total number of registered positive covid- cases stands at more than million from which almost . million cases are still active. the total number of deaths due to covid- is last recorded as . million. the numbers however are increasing every hour and hence may differ time to time. nearly half of the world's population comes from the asian countries. the socioeconomic evolution of these asian countries in the past few decades has been tremendously contributing to the growth of the overall global economy. hence, in a situation as scary and hazardous as a "pandemic" the study of the determinants of covid- pandemic in the asian countries plays an important role. according to some experts, the hardest-hit countries also had an aging population (gardner, states, & bagley, ; lima et al., ) or an underdeveloped healthcare system (mikhael & al-jumaili, ; tanne et al., ) . some others emphasized the role of the natural environment (marco et al., ; wu et al., ) . in addition to this, several other factors like urbanization, poverty, low per capita income may also have some significant impact on the same. the argument however arises from the fact that the countries which have relatively low per capita income tend to perform poorly in managing health care services and providing health equipment like testing kits, personal protective equipment (ppe), and ventilators which are some of the urgent infrastructure needs. however, evidences also suggest that the countries with high per capita income have also been affected with high incidence of the pandemic. these contrasting evidences are also seen in asian countries. asia being the amalgamation of both developed and developing countries gives us an ample scope to further analyze these evidences along with checking for other strong determinants of covid- such as social capital or people's participation ratio. a number of studies have addressed the role that community participation has played through services like volunteering, adhering to the lockdown norms, and major steps people should take while countries are easing restrictions (khongsai et al., ) . the lockdown has created numerous difficulties to a larger section of the society. therefore, the importance of social participation through sensitization of the issue as well as social services would help economies in controlling the virus and minimizing the aftershock of the pandemic (gillespie et al., ; marston, renedo, & miles, ) . by the development of an economy, we do not always mean an increasing income or just reducing the poverty rates but it also includes an entire gamut of characteristics such as making people capable enough to perform different socioeconomic activities. people should act as both the agent to bring about the change as well as the beneficiary in the development process. hence, people's participation too plays a key role in the development process. besides people's participation, there are several other socioeconomic factors which may strongly determine the number of covid- registered cases and therefore there is an urgent need to study and identify the same mainly in asian countries for the aforementioned reasons. the rest of the paper is organized as follows: section provides the review of selected literature; section outlines the data and methodological framework of the study. section provides the analysis and interpretation of findings pertaining to the study and section concludes the study. in this section selected literature pertaining to socioeconomic factors determining contagious diseases including covid- have been reviewed. ghose, seydou, and sharmistha ( ) have a negative impact on the registered covid cases. mishra, rath, and dash ( ) have observed that the impact of covid- on stock returns is severe. even the same is much worse than the effect of demonetization and gst implementation on stock returns. szulczuk and cheema ( ) have determined how a country's socioeconomic characteristics influence the covid- fatality rate making a cross country analysis. they have found that the number of medical doctors per , people is one of the significant factors and it has helped reduce the fatality rate from covid- the most. the number of hospital beds comes as second important factor. also, a country with a higher unemployment rate seems to raise the fatality rate of covid- the most. according to them, the elderly and obese raise the fatality rate from covid- the most while current smokers and urban dwellers raise the fatality rate the least. ray and subramanian ( ) have observed that most countries have adopted a lockdown strategy for flattening the curve. but the effectiveness of the same will depend upon how stringent countries are in implementing the model. bahinipati et al. ( ) have analyzed the impact of covid- in the context of andhra pradesh, india. the study states that the policy makers take insights from behavioral economics to handle the pandemic in a more effective way. the states' informal sector is suffering and continues to suffer until normality returns. the regional food supply and farmers' income will have some serious effects if the lockdown goes on. the study suggests that the pds system should be revamped and modernized in order to adjust to the current scenario. sumner, hoy, and ortiz-juarez ( ) have analyzed the social and economic impact of covid- on reduction in the per capita household income and consumption. they have observed that the covid- would increase the number of people living below the poverty line by to million. bartscher, seitz, slotwinski, siegloch, and wehrhöfer ( ) have analyzed influence of social capital on the containment of covid- and mortality rate associated with the disease for seven european countries such as germany, austria, the netherlands, italy, switzerland, sweden, and the united kingdom. the results show that an increase in social capital leads to % fewer cases in germany and % fewer cases in italy. patel et al. ( ) in his article mentioned that low socioeconomic status causes a number of factors through which covid- may occur. overcrowded accommodation, employment opportunities that do not provide work from home facility, unstable work, and income conditions, reduced immunity due to poverty and seeking medical services at a more advanced stage of illness due to the same are some of the factors that he put out in his article. according to him, poverty makes an individual more vulnerable and hence susceptible to covid- . he then urged the policymakers to introduce long-term legislation to improve social welfare. weill, stigler, deschenes, and springborn ( ) have observed that the lower-income communities show less social distancing than the same among the high-income areas. jalan and sen ( ) have observed that public actions and enhancement of public trust by the people have helped kerala, india in containing the covid cases in the initial stage. it is a known and studied fact that most of the asian countries excluding few countries such as china, japan, south korea, malaysia, singapore, and israel are characterized by low per capita income, slow gdp rate, and poor health infrastructural facilities. according to the human development index (hdi) report, the hdi of countries like india, pakistan, bangladesh, afghanistan, and iraq stands extremely low. in such a case, a pandemic as distorting as covid- only worsens the economic as well as social condition of these countries. though the fight against covid- and checking spread of the disease mainly depend on its preparedness, management strategies, and resources they spent, but underlying socioeconomic factors are crucial in determining the number of cases and incidence. the geographic locations and ethnographic varieties attract quite a sum of tourists into these countries and therefore a huge influx of the same is experienced by these countries which certainly make sense for the increasing number of covid- positive cases. therefore, the present study is an attempt to capture the socioeconomic determinants that affect the incidence of covid among asian countries. socioeconomic factors like health expenditure share in gdp, net migration, old-age dependency ratio, and gross national income per capita are important in understanding the prevailing situation and socioeconomic condition of the countries. public choice variable such as voters' turnout ratio (vtr) is used as proxy for people's participation in countries. in order to understand the comorbidity factors, diabetic prevalence has been also considered in the analysis as a proxy. in order to understand the severity of covid- , total covid cases per million population, and new covid cases per million population have been used as dependent variable alternatively. though for pattern analysis we have used daily data up to june , , for regression analysis, data have been used in cross-sectional framework for table . variables have been selected with proper reasons and considering their potential influence on the occurrence of infectious diseases. health expenditure measures the preparedness of a country with respect to the covid outbreak. higher level of expenditure in health would ensure a country with ample health infrastructure both physical and manpower that will help to tackle the crises. net migration is an important variable that affects the population density in urban areas. countries with high migration rates are supposed to be affected by larger covid incidences. thirdly, the old-age dependency ratio has been taken as countries with higher proportion of the old population are more susceptible to the disease. another variable considered for the analysis includes the per capita gross national income. the reason for the inclusion of the variable is to analyze the impact of income on the incidence of the disease. an interesting variable of concern is the social capital. social capital refers to the collective action of people in achieving a common objective. an attempt is made to measure people's participation or social capital through vtr. therefore, collective action and more public response would have a negative impact on the incidence of the disease. co-morbidity factor like the diabetic prevalence rate has been taken into account in order to understand whether people with co-morbidity are more affected by covid- . the reason for the same is that people with diabetes have low immunity as a result of which are largely susceptible to the disease. lastly, an important variable considered in the analysis is the poverty rate. this is considered alternatively in lieu of per capita national income in order to avoid multi-collinearity. countries with a larger proportion of population living below the poverty line also indicate that a large section of people in those countries may not have access to basic amenities. large scale poverty also denotes the accumulation of slums in urban centers. therefore, both lack of immunity and proliferation of slums lead to a faster spread of the disease. the descriptive statistics of variables used in the study are given in table . in addition, the pattern of total cases and new positive covid- cases in asian countries has been analyzed. multivariate cross-sectional regression has been performed to analyze the impact of these factors on the total cases and new cases of covid- . for the regression analysis the study uses only countries as data pertaining to palestine, turkmenistan, syria, and timor have not been included due to the non-availability of data. the general functional forms of the model to indicate dependent and explanatory variables are given as: ordinary least square estimation technique is adopted to obtain the regression coefficients. correlation matrix of the independent variables is computed to check for the presence of multi-collinearity. it is shown in tables and . it is observed that there is no problem of multi-collinearity. as analysis involves cross country analysis, presence of heteroscedasticity may influence the coefficients. in order to correct for the existence of heteroscedasticity, white heteroscedasticity-consistent standard errors and covariances have been used. asian countries have been presented and discussed in this section. the pattern of covid- cases and new cases on daily basis for asian countries are shown in this subsection. figure shows the pattern has been increasing over the time period for asian countries. the scatter plot for both total cases and new cases are shown in the third graph in the second column and the second graph in the third column. the responsiveness of new cases to total cases is elastic in the initial stages and becomes inelastic towards the latter time period. therefore, it has been observed that over time although the total cases have been increasing, the change that is measured by the new cases is now at a constant rate. in this section, results pertaining to socioeconomic determinants are presented. table presents the determinants of total number covid positive cases per million population. model a in table old age dependency ratio (odr) has a negative significant relationship on the total number of cases per million. studies have verified that the morbidity rate was higher in the younger generation than in the older sections of the society (cortis, ) . though there is observations from earlier infectious diseases that old aged population are more prone to be affected in spread of virus, but in the recent covid cases, even young adults and children are also affected. another variable that was proved to be positively significant was the poverty rate. countries having a higher poverty rates are those countries where more people live below the income line deciding poverty rate. the income is an important factor determining the nutritional intake of the citizens. the nutritional intake plays a very important role in deciding the immunity resistance of people. studies have confirmed the importance of immunity in fighting the pandemic. a similar result has been obtained in model c and model d in which poverty ratio is used in lieu of pcgni in order to understand the influence of poverty on incidence of covid. countries having high poverty rates have been susceptible to more covid cases (model c in table ). health expenditure and diabetes prevalence rate are not significant in the analysis above. models b and d use vtr dummy in place of vtr ratio. however, both the variables are not significant for total number of covid cases. the study analyses the socioeconomic determinants of covid- for the asian countries. a linear multiple regression model in a crosssectional framework has been used to study the factors that contribute to the incidence of the pandemic. a number of factors like the net migration and per capita gross national income are found to have a positive significant relationship on the occurrence of total covid cases in asian countries. in alternate models, countries having high incidence of poverty are also having higher cases of covid. in addition, voter's turnover ratio as a proxy for people's participation emerged significant and negative for daily new cases. fighting poverty has been the target for both millennium development goals as well as sustainable development goals. it is a known fact that a number of asian countries have low per capita incomes and low infrastructure facilities in health. the need to eradicate poverty is of utmost interest as countries facing poverty have also faced high incidence of the disease. the countries in asia which are more poverty ridden are also affected with higher covid rates. though it is contrasting to findings of high-income countries are also more affected because of more economic activities and movement of people. however, the implementation of social distancing and safe sanitary practices in areas of more concentration of poor is not relatively easy. creating awareness, provision of sanitary kits, and making people more participatory are important in managing covid crises. therefore, countries in asia will have to follow an inclusive strategy to be well equipped to manage crises. covid- : policy interventions and socio-economic impact in andhra pradesh social capital and the spread of covid- : insights from european countries on determining the age distribution of covid- pandemic covid- : impact on the indian economy the coronavirus and the risks to the elderly in long-term care social determinants of infectious diseases in south asia. international scholarly research notices social mobilization and community engagement central to the ebola response in west africa: lessons for future public health emergencies containing a pandemic with public actions and public trust: the kerala story combating the spread of covid- through community participation the emotional impact of coronavirus -ncov (new coronavirus disease) opinion: sustainable development must account for pandemic risk community participation is crucial in a pandemic can developing countries face novel coronavirus outbreak alone? the iraqi situation does the indian financial market nosedive because of the covid- outbreak, in comparison to after demonetisation and the gst? emerging markets finance and trade the socio-economic implications of the coronavirus pandemic (covid- ): a review poverty, inequality and covid- : the forgotten vulnerable impacts of social and economic factors on the transmission of coronavirus disease (covid- ) in china india's lockdown: an interim report the economic toll of covid- on southeast asia: recession looms as growth prospects dim center for strategic and international studies (csis) coronavirus and migration: analysis of human mobility and the spread of covid- the socio-economic determinants of the coronavirus disease (covid- ) pandemic estimates of the impact of covid- on global poverty covid- : the impact of socioeconomic characteristics on the fatality rate covid- : how doctors and healthcare systems are tackling coronavirus worldwide social distancing responses to covid- emergency declarations strongly differentiated by income exposure to air pollution and covid- mortality in the united states the authors would like to extend their sincere thanks to prof. a. p.dash for his suggestions and constant encouragement. thanks are due to anonymous reviewers for useful suggestions for development of the work. however, the authors are solely responsible for errors if any. https://orcid.org/ - - - prasant k. panda https://orcid.org/ - - - key: cord- -v sdowb authors: bird, jordan j.; barnes, chloe m.; premebida, cristiano; ekárt, anikó; faria, diego r. title: country-level pandemic risk and preparedness classification based on covid- data: a machine learning approach date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: v sdowb in this work we present a three-stage machine learning strategy to country-level risk classification based on countries that are reporting covid- information. a k% binning discretisation (k = ) is used to create four risk groups of countries based on the risk of transmission (coronavirus cases per million population), risk of mortality (coronavirus deaths per million population), and risk of inability to test (coronavirus tests per million population). the four risk groups produced by k% binning are labelled as ‘low’, ‘medium-low’, ‘medium-high’, and ‘high’. coronavirus-related data are then removed and the attributes for prediction of the three types of risk are given as the geopolitical and demographic data describing each country. thus, the calculation of class label is based on coronavirus data but the input attributes are country-level information regardless of coronavirus data. the three four-class classification problems are then explored and benchmarked through leave-one-country-out cross validation to find the strongest model, producing a stack of gradient boosting and decision tree algorithms for risk of transmission, a stack of support vector machine and extra trees for risk of mortality, and a gradient boosting algorithm for the risk of inability to test. it is noted that high risk for inability to test is often coupled with low risks for transmission and mortality, therefore the risk of inability to test should be interpreted first, before consideration is given to the predicted transmission and mortality risks. finally, the approach is applied to more recent risk levels to data from september and weaker results are noted due to the growth of international collaboration detracting useful knowledge from country-level attributes which suggests that similar machine learning approaches are more useful prior to situations later unfolding. according to the future of humanity institute there is a . % chance that mankind will go extinct by the year , through either a natural or engineered pandemic [ ] . if there is one lesson to learn from the ongoing covid- coronavirus (sars-cov- ) pandemic, it is that a a a a a we were not prepared. the virus initially spread rapidly across the globe, mortality began to rise, and countries desperately struggled to test their citizens for the virus once it became known that many infectious carriers of it show no noticeable symptoms [ ] [ ] [ ] . this suggests three main risk factors to be observant of: the initial risk of transmission due to varying factors such as, for example, population density [ ] and international travel [ ] ; the risk of mortality due to ageing populations [ ] and underlying health issues [ , ] ; and finally the risk of a country not being able to test citizens aptly and thus producing possibly under-reported measures of the previous two [ ] . machine learning has shown success in contributing to research during the covid- pandemic. health service data trend models have shown to aid in classification of the virus [ , ] , vaccine design [ ] , estimation of cases, deaths, and recoveries [ , ] , simulating what could have happened if 'lockdown' was not instituted [ ] , and also simulating behaviour of the spread of the disease by prior knowledge from other locations [ ] . in this work, we devise a machine learning based strategy to predict three-fold risk at the country-level: (i) risk of transmission, (ii) risk of mortality, and (iii) risk of inability to test. through these three quantifiable measures, preparedness and risk can be assessed, providing some quantitative reasoning behind global decisions, should another deadly disease grip our species again. our main contribution is the exploration of the idea that country-level demographic and geopolitical attributes can aid in the classification of pandemic risk and preparedness in terms of transmission, mortality, and an inability to test (which the previous two depend on, since testing allows for accurate measurements of transmission and mortality). in order to do this, various supervised learning classifiers are explored in order to discern how much useful information these country-level attributes carry for the classification of these three risks. we note that the classification problems are difficult, where many powerful techniques achieve unsatisfactory scores on the dataset, scoring around - % higher than an approximate % random guess on the dataset, showing that learning useful rules from the data is not an easy task. this is not unexpected, since the classes have not been directly derived from the data used to predict them, rather, they have been derived from covid- statistics and then given as classes for country-level demographic and geopolitical information. due to this, strategies of linear searching and genetic optimisation are also followed in order to achieve more accurate results. although results are varied, the fact that all final models achieve much higher than % accuracy we formulate the problem as a -class problem. (which would be achieved via a random guess), shows that the geopolitical and demographic attributes at the country-level do carry predictive ability when it comes to pandemic risk and preparedness. the final models chosen are characterised by high classification accuracy for the risks of transmission, mortality, and inability to test, and are trained with no prior knowledge of the new coronavirus pandemic (other than the class). this may allow for generalisation to classify a nation's risk in the early days of a future pandemic. the remainder of this work is organised as follows: section details the method followed with subsection . describing machine learning approaches in particular. section presents the results for the risk of transmission ( . ), the risk of mortality ( . ) and the risk of inability to test ( . ) . finally, the limitations of the study are described, future work is suggested, and the study is concluded in section . collected from [ ] formalised on the th may , updated experiments for newer data can be found in section . , with the relative ordering based on the three metrics with regards to population (cases, deaths, and tests per million). the risk classes are low, medium-low, medium-high and high for each type of risk. as defined in other works [ ] [ ] [ ] , discretisation of the continuous features into bins is performed by the k% method in which k = (equal frequency binning), resulting in four close-to-equal classes, with the difference being that the highest risk class is a minor . % larger than the other three classes. future work aims to explore other methods of discretisation, whereas this work initially focuses on the machine learning pipeline on the basis of equal class error weighting. covid- data are then removed, and the attributes to complement the country-level classes are the following: un region [ ] , population estimate [ ] , median age [ ] , population density per km [ ] , urban population % [ ] , urban population total [ ] , nursing and midwifery personnel per , (most recently recorded) [ ] , medical doctors per , (most recently recorded) [ ] , tobacco prevalence [ ] , obesity prevalence [ ] , gross domestic product [ ] , land area km [ ] , net migration [ ] , infant mortality per , births [ ] , literacy rate % [ ] , arable land % [ ] , crop land % [ ] , other land % [ ] , climate classification type [ ] , birth rate per , [ ] , death rate per , [ ] , gdp expenditure on agriculture [ ] , gdp expenditure on industry [ ] and gdp expenditure on services [ ] . since some countries are not recorded by the world health organisation, figures for nursing, midwifery and medical doctors personnel per , people from hong kong are collected from an alternative source [ ] . missing data which occurred mostly for tobacco prevalence, was given as '- ', which flags as an attribute that the data have not been collected (which could in itself provide useful information). the classification problem of risk is therefore formulated based on prior knowledge of the pandemic in terms of class only, but the attributes to attempt to classify them are purely country-level information regardless of number of cases, deaths and other coronavirus specific data. thus the problem becomes a pandemic risk and preparedness classification problem based on demographic and geopolitical attributes only. we aim for a generalisable model, which can be applied to the future state of countries, should another potential pandemic begin prior to any meaningful measurements being available. the method is illustrated in fig . following this, a set of machine learning models are tasked with predicting a country's risk class by learning from all other countries in a process of leave one out cross-validation [ ], which is performed for all three types: finally, the best models for each risk factor are organised into a predictive framework, which produces an output for the three risks. since testing is taken into account, countries that have not reported testing data cannot be considered, but are later classified by the model generalised on those countries that do. a three-fold machine learning approach is proposed following observing the maps for the three separate risk quarters in figs , and which show the discretised inability to test risk, transmission risk, and mortality risk respectively. we note that the countries with seemingly fewer cases have performed far fewer tests as can be observed in that the growth of cases and testing tend to increase alongside one another. that is, a country with more cases will test more, and as such will have more confirmed cases, since the larger number of tests have identified more cases. the data for the two experiments were accessed on th may and th september . trained with the strategy of leave one out cross-validation (loo cv) where every country's risk is predicted based on learning from all other countries, a set of supervised classification models are benchmarked. this section details the models focused upon, and the methods used to search for others. the metrics reported following the models described in this section are mean classification accuracy due to close-to-equal class balance [ ] (low, med-low, med-high are equal and high is minimally larger by a factor of . %) and high variance often observed due to the nature of loo cv [ , ] . decision trees are tree structures, where each internal node represents a condition based on attributes that allows splitting the data and leaf nodes represent class labels [ ] . a random decision forest (rdf) [ ], used in this study, creates multiple random decision trees, where note that many countries at "low risk" by number of cases are at "high risk" for inability to test. https://doi.org/ . /journal.pone. .g note that many countries at "low risk" by number of deaths are at "high risk" for inability to test. https://doi.org/ . /journal.pone. .g each decision tree votes on the class of the input data object, and the predicted class is that, which receives the majority vote. splitting of the trees is based on information gain: where ig is the observed difference in information entropy, which is expressed in eq ( ), that is, the nodes split data based on reducing the randomness of object class distribution. k-nearest neighbours (knn) is similar to an rdf in that the prediction is derived by a majority vote. the voters, rather than decision trees, are the data objects within the observations that are closest in terms of n-dimensional euclidean space where n is the number of attributes. gradient boosting [ ] forms an ensemble of weak learners (decision trees) and aims to minimise a loss function via a forward stage-wise additive method. in these classification problems, deviance is minimised. at each stage, four trees (n = classes) are fit on the negative gradient of the multinomial deviance loss function, or cross-entropy loss [ , ]: where, for k classes, i is a binary indicator of whether the prediction that class y is the class of observed data x is correct, and finally p is the probability that aforementioned data x belongs to the class label y. xgboost [ ] differs slightly in that it penalises trees, leaves are shrunk proportionally, and extra randomisation is implemented. naïve bayes is a probabilistic classifier that aims to find the posterior probability for a number of different hypotheses and selecting the most likely case. bayes' theorem is given as: where p(h|d) is the posterior probability of hypothesis h given the data d, p(d|h) is the conditional probability of data d given that the hypothesis h is true. p(h) i.e., the prior, is the probability of hypothesis h being true and p(d) = p(d|h)p(h) is the probability of the data. naïvety in the algorithm is due to the assumption that each probability value is conditionally independent for a given target, calculated as pðdjhÞ ¼ q n i¼ pðd i jhÞ where n is the number of attributes/ features. linear discriminant anaylsis (lda), based on fisher's linear discriminant [ ] , is a statistical method that aims to find a linear combination of input features that separate classes of data objects, and then use those separations as feature selection (opting for the linear combination) or classification (placing prediction objects within a separation). classes k { , . . ., k} are assigned priorsp k ( ( ) in mind, maximum-a-posteriori probability is thus calculated as: where f k (x) is the density of x conditioned on k: s k is the covariance matrix for samples of class k and class covariance matrices are assumed to be equal. the class discriminant function δ k (x) is given as: wherem k is the class mean, and finally classification is performed via quadratic discriminant analysis (qda) is an algorithm that uses a quadratic plane to separate classes of data objects. following the example of lda, qda estimates the covariance matrices of each class rather than operating on the assumption that they are the same. qda follows lda with the exception that: support vector machines (svm) optimise a high dimensional hyperplane to best separate a set of data point by class by maximising the margin and minimising the empirical risk, and then predict new data points based on the distance vector measured from the hyperplane [ ]. the optimisation of the hyperplane is to achieve the goal of maximising the average margins between the points and separator. generation of a multi-class svm is performed through sequential minimal optimisation (smo) [ ] by breaking down the optimisation into smaller linearly-solvable sub-problems. for multipliers a, reduced constraints are given as: where there are data classes y and k are the negative of the sum over the remaining terms of the equality constraint. stacked generalisation (stacking) [ ] is the process of training a machine learning algorithm to interpret the predictions of an ensemble of algorithms trained upon the dataset in a process of meta-learning. generally, a stack can represent any kind of ensemble, but the interpretation algorithm is often logistic regression. it has been noted in multiple domains that stacking often outperforms the individual models in the ensemble [ - ]. it was observed during experimentation that the classification problems were difficult, leading to many models achieving relatively bad results, i.e., the results outperformed an approximate % chance random guess by around - % classification accuracy, with many stateof-the-art models predicting the wrong value more than half of the time (< %). the solutions explored to solve this are the following: a linear search is performed for random decision forests (rdf) and k-nearest neighbours (knn) from , , . . ., decision trees and , , . . ., neighbours, respectively. random forests are often found to be powerful ml algorithms, and so an in-depth search is performed in order to maximise their ability. this is also followed for knn since it is of low complexity and can thus be quickly benchmarked. a genetic search is also performed via the tree-based pipeline optimization tool (tpot) algorithm detailed in [ ] with consideration to the whole scikit-learn toolkit [ ] where not detailed in the previous section, more information is available on the models in [ ] . tpot is an algorithm that treats each machine learning operator as a genetic programming (gp) primitive which include, modified features, feature combinations, feature selections and dimensionality reductions, learning algorithms as well as their predictions (for exploration of ensembles). gp trees were chosen since they best represented a machine learning pipeline and are implemented with the deap framework [ ] , and best solutions are selected by the multi-objective nsga-ii algorithm [ ] by aiming to increase classification accuracy while reducing minimising the number of machine learning operators as previously described. % of offspring produced by the best models cross-over with another through a process of onepoint crossover, and the remaining offspring randomly mutate at a % chance of point, insertion, or shrinkage. thus, the algorithm introduces and tunes ml operators with promising effect and removes operators that cause the results to degrade. finally, the best machine learning pipeline is presented from the search. to conclude, the method described in this section follows the process of manual exploration, linear search, and genetic programming in order to explore the best classification models for these problems in terms of classification accuracy. as previously described, accuracy is chosen as the metric of comparison since the datasets are closely balanced, and the drawback of loo is high variance (large standard deviation due to binary per-fold results) while enabling classification model validation of a small dataset. all of the experiments in this paper were performed using the scikit-learn toolkit [ ] implemented in python. the algorithms were executed on an intel core i processor ( . ghz). due to the large computational complexity when searching a problem space with loo, the algorithm was executed three times with a population size of for generations, if a model scored lower than the manually or linearly explored models then it was discarded, and otherwise presented if it achieved a higher score. this decision was based on the fact that results for the three problems attained were only . %, . %, and . %, and more robust models were required in order to provide accurate predictions. in this section, the three sets of results are presented. for readability purposes, linear searches of rdf and knn are presented as the same figs ( ) and ( ). the linear searches for rdf and knn are shown in figs and , respectively. the best rdf was a forest of trees which scored . %, and the best knn had a value of k = which scored . %. fig shows the model comparison for risk of mortality. the difficulty of the problem can be seen with the low results achieved, with the exception of two models discovered by the genetic model search algorithm. the second best model, which utilised extra trees via recursive feature elimination scored . % and the best model found was a process of stacking svm and extra trees which had a classification ability of . %. country-level pandemic risk and preparedness classification based on covid- data fig shows a comparison of other models that were explored. many solutions were quite weak, but achieving higher results in comparison to the other two problems, suggesting that the problem is a slightly less difficult one. the best algorithms, as was the case for the other problems, were also discovered by the genetic search algorithm. unlike the previous two problems, the best models found were singular rather than either an ensemble or feature elimination pipeline, where extra trees scored . % and gradient boosting scored . %. following the original outline of the experiment in figs and builds upon this by including the best findings from the three benchmarking experiments. the best model for risk of transmission was a stacking algorithm combining gradient boosting and a decision tree for . % accuracy, the best model for risk of mortality was a stacking algorithm combining support vector machine and extra trees for . % accuracy, and the best model for risk of inability to test was a gradient boosting algorithm for . % accuracy. all of the best models were found by the genetic model search algorithm. as previously discussed, the classification of risks must be interpreted relative to one another. for example, if the maps in figs , and are observed, note that countries that do not test much also seemingly, on the surface, report fewer cases and deaths per million. on one hand, this could simply be due to the fact that there are fewer cases and thus fewer tests are country-level pandemic risk and preparedness classification based on covid- data required, but on the other hand, could imply that fewer tests performed have themselves led to unreported figures of the other two [ ] [ ] [ ] [ ] . with this in mind, it is important to consider the output for risk of inability to test in order to interpret the other two risks. in the case where the risk of inability to test is towards the lower end of the spectrum, then risks for transmission and mortality are more likely to be an accurate representation of the situation. vice versa, though, where there is a high risk of inability to test, this in itself should be considered the most descriptive risk factor for the country since there is less prior knowledge to base risks of transmission and mortality upon. country-level pandemic risk and preparedness classification based on covid- data table shows the predicted class values for the best models applied to each of the respective risk classification problems. please note the discussion of interpretation in section . , where high inability to test is often coupled with lower risks of the prior two, as can be seen in fig , for as of yet unknown reasons i.e. they could either be actually true to the pattern observed, or on the other hand, very low testing leads to naturally fewer reported cases and deaths than the actual values. many countries bare similarity to others and so have been generalised, further outliers still such as china may not have accurately predicted labels since the population is much larger than those observed in the training data, likewise this may be the case with other geopolitical information within the outlier set. in this section, we perform a preliminary exploration of how useful country-level attributes are in addition to lag-window features (seven days prior, with mean and standard deviation for days − n via a growing lag-window). the process is implemented via a -fold temporal validation process (predicting future fold k from growing training data to k − ). this approach is explored for the forecasting of cases and deaths. appendix a in s appendix shows the pearson correlation coefficient of each attribute in relation to the total cases for each day. as can be expected, the most correlative feature are the cases recorded for the previous day. interestingly, mean values of the previous two and three days have more correlation to the total cases on the current day compared to the previous day lag value alone. gross domestic product and urban population have a weak but useful correlation for regression of the total cases. as can be expected, the singular pearson's correlation coefficient of each of the isolated attributes tend to be low with exception to the lag windows due to the nature of increasing growth in infections. the tables within appendices b, c, and d in s appendix detail the scores given to the attributes by linear regression, m p and svr respectively. it is observed that the rankings achieved by the lag window attributes are the same for each algorithm, and the order otherwise is relatively similar. all algorithms then rank the country at the same place above other features, which actually had a negligible correlation of . . another interesting observation is that the m p algorithm ranks medical doctors per , population as relatively high in the ranking, second only to country when lag windows are not considered. urban population totals are considered important by all of the algorithms, likely since this is an indication of both spread as well as a rule of thumb for total number of infected. table shows the results for total case prediction by all of the chosen algorithms. the best algorithm achieved a rmse of . when considering features chosen by linear regression ranking, which were the time-window attributes and geopolitical or demographic attributes. this provides a decrease in rmse of . when this algorithm only considers lags of the series, and many instances can be observed in which this metric was reduced by considering additional attributes explored within this study. the best results achieved by all of the seven algorithms considered at least two of the additional attributes, it is worth noting that the best of the best models is also the model which chose the most of the additional attributes (as well as the best svr, which also chose attributes in total). appendix e in s appendix shows the correlation of each singular attribute towards the prediction of deaths. as can be observed, the rankings of the lag windows are the same as those for total confirmed infections described in the previous section. otherwise, rankings are similar and differ only slightly, as well as their observed correlation. appendices f, g, and h in s appendix detail the scores given to each attribute by the linear regression, m p and support vector regression algorithms respectively. as can be expected, the rankings match those of the highest correlation coefficient. interestingly, a small change is noted within the attributes for svr whereas quite a disparity can be seen when observing the scores given by the other two algorithms. table shows the models trained for forecasting total deaths. similarly to the total case predictions, the best model found was within a voting ensemble of linear regression and svr. unlike total case predictions, introducing geopolitical and demographic attributes had negative effect on the result, with the best model taking only the temporal lag window features as input. once attributes were introduced, the linear regression model had an absurdly high rmse of . e+ , which since average values were taking during voting regression, also affected the ensembles that included it. given the nature of research and peer review, the approach in this work was formalised on the th of may and as such the data is over three months out of date at the time of writing ( th of september, ). given this, the experiments devised in this work are re-applied to the new data. it was noted that all manual models failed to generalise with the new data. that is, a range of scores between . % to . % for all models, for all three risk classification problems. this is most likely due to international collaboration towards the three risk factors, and as such, country-level attributes lose classification prediction ability towards the risk factors. with the previous successful experiments in mind, this argues that risk classification would be more useful when performed prior to the situation unfolding, given that country-level information is seemingly more important at this stage when compared to the current postpeak climate. though much weaker results are now observed, this could in fact be viewed as a positive situation, given that country-level data i.e. who you are and where you are from no longer impacts risk as it was observed to in the initial experiments performed in may . it has been noted during mid- that organisations such as the united nations and world health organisation have implemented and released humanitarian packages to lower economically developed countries (ledcs) [ ] [ ] [ ] . it has also been noted that many healthcare professionals returned to their native countries (often also ledcs) in order to aid in tackling the virus [ ] . the positive effects of these factors likely contribute towards the reason why country-level information was useful for risk classification earlier in the pandemic, but are less-so later on post-peak. with the nature of the data streaming from the ongoing pandemic with regards to the time taken to run model benchmarks, the largest and most obvious limitation to this study is that the models are constantly going out of date by the day, since more up to date data is constantly becoming available. it is for this reason that the models should be updated at a later date, and the statistical differences that occur, if any, noted. secondly, though relatively good results were found through a complex process of genetic optimisation, further models could be explored in order to possibly reach better results than the final models in this study. finally, the interpretation that is required as aforementioned, i.e. that the risk of inability to test is the most important metric and possibly enables the other two for interpretation, suggests that the ternary approach followed could be better optimised through a unified approach. that is, one singular "metric of risk" that is calculated via the three metrics explored in this work as separate problems. prior to this study, a metric of (c + d)/t was explored (where c, d, and t denote cases, deaths, and tests respectively, all with regards to per million population), but this metric is, at this point, impossible to classify. the k% method was used to divide the continuous features into four bins where k = . other methods of binning such as mdl [ ] , caim, cacc, and ameva [ ] could also be explored and benchmarked in future experiments. to conclude, the main hypothesis that this work has argued in favour of is that geopolitical and demographic attributes at the country-level hold value in terms of classifying risk produced by the covid- dataset. this was shown when the four class distribution which was close to equal ('high' was . % larger than the other classes) could be classified far above the approximate % class distribution through loo cv. though this is observably possible from the results presented in this study, it is worth noting that the classification problem proved extremely difficult for many powerful machine learning techniques, which often scored around only %, and a genetic search had to be followed in order to devise complex strategies of ensemble and hyperparameter optimisation in order to achieve better results at . %, . %, and . % for the three problems. future work aims to keep the data up to date to the point at which the pandemic is over, and also to explore other methods of solving the issue of risk and preparedness classification through a more 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country ensemble of machine learning algorithms using the stacked generalization approach to estimate the warfarin dose evaluation of a tree-based pipeline optimization tool for automating data science scikit-learn: machine learning in python api design for machine learning software: experiences from the scikit-learn project deap: evolutionary algorithms made easy a fast and elitist multiobjective genetic algorithm: nsga-ii correcting under-reported covid- case numbers. medrxiv internationally lost covid- cases level of under-reporting including under-diagnosis before the first peak of covid- in various countries: preliminary retrospective results based on wavelets and deterministic modeling estimating the fraction of unreported infections in epidemics with a known epicenter: an application to covid- will covid- be a litmus test for post-ebola sub-saharan africa? the coronavirus knows no borders. tidsskrift for den norske legeforening health prevention and response policies against infectious diseases: is the world ready for a novel coronavirus pandemic? proceedings book the world health organisation. how is who responding to covid- ? azerbaijani doctors return home to help their country face covid- multi-interval discretization of continuous-valued attributes for classification learning supervised and unsupervised discretization of continuous features the authors would like to show their gratitude to all of the medical professionals working to treat and cure covid- across the world, as well as the researchers working vigorously on vaccines and antibody tests for the disease. we would also like to thank all of the key workers for their effort to make life as normal as possible during these difficult times. key: cord- -l sv hj authors: schindler, seth; jepson, nicholas; cui, wenxing title: covid- , china and the future of global development date: - - journal: nan doi: . /j.resglo. . sha: doc_id: cord_uid: l sv hj abstract tensions between the united states and china have been escalating in recent years, and the covid- pandemic has intensified their competition. if sustained, china's more effective public health response and economic restart will burnish its leadership credentials in the field of global development. this article lays out the origins and distinctive features of china's development policies and vision, and argues that in a post-covid world these may constitute an appealing alternative to the us-led development paradigm for many developing countries. we contrast the universalism and rigidity of contemporary development orthodoxy with china's emphasis on bilateral and pragmatic forms of development cooperation borne out of its domestic experience. while chinese development assistance and loans enhance its soft power, partner countries are offered significant autonomy and flexibility. we conclude by outlining three factors which may impact the future of chinese leadership in the field of global development; a reconciliation of global financial governance and china's development lending, the outcome of the upcoming american presidential election and domestic discontent within china over the belt and road initiative. j o u r n a l p r e -p r o o f aides (bbc, ) . china's response to the crisis and its aftermath was effective by comparison. to recap events, chinese authorities reported an outbreak of pneumonia cases of unknown origin in wuhan to the world health organization on december , . by january th chinese officials had identified a novel coronavirus as the cause and its genetic sequence was shared with the who on january th (who, a) . by late-july china had reported , covid- related deaths to the who ( b). the us government and usbased researchers have charged that the actual number of deaths in china is in the neighbourhood of , (he et al., ) and this controversy is unlikely to be resolved. what is indisputable, however, is that minor outbreaks in china have been contained and at the time of writing, life has returned to normal in most of china. meanwhile, the us registered its first case of covid- on january . by february fifty-eight people had tested positive for the virus and donald trump assured the public that "you have people , and the within a couple of days is going to be down to close to zero." community transmission of covid- accelerated in the us in march, and by the second week of april new york state had registered more cases of covid- than any country. new infections levelled off for a brief period, but then accelerated in july, particularly in southern and western states. by late-july florida was registering more new cases than any country on a daily basis. as this article goes to print about , people have died as a result of covid- , and to put it in perspective, that's equivalent to nearly fifty september terror attacks and american casualties in . vietnam wars. animosity between the us and china intensified in the midst of the pandemic. trump began to refer to covid- as a "chinese virus" in march, while his aides called it the "kung flu." american and british officials have repeatedly charged that china inhibited a concerted global response by withholding important information about covid- . meanwhile a narrative began to circulate widely in china that covid- was brought there by members of the american military. this is not beijing's official line, but it has been repeated by officials and media outlets close to the government (scarborough, ) . western media have also questioned the official version of events, such as a british tabloid that interrupted coverage of quarantined celebrities to report that covid- may have leaked from a us-backed virus research laboratory in wuhan (mulraney and owen, ) . not to be outdone, trump countered that the novel coronavirus actually originated in a lab in wuhan, although he claimed he could not share the evidence publicly (sevastopulo and manson, ) . tension escalated further when washington closed the chinese consulate in houston, and in a tit-fortat move beijing closed the american consulate in chengdu. this dispute will not be settled in press briefings, diplomatic communiques or on social media. instead, the narrative will fall into place in the wake of covid- 's epidemiological curve. covid- is sweeping across the us from coast to coast, and american leadership will be eroded if the death toll runs into the hundreds of thousands. a recent global survey confirmed that the vast majority of people around the world think that china's response to covid- has been far more effective than the united states' (wintour, ) . if china manages to contain further outbreaks and restart its economywhich is by it is important to note that china is not the only country that responded effectively to limit the spread of covid- . for example, other commendable policy responses were implemented by governments in vietnam, south korea, the state government of kerala. for data on covid- in the us see: https://www.nytimes.com/interactive/ /us/coronavirus-us-cases.html j o u r n a l p r e -p r o o f no means assuredits leadership credentials will be burnished, and the enhancement of chinese leadership will be evident in the field of global development. in the remainder of this essay we explain why covid- differs from the financial crisis in which similar predictions were made surrounding the inexorable rise of china. we then explain in brief the origins of the notion of 'development' in china and we explore the implications of chinese leadership for the field of global development. this paradigm outlined by horner and hulme ( ) accounts for emergent patterns of wealth distribution and wellbeing in the st century, and the emphasis is on increasing inequality within countries while there is a convergence among countries. this leads to the rejection of "a clear spatial demarcation between first and third worlds, 'developed' and 'developing', or rich and poor, countries" (ibid., p. ) , in favour of the recognition of the global scope of civilizational challenges (e.g. global health pandemics and climate change). it is in this context that the world has taken note of china's response to covid- and we conclude with future scenarios in which china's leadership is cemented, or challenged by a renewed pax americana. american foreign policy guru henry kissinger ( ) proclaimed that covid- threatens to "set the world on fire" and it may ultimately upend the global order. implicit is an assumption that china will replace, or at least challenge, american supremacy. in some sense, of course, we've been here before and predictions of china's unstoppable rise sound all too familiar. the financial crisis, with its origins on wall street, prompted a slew of obituaries for highly financialised us capitalism. the era of unrestricted capital flows and unregulated markets seemed a thing of the past as the world's economic and geopolitical centre of gravity appeared to move both east and south. china emerged from the crisis relatively unscathed and of sufficient economic heft to play a central role in dragging the world economy out of the mire through a huge and decidedly non-neoliberal stimulus programme (tooze, ) . although talk of china's global hegemony was premature at minimum, its sustained economic growth lifted hundreds of millions of people out of poverty. crucially, china employed a pragmatic and eclectic mix of policies which ran counter to orthodox development policy promulgated by the likes of the world bank and the international monetary fund. one enduring impact of the crisis has been a gradual hollowing out of the neoliberal edifice. this did not turn out to be the simple return to keynesianism which some predicted at the time, and the neoliberal 'zombie' shuffled on (peck ) . but in much of the oecd, neoliberal ends are increasingly sustained via means antithetical to the paradigm's intellectual foundations (not least in juicing the stock market via quantitative easing). many neoliberal regimes had previously fused corporate welfare with austerity for everyone else, but these practices became so apparent after that the sense of a coherent project with the potential to deliver broad-based progress has been lost. few now believe in neoliberalism's promises, and the missionary zeal with which these were pursued during the reagan and clinton eras now seems bizarrely anachronistic. this disintegration of neoliberal ideology almost went unnoticed in the us because american hegemony remained unchallenged. importantly, however, it was no longer sustained by faith in free markets and global economic integration, but by the expansive policies of the us treasury and federal reserve under the resolute leadership of barack j o u r n a l p r e -p r o o f obama. indeed, while the eu fumbled its response to the crisis, the us provided a host of central banks with dollars and maintained global liquidity. this decisive action at once prevented a financial collapse while simultaneously compounding the dysfunctions of global finance. the injection of massive amounts of liquidity into the world economy by the fed (joined by the banks of japan, england and later the european central bank) encouraged a build-up of debt by corporations and individuals. stock market bubbles were inflated and the financial sector's dislocation from the real economy deepened. that profound cleavage is one of the most important legacies of . it is handily illustrated by the performance of the the s&p index, which as of june had made net gains over the year so far, despite a global pandemic and shutdown of activity in most major economies (winck ; krugman, ) . this crisis differs from in three very important ways. first, the scale and scope of the impending economic crisis will require unprecedented state intervention that will be even more difficult to reconcile with neoliberal ideology. on this point the economist ( ) and new left review (brenner, ) are in agreement. we have already seen countries move to impose capital controls, bail out private corporations, roll out basic income grant schemes and expand social welfare programs. some countries may have little choice but to nationalize failing companies and manage production of essential goods. second, china was an engine of growth after the crisis but its global presence was modest in comparison to today. since the announcement of its signature belt and road initiative in , china has ramped up its activity abroad and significantly enhanced its soft power. finally, the us has scorned multilateralism under donald trump's banner of america first, and even long-time allies are weary of washington's transactional diplomacy. meanwhile, the murder of george floyd at the hands of minneapolis police officers unleashed pent up rage across the us that exposed deep rifts in american society (cobb, ) . the us department of homeland security deployed troops to portland, oregon, and they have used unmarked vehicles and detained protestors without warrants (green, ). the result is that the us government faces a crisis of legitimacy at home and abroad, and its leadership has not been this tenuous in the post-war era. the us will enjoy certain advantages as long as the dollar is the world's primary reserve currency. this is not necessarily apparent when times are good because managing the world's reserve currency does come with costs that can make it seem like a burden (pettis, ) . however, it affords the us tremendous agency in times of crisis because it can borrow vast sums at the very moment when other countries are trying to stem capital flight. indeed, control over the world's common unit of account and largest asset class has emerged in this crisis as perhaps the main remaining weapon in the american hegemonic arsenal. no serious challenger to the dollar looks likely to emerge in the medium term, barring a complete collapse of world financial systems (in which case, all bets are off). while chinese authorities are cautiously promoting renminbi internationalisation, its current lack of convertibility means it has a great distance to travel before even entering the conversation as a possible global reserve currency. in , then people's bank of china governor zhou xiaochuan called for imf reform in order to position the special drawing rights (sdrs) as a possible alternative to the dollar (zhou ). sdrs are based on a basket of five currencies and are issued by the imf to member as a form of foreign exchange reserve asset. the imf's control over the sdrs makes any use of it to undermine dollar hegemony highly unlikely so long as the us retains its veto at the fund. recently, for example, the us has scuppered an imf plan j o u r n a l p r e -p r o o f to issue new sdrs to members, which was intended as a quick fix for countries' liquidity needs (birdsall ) . instead, the us prefers to work directly, unilaterally and selectively in providing liquidity through the fed. favoured states have been granted dollar swap lines, while others are afforded much more limited assistance (johnson ) . the choice to restrict assistance in this way is causing disquiet among those left out, including key developing countries like turkey, indonesia, south africa and nigeria. thus, maintaining global liquidity through the selective provision of access to dollar swap lines will not be enough to shore up american leadership, which will be eroded in the absence of a convincing ideology or guiding principle beyond self-interest. the dollar is likely to remain the global reserve currency by default, but as countries grapple with the health impacts and economic fallout from covid- , many will turn to china for leadership given the effectiveness of its response. chinese leaders are well aware that they may be able to steal a march against the us. the chinese government and chinese firms recently began donating protective medical equipment to countries around the world. this was met with derision by the eu's leading representative for foreign policy, who warned that "there is a geopolitical component including a struggle for influence through spinning [the narrative] and the 'politics of generosity'" (lau, ) . lowand middle-income countries will be disproportionately impacted by the looming economic crisis (goodman et al., ) , and they are unlikely to be offended by the politics of generosity. in contrast, the us has provided approximately $ million to developing countries "to support virus prevention, detection, and control" (pompeo, ) but it cannot be used to purchase personal protective equipment (eg masks and gowns for frontline healthcare workers) in order "to ensure there would be enough ppe for the u.s." (gharib, ) . in a stunning plot twist, the us was accused by a german official of "modern piracy" after intercepting a shipment of n respirators bound for berlin and redirecting them to the us (willsher et al., ) . we argue that developing countries will be less offended by the politics of generosity than they will by modern piracy, and we anticipate that china will become the primary development partner for many countries as a result. china's assertiveness in the field of global development poses a direct challenge to traditional donors, such as the us and uk, as well as international financial institutions such as the world bank (mawdsley, ) . one common misconception is that the norms, objectives and practices of global development are agreed upon, and that china is elbowing its way into the crowded group of countries and institutions that provide aid and expertise. on the contrary, china is beginning to shape the very notion of development, and this raises the question: what is the meaning of 'development' according to china? to answer this question, it is necessary to understand how the concept of 'development' evolved from earlier understandings of state-induced change on a grand scale. the us government launched a raft of measures designed to 'reconstruct' the southern states whose economies were ravaged by the country's brutal civil war ( - ). in the late- th century american policy makers turned their attention overseas to their quasi-colonies. american exceptionalism and technological mastery were meant to catalyze the modernization of stagnant primitive societies. development became a cornerstone of american efforts to halt the spread of communism after the second world war. the ussr and the us competed for client states during the cold war, yet their development aid programs were strikingly similar in terms of their objectives and practice. both were informed by the experience of colonizing a vast internal frontier, and both leveraged the command of technology and a rationalized organizational structure to foster industrialization. large-scale investments in turnkey projects in remote areas, such as dams and steel plants, were designed to have ripple effects and result in the growth of industry and the enhancement of productivity in agriculture. historian michael adas ( , p. ) explained that this served to limit the policy space of recipient countries: the underlying similarities in the developmentalist ideologies and policies advanced by the rival superpowers in the cold war meant that the options available to leaders and planners in post-colonial societies were much more limited than currently prevailing interpretations of the era, which stress superpower differences and competition, would suggest. china remained aloof from debates surrounding mainstream development policy advocated by the americans and the soviets throughout the cold war. china's irrevocable split with the ussr in the late- s led to the departure of soviet technical advisors (lüthi, ). one result was that the chinese communist party's reputation was never tarnished by its association with stalinism. in contrast, revelations of stalinism's excesses led to the collapse of mass support for communist parties in western europe. communist ideology advanced by organized parties was replaced by a distrust of metanarratives and it gave way to a preference for relativism, difference and local particularisms that inhibited a coordinated resistance to the rolling back of keynesian welfare states in the s. neoliberalism became the ideological foundation of development in the s, and according to colin leys ( , p. ) , "the only development policy that was officially approved [by the washington consensus] was not to have one." the human and environmental costs of neoliberal restructuring were increasingly apparent as the s wore on, yet opposition remained convulsed by conflict that pitted marxists, who had regrouped under a banner of critical political economy, against adherents of post-development who were committed to identity politics. china avoided the ideological battles that characterized development studies in the west throughout the s and s. china was never forced to accept a loan from the international monetary fund under duress, and the political autonomy it has enjoyed as a result sets it apart from other brics countries. most importantly, chinese policy makers have had the time and policy space to experiment with an eclectic mix of pragmatic reforms. to this end, five special economic zones were established in the mid- s and served as policy laboratories where western institutions were tested (yeung et al., ; chen, ) . political reforms were decidedly abandoned after , but economic experimentation and reforms continued apace. while sectors of china's political economy became increasingly market-oriented, it avoided the radical shock therapy implemented in other developing countries and the state remained sovereign vis-à-vis markets. policy makers pursued a set of objectives strikingly similar to what western theorists outlined in 'modernization theory,' that is, broad-based structural transformation from an agrarian society to a center of advanced techno-industrial production and innovation that exhibits an increasingly sophisticated j o u r n a l p r e -p r o o f division of labour. hundreds of millions of people were lifted out of poverty and living standards improved for the vast majority, which explains why the chinese government enjoys a high level of trust and legitimacy among its citizenry (tang, ) . this hybrid and pragmatic approachrather than a universally applicable policy framework informed by ideology -informs china's understanding of development. in the years after , a conversation emerged in academic and development circles around the potential for countries to follow the example of an alternative 'china model.' after an initial wave of interest, though, these debates subsided for two main reasons. first, the identification of a 'beijing consensus' surrounding development policy proved elusive. it was impossible to identify the parameters of a concrete set of ideologically-informed policies in the manner of john williamson's ( ) original washington consensus. second, china's post- economic miracle was the result of very particular circumstances that developing countries could not hope to replicate. most important was china's virtually unlimited supply of cheap but relatively productive labour, whose integration with east asian value chains was mediated by the chinese diaspora. for countries used to adhering to an economic orthodoxy that has too often wrought instability and crisis, the absence of an ideologically informed policy framework is precisely what makes china an appealing development partner. for the most part, china's development cooperation is not conditional upon domestic policy reforms. the most notable exception is the chinese leadership's sensitivity towards perceived support for separatism or 'splitism.' for example, mongolia's attempt to secure chinese loans was temporarily derailed as a result of a visit by the dalai lama to ulan bator (wong, ) . critics maintain that china's official policy of non-interference is a defensive manoeuvre aimed at pre-empting foreign criticism of politics surrounding taiwan, hong kong, tibet and xinjiang regardless of china's motives, many governments find it easier to meet this condition than to implement the suite of reforms demanded by neoliberal institutions that act as custodians of mainstream development policy such as the imf and world bank. china's growing economic and political entanglements abroad, particularly in east asia and africa, have necessitated a gradual de facto shift away from non-interference. in the aftermath of south sudan's independence, for example, china leaned on the juba government to end conflicts with both khartoum and rebels which threatened chinese oil interests. nevertheless, chinese envoys have cultivated relationships with ruling and opposition parties in numerous countries. and when friendly governments have been ousted by elections or coups, chinese diplomats have courted their replacements (holslag, ) . in general, china j o u r n a l p r e -p r o o f has been happy to lend to democracies and autocracies alike, as well as both us allies and socalled rogue states. chinese development assistance incorporates spatial planning strategies that are a legacy from the post-reform period when china's slumbering interior was activated through its integration with entrepot cities along its south-eastern coast. plans tend to emphasize the importance of inter-city, regional and even transnational connectivity via expansive corridors (mayer and zhang, ) . the realization of these ambitious plans requires significant investments in infrastructure such as regional energy grids, railways, highways and ports (schindler and kanai, ) . chinese planners consider this turnkey infrastructure a necessary precondition for economic growth, and countries are encouraged to finance construction through loans. most loans for large-scale infrastructure projects are issued by the china development bank and china exim bank, and neither institution has shown any interest in reforming the domestic economic policies or institutional structures of borrowers. while project-specific conditions are common (the insistence that chinese firms are the lead contractors, for example), pragmatism and flexibility remain the guiding principles of china's overseas development policy (lee, ) . the trump administration has promoted the idea of chinese 'debt trap diplomacy' (schindler, ) . the charge is that china is acting as a kind of international loan shark by deliberately lending countries unsustainable amounts, then using debt as leverage to force borrowing governments to accept chinese domination or relinquish strategic infrastructure in exchange for debt relief. proponents of this narrative often cite the example of hambantota port in sri lanka, which was handed over to china in . there is speculation that hambantota will eventually become a chinese naval base. the reality is rather different. the port was a loss-making venture and associated with the previous government's national development plans. the new government in colombo struck a deal to sell a % share to china merchants port for $ . billion. it is certainly true that sri lanka was struggling with a heavy debt burden at the time, but only % of its outstanding debt was owed to china. the idea that beijing engineered a debt crisis in sri lanka in order to take possession of hambantota does not bear scrutiny (sautman and hairong, ; brautigam, ) . as china has expanded its lending portfolio some states have indeed struggled to repay their loans. china's responses highlight its preference for bilateral negotiations and pragmatic solutions over multilateral engagement. ordinarily, governments seeking debt relief must deal with the paris club. it is a grouping of the major lending states that act in concert to establish a common negotiating position. getting a paris club deal, in turn, depends on a country agreeing to an imf program, that typically includes policy reforms designed to ensure outstanding debt is repaid. china is not a member of the paris club. instead, it conducts its own separate talks with governments in debt distress, and again, china appears to approach these negotiations on a case-by-case basis. some small debts have been written off entirely (kratz et al., ) , other loans have been restructured and expanded or amortized over a longer period to ease the immediate burden (south china morning post, ; white, ) . finally, in some cases the cost of planned infrastructure projects has been revised downward (mitchell and woodhouse, ) . rather than a model with universal applicability, china's development assistance is goal oriented. first and foremost, chinese development assistance appears designed to reorient the global economy in ways that strengthen sino-centric production networks (hung, ) . according to zhang ( , p. ) the belt and road initiative "could entrench sino-j o u r n a l p r e -p r o o f centric networks of trade, investment, and infrastructure in east asia, southeast asia, eurasia and beyond, echoing japan's 'flying geese' model, but on a much more expansive geographic dimension, and in a more complicated, diverse and multi-scalar manner." this entails unbundling existing value chains driven by lead firms within china and offshoring certain segments. to this end, china builds hard infrastructure first (eg ports, railways, energy grids), firms locate production facilities in proximate industrial parks and officialdom subsequently exerts soft power if necessary. this is a marked difference from washington consensus institutions which, throughout the s and s first exerted soft power to open markets, and then allowed market forces to determine whether hard infrastructure was built. china's approach has proven attractive to many developing countries, which is evident from the number of countries that have agreed to participate in the belt and road initiative. shortages of basic medical equipment in advanced-industrial countries has led to a realization that they are entirely dependent on china. the us and japan have made initial moves to decouple their domestically-anchored value chains from china, while china is simultaneously seeking to unbundle its domestic value chains. if these trends continue they could radically re-shape economic geography in the st century, and at the very least, we anticipate an expanded role for china in the field of global development. the true scale of covid- 's impact on the global economy is impossible to assess at present. the imf currently predicts that will see the worst recession since the s, though the damage could be even greater if the pandemic persists into the second half of the year (gopinath, ) . developing countries face capital flight, currency crises and cratering export revenues, and many are only beginning their battle against the virus. this situation has already made it difficult for countries to meet repayments on debts owed to governments, international organisations and private creditors. the world bank backed a g initiative to suspend debt repayments from developing countries (malpass, ) , and china urged the world bank to "lead by example" and do the same (lawder, ) . debt relief in the short term will provide many countries with necessary reprieve. however, a long-term solution will be far more difficult to engineer because the us retains a dominant position at the world bank and imf and insists that no assistance from either institution be used to pay off debts to china (lawder and crossley, ) . this is an attempt to slow china's economic expansion overseas, but it also reflects an incompatibility between china's lending and washington consensus principles. up until now, this impasse has been managed by borrowing countries first reaching bi-lateral debt relief deals with china, before then turning to the imf. this is a slow but feasible workaround for individual countries, but it cannot work if dozens of countries require debt relief at the same time. any sustainable solution will require china to be fully integrated into the multilateral debt system of the paris club and imf, yet doing that successfully will mean accommodating china's very different lending philosophy. this would require an overhaul that would lead many g countries to balk, not least the us. if an accommodation is not reached between china and the paris club, developing countries may find themselves in a position where they have to choose between defaulting on either chinese loans or paris club and imf debt. at present this impasse is far from being resolved (parkinson et al., ) , and one result of a prolonged struggle surrounding debt could be the emergence of two distinct economic blocs j o u r n a l p r e -p r o o f reminiscent of the cold war. there are signs this is already be happening. for example, after the us withdrew from the nuclear deal with iran and sanctions were re-imposed. european countries balked at us intransigence but they were unable to piece together a program to mitigate american sanctions. rather than forcing the iranians to the bargaining table, however, this drove them into a $ billion deal with china (cohen, ) . second, if trump is elected to a second term in november we can expect more of the same. american policy will remain jingoistic and self-serving, while incompetence will continue to characterize the us government's operations at home and abroad. in this scenario china would continue to be harassed by the us in ad hoc ways that beijing would likely be able to parry. developing countries would continue to hedge their bets (see kuik, ) and avoid alienating the us but many would look to china for leadership and stability. if joe biden wins the us election in november the situation will become more complicated for china. while biden's approach to china would surely be more civilized in tone than trump's, issues such as the balance of trade and intellectual property rights would nevertheless have to be resolved before relations could be reset. the countries would remain competitors, yet unlike trump, biden could go on a global charm offensive and marshal support among traditional american allies. even before the covid- pandemic european companies were seeking to reduce their dependence on china (rapoza, ) while the eu has soured on a trade deal with china (bermingham, ). similarly, japan followed suit by providing support in its covid- stimulus package for the repatriation of supply chains from china (nakazawa, ) . more recently, tensions flared between china and india over disputed territory in the himalayas (agrawal, ) , and the united kingdom has ruled that huawei hardware must be removed from its g infrastructure by (kelion, ) . a biden victory in november could signal the revival of a pax americana whose primary purpose would be to limit beijing's disruption of global systems (e.g. trade, finance, production, etc.). the prospect of a revived pax americana draws attention to the importance of the geopolitical context that will shape global development. thus far we have noted that japan may attempt to decouple its value chains from china, while the eu seeks to manage its current and future member states' relations with china, but many other countries will influence geopolitics. the pace, scope and terms of eurasian integration will be influenced by russia, which is intent on regaining influence in former soviet republics (plokhy ; dutkiewicz and sakwa, ) . a host of so-called 'rising powers' across eurasia bolster geopolitical claims with historical narratives of their supposed greatness (onar, ) , while the indian ocean is subject to competing visions (fanell, ). these geopolitical visions and strategies will influence the extent to which the developmental components of americanled neoliberal globalization or the belt and road initiative are rolled out, maintained and realized. additionally, the post-covid- economic crisis could jeopardize the bri. there are already rumblings within the chinese state and society that label it a wasteful extravagance (海外网, ) . given its close association with xi jinping and its inclusion in china's constitution, the bri enjoys ideological reverence among chinese officialdom and it has become common sense that it is the framework through which china will engage other countries. while this is unlikely to change, beijing may prefer to scale back the bri than face internal dissent. a more modest version of the bri would probably focus on strategic largescale projects undertaken by central government state-owned enterprises (see liu et al., j o u r n a l p r e -p r o o f ). the gwadar port in pakistan, for example, is an example of a project whose strategic importance far outweighs its potential to generate returns. mining is another strategic priority which may see a post-pandemic boost. with worries over security of supplies rising along with geopolitical tensions, greater bri financing for mining ventures in iron ore, copper and coal appears likely in order to reduce china's dependence on australian resource imports in particular. in contrast, small-scale entrepreneurial initiatives whose strategic value is not readily apparent may be curtailed. these projects tend to be undertaken by private firms, state-level or municipal soes, and many are already in financial trouble given the current economic crisis (russel, ) . projects of this sort may struggle to get approval from beijing in a post-covid- bri-lite. in broader terms, questions have long been raised regarding the sustainability of china's economic model, and the covid- pandemic has brought these into sharper focus. chinese leadership has declined to set a gdp growth target for , breaking with decades of tradition and signalling an end to the economy's unbroken thirty-year run of breakneck economic expansion (feng and bermingham, ) . with the country's total debt now exceeding percent of gdp, recently announced stimulus measures are understandably somewhat more cautious than those seen in , at least in gdp terms (shen ) . it is unlikely that china will be able to serve as a lighthouse in the coming economic storm in the manner seen twelve years ago. despite the weakness of its own position in comparison with , china seems likely to emerge with a relative advantage in a situation where all major economies are taking a battering. the oecd projects, for example, that china's gdp will shrink between . and . percent in , compared to equivalent figures of between . and . percent for the us (as well as and percent for eurozone economies) (oecd ). also in china's favour is its relative insulation from volatile global financial markets. so long as the country can avoid its own domestic financial meltdown, which is by no means a given, china's centrality to the global economy only looks set to grow. in conclusion, the covid- pandemic is the context that will shape the ongoing competition between china and the us. it will not be decided by policy makers in beijing and washington alone, however, because both the us and china will have to calibrate their global development policies in response to widespread demands 'from below,' in particular for coordinated action to mitigate climate change. chinese policy makers are not particularly adept at responding to demands from below, but beijing will enjoy a reputation as an effective development partner for the time being given its effective handling of covid- . the notion of 'development' in china has unique originswhile it adheres to an understanding of development that is strikingly similar to modernization theory, the development policies it advocates are characterized by pragmatism and flexibility. thus, china is an attractive development partner for many countries, but the durability of its leadership is dependent on us elections, and its ability to continue to support the bri while also responding to demands from below. india and china step back from the brink-for now dominic cummings: did he break lockdown rules new sdrs? that pesky percent approval ) a critical look at chinese 'debt-trap diplomacy': the rise of a meme escalating plunder change and continuity in special economic zones: a reassessment and lessons from china an american spring of reckoning: in death, george floyd's name has become a metaphor for the stacked inequities of the society that produced them china and iran approach massive $ billion deal deng xiaoping wenxuan (selected works of deng xiaoping) protecting china's overseas interests: the slow shift away from non-interference, spiri policy paper no. eurasian integratoin -the view from within. abingdon: routledge china gdp: beijing abandons economic growth target, premier li keqiang confirms at npc. south china morning post the u.s. is giving vast sums of money to fight covid- abroad in world's most vulnerable countries, the pandemic rivals the crisis the great lockdown: worst economic downturn since the great depression homeland security was destined to become a secret police force top economist: us coronavirus response is like 'third world' country. the guardian cremation based estimates suggest significant under-and delayed reporting of covid- data in wuhan and china china and the coups: coping with political instability in africa from international to global development: new geographies of st century development the china boom: why china will not rule the world dollar liquidity measures leave some countries out in the cold huawei g kit must be removed from uk by . bbc news the coronavirus pandemic will forever alter the world order new data on the "debt trap" question. rhodium group market madness in the pandemic: why are investors rushing to buy junk hedging in post-pandemic asia: what, how, and why? the asian forum eu fires warning shot at china in coronavirus battle of the narratives. south china morning post china urges world bank to suspend debt payments for poorest countries mnuchin says imf and world bank funds won't repay debts to china the specter of global china: politics, labor, and foreign investment in africa the rise and fall of development theory demystifying chinese overseas investment in infrastructure: port development, the belt and road initiative and regional development u.s. and china turn coronavirus into a geopolitical football world bank group president malpass: remarks to the development committee south-south cooperation . ?: managing the consequences of success in the decade ahead theorizing china-world integration: sociospatial reconfigurations and the modern silk roads malaysia renegotiated china-backed rail project to avoid $ bn fee revealed: u.s. government gave $ . million grant to wuhan lab at center of coronavirus leak scrutiny that was performing experiments on bats from the caves where the disease is believed to have originated. daily mail online xi fears japan-led manufacturing exodus from china oecd economic outlook historical legacies in rising powers: toward a (eur)asian approach the logic of contingency in china's insistence on the noninterference principle as africa groans under debt, it casts wary eye at china zombie neoliberalism and the ambidextrous state an exorbitant burden: why keeping the dollar as the world's reserve currency is a massive drag on the struggling the last empire: the final days of the soviet union additional u.s. foreign assistance builds upon u.s. leadership in the global covid- response europe joins u.s. companies moving out of china the coronavirus will not be fatal for china's belt and road initiative but it will strike a heavy blow the truth about sri lanka's hambantota port, chinese 'debt traps' and 'asset seizures china falsely telling arab world u.s. behind coronavirus how china is driving america's new africa strategy getting the territory right: infrastructure-led development and the re-emergence of spatial planning strategies trump says he is confident covid- came from wuhan lab a thawing arctic is heating up a new cold war china's stimulus sceptics need not fear side-effects this time china agrees to restructure republic of congo's debt, african nation says the "surprise" of authoritarian resilience in china rich countries try radical economic policies to counter covid- crashed: how a decade of financial crises changed the world the death of american competence china extends us$ mn to sri lanka in covid- support who ( a) pneumonia of unknown cause -china. world health organization situation report - a short history of the washington consensus accused of 'modern piracy' after diversion of masks meant for europe here's how much each sector jumped after the coronavirus sell-off only three out of countries say us has handled coronavirus better than china. the guardian mongolia, with deep ties to dalai lama, turns from him toward china china's special economic zones at chinese capitalism and the maritime silk road: a world-systems perspective key: cord- -vm yy i authors: krywyk, j.; oettgen, w.; messier, m.; mulot, m.; toubiana, l. title: dynamics of the covid- pandemics: global pattern and between countries variations date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: vm yy i the covid- pandemic affected countries between december and july . the early epidemic "wave" affected countries which now report a few sporadic cases, achieving a stable late phase of the epidemic. other countries are beginning their epidemic expansion phase. the objective of our study is to characterize the dynamics of the covid- spread. data science methods were applied to pandemic, focusing on the daily fatality in countries with more than , deaths, our analysis kin the end retaining countries that have completed a full cycle. the analysis demonstrates a covid- dynamic similar in these studied countries. this -phase dynamic is like that of common viral respiratory infections. this pattern, however, shows variability and therefore specificity which the method categorizes into clusters of "differentiated epidemic patterns". among the detected clusters, main ones regroup of these countries, representing % of the world deaths (as of june , ). the pattern seems common to a very large number of countries, and congruent with that of epidemics of other respiratory syndromes, opens the hypothesis that the covid- pandemic would have developed its "natural history" by spreading spontaneously despite the measures taken to contain it. the diversity highlighted by the classification into "formal clusters" suggests explanations involving the notion of demographic and geographic epicenters. the first sars-cov- patients were detected around a food market in the city of wuhan, in china, in december [ ] . the outbreak then spread rapidly to all countries. it reached europe at the end of february . to date, the covid- pandemic has struck most countries in the world: countries have registered at least case. the pandemic continues to expand geographically, with very high impacts in the americas but also in some countries, such as india, which had been spared so far. each country starting on different dates illustrates various epidemic phases. countries that were affected at the beginning of the pandemic (china and many european countries) consider a completed epidemic cycle, while in other countries are in their early phases. the availability of data on the evolution of the pandemic is one of the remarkable features of this global event. this data was available quickly and has been compiled in unique sources, updated daily with a fairly good accuracy and relative completeness for each country [ ] . while acknowledging some heterogeneous reporting policies, the daily data sets present the advantage of reflecting real world dynamics of the epidemic, over time and in different places. modern data science techniques can characterize and compare temporal data. it seemed relevant to apply these methods to the covid- pandemic. among the available indicators, the evolution of deaths was considered most reliable to compare across countries. a preliminary analysis of the evolution of mortality selecting only countries with a complete epidemic cycle -determined a general pattern of covid- similar to some common winter respiratory viral . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july , . . infections. thus, covid- appears to reproduce a three-phase pattern: a phase of rapid progression of incidence ( ) until a peak is reached ( ) from which a decrease ( ) begins, until a low point of stabilization where the cycle is considered to be over. although this pattern is rather universally verified, there is some variability in the dynamic behavior of covid- between countries. the objective of this analysis is to characterize the dynamics of the propagation of covid- . to do so, requires a rapid and robust methodology: countries were categorized according to "differentiated epidemic patterns" based on their similarities or dissimilarities in terms of epidemic dynamics. we hypothesized a dynamic variability in time and space. the goal was to test the hypothesis looking for a specific epidemic pattern for covid- , exploring the natural history of this pandemic independently of the measures taken to contain it. the data used are those available on the john hopkins university website [ ] . this university makes several indicators available to the general public in open access, including the daily cumulative number of new cases, deaths and cured individuals. however, although the who published a clinical definition of cases very early on, it has evolved over time in part due to the evolving diagnostic tests. there are caveats about the reliability of case counting and definition, the number of tests performed, and whether or not some cases (eg. from retirement homes) are even reported or defined in different countries. these limitations pose serious difficulties to compare the dynamics in terms of the number of infected people. this determined the choice to more robust indicators such as the "daily death" used in all our analyses. the data have been subject to the following selection and specific processing operations: • selection o only countries infected with more than covid- deaths, representing the ninth decile (d ) were considered, i.e. a total of countries. o only countries that are advanced in the development of the epidemic, i.e. have passed the peak (stage ) and are well into the phase decline [ figure ] have been retained. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . affected by the covid- epidemic can be found on all continents. the most advanced in the epidemic cycle, shown in red in the graph, are those that were affected earliest and chronologically, moving from east to west: china then europe then north america. analyses of the epidemic pattern are carried out on the subset of countries for which the three phases of growth, peak and decline have been observed. • pre-processing o the curves for each of the selected countries were initially constructed using an n= day incidence o deferred readjustment values (i.e. by catching up) are anomalies and replaced, where appropriate, by the average value of the two closest neighbors (n+ ; n+ ). o negative impacts, corresponding to corrections for over-reporting of deaths, have been replaced by the average value of the two closest neighbors (n+ ; n+ ). o a double smoothing of the curves, in increments of , was performed using a triangular moving average (tma). this smoothing, often used in other fields [ ] , removes background noise, smooth curves further and highlights trend. the tma used here has two components: a -day moving average (sma) and a -day moving average, which buffers the possible effects of under-or over-reporting observed on week-end data. sma of size n for each pi was computed as follow where pi is the value at date i and n the window size, in days. it follows that tma of each point p is computed as: o time series were reduced centered [ ] for each country to cancel the influence of a size effect during clustering. o all country curves were rescaled from a "start of the epidemic" as reaching a slope of . [ ] . o once pre-processed, the average of the curves for the selected countries was calculated, with a % confidence interval [ figure ]. the study of time series is a very active field of research, this data format frequent and exploited, especially in acoustics [ ] , power management [ ] or health [ ] . in addition to prediction, time series can also be considered from a classification point of view, i.e. the grouping of curves according to their similarities/dissimilarities. the unsupervised classification approach makes it possible to apprehend logics and structures that differentiate behaviors [ ] . for this purpose, and in many applications [ ] , the k-means algorithm [ ] is used, together with the euclidean distance function. although the euclidean distance is intuitive and simple, it is not optimal for time series of variable ranges. dynamic time warping distance (dtw) [ ] is suitable for comparing time series of different sizes. this distance, used in the k-means algorithm, gives more accurate results than the euclidean distance [ ] . the following section provides a general explanation of k-means clustering and dtw distance measurement. k-mean clustering k-means clustering [ ] is a well-known and very simple clustering algorithm. the principle consists in regroup similar data in the same cluster using an objective function that minimizes the sum of squared errors between a cluster center and its members. the algorithm works as follows: . initialization of the k cluster centroids . measuring the membership between each data and all cluster centers and assigning the data to the appropriate cluster . calculating a new cluster centroid for each cluster using an averaging function . repeat steps and until the data in the clusters is stable the dtw distance [ ] is a measure of similarity that is generally used for time series, especially in classification [ ] . the optimal alignment and distance measurement between two p and q sequences can be determined as follows: the dtw distance is used to measure the similarity between time series and calculate the relative cluster centers to optimize our clustering. the optimal number of clusters was determined with the silhouette coefficient, a measure of the quality of the data segmentation. this was assessed by varying the number of clusters from to , with a gamma parameter from . to . , and by selecting the solution maximizing the silhouette score. the chosen solution, with a silhouette score of . , segmented the countries into clusters. the apparent similarity of the epidemic dynamics of the selected countries are prone to construction of the average curve of the evolution of the number of deaths, covering a period of days [ figure ]. the global pattern can be clearly identified, consisting of characteristic phases: strong growth over a period of to weeks, until a "peak" is reached, where the incidence of deaths gradually decreases, at a slower rate than the first phase of growth. this general pattern is therefore observed overall for all the countries under consideration. averaged epidemic dynamics -incidence of deaths -for the countries studied. the above curve represents the average profile of the country curves, shifted to phase growth from the reduced centred death data. a characteristic pattern consisting of phases emerges: an exponential growth phase, a peak with a slightly extended plateau and a decrease phase with a relatively regular slope, more linear than the first phase. a comparison of the countries can be assessed using the epidemic curve classification [ figure ] [ figure ]. we distinguish clusters, with specific profiles: . cluster gathers european countries (germany, belgium, spain, france, the netherlands) plus turkey, with a very strong similarity of their epidemic dynamics: a high peak and a regular decreasing phase. nevertheless, within this cluster, highlights germany, the netherlands and turkey, with a slightly more crushed peak and therefore a slightly longer maintenance at this stage of transition. . cluster brings together countries (canada, united states, united kingdom, italy, sweden) which share a common pattern: the decline phase is more uneven. . cluster , exclusively made up of iran, has a characteristic profile with a rebound from the th day. . cluster , made up of china, has a very symmetrical curve profile between growth and decline phases, and a short time to plateau. note the return to a (counter-intuitive) negative value due to the centered-reduced moving average, . cluster highlights the atypical nature of ecuador: a plateau more spread out at the peak and a less advanced stage in the epidemic cycle. the covid- epidemic, like other viral diseases, has an unsurprising dynamic characterized by the phases of growth, peak and decline. the incidence of deaths can be observed with a certain similarity between the countries that are most advanced in the epidemic, revealing a dynamic specific to covid- . behind this common global pattern, however, lie differences from one country to another, which this work highlights by classifying into time series. at this stage of the analysis, we can hypothesize which factors contribute to the differences between countries reflected in the classification. the notion of epicenter may play a role in the process of epidemic propagation, and consequently on the shape of the epidemic pattern, particularly in phase- of decline. an epicenter constitutes a locally active propagation hotspot. • it should be noted that countries of relatively small surface area (germany, belgium, spain, france, the netherlands, turkey), which have had a small number of epicenters, present an epidemic pattern characterized by a regular decrease, i.e. without marked rebounds. no doubt the epidemic control policies (lockdown, screening policies, etc.) may also have had an impact in limiting the multiplication of epicenters. in this respect, china reflects the case of a single controlled epicenter (city of wuhan) and perhaps constitutes the basic pattern of covid- . • conversely, countries with a larger surface area (canada, united states, iran), involving a larger number of potential epicenters, are characterized by a dynamic with a more uneven phase of decline, i.e. with rebound phenomena probably linked to the appearance of successive epicenters. the cases of russia and brazil will be assessed closely and could -a hypothesis yet to be confirmed -ultimately present an epidemic pattern resembling that of the united states or canada. • finally, the situation in the united kingdom or sweden, with a longer plateau phase, followed by a slower and relatively uneven decline, may relate to the specific containment policies in these countries. this analysis will be updated when more country epidemic cycles are complete, which is not the case for many of the affected countries. a study of epidemic patterns performed by epicenter could also refine previous hypotheses. when such data become available, it will be useful to work on excess mortality attributable a posteriori to covid- . finally, the variations observed through our analyses should be confronted with other explanatory hypotheses: can the different strains of the virus be associated with the general epidemic pattern? to what extent do the epidemic management policies also contribute to this pattern? how do the sociogeographical characteristics of the territory (surface area, urbanization poles, number and distance between epicenters, communication axes) affect the epidemic dynamics? the study addresses the epidemic form specific to covid- and, its characteristics. to answer this question, techniques from the field of time series data science were applied. the upstream preparation of the data, drawing the shape of curves, and the subsequent classification of these dynamics, according to their similarities/dissimilarities, illustrates an epidemic form. the dynamics of the covid- epidemic must be considered as having a general pattern. firstly, the average envelope of death curves, constructed from the most affected countries (i.e. % of global deaths), shows a characteristic pattern. secondly, within this envelope itself, there are dissimilarities that encourage segmenting the curves. the method used highlights two main clusters for of these countries, representing % of the world's deaths (as of / / ). the search for a history common to the countries of the same cluster resulting from the classification suggests geographical and demographic explanations involving the notion of epicenters contributing according to their numbers and their relationships within countries. ultimately, we wish to quantify the intrinsic characteristics of clusters, and to know how to describe and differentiate them objectively. in particular, we could explain the rebounds, visible in certain curves and invisible in the one we call the basic pattern of covid- , rebounds that we imagine result from the contributions of new epicenters, rather than from the resurgence of the covid- epidemic itself. « early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia coronavirus -ncov, csse. coronavirus -ncov global cases generating moving average trading rules on the oil futures market with genetic algorithms « clustering of time series data -a survey mckendrick et w. o. kermack, « a contribution to the mathematical theory of epidemics speaker verification using adapted gaussian mixture models a novel hybrid algorithm to forecast functional time series based on pattern sequence similarity with application to electricity demand » « decision system integrating preferences to support sleep staging « how much sugar do consumers add to plain yogurts? insights from a study examining french consumer behavior and self-reported habits. », appetite « a wavelet-based anytime algorithm for k-means clustering of time series « refining initial points for k-means clustering « using dynamic time warping to find patterns in time series description des alignements formés par dtw. ffhal- f this work was carried out within the biotechnology department of well&wiz, with the academic support of the laboratoire d'informatique de paris and the biotechnology department of esiee-paris. the authors declare no conflict of interest. key: cord- - c ec b authors: radfar, s. r.; de jong, c. a. j.; farhoudian, a.; ebrahimi, m.; rafei, p.; vahidi, m.; yunesian, m.; kouimtsidis, c.; arunogiri, s.; massah, o.; deylamizadeh, a.; brady, k. t.; busse, a.; isam-ppig global survey consortium,; potenza, m. n.; ekhtiari, h.; baldacchino, a. m. title: reorganization of substance use treatment and harm reduction services during the covid- pandemic: a global survey date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: c ec b background: the covid- pandemic has impacted people with substance use disorders (suds) worldwide, and healthcare systems have reorganized their services in response to the pandemic. methods: one week after the announcement of the covid- as a pandemic, in a global survey, addiction medicine professionals described covid- -related health responses in their own countries in terms of sud treatment and harm reduction services. the health response is categorized around ( ) managerial measures and systems, ( ) logistics, ( ) service providers, and ( ) vulnerable groups. results: respondents from over % of countries reported that core medical and psychiatric care for suds had continued; however, only % of countries reported having had any business continuity plan, and . % of countries reported shortages of methadone or buprenorphine supplies. participants of % of countries reported partial discontinuation of harm-reduction services such as needle and syringe programs and condom distribution. % of overdose prevention interventions and % of outreach services also having been negatively impacted. conclusions: participants reported that sud treatment and harm reduction services had been significantly impacted globally early during the covid- pandemic. based on our findings, we provide a series of recommendations to support countries to be prepared more efficiently for future waves or similar pandemics to ) help policymakers generate business continuity plans, ) maintain the use of evidence-based interventions for people with suds, ) be prepared for adequate medication supplies, ) integrate harm reduction programs with other treatment modalities and ) have specific considerations for vulnerable groups such as immigrants and refugees. global response to covid- pandemic in substance use treatment services  covid- negatively impacted services for pwsud globally.  addiction medicine downgraded more than other psychiatry services.  business continuity plan for pwsud services reported only in about half of the countries.  refugees & migrants had more negative impact compared to other vulnerable groups.  harm reduction services discontinued partially or totally during pandemic. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . abstract background: the covid- pandemic has impacted people with substance use disorders (suds) worldwide and healthcare systems have reorganized their services in response to the pandemic. methods: one week after the announcement of the covid- as a pandemic, in a global survey, addiction medicine professionals described covid- -related health responses in their own countries in terms of sud treatment and harm reduction services. the health response is categorized around ( ) managerial measures and systems, ( ) logistics, ( ) service providers and ( ) vulnerable groups. respondents from over % of countries reported that core medical and psychiatric care for suds had continued; however, only % of countries reported having had any business continuity plan, and, . % of countries reported shortages of methadone or buprenorphine supplies. participants of % of countries reported partial discontinuation of harm-reduction services such as needle and syringe programs and condom distribution. % of overdose prevention interventions and % of outreach services also having been negatively impacted. conclusions: participants reported that sud treatment and harm reduction services had been significantly impacted globally early during the covid- pandemic. based on our findings, we provide a series of recommendations to support countries to be prepared more efficiently for future waves or similar pandemics to ) help policymakers generate business continuity plans, ) maintain use of evidence-based interventions for people with suds, ) be prepared for adequate medication supplies, ) integrate harm reduction programs with other treatment modalities and ) have specific considerations for vulnerable groups such as immigrants and refugees. is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . coronavirus disease (covid- ) was announced as a pandemic by the world health organization (who) on march th, ("coronavirus disease (covid- ) pandemic," ). covid- quickly became a global concern given the rapid transmission of sars-cov- (the infectious agent), lack of a vaccine or evidence-based treatments, person-to-person airborne spread of sars-cov- and high mortality of covid- in specific populations, especially marginalized groups and/or those with pre-existing conditions (han, kim, chung, park, & cheong, ; masozera, bailey, & kerchner, ; onder, rezza, & brusaferro, ) . lack of capacity to anticipate, cope with, resist, and recover from covid- -related health consequences are related to individual vulnerability (adger, ) . to manage the current situation as best as possible, vulnerable groups should be recognized and helped with special considerations by relevant health systems (marsden et al., ) . according to the world drug report , among approximately million people with pastyear drug use, over million people experienced substance use disorders (suds) (knopf, ) . people with suds (pwsuds) may be particularly vulnerable to covid- and complications for multiple reasons (volkow, ) . pwsuds experience underlying diseases that constitute risk factors for covid- infection or can be exacerbated by it; for instance, long-term use of substances may cause cardiovascular problems (havakuk, rezkalla, & kloner, ) and chronic obstructive pulmonary disease (riezzo et al., ) . such co-morbidities may exacerbate superimposed covid- symptoms and lead to higher mortality rates (arya & gupta, ; lai, shih, ko, tang, & hsueh, ). poor immune system functioning is also prevalent in pwsuds as a result of chronic alcohol and drug use and blood-borne or sexually transmitted illnesses (cook, ; szabo & mandrekar, ) , poor nutritional status (bhaskaram, ) , and socioeconomic factors (spooner & hetherington, ) . among pwsuds, people who inject drugs (pwids) are at particularly high risk of covid- , as well as overdoses, unsafe injections and risky sex (vasylyeva, smyrnov, strathdee, & friedman, ) . . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . psychological conditions (e.g. phobia, anxiety and panic attacks) during natural disasters and pandemics that may precipitated, perpetuated or exacerbated through social isolation and quarantine, may lead at-risk people to start and/or relapse into drug-taking (arya & gupta, ; nobles, martin, dawson, moran, & savovic, ) . psychiatric comorbidity has a negative impact on recovery from covid- and may increase risk of non-fatal and fatal overdoses and suicides (clay & parker, ; de sousa, mohandas, & javed, ; frank, fatke, frank, förstl, & hölzle, ; nobles et al., ) . in the general population, covid- and related concerns such as potential mortality may act as internal stressors (liu & doan, ) and promote cognitive impairments (zarrabian & hassani-abharian, ) in domains such as decisionmaking (starcke & brand, ) , problem-solving (cheng & lam, ) , and attention (dutra, marx, mcglinchey, degutis, & esterman, ) , and thus may increase the incidence and prevalence of psychiatric disorders including pwsuds (fiorillo & gorwood, ; pfefferbaum & north, ) . stigma may undermine social cohesion, contributing to situations in which the virus is more, not less, likely to spread. such spread may result in more severe health problems and difficulties controlling a disease outbreak (ren, gao, & chen, ) . there is an elevated likelihood for pwsuds to be homeless and live in crowded shelters and neighborhoods (coetzee & kagee, ) . synergistically, poor economic status linked to limited accessibility to health care (ahern, stuber, & galea, ; o'sullivan & bourgoin, ) may exacerbate risks for pwsuds and pwids (vasylyeva et al.; ying, yang, & jianming, ) . drug supply chains may be disrupted, and changes in licit and illicit markets may be accompanied by reductions in quality and safety (knopf, ; nagelhout et al., ; rowe et al., ; emcdda, europol, ) . furthermore, patients' accessibility to treatment services could be restricted due to lockdown policies (bojdani et al., ; roncero et al, ) . patients receiving opioid agonist treatment (oat) may not be able to access daily doses of medications (arya & gupta, ) ; spatial distancing may make home detoxification difficult; closing of non-essential services and utilising staff and other resources to manage acute covid- cases could result in sudden and uncoordinated closures of services for pwsuds (emcdda, ) . individuals who use multiple . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . substance may be particularly impacted (mellis am, in press ). adaptive capacities of systems to epidemic situations that need coordinated responses may relate directly to vulnerabilities of the same systems (smit & wandel, ) . accessibility to and equal distribution of wealth (financial and other resources, reliable and correct information and communication channels, appropriate and proportionate working technologies) compounded by reductions in social and relationship capital may impact social resilience to coping with pandemics (dolan & walker, ) . to understand better complexities that are challenging addiction treatment and harm reduction services globally, the international society of addiction medicine (isam) has been conducting a longitudinal global survey aiming to evaluate rapidly and over time how different countries are maintaining and/or reorganizing their substance use treatment and harm reduction services during the covid- pandemic. this paper will report on how different countries have adapted their health system response to emerging needs in the first month after the official announcement of the pandemic by the who. description of the methodology used for this survey has been published as a study protocol (baldacchino et al., ) . potential respondents were contacted on april th , asking about the covid- pandemic impact on pwsuds in their own countries. data collection was concluded on may th , . the questionnaire consisted of questions in two main areas: ( ) situation assessment during the pandemic; and, ( ) health responses to the pandemic. this paper will focus on health responses during the covid- pandemic period (baldacchino et al., ) . results on the situation assessment is reported in another publication (farhoudian, radfar, et al., ) . questions around health responses to the pandemic were grouped into categories: ( ) systems available to respond to acute emerging needs due to the covid- pandemic within substance use services; . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . ( ) availability of protocol and/or guidelines around covid- and pwsuds; and, ( ) reduction in face-to-face contacts as a result of lockdown policies. to assess respondents' overall views, they were asked to score the "overall situation at a glance" rating scale questions (rsq) (between to with for the worst situation and for the best situation) based on their opinion regarding the overall quality of the situation of their country for each of the above sections. the statistical annex of world economic situation and prospects (wesp) ("world economic situation and prospects ," ) was used to categorize responding countries. very low-and low-income categories were merged into one, retaining middle-and upperincome countries designations. in figures, countries' names are sorted alphabetically in each group of high-, middle-and low-income categories. the number of respondents (for countries with more than one respondent) is indicated in front of their names, and numbers in each column represent valid responses from each country. statistical analyses were performed using spss version (ibm corp., armonk, n.y., usa) and rstudio (version . . ). descriptive data are presented as means and percentages for each country's response mean (percentage), as well as an average to the global responses. the survey protocols and all materials, including the survey questionnaires, received approval from the university of social welfare and rehabilitation sciences, ethics committee in tehran, iran (code: ir.uswr.rec. . ). a total of respondents from countries participated. figure shows the distribution of the countries and number of participants from each. among respondents, ( . %) were . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint from high-income, ( . %) from middle-income, and ( . %) from low-income countries ("world economic situation and prospects ," ). table shows respondents' demographic characteristics classified by their associated countries' income. among respondents from high-income countries (n= ), % answered that business continuity/contingency plans had been implemented in their countries to make sure that services continued to operate for pwsuds during the covid- pandemic compared to . % in middle-income (n= ) and . % (n= ) in low-income countries. overall, respondents from % of participating countries reported that business contingency plans had been arranged to help ensure that continuity of services during the pandemic (figure ). . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint among respondents from high-income countries (n= ), % answered that treatment and harm reduction services for pwsuds had been available and accessible in their countries during the pandemic onset compared to . % in middle-(n= ) and % in low-(n= ) income countries. overall, respondents from % of participating countries reported that treatment and harm reduction services for pwsuds had been available and accessible during the initial period of the covid- pandemic (figure ) . respondents from over % of participating countries (n= ) reported having experienced limitations in the usage of any outreach services due to lockdown policies for homeless pwsuds. furthermore, respondents from % of participating countries reported having experienced limitations in their harm reduction overdose services during the initial period of the pandemic. problems with the distribution of take-home naloxone were reported by respondents from % of participating countries. respondents from . % of the participating countries reported shortages in needle and syringe programs (nsps) and/or with respect to condom distribution. among respondents from high-income countries (n= ), % answered that medical and psychiatric care for pwsuds had been available during the initial stages of the pandemic compared to . % in middle-income (n= ) and . % in low-income (n= ) countries. overall, respondents in % of participating countries reported that necessary medical and psychiatric care for pwsuds had continued in their countries during this period (figure ). however, respondents in . % of participating countries reported having experienced shortages of opioid medications (methadone or buprenorphine). . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . only . % of respondents from high-income (n= ), . % from middle-income (n= ) and . % from low-income (n= ) countries reported that covid- screening and/or diagnosis test kits based on local/national guidelines for pwsud had been available in their country. overall, respondents from only % of the participating countries reported that there had been enough personal protective equipment (ppe) available for pwsuds during the initial stage of the pandemic. respondents from . % of participating countries reported sud health workers' safety as a concern for employers in the outpatient treatment centers, . % had received training regarding their safety and . % reported that they had had access to enough ppe. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . distribution of other responses on the effect of covid- on substance use treatment and/or harm reduction services to vulnerable groups such as children, women, pregnant women and immigrants or refugees can be seen in table and figure . table shows existence of services for children, women, pregnant women and refugees or immigrants among the countries based on their income group. overall, . % of all respondents replied that service for children continued as usual compared to . % that replied service for children continued but with limitations. according to the responses, in all three groups of income countries treatment and/or harm reduction services for pregnant women were a group with minimum impact from covid- . refugees and . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint immigrant population was the group that their services impacted more than other groups due to covid- . only . % replied that service for refugees and/or immigrants population continued as usual and . % replied that this service continued but with limitations. services for children, pregnant women, refugees, and women, in high, middle-and low-income countries are depicted. the red, yellow, and green bars depict the responses indicating lack of availability of services during the covid- pandemic, existence of limited services, and usual service provision, respectively. overall, respondents from % of the participating countries reported the presence of local and/or national guidelines tailored to be used during the initial stage of the pandemic ( . % in high-income, . % in middle-income and % in low-income countries). among respondents from high-income countries, . % answered that there had been a protocol available for covid- screening in different sectors of treatment for pwsuds or harm reduction facilities compared to % in middle-income and . % in low-income countries. over % of respondents from high-income, . % from middle-income and % from lowincome countries reported that there had been guidelines available that helped service providers in the management and/or referral of pwsuds with symptoms of covid- . . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . most respondents replied that there had been plans to restrict personal contacts and decrease patients' commutes for treatment in their countries ( %, %, . % in high-, middle-and low-income countries, respectively and % overall) due to their national and regional lockdown policies. as a result, respondents from % of the participating countries reported that clinicians had been prescribing longer-period prescriptions (e.g., days rather than weekly) to pwsuds during the onset of the pandemic ( figure ) . additionally, around % of participating countries reported that clinicians within oat programs had provided more take-home doses of methadone and/or buprenorphine during the onset of the pandemic. regionally, . % of respondents from high-income, % from middleincome and . % from low-income countries reported this approach had been used in their countries ( figure ). respondents from high-income countries most frequently reported having had availability of long-acting injectable buprenorphine ( . %; n= ). overall, respondents from % of participating countries reported that long-acting injectable buprenorphine had been available as a therapeutic option. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . figure shows the average score of each question based on income categorization. maximum contrast between high-and low-income countries was seen in the availability and access to treatment and harm reduction services. maximum and minimum differences between highand middle-income countries were observed in flexibility in service provision and countries' reactions to the covid- pandemic, respectively. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . https://doi.org/ . respondents were asked to rate the overall flexibility of their health system in different domains from (extremely poor) to (extremely good). an average for all rating scale questions in different domains has been calculated, and figure shows the results in a global map format. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint figure . score represents for the worst quality in response and represents the best situation in favor of health services. average scores for each country are shown using a color spectrum from yellow to blue. the emergence of covid- in early raised considerable challenges for substance use treatment and harm reduction programs around the world as reflected in this global survey. the need for effective spatial distancing and isolation to protect patients, the treatment workforce, and people in contact with patients and health workers has placed increased demands on treatment services provision, with potential imbalances in impact on particularly vulnerable patient populations (mellis et al., in press) . here, in this global survey we have explored different challenges and health responses in countries. our findings showed that respondents from % of participating countries reported business contingency plans had been arranged to help ensure that services would continue to operate during the pandemic, which is compatible with responses to another question indicating that % of respondents believed there had not been sufficient availability and accessibility of treatment and harm reduction services during the onset of the pandemic in their countries at the time of survey completion. as a preventative measure to reduce covid- spread, all international and national published guidelines advised limited but effective ways regarding how to initiate treatment, support . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint stabilization and maintenance and continue to provide harm reduction measures to treatmentseeking and other populations with substance use problems (farhoudian, et al., ; marsden, et al., ) . these recommendations often included extending flexibility in oat services with reduced supervision of doses and increased home delivery (dunlop et al., ; peavy et al., ) . another step taken to adjust to the present situation included expanding telemedicine and teletherapy services (farhoudian, baldacchino, et al., ; knopf, ; elizabeth a samuels et al., ; mellis et al., in press ). the covid- pandemic issynergistic interacting with a substance use epidemic globally creating a syndemic (defined as a synergistic epidemic, the aggregation of two or more concurrent or sequential epidemics, which exacerbate the prognosis and burden of disease (singer, bulled, ostrach, & mendenhall, ) ). during the covid- pandemic, marginalized people including pwsuds are at greater risk of increased morbidity and mortality (dorahy et al., ) . these syndemically disadvantaged populations may be more likely to experience disparate, possibly substandard, service provision in systems prioritizing resource needs around a pandemic response (inverse response law and inverse care law) (phibbs, kenney, rivera-munoz, & huggins, ) . such inequities may present at macro levels around effective and appropriate policymaking at national, organizational, and local levels (phibbs et al., ; watt, ) and at micro levels around areas of access to resources, social services, public health benefits of medical treatments, pharmacies, health care facilities and provision of medical equipment (davis, wilson, brock-martin, glover, & svendsen, ; runkle, brock-martin, karmaus, & svendsen, ; watt, ) . proactive business continuity plans for pwsuds are important for all governments as part of covid- re-mobilization plans and possible future responses to similar pandemics to support and avert delays and inequities in responses. pwsuds are at risk for negative impact of covid- (khatri & perrone, ; volkow, ) , and our findings showed that % of respondents reported continuity of other necessary medical and psychiatric care compared to less than % who reported existence of business continuity/contingency plans and enough availability and accessibility of treatment and harm reduction services for pwsuds. these findings suggest that . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . policymakers and health authorities in each country could have possibly made more appropriate decisions in order to protect at-risk and marginalized pwsuds including those who may be homeless, have hiv/aids, hepatitis, or multiple and complex morbidities. such decisions may involve considering how best to provide scheduled and new appointments and prescription medications in the circumstances of lockdowns. based on our finding in this global survey, we provide the following recommendations. continuity of services especially in crisis situations needs certain, evidence-based, and locally tailored protocols and guidelines. in our study, addiction medicine professionals reported that most of their countries did not provide early guidelines or protocols to tailor their services to the pandemic. it is important to consider that respondents in only one-third of low-income countries reported the availability of such guidelines compared to respondents in half of highincome countries. another survey (mongan, galvin, farragher, dunne, & nelson, ) conducted in four high income regions (new south wales, ireland, scotland, new york state, and british columbia) found that special guidelines in response to the new situation and assurance of continuity of the services were available very soon after the start of lockdown, which is consistent with our findings that high income countries had a more timely response in this domain. in the absence of guidelines and protocols, clinicians and service providers may not effectively balance different competing ethical and professional issues when they are making clinical and operational decisions when many things may be happening that could potentially be conflicting in nature (e.g. maintaining stability but reducing therapeutic contacts). guidelines also allow stakeholders to improvise and identify innovative ways through . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint evidence-based solutions to help decrease the dual burden of substance use and covid- infection sokol, gupta, powers, hoffman, & meza, ) . governments and local authorities should be cognizant that an effective response system is based around a well informed and supportive environment. available and communicated international and national clinical guidelines are pivotal in future responses to similar pandemics when supporting pwsuds. the world drug report stated that, "if governments respond the same way to the current economic slump, interventions such as prevention of drug use and related risk behaviors and drug treatment services could be hard hit" (nations, ) . substance use accounts for approximately % of the global health burden (forouzanfar et al., ) . treatment is one important strategy for reducing the burden of disease. a study of world mental health surveys (organization, ) found that only . % of pwsuds had received at least minimally adequate treatment in the past year ( . %, . % and . %, respectively, in high-, upper-middle, and low/lower-middle income countries) (degenhardt et al., ) . poor access to treatment, awareness/perceived treatment need, and compliance (on the part of both provider and client) have been reported to be main barriers for substance use treatment (degenhardt et al., ) . our results showed that shortage of opioid medication for maintenance treatment was reported by respondents from about % of participating countries. lack of opioid medications in patients undergoing maintenance treatment is a risk factor for lapse, relapse and/or overdoses. this situation may become more severe when transport and other supply chains are disrupted compounded with reduced provision by pharmacies and other dispensing outlets either due to spatial distancing, reduced hours of service and/or closing during the pandemic. international organizations with regional and local government structures should create contingencies around adequate supplies of medications such as methadone and buprenorphine. harm reduction services, especially outreach services, are among the most effective strategies for prevention of hiv, hcv and hbv transmission among the most at risk . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . populations (nazari et al., ; needle et al., ; peak, rana, maharjan, jolley, & crofts, ) . harm reduction services seem to be among the most affected during the initial stages of the covid- pandemic. eighty-one ( ) % of participating countries reported limitations in usage of any mobile and other outreach services due to lockdown policies for homeless pwsuds, with respondents from % of participating countries reporting limitations in their harm reduction overdose services during the initial period of the pandemic. this was compounded with reported problems with the distribution of takehome naloxone as reported by respondents from % of participating countries. finally, respondents from . % of participating countries reported that there have been shortages at needle and syringe programs and/or of condom distribution. harm reduction initiatives should be seen as an integral part of an evidence-based treatment program and not as an adjunct to failed treatment and/or solely as a public health response to reduce blood-borne diseases. service providers should be considering identifying person-centered, continuous care provision in all therapeutic options available (harm reduction initiatives included) especially during pandemic situations pregnant women and immigrants /refugees with suds are particularly vulnerable groups. according to survey responses, pregnant women were perceived as relatively less impacted during the initial period of the pandemic. this is reassuring as discontinuity of treatment services could place not only a pregnant woman at high risk, but also the developing fetus. however, refugee and immigrant populations were reported as having had their services impacted more than other groups due to the pandemic. only . % of respondents replied that service for refugees and/or immigrants population continued as usual, and . % replied that this service continued but with severe limitations. . cc-by . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . availability of all relevant resources is essential in the delivery of quality services. our findings suggest that in general in multiple domains of countries' reactions to the pandemic (e.g., availability of and access to treatment and harm reduction, screening and early interventions, flexibility in service provision and services for special and high-risk populations), the covid- pandemic has had more negative impact that is linked to the income level of countries. this study has multiple limitations. the responses obtained was intentionally based around personal opinions of addiction medicine experts to help understand the "state of things in real life" rather than objective epidemiological data which would have been considerably delayed. the limited number of respondents makes this information non-representative and possibly biased. given the urgency of the covid- pandemic, the aim of the paper is to alert and inform colleagues around the world and facilitate collaboration. due to the time limitations, the questionnaire was circulated only in english. therefore, some experts may have withdrawn from the survey for lingual reasons and others may have answered questions less precisely. addiction medicine systems in all countries, regardless of income level, have been affected to some degree by the covid- pandemic. depending on the different domains and the ability of countries to adapt to existing conditions, these effects may differ across jurisdictions. income level may relate importantly to responses and impact vulnerable groups like pwsuds. our recommendations will hopefully support a more resilient system of care that improves responses to future covid- waves and other pandemics. authors declare no conflict of interests. anja busse is a staff member of unodc. the authors alone are responsible for the views expressed in 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telemedicine neighborhoodlevel and spatial characteristics associated with lay naloxone reversal events and opioid overdose deaths secondary surge capacity: a framework for understanding long-term access to primary care for medically vulnerable populations in disaster recovery innovation during covid- : improving addiction treatment access innovation during covid- : improving addiction treatment access syndemics and the biosocial conception of health adaptation, adaptive capacity and vulnerability guidance for treating patients with opioid use disorder (oud) with buprenorphine-naloxone (b/n) in the covid- era via telehealth: a review of previous evidence, new covid- oud treatment guidelines social determinants of drug use: national drug and alcohol research centre decision making under stress: a selective review a recent perspective on alcohol, immunity, and host defense challenges posed by covid- to people who inject drugs and lessons from other outbreaks collision of the covid- and addiction epidemics: american college of physicians psychiatry hospital management facing covid- : from medical staff to patients covid- pandemic and the importance of cognitive rehabilitation. basic and clinical neuroscience authors would like to thank arash khojasteh zonoozi and hossein mohadess ardebili for their insightful comments into the initial draft of the manuscript. key: cord- - ao rq authors: cossart, yvonne e title: the rise and fall of infectious diseases: australian perspectives, ‐ date: - - journal: med j aust doi: . /mja . sha: doc_id: cord_uid: ao rq australia has been fortunate in its experience with infectious diseases over the past century. by the s, many communicable diseases were controlled through a combination of high living standards, progressive adoption of vaccines and antimicrobial treatment. australian medical scientists have made substantial contributions to the understanding of many historically significant communicable diseases and global initiatives for control. new challenges have emerged as previously unrecognised viral infections have emerged, and microbial resistance to antibiotics has developed in many old pathogens. ongoing evolutionary forces, both environmental and social, change the balance between humans and microbes. the effects of these forces are most sorely felt in poor countries and communities. i n , when the british medical association launched the medical journal of australia, the medical profession and the general public believed that infectious diseases would soon be conquered. acrimonious th century disputes between the contagionists and the sanitarians had given way to an alliance which was steadily improving health. rising living standards reduced infant deaths from gastroenteritis, through better food and water hygiene, and reduced deaths from "consumption" (tuberculosis), because of better nutrition. the success of rat extermination in controlling plague in sydney provided a triumphant validation of new microbiological theories; joseph lister's carbolic spray was adopted by local surgeons; emil von behring's antitoxin treatment reduced mortality from diphtheria; and paul ehrlich's vision of a magic bullet to cure all infections was given credibility by the effi cacy of salvarsan (arsphenamine, an arsenic-containing compound) against syphilis. maritime quarantine provided a signifi cant, if not impregnable, barrier to the introduction of epidemic diseases. the mja refl ected the progressive mentality of australian doctors through reports on new international discoveries and leading articles. in reality though, infection still caused at least a quarter of all deaths, % due to tuberculosis alone. many of the victims were children or young adults. eradication of bovine tuberculosis produced a welcome fall in infant cases, but about cases continued to be notifi ed annually between and . the fi ne sanatorium buildings in "healthy" locations such as the blue mountains are reminders of the desperate attempts to combine sanitary and microbiological principles by isolating patients to prevent spread of the disease while they were treated with rest and diet. , , during world war ii (wwii), intensive screening of australian troops by miniature x-ray was followed up with bacteriological testing to identify patients with active infection, for whom treatment was compulsory. the success of this program prompted a postwar attempt to eradicate the disease from the civilian population, and the advent of streptomycin and sickness benefi t payments made compulsory treatment acceptable to the community. tuberculosis has again become resurgent in many countries. the high expense and long duration of triple therapy test the resources of the poorest countries. undertreatment allows emergence of multidrug-resistant strains for which treatment reverts to pre-antibiotic options. in australia, such strains are, mercifully, still uncommon. syphilis also imposed a high burden of chronic disease on society. in , about % of admissions to mental institutions and % of cases of aortic aneurysm in victoria were due to tertiary syphilis, while % of pregnant women had positive wassermann test results. the social stigma of sexually transmitted diseases and the heroic nature of combined mercurial and salvarsan therapy deterred many asymptomatic patients from seeking treatment. notifi cation of acute cases and compulsory treatment were not successfully implemented, even in the army. in civilian settings, policies of testing only female prostitutes doomed any hope of eradication. many acute infections also remained endemic. there were dedicated wards for patients with typhoid in general hospitals, and the prevalence and mortality of typhoid remained high until the advent of antibiotics. bedside vigils to await the crisis of pneumonia were all too familiar, and childhood infections claimed many young lives. in , gastroenteritis, diphtheria, scarlet fever, whooping cough and measles between them killed one of every live-born children. about as many more died from pneumonia and meningitis. in the interwar decades, diphtheria and pertussis vaccines were produced in the newly established commonwealth serum laboratories and school-based vaccination began. but in , public confi dence was shaken by the bundaberg tragedy, in which a multidose vial of diphtheria toxin-antitoxin became contaminated with staphylococci from the skin of a vaccinee. twelve other children died. this galvanised regulation of vaccine manufacture, safety testing and surveillance for adverse effects. however, almost a century on, the antivaccination movement still opposes mass vaccination of children in early life. during its fi rst few years of publication, the mja reported on mortality due to infection among wwi troops, which exceeded combat deaths. but the battlefi elds were also a clinical laboratory where the effi cacy of tetanus antitoxin was proven and typhoid vaccination was introduced. the mja also reported episodes which, with hindsight, showed that evolutionary forces were altering the balance between microbes and their human hosts. in , infl uenza killed more europeans than had perished in the war. the source of the pandemic strain remains obscure, but there is no doubt about the role of returning troops in its global spread. australia's isolation and its quarantine system protected it for some time, but eventually the country experienced a catastrophic outbreak. australia became an active participant in the subsequent international efforts to maintain surveillance and produce effective infl uenza vaccines. pivotal infl uenza studies led by frank macfarlane burnet at the walter and eliza hall institute were conducted during this period, and the institute's interests soon broadened into basic scientifi c research on many important infections. in the postwar period, the establishment of the australian national university strengthened the national capability in infectious diseases research. poliomyelitis was on the increase in the most "hygienic" countries of scandinavia, north america and australasia: a paradox for an infection spread by the faecal-oral route. this was the penalty for the delay in the average age when infection occurred, which was a consequence of improved hygiene. this in turn increased the numbers of clinical cases because the chance of neurological involvement increased spectacularly with age. the crippling legacy of infection made the sight of children with leg braces all too familiar in schools nationwide, while the invention of the iron lung enabled many patients with respiratory paralysis to survive. norman gregg's pivotal discovery of the role of rubella in causing congenital defects altered scientifi c attitudes to infections during pregnancy. it was almost two decades before cell culture techniques paved the way for vaccines against polio, and then other childhood infections. the growing list of vaccines demanded new combinations to reduce the number of injections needed, and the cost became an issue even in wealthy countries where the plummeting prevalence of vaccine-preventable diseases justifi ed the investment. in the second half of the th century, even the basic triple antigen (diphtheria, tetanus, pertussis) was unaffordable in many developing countries, but international philanthropy plus political support have progressively been mobilised, resulting in signifi cant reduction of vaccine-preventable disease. money is not the only problem. the projected global eradication of polio has stalled because confl icts in africa and pakistan have disrupted infrastructure and fanned ideological doubts about the political motivations of governments and charities. in the optimistic political climate of the post-wwii years, the world health organization undertook an unprecedented program to achieve global eradication of smallpox. frank fenner was chairman of the project's management commission. using edward jenner's th century vaccination technique and an international army of fi eld workers, smallpox eradication was achieved in . it remains the only example of intentional eradication of a human infectious disease. not all microbial evolution resulted in populations of organisms with increased virulence for humans. scarlet fever, after causing devastating epidemics in the late th century, declined in terms of incidence and mortality by the s. this was attributed to the loss of toxin-encoding genes from streptococcus pyogenes. conversely, recent resurgence of severe streptococcal infections underlines the mutability of "old" pathogens. antimicrobial drugs sulfonamides made their spectacular entry into medicine just before wwii and cut the mortality from pneumonia and puerperal fever dramatically. prontosil, a forerunner of all sulfonamide drugs, was not patentable, and manufacturers fl ooded the market with sulfonamide-like drugs. penicillin soon followed -with australian scientist howard florey being a key fi gure in its development -and was quickly adopted in military medicine. the antibiotic era had begun; as discovery followed discovery, it seemed that no bacterial infection would remain untreatable. osteomyelitis, empyema, rheumatic fever and subacute bacterial endocarditis disappeared from the wards, and gonorrhoea and syphilis notifi cations plummeted. patients expected to recover from septicaemia, pneumonia and even meningitis; but it did not take long for the fi rst drug-resistant organisms to appear. sophisticated medical technology has offered unprecedented opportunities to microorganisms. drug resistance has rapidly developed owing to selective pressure resulting from profl igate use of antibiotics in medicine and agriculture. australian hospitals experienced some of the earliest outbreaks of antibiotic-resistant staphylococci, which led to radical improvements in infection control. although most of the resistant organisms were no more (and often less) virulent than the original susceptible strains, their competitive advantage meant that acute urinary infections could no longer be reliably treated with ampicillin, nor gonorrhoea with penicillin, by the mid s. discovery of new antibiotics could not keep pace, and regulatory attempts to restrict their use have proved diffi cult. transfusion-associated hepatitis b infection was discovered during wwii. after the virus was identifi ed in , it was found that about . % of most western populations were chronically infected, but carrier rates of % or more were common in asia and africa. moreover, these rates diptheria* patients expected to recover from septicaemia, pneumonia and even meningitis; but it did not take long for the fi rst drug-resistant organisms to appear were maintained by silent transmission -from mother to infant during delivery, rather than by intravenous drug use or blood transfusion. before blood banks started screening donated blood for hepatitis b, transfusion was a major route of transmission of acute hepatitis b infection in western countries. the need for mass screening prompted development of commercial testing kits, which have revolutionised laboratory diagnostic services. the most concerning feature of hepatitis b infection was the recognition during the s that adult carriers often developed liver cancer, which was then the leading cause of cancer deaths in asia. rather than a rarity, hepatitis b was a major global health problem; this justifi ed universal infant vaccination, which was made possible by recombinant dna technology in the s. the hepatitis b vaccine was the fi rst human recombinant dna vaccine and the fi rst human cancer vaccine. other agents soon emerged from obscurity, often in response to changes in human activity. aids fi rst appeared in the gay communities of "world cities" in the early s -the downside of sexual liberation. the inexorable rise in prevalence and apparently inevitable mortality of hiv infection spurred public health initiatives and scientifi c investigation. in australia, safe-sex campaigns had an almost immediate effect in reducing numbers of new cases, as did controversial needle-exchange and harm-minimisation strategies for injecting drug users. global investment in research led to effective antiviral drugs and greatly extended the healthy lifespan of infected individuals in western countries. however, in the populous countries of africa, south america and asia, heterosexual transmission dominated and led to epidemics of neonatal infection via transplacental transmission. this social and economic catastrophe reawakened respect for infection, and also fuelled fear of nosocomial transmission of bloodborne viruses. the shadowy entity of non-a, non-b hepatitis unexpectedly proved to cause both liver cirrhosis and cancer. acute hepatitis c infection causes only minor symptoms, but the hepatitis c virus often establishes chronic infection with sinister consequences. tests were developed to screen donated blood and it soon became apparent that injecting drug use had silently amplifi ed prevalence of hepatitis c infection in young people in western countries. hepatitis c infection became the commonest indication for liver transplant in australia, and health authorities struggled to fi nd an effective control strategy. treatment was protracted and beset by the adverse effects of interferon, a key component of drug regimens that were initially used. newer drugs achieve high cure rates, but cost puts them out of reach for patients in poor countries, where the reservoir of infection remains high. human papillomavirus was the fourth "new" infection to engage late th century society. genital warts were well known to the ancient romans, and for centuries they were regarded as an embarrassing but harmless sexually transmissible disease. this attitude changed dramatically when their association with cervical cancer was established in the s. the high-risk types of papillomavirus produce "fl at" penile warts which are easily ignored, but results of cervical cytology testing made the cancer connection -it was noted that cells with telltale warty changes were often seen in cervical smears which had malignant or premalignant changes. in australia, preventive human papillomavirus vaccination was pioneered by ian frazer and viral dna detection has been added to screening by pap smear, but neither of these approaches are affordable in poor countries, where death rates from cervical cancer are highest. the challenges of demographic and environmental change in , old infections still lurk, while human and environmental changes create new opportunities. malaria -which depends on humans as a reservoir for the parasite and mosquitoes for transmission -was vulnerable to a combination of treating patients with drugs and spraying the environment with dichlorodiphenyltrichloroethane (ddt) to kill mosquitoes. large areas of the temperate zone and even the tropics became malaria free but, because mosquito eradication measures were inconsistently applied, drug-resistant parasites and ddt-resistant mosquitoes soon emerged. in the absence of an effective vaccine, prevention now relies on avoidance of mosquito bites by use of repellents, protective clothing and screens, plus an ever-diminishing number of effective prophylactic drugs. malaria has been holding its own in many countries, aided by global warming. military deployment of troops in exotic areas and largescale movement of refugees are associated with outbreaks of communicable diseases. cholera has been a recurrent problem when people seek shelter from war or natural disaster, most recently in haiti. hantaan virus caused over cases of korean haemorrhagic fever and almost deaths among american troops during the korean war. the soldiers were exposed through inhalation of aerosolised rodent faeces when camped in wilderness areas. other haemorrhagic fevers -such as ebola virus disease and lassa fever, for which native wildlife act as reservoirs -have caused human outbreaks with high mortality, particularly in sub-saharan africa. australia has several indigenous arboviruses, including murray valley encephalitis, and ross river and barmah forest viruses. as global population pressure drives clearance of forested areas for agriculture, humans have become targets for many infections carried by wild animals. in australia, outbreaks of hendra virus infection and the emergence of the australian lyssavirus have been linked to contact with fl ying foxes. severe acute respiratory syndrome (sars), which caused a deadly outbreak of respiratory disease centred in southern but was transmitted to humans via infected palm civets, which were often for sale in chinese markets. control of sars was achieved through international cooperation in identifying the new coronavirus and applying strict isolation procedures. even so, the high mortality brought home to the world the potential threat of contagious disease. memories of the infl uenza pandemic lent renewed vigour to the who surveillance system for respiratory infections that emerge from reservoirs of infl uenza viruses in pigs, horses, poultry and wild birds (the latter two in particular). alas, the ability to identify novel strains has not been matched by the ability to predict infectivity and severity of disease. intensive agricultural production also provides new routes of infection. mad cow disease resulted from the use of inadequately rendered animal-based food supplements for cattle which allowed the variant creutzfeldt-jakob disease agent to survive. infected cattle often reached maturity and were slaughtered for human consumption before they developed clinical disease, and then humans became infected. the ramifi cations of this outbreak were economic and social. more new infections will undoubtedly emerge as humans change their environment. these pressures also affect old infections such as tuberculosis, malaria, cholera and even plague. the lessons of the past should not be forgotten. for a hundred years, the mja has reported on the overall decline of most infections in our "lucky country" -the result of our high standard of living combined with rational treatment and control measures. aboriginal australians who endure poverty and limited access to medical resources have not shared this luck. this mirrors the disparity in communicable diseases mortality between industrialised and developing countries. abolishing this gap is the immediate priority for the forthcoming century. provenance: commissioned; externally peer reviewed anticontagionism between and the australian mortality decline: all-cause mortality - on the epidemiology of plague the beginning of antiseptic surgery in australia the diphtheria prophylactic of e. von behring sex, disease and society: a comparative history of sexually transmitted diseases and hiv/aids in asia and the pacifi c australian quarantine service. maritime quarantine administration. melbourne: arthur j mullett, government printer tuberculosis in new south wales: a statistical analysis of the mortality from tubercular diseases during the last thirty-three years consumption: report of a conference of principal medical offi cers on uniform measures for the control of consumption in the states of australia tuberculosis: its nature, prevention, and treatment, with special reference to the open air treatment of phthisis the epidemiology, mortality and morbidity of tuberculosis in australia: - health and disease in australia: a history the mortality in australia from measles, scarlatina and diphtheria the hazards of immunization the australian army medical services in the war of - . volume ii. canberra: australian war memorial natural history of infectious disease congenital cataract following german measles in the mother immunisation: a public health success progress toward global polio eradication -africa a successful eradication campaign. global eradication of smallpox severe streptococcal infections in historical perspective history of staphylococcal infection in australia control of fl uoroquinolone resistance through successful regulation jaundice occurring one to four months after transfusion of blood or plasma recent advances in the study of the epidemiology of hepatitis b vertical transmission of hepatitis b antigen in taiwan hepatitis b virus. the major etiology of hepatocellular carcinoma clinical and immunologic sequelae of aids retrovirus infection in and out of africa epidemiology of hepatitis c virus infection among injecting drug users in australia liver transplantation for hepatitis c-associated cirrhosis in a single australian centre: referral patterns and transplant outcomes papillomaviruses and cancer: from basic studies to clinical application hpv immunisation: a signifi cant advance in cancer control global malaria mortality between and : a systematic analysis cholera surveillance during the haiti epidemic -the fi rst years hemorrhagic fever with renal syndrome in korea emerging viral infections in australia bats are natural reservoirs of sars-like coronaviruses world health organization multicentre collaborative network for severe acute respiratory syndrome diagnosis. a multicentre collaboration to investigate the cause of severe acute respiratory syndrome an overview of bovine spongiform encephalopathy (bse) in britain indigenous disparities in disease-specifi c mortality, a cross country comparison: new zealand, australia, canada, and the united states key: cord- -q dqsl n authors: milani, fabio title: covid- outbreak, social response, and early economic effects: a global var analysis of cross-country interdependencies date: - - journal: j popul econ doi: . /s - - - sha: doc_id: cord_uid: q dqsl n this paper studies the social and economic responses to the covid- pandemic in a large sample of countries. i stress, in particular, the importance of countries’ interconnections to understand the spread of the virus. i estimate a global var model and exploit a dataset on existing social connections across country borders. i show that social networks help explain not only the spread of the disease but also cross-country spillovers in perceptions about coronavirus risk and in social distancing behavior. in the early phases of the pandemic, perceptions of coronavirus risk in most countries are affected by pandemic shocks originating in italy. later, the usa, spain, and the uk play sizable roles. social distancing responses to domestic and global health shocks are heterogeneous; however, they almost always exhibit delays and sluggish adjustments. unemployment responses vary widely across countries. unemployment is particularly responsive to health shocks in the usa and spain, while unemployment fluctufations are attenuated almost everywhere else. after being identified in december in wuhan, china, the novel coronavirus (sars-cov- ) initially spread in the hubei region and later across mainland china. although the rest of the world soon learned about the first publicly known cases, several countries did not perceive an immediate risk for their populations. starting in january , the epidemic spread outside china, first in thailand, south korea, japan, and in the usa, and in many cases it was connected to recent travelers to the country. in europe, italy reported its first official community-based case on february , and, very quickly, clusters of cases developed in the lombardy region. it was later discovered that the virus had been circulating in lombardy since at least early january (cereda et al. ) and, possibly, since december. by mid-march, the vast majority of countries in the world had multiple cases, with the centers of the outbreak moving first to europe and later to the usa. most countries responded by requiring their populations to adhere to some form of social distancing to reduce the rate of infection and lessen the strain on healthcare providers. responses, however, have been widely heterogeneous. italy reacted with a few-days delay after the outbreak and then implemented restrictive stay-athome policies. a minority of countries initially experimented with laxer restrictions, either based on a misguided attempt to have their populations achieve herd immunity on their own (the uk, which soon moved away from the policy), or because of an unwritten "social contract" with citizens rather than enforcement from policymakers (sweden). others acted quickly and decisively to attempt to eradicate the disease before it became widespread (new zealand). the spread of coronavirus has highlighted the importance of interdependencies across different regions. depending on business links and other existing relationships, the virus rapidly moved across borders. perceptions about the crisis and social behavior responded generally with lags, but they were also likely affected by observed experiences abroad. countries had the opportunity of learning from others about social adjustments that were more or less effective in containing the disease. the main objective of this work is to study these global interrelationships in the early response to covid- shocks. in particular, this paper exploits information about social networks across countries to study interdependencies in the number of disease cases, in the perceptions of their citizens about coronavirus risk, and in their social responses. i also provide some preliminary evidence on the early economic effects of the pandemic by looking at a potential leading indicator of unemployment. i include in my sample countries and use a variety of data sources. to capture the extent of pairwise country social connections, i use data obtained from facebook, which measure the total number of friendships across pairs of countries as a fraction of the total number of combined users in the two countries. this social connectedness indicator allows me to have a measure that can account for different types of relationships: regular friendships, business links, family ties, relations based on older and more recent patterns of immigration, and tourism flows. social networks can help explain the transmission of covid- cases across borders, and they are likely to represent a superior measure compared with the use of geographic distance alone. other contemporaneous papers make a similar observation (e.g., kuchler et al. ) . at the same time, social networks not only can potentially explain patterns of disease contagion, but they can also help account for spillovers in ideas and behavior. controlling for the country-specific dynamics of covid- cases, people's risk perceptions may respond differently and also be affected by the experience and perceptions of individuals in their networks of social connections, including those residing abroad. the same is true for responses in terms of social distancing: individuals who had large connections to countries where the virus outbreak and the social distancing responses were already happening may have learned from their early experiences, taken the epidemic more seriously, and responded similarly. to measure the actual social distancing response in each country, i exploit a novel dataset made available by google through its country-specific social mobility reports. finally, i use internet data from google trends to measure coronavirus risk perceptions and to have a real-time, daily indicator of unemployment. i estimate a global var model to study the transmission of pandemic health shocks both domestically and globally. in my global framework, for each country, covid- cases can affect risk perceptions about the virus, which can trigger a social distancing response. as a result of social distancing or general uncertainty, unemployment may increase. the model allows me to treat all these variables as endogenous. this is necessary since social distancing, for example, is likely implemented in response to rising numbers of covid- cases, but it also itself has an impact on the future number of cases. moreover, domestic variables in the model are also allowed to respond to foreign aggregates. the foreign variables enter each domestic model with weights that depend on the matrix of social connections. the relevant foreign aggregate for each country is different, since the patterns of connections are unique to the country. in the gvar literature, the domestic models can be estimated separately as conditional vars. all endogenous variables can then be stacked together to form a large-scale global var; it is then possible to track the responses of all variables to each shock in each country. through the use of a connectivity matrix (my social connection matrix), the global var model offers a relatively simple and parsimonious way to deal with potentially complex interactions across different variables and countries. main results my estimates highlight the importance of interdependencies and social networks in the transmission of coronavirus cases, in the increase of risk perceptions, and in social distancing behavior. domestic variables, for the vast majority of countries, are significantly affected by foreign aggregates, constructed with weights based on the strength of social connections across countries. for example, as documented in brynildsrud and eldholm ( ) , the first cases in nordic countries (in their case, norway, but likely similar in neighboring countries) were due to travelers returning from vacations in lombardy. to the extent that some of these tourism patterns increase the probability of facebook links as well, which i believe reasonable, my measure will allow me to track likely routes for the spread of the disease. the gvar model has been proposed by pesaran et al. ( ) and is surveyed in chudik and pesaran ( ) . given the role played by italy and the usa as centers of the outbreak in different phases of the epidemic, i study how variables in the rest of the world respond to coronavirus shocks originating in these countries. i document strong and significant responses of risk perceptions and social distancing to the italy covid shock almost everywhere in the world. countries also respond to the subsequent us shock, although with a smaller magnitude. spillovers from spain and the uk also play a sizable role. the countries' responses to foreign and their own domestic coronavirus shocks are heterogeneous. i can, however, reveal some common patterns. the countries that respond with social distancing do so with a delayed and sluggish adjustment. they seem to learn from the experience of other countries, but they display an adaptive behavior: they do not adjust their habits instantly; instead, they gradually reduce their social mobility, which reaches a negative peak almost a week after the shock. in the opposite direction of causality, changes in social distancing lead to a decline in the growth rate of covid- cases. the implications of the pandemic for unemployment also vary significantly by country. labor markets in the usa and spain are the most negatively affected, with large expected increases in unemployment rates. but large spikes in unemployment are not inevitable since most other countries seem to experience much more contained fluctuations. the results suggest that different institutional features can partly insulate the corresponding populations from the worse effects of large exogenous shocks. due to the historical importance of the covid- pandemic, research related to the disease and its effects has been growing swiftly. many papers use the leading model in epidemiology, the sir (or, alternatively, the extended seir) model based on kermack and mckendrick ( ) , to simulate the evolution of the disease (e.g., ferguson n and et al ( ) ). in economics, a number of recent papers have adopted a similar framework and developed the theory further by adding relevant trade-offs between health and economic costs (e.g., eichenbaum et al. ( ) , alvarez et al. ( ) , jones et al. ( ) ). this paper, instead, takes a different route by providing empirical evidence related to the social response to the outbreak, and using an alternative framework. in contrast to studies using the sir model, i do not aim to predict the evolution of the number of infected individuals in a population; my focus lies more on explaining the social responses to the original health shocks around the world. other recent works investigate the determinants of different approaches to social distancing. gupta and et al. ( ) find that social distancing responses do not necessarily correspond to policies mandated by state and local governments. painter and qiu ( ) and adolph et al. ( ) find that political beliefs affect compliance with social distancing indications in the usa. andersen ( ) finds evidence of substantial voluntary social distancing, and he also shows that it is affected by partisanship and media exposure. in light of these results, my approach does not use data on mandates, but it exploits, instead, the actual decline in mobility, as measured using location tracking technologies. qiu et al. ( ) focus on the early months of the pandemic. they provide empirical evidence on the transmission of coronavirus cases across cities in china between january and february. they estimate how the number of new daily cases in a city is affected by the number of cases that occurred in nearby cities and in wuhan, over the previous weeks. they show that social distancing measures reduced the spread of the virus, whereas population flows out of wuhan increased the risk of transmission. my paper stresses the importance of modeling cross-country interrelationships to understand the evolution of the next phase of the pandemic. a recent work by zimmermann et al. ( ) shares a similar goal. they find that countries that are more globalized are affected by the pandemic earlier and to a larger extent. therefore, they discuss how early measures that temporarily reduce inter-country mobility would be beneficial. outside of the recent covid- literature, my paper also provides a contribution to the literature on gvar models (see chudik and pesaran , for a survey) . most papers in the literature consider macroeconomic applications and study the global spillovers of policy and other shocks (e.g., pesaran et al. ; chudik and fratzscher ; dees et al. ) . others have studied interdependencies in housing markets (holly et al. ) , firm-level returns (smith and yamagata ) , and a variety of other applications (di mauro and pesaran ; pesaran et al. ). the effect of foreign variables is usually assumed to depend on trade balances across countries. my framework, instead, introduces a different connectivity matrix, based on social networks, which can be promising for a different set of applications. therefore, my paper is also connected to recent papers that propose the use of facebook connections to measure social networks across locations (bailey et al. ) . finally, i measure risk perceptions and fears of unemployment using google trends data. this approach has become more and more popular and is now exploited in different fields to measure people's attention (da et al. ) , in forecasting and nowcasting economic variables (see the various examples discussed in choi and varian ) , and to track the spread of diseases (e.g., ginsberg et al. ; brownstein et al. ) in the absence of easily observable private information. askitas and zimmermann ( ) discuss how internet data can be useful for empirical research in a variety of social science applications and, in particular, for research about human resource issues (askitas and zimmermann ( ) and simionescu and zimmermann ( ) provide evidence directly related to the unemployment rate). the paper exploits a variety of newly available datasets to study the interrelationship between health shocks originating from the covid- pandemic, people's real-time perceptions about coronavirus risk, the extent of their social distancing response, and unemployment. i investigate the connections among these variables both within countries, and across borders, by studying contagion and spillovers internationally. the data are collected on a sample of countries. those include current oecd member countries, candidate countries that applied for membership, and the countries that the oecd defines as key partners (brazil, india, indonesia, south africa). the countries account for % of global gdp (besides china, the main omission is russia, which accounts for about %) and % of global population; they also account for % of coronavirus cases in the sample period. data on novel covid- cases each day for each country are made available by johns hopkins university's center for systems science and engineering (csse). the estimations use either the growth rate or, as a robustness check, the number of daily cases. the epidemiology literature stresses the importance of social distancing to contain the spread of the virus, by reducing the basic reproduction number r (the expected number of secondary infections produced by a single infection in a population where everybody is susceptible) and flattening the curve of infected individuals. the response has been different across countries, either in terms of policies, enforcement, or voluntary reductions in mobility. therefore, it is important to have accurate data on actual social distancing by different populations to track the implied health and economic effects. to this scope, i use daily time series indicators on social mobility made available by google. the indicators are obtained using aggregated, anonymized data from gps tracking of mobile devices, for users who opted in to "google location history." the data measure the change in the number of visits and length of stay at different places compared with a baseline. for each day of the week, mobility numbers are compared with an historical baseline value, given by the median value for the corresponding day of the week, calculated during the -week period between january and february , . the data are reported for five place categories: grocery and pharmacies, parks and beaches, transit stations, retail and recreation, and residential. in addition to the official number of covid- cases, which may be an imperfect measure of the pervasiveness of the virus in the population, i also measure the population's risk perception about coronavirus. the risk perception is measured using daily data on web searches from google trends. i use the search results for the whole "topic" category; therefore, the indicator also includes all related search terms, such as "coronavirus symptoms," "coronavirus treatment," "coronavirus vs. flu," and so forth. finally, i similarly use an indicator of unemployment to measure the initial economic effects of the outbreak. given that actual unemployment data are typically available only at monthly frequency and that their release is lagged by more than a the full list of countries is as follows: australia, austria, belgium, brazil, canada, chile, colombia, costa rica, czech republic, denmark, estonia, finland, france, germany, greece, hungary, india, indonesia, ireland, israel, italy, japan, south korea, latvia, lithuania, luxembourg, mexico, netherlands, new zealand, norway, poland, portugal, slovak republic, slovenia, south africa, spain, sweden, switzerland, turkey, uk, the usa. the only country that has been removed from the oecd list is iceland, since google mobility data were not available. for non-oecd key partners, i exclude china, since for my sample the numbers of cases had already declined (google mobility data would also be unavailable for the country). google llc "google covid- community mobility reports." https://www.google.com/covid / mobility/ month, i also exploit google trends data about unemployment as a variable that can be used to have early and real-time indications of the official variable. as before, i use google searches about the unemployment topic (again, including all searches related to unemployment, such as "unemployment benefits," "unemployment insurance," "how to apply for unemployment," "losing my job," and so forth). askitas and zimmermann ( ) and choi and varian ( ) , among others, show that unemployment searches can help predict initial unemployment claims and the unemployment rate. more recently, askitas and zimmermann ( ) and simionescu and zimmermann ( ) document how internet data can be useful for nowcasting and forecasting the unemployment rate in a diverse set of countries. my unemployment variable can, therefore, be interpreted as a real-time signal for unemployment, or, alternatively, as a measure of people's perceptions, attention, or fears, about unemployment over the time period that i study. finally, i measure international social connections using facebook's social connectedness data. the index uses active facebook users and their friendship networks to measure the intensity of connectedness between each pair of locations. the measure of social connectedness between two locations i and j is given by: where fb connections i,j denotes the number of friendship connections between region i and j , and fb users i , fb users j denote the number of facebook users in i and j . the social connectedness index, therefore, measures the relative probability of a facebook connection between any individual in location i and any individual in location j . the data used in this paper refer to the measure calculated for march . bailey et al. ( ) proposed the measure to study the effects of social networks across us counties. other current papers are uncovering the link between social networks and the diffusion of covid- (e.g., kuchler et al. ) . the measure can be preferred to alternatives based simply on inverse geographic distance, since it can provide a more accurate account of business relations, tourism patterns, and family or friendship ties, across different areas. i argue here that the strength of social connections can also affect information about the outbreak and social distancing responses. as bailey et al. ( ) show, facebook friendship links between the usa and other countries, for example, are strongly correlated both with bilateral migration patterns and trade flows. they regress social connectedness on geographic distance, the number of residents with ancestry in the foreign country (as an indicator of past migration), and on the number of residents born in the foreign country (indicating current migration), and show that all three are strongly significant. friendship connections also lead to statistically significant increases in both exports and imports between the usa and the foreign country. for italy, the strongest social connections are with switzerland and slovenia, followed by austria, germany, spain, belgium, and the uk. distance is clearly a determinant of social networks, but not the only determinant. social connections are stronger between italy and australia, italy and the usa, and italy and canada, than between italy and turkey, although the latter is geographically much closer. for the usa, as expected, the most socially connected countries are mexico and canada, followed, at lower levels, by ireland and israel. the usa have strong connections with australia and new zealand, which would be downplayed based on a pure measure of distance. figure shows, instead, the social distancing response across a sample of major countries in the sample (for easiness of exposition, i show the experiences of out of countries in the figure). mobility declined by % or more in italy, france, spain, and new zealand. while in some countries, the adjustment was abrupt (e.g., new zealand, france, spain), it was slower and more gradual in others, such as the uk (where the response starts a few days later) and the usa; their overall declines in mobility were also more modest. sweden is an outlier in europe, as it maintained only small fluctuations of mobility around the historical mean. japan and korea observed their first cases earlier; therefore, their social distancing responses during this period appear more limited. in many european countries and in the usa, mobility returns to its historical average by the beginning of june. to model global interdependencies in the spread of the disease and countries' responses, i follow the gvar approach proposed in pesaran et al. ( ) and surveyed in chudik and pesaran ( ) . assume that there are n units, representing countries in this case, and for each unit, the dynamics is captured by k i domestic variables. for each country i, the k i × vector x i,t of endogenous variables includes four domestic series: the growth rate of covid- cases, the risk perception about covid- , the change in social mobility, and the perception about unemployment. the vector of domestic variables is modeled as: for i = , , ..., n, and where il , i , and il denote matrices of coefficients of size k i × k i and k i × k * i , where k * i denotes the number of "foreign" variables included in the vector x * i,t , and ε i,t is a k i × vector of error terms. in the empirical analysis, i select the optimal number of lags p i and q i for each country using schwartz's bayesian information criterion (bic). for each country i, therefore, domestic variables are a function of their p i lagged values, possibly of the contemporaneous values and q i lagged values of foreign, or global, variables. the foreign variables x * i,t are k * i × cross-section averages of foreign variables and they are country-specific: the matrixw i has size k × k * i and contains countryspecific weights, with diagonal elements w ii = . my approach uses the extent of social connections across country borders from the facebook social connectedness index dataset to measure the weights. gvar models assume that the variables x * i,t are weakly exogenous. this corresponds to the popular assumption in open-economy macro models that the domestic country is treated as "small" in relation to the world economy, i.e, it does not affect global variables. this assumption can be easily tested for all the variables. for cases in which a domestic variable has an unduly large effect on global variables, weak exogeneity will not be invoked there and the foreign variable, instead, will not be included in that var. the estimation works in two steps. first, varx* (that is, vars with weakly exogenous foreign variables) models can be estimated for each country separately. since i study the social responses to the covid- outbreak, i include in the domestic var also the risk perception variable, in addition to the number of cases. i believe that changes in the number of confirmed coronavirus cases may lead to different risk perceptions in the different countries, which, in turn, can affect people's willingness to adhere to stay-at-home orders or to voluntarily engage in social distancing. as a measure of economic consequences, i choose an indicator of unemployment. other options that are available at daily frequencies include stock returns, interest rates, and electricity data. stock returns and interest rates are inferior indicators of economic activity in this period as they were largely influenced by government and central banks' emergency interventions. electricity data would be appropriate, but they have been made available only for a small selection of european countries (mcwilliams and zachmann ). in the analysis, the number k * i is also equal to , as the vector x * i,t contains the country-specific global counterparts for the same variables in x i,t , i.e., the growth rate of covid- cases, coronavirus risk perceptions, social mobility, and unemployment. second, the estimated country models are stacked to form a large gvar system, which can be solved simultaneously. domestic and foreign variables are stacked in the the model in eq. can be rewritten as: where gives: substituting into eq. and stacking all the unit-specific models yield: where with g invertible, as it is in this case, the gvar is given by: with f l = g − g l . the gvar solution can be used to trace the impact of shocks on the variables of interest, both domestically and globally. to find the impulse response to shocks, i adopt the generalized impulse response function (girf) approach, proposed by koop et al. ( ) , pesaran and shin ( ) , and also used in pesaran et al. ( ) . the vector of girfs is given by: where j indexes the different shocks, h denotes the horizon for the impulse response function, i t = x t , x t− , ... denotes the available information set at time t, and where √ σ jj indicates that the magnitude of the shock is set at one standard deviation of the corresponding ε j,t . the gvar specification can be seen in relation to a number of econometric alternatives: spatial vars, panel vars, and dynamic factor models. spatial vars are very strongly connected. they also assume a connectivity matrix, which is usually based on geographic distance. the main difference between the two approaches lies with the structure of correlations: as discussed at length in elhorst et al. ( ) , spatial vars may be preferred when correlations across units are extremely sparse, for example, when a unit is only affected by few bordering units ("weak," or local, crosssectional dependence). the gvar is meant to capture stronger interrelationships, with dense connectivity matrices, where each country unit is affected, in different ways, by several other countries, or by an aggregate measure ("strong" crosssectional dependence). spatial vars can also be seen as a particularly restricted case of a gvar model. the approach can similarly be seen as a particular form of panel var. the main advantage here is that, through the weight matrix w i , this approach exploits knowledge about social networks and uses that knowledge to inform the magnitude of cross-country interdependencies. panel vars often impose the same coefficients for each unit, shutting down static and dynamic heterogeneity, as well as neglecting cross-country interdependencies. an exception is provided by canova and ciccarelli ( ) : they introduce a factor structure in the coefficients to solve the curse of dimensionality. their approach is particularly useful when there is no a priori knowledge that can be exploited about the spillovers. in this case, the extent of social networks can be, instead, exploited to provide some information about the relative strength of interdependencies. finally, the gvar has relations with dynamic factor models. as chudik and pesaran ( ) show, the gvar specification approximates a common factor across units, and it extracts common factors using structural knowledge. the model is particularly suited to account for potentially complex patterns of interdependencies across countries. at the same time, the gvar specification does so while maintaining simplicity and parsimony. the dimensionality issue is resolved by decomposing a large-scale var into a number of smaller scale vars for each unit, which can be estimated separately, conditional on the dynamics of weakly exogenous foreign variables. the interdependencies are not left entirely unrestricted, since it would be unfeasible to estimate all the parameters, but they are given a structure based on knowledge of the data. in the benchmark analysis, i estimate the gvar model using daily data from february to april , . the dates are chosen based on availability of google social mobility data at the time the paper was written. the exogeneity assumption is relaxed where it appears unlikely: for covid cases, i do not include foreign variables in the model for the usa, italy, and spain, since they may be endogenous. those countries, at different times, have accounted for a large share of global cases. i allow the covid variable for all other countries to be affected by foreign series. i also allow risk perceptions in each country, as well as social distancing outcomes, to be affected even contemporaneously by corresponding variables in different countries. finally, i assume that domestic unemployment perceptions are affected by foreign unemployment perceptions, but not within the same day. this assumption is not important for the results (which are robust), but it is motivated by the idea that the unemployment data are driven more by country-specific, than across-the-border, factors. i test the weak exogeneity assumptions for all foreign variables, and they are never rejected in the data. recently, some studies have emphasized the importance of superspreaders in the transmission of the virus (e.g., adam et al. , who study clusters in hong kong). beldomenico ( ) discusses how sars-cov- appears to start by spreading gradually in a region, until transmission is triggered by a possible cascade of superspreader events, and cases explode. as a result, the pattern of transmission can become highly heterogeneous. here, i focus on numbers of cases aggregated at the country level. my framework can account for heterogeneous responses across countries. however, even if the weak-exogeneity tests suggest that domestic countries do not affect global variables in a statistical sense, it is conceivable that, with superspreaders, covid infections can transmit very quickly, and do so even between country pairs with a limited degree of social connections. my identification assumption, however, requires that the impact of a superspreader from country i on the total number of global cases remains small enough. first, to study the magnitude of global interdependencies, table shows the contemporaneous effects of foreign variables on domestic variables, for each country. the table reports the estimated coefficients, alongside the associated standard errors. domestic variables are significantly affected by the country-specific foreign aggregates, computed using the matrix of social connections as country-by-country weights. the results indicate that the international spread of covid- cases can be, in part, explained by existing social networks across country borders. moreover, the contagion not only relates to the number of cases and the spread of the disease, but it also affects the spread of perceptions and social behavior. both the measure of risk perceptions about coronavirus and the social distancing responses are significantly influenced by developments in the rest of the world. only few countries do not show a statistically significant response to global conditions. risk perceptions do not rise in response to increasing international distress only in brazil, south africa, and turkey. it is likely that their populations initially underestimated the likelihood of the pandemic reaching them, as they were farther from the epicenters. most countries also gradually learn from each others' social distancing responses. among the few exceptions, japan and korea are not significantly affected by foreign experiences: they implemented social distancing earlier than other countries, but they already relaxed many of the restrictions before the period that i consider. these results highlight the importance of considering global interrelationships and social connections in understanding the transmission of the virus and societal responses. my results add to those in zimmermann et al. ( ) , who investigate the role of globalization during the pandemic. countries with a higher index of globalization had faster transmission speed and higher infection rates, although they responded better to the challenges by achieving lower fatality rates. international travel and migration play key roles in the transmission. their paper, therefore, discusses the benefits of inter-country distancing, based on the imposition of temporary travel restrictions. my empirical results point to similar policy implications: since the table reports the estimated gvar coefficients with the associated standard error shown below in parentheses. significance at the % level is denoted by ***, at the % level by **, and at the % level by * coronavirus cases spread internationally as a result of existing social networks, early border closures and travel restrictions can be effective. i study the global responses to shocks from italy and the usa since these countries played outsized roles in different phases of the pandemic. figures and show the impulse response functions for all countries in the sample for the risk perception and social distancing variables to a one-standard-deviation covid shock originating in italy. risk perceptions increase, with some sluggish impulse responses across countries of coronavirus risk perception to a covid- growth rate shock originating in italy adjustment, almost everywhere in the world in response to the initial shock from italy. the responses typically reach their peak about - days after the original shock. the response is more delayed in brazil, india, and south africa. as seen in the previous section, these countries are less influenced by global variables in this period. populations in neighboring european countries, as well as in the usa, australia, and canada, instead significantly update their perceptions. the overall effect is much smaller in sweden, finland, turkey, israel, and lithuania. again, japan and south korea do not seem to significantly respond, as they experienced their outbreaks earlier than the rest of countries. similarly, most countries respond with reductions in social mobility. the social distancing response, however, is already delayed and sluggish in italy, with a negative impulse responses across countries of social mobility to a covid- growth rate shock originating in italy peak in mobility occurring days after the shock. other european countries, such as france, switzerland, and the uk, do not seem to adjust at all for the initial - days, after which they gradually reduce their social mobility as well. the patterns are similar everywhere: after the situations worsen in one country, the others do not immediately learn from its experience and change their behavior. instead, they appear to behave more adaptively, by only gradually altering their habits in response to the evolving situation. one issue to consider is whether the joint declines in social mobility are driven by policies that happened at the same time. my measure of actual mobility captures both the effects of mandates and those of voluntary distancing. i use data on the government response index made available for different countries through the oxford covid- government response tracker (oxcgrt)'s website and discussed in thomas hale et al. ( ) . i regress the google mobility indicator on a constant and on the government response index for each country. figure shows the estimated coefficients for the sensitivity of mobility to the government response, and the resulting r for each country's regression. the results clarify that measures based on actual mobility carry additional information that goes beyond what can be captured by looking only at the implemented policies. for many countries, mobility responds negatively to policy restrictions, with r coefficients falling in the . - . range. the explanatory power is particularly strong in mexico and new zealand. but simply using policy responses would miss the extent of social responses in many other countries, where the explanatory power is closer to (as in korea, netherlands, and scandinavian and baltic countries). the focal point of the pandemic later moved to the usa, at least starting from mid-march. figure displays the effects on coronavirus risk perceptions in the rest of the world to a us coronavirus risk shock. i consider the risk perception shock for the usa, rather than the one based on the number of cases, since testing was initially fig. relation between voluntary social distancing and government lockdown policies. the results are based on the regression social mobility t = β + β govt. response t + ε t for each country. the top panel shows the estimated coefficient β , the second the regression r the spillovers in risk perceptions are again statistically significant, but much smaller in magnitude than those observed in response to the corresponding italian shock. the same is true for responses of social mobility to a us coronavirus risk shock, shown in fig. . for many countries, i observe a slight increase in social distancing, including for the usa themselves. in terms of policy implications, the results highlight the importance of rapid interchanges of information: the rest of the world can learn from policies and behaviors that seemed to work in the countries that were reached early by the virus. the results show that perceptions about the pandemic spread to different countries. the resulting the responses to the pandemic have been heterogeneous across countries. figure overlaps, for a selection of countries, the impulse responses of social distancing and unemployment to the country's own coronavirus risk shock. i single out the responses for italy, spain, the uk, the usa, sweden, and japan, since they characterize somewhat different approaches to the crisis. the populations of italy and spain sharply decreased their social mobility after the domestic coronavirus shock. the responses reach their maximum effects after - days, and they last for weeks. their behavior suggests that even in the countries that were most affected by the virus, their social distancing responses, while substantial, have been unnecessarily delayed. japan displays a smaller, and more sluggish, response. the usa and the uk are also characterized by negative and statistically significant adjustments in mobility, but their responses are many order of magnitudes smaller than the ones observed in italy and spain. finally, it is well documented that sweden adopted a more permissive approach, by letting its citizens adjust their ita spa uk usa swe jap fig. impulse response functions of coronavirus risk perceptions and unemployment to the country's own coronavirus risk shock behavior without the same strict enforcement that was observed in other countries. the response for sweden, accordingly, does not show any significant decrease in mobility to the country-specific risk shock. turning to the early estimates about potential economic effects, i show the responses of the real-time unemployment indicator to each country-specific coronavirus shock. the figure shows that unemployment does not necessarily need to skyrocket in response to health shocks. unemployment insurance claims have reached record levels in the weeks after the outbreak in the usa. the impulse responses are consistent with the behavior of unemployment claims, revealing an extremely large response of the google unemployment indicator. unemployment is also set to considerably increase in spain. the country has a large share of workers on temporary contracts, who are more likely to become unemployed due to the uncertainty generated by the pandemic. other countries in the sample, however, as well as the vast majority of countries not shown in the figure, appear more successful in insulating their labor forces from the crisis. even if the recessionary effects on output are likely to be large almost everywhere, for most countries, early indicators of unemployment suggest that local labor markets are not going to experience the same turbulence as those in the usa. so far, the analysis has focused on the direction of causality that goes from covid cases to social and economic responses. here, i provide evidence on the opposite direction: the effects of social distancing on new covid cases. figure shows the impulse responses of the growth rate of covid- cases in different countries to a social distancing shock, measured as a one-standard-deviation decline in social mobility. social distancing leads to declines in the growth rate of coronavirus cases in the days after the shock. the only country in the figure that does not show a negative response is the uk, for which social distancing has, in fact, been much slower to start. the results reaffirm the importance of social distancing, whether through mandatory policy or voluntary behavior, in reducing the spread of the virus. while in epidemiology, the benefits of social distancing are usually modeled as changes in the parameters of a sir model, here i show that the effects can be uncovered also in a simpler linear framework. moreover, the results regarding unemployment, presented in the previous section, suggest that social distancing does not necessarily have to translate into high unemployment rates. a prompt social distancing response, coupled with labor institutions that attenuate the impact of business cycles, can successfully limit the health shocks from the pandemic, without causing extensive economic damage. the empirical analysis, so far, has been based on data up to mid-april. i now update the dataset to include the most recent months. after april, the social distancing efforts were successful in most of europe: the number of daily cases in italy, spain, germany, france, and most neighboring countries, declined; as a result, the countries started to relax most restrictions on mobility. the global centers of the virus moved instead to the americas, with us cases still remaining high, and with brazil's situation rapidly deteriorating. the situation also worsened considerably in india. to incorporate data for this second phase, i re-estimate the gvar model for the more recent sample between april and june (the last day of availability of google mobility data at the time of writing). the results are reported in tables and . table shows the values of the peak responses for the impulse response functions of coronavirus risk perceptions in each country in the sample to corresponding coronavirus risk shocks from seven countries: italy, the usa, spain, uk, brazil, chile, and india. these countries are selected as they had large number of cases at different times, during the sample. table reports similar information (in this case, the size of the largest negative responses across horizons) for the social distancing responses, instead. to compare the role played by the different countries, i show the results for both the first phase, starting in mid-february and ending in mid-april, and for the second phase, from mid-april to mid-june. most countries were significantly affected by italy's shocks during the first phase. risk perceptions particularly increased in spain, the uk, and the usa. higher risk perceptions led to a much larger decline in social mobility in spain (− . ), though, than in the other two countries (− . and − . , respectively). in the second phase, italy's role diminished, and many countries reacted instead to shocks from the usa, spain, and the uk. although cases exploded in brazil, chile, and india, between april and june, the spillovers from these countries to the rest of the world have remained more limited. the largest effects may be detected in neighboring countries: for example, the largest increase in risk perceptions in response to shocks in brazil and chile is observed in colombia. the effects on social mobility are somewhat larger, but far from the values obtained in response to shocks from spain and the uk, for example. the results suggest that, in most countries, public perceptions and behavior respond to global, not only to domestic, variables. the impact of individual countries, instead, varies over different phases of the pandemic and depending on the extent of social connections. overall, this paper's results highlight the importance of interconnections to understand not only the spread of the virus, but also adaptation and gradual learning in importing ideas and behavior from other countries. risk perceptions and the willingness to engage in social distancing by the populations of most countries significantly respond to the corresponding variables in socially connected countries. i stress the role of existing social networks across borders in the transmission of health shocks, perceptions about the risk of the disease, and ideas regarding the merit of social distancing. the results reveal heterogeneous responses across countries to their own domestic coronavirus shocks. a common feature in all responses is that individuals responded with a lag and only gradually reduced their social mobility. this observation is consistent with epidemiological models that include adaptive human behavior, such as the model presented in fenichel and et al ( ) . that research stresses the role of public policies based on informing and motivating people to reduce person-to-person contacts. this may be particularly important for countries in which citizens have weaker social connections to the rest of the world, and in which, policymakers may delay in implementing mitigation policies. institutional differences among the countries' labor markets are likely responsible for substantially different increases in unemployment. the lower degree of employee protections in the usa and the large share of temporary workers in the spanish economy are likely to account for the far worse outcomes in these countries. everywhere else, fluctuations in unemployment have remained more subdued. there are some possible limitations related to the data series used in the analysis. unemployment indicators based on internet data may be more or less accurate depending on the country: as discussed in simionescu and zimmermann ( ) , their predictive power for actual unemployment may depend on the internet penetration in the country, and on demographic variables, such as the age composition of internet users. internet use may also vary across the income distribution, particularly in less economically developed countries. perceptions about coronavirus risk may not be captured equally well in all countries in the sample. the matrix of social connections based on facebook friendships may be subject to similar problems: facebook users may have different average income and age than the population as a whole, and such friendships may capture to a larger extent personal, rather than business, links. my sample of countries necessarily excludes others (for example, china), which may be important in terms of social connections. their omission may potentially lead to an omitted variable bias in the var regressions. this section assesses the sensitivity of our estimates to alternative data and econometric choices. the benchmark estimation used data on covid- cases transformed into daily growth rates. i can examine the sensitivity of the results to using the number of new daily cases instead. table reports the estimated interdependencies corresponding to those previously shown in table . to save space, the results are shown for a subset of six countries. the estimates remain similar, with the exception of a smaller spillover of global risk into the domestic italian risk perception variable. also, in the benchmark estimation, the conditional country-specific models corresponded to vars with the addition of weighted foreign aggregates. another option sensitivity check i) repeats the estimation using the level of new daily covid- cases rather than their growth rate; case ii) estimates conditional vector-error-correction models rather than a var for each country; case iii) computes changes in social mobility excluding the series related to residential mobility often used in the gvar literature is to allow for long-run relationships and estimate vector error correction (vecm) models instead. the results shown in table , as well as all the main findings, remain in line with those discussed so far. finally, the google mobility indicator was computed by taking the average of mobility changes across all available categories. it can be argued that the relevant social distancing measure that matters for health outcomes should exclude residential mobility. therefore, i repeat the analysis by constructing social mobility, but now excluding the residential component. again, the results remain substantially unchanged. i estimated a global model of countries to examine the interconnections in coronavirus cases and in social and economic responses during the first months of the covid- pandemic. the results suggest that social connections across borders are helpful to understand not only the spread of the disease, but also the spread in perceptions and social behavior across countries. initial shocks from italy affected risk perceptions about coronavirus in most countries in the world. many of them responded by significantly reducing their mobility. populations in most countries, however, displayed a degree of behavioral adaption: they did not change their habits instantly, but only gradually over time. shocks from the usa, spain, and the uk also had significant effects later on. a subset of countries did not respond much through social distancing to global or domestic shocks. as a result, they do not show the same reduction in the growth rate of covid- cases in response to social distancing that is observed in other countries. the original health shocks, either directly, or through increased uncertainty and social distancing, have economic effects. while i do not have data at high frequency on realizations of the unemployment rate, i exploit daily data on an indicator that has been shown to predict actual unemployment quite accurately: unemployment from google searches. the response of unemployment across countries is very heterogeneous. in the usa, unemployment skyrockets. this is consistent with the response of initial unemployment claims in the country. the same happens in spain, with a large increase of unemployment in response to health shocks. in other countries, the responses are more muted, as public programs intervened to provide subsidies to employers and employees to protect existing employment relationships. clustering and superspreading potential of severe acute respiratory syndrome coronavirus (sars-cov- ) infections in hong kong, preprint pandemic politics: timing state-level social distancing responses to covid- . medrxiv, . . early evidence on social distancing in response to covid- in the united states google econometrics and unemployment forecasting the internet as a data source for advancement in social sciences simple planning problem for covid- lockdown, nber working papers social connectedness: measurement, determinants, and effects do superspreaders generate new superspreaders? a hypothesis to explain the propagation pattern of covid- digital disease detection-harnessing the web for public health surveillance high covid- incidence among norwegian travellers returned from lombardy: implications for travel restrictions estimating multicountry var models the early phase of the covid- outbreak in lombardy, italy predicting initial claims for unemployment insurance using google trends predicting the present with google trends identifying the global transmission of the - nancial crisis in a gvar model infinite dimensional vars and factor models theory and practice of gvar modelling search of attention exploring the international linkages of the euro area: a global var analysis the gvar handbook: structure and applications of a macro model of the global economy for policy analysis spillovers in space and time: where spatial econometrics and global var models meet impact of non-pharmaceutical interventions (npis) to reduce covid mortality and healthcare demand. mar fenichel ep et al ( ) adaptive human behavior in epidemiological models detecting influenza epidemics using search engine query data tracking public and private responses to the covid- epidemic: evidence from state and local government actions annalena pott ( ) variation in us states responses to covid- the spatial and temporal diffusion of house prices in the uk optimal mitigation policies in a pandemic: social distancing and working from home nber working papers contribution to the mathematical theory of epidemics impulse response analysis in nonlinear multivariate models the geographic spread of covid- correlates with structure of social networks as measured by facebook bruegel electricity tracker of covid- lockdown effects, bruegel datasets political beliefs affect compliance with covid social distancing orders forecasting economic and financial variables with global vars modelling regional interdependencies using a global error-correcting macroeconometric model generalised impulse response analysis in linear multivariate models impacts of social and economic factors on the transmission of coronavirus disease (covid- ) in china big data and unemployment analysis, glo discussion paper series , global labor organization (glo) firm-level return-volatility analysis using dynamic panels inter-country distancing, globalisation and the coronavirus pandemic acknowledgments i would like to thank the editor, klaus f. zimmermann, and three anonymous referees for comments and suggestions that substantially improved the paper. i outline here the steps for the estimation of the gvar model (see also smith and galesi ): . first, the connectivity matrix w (of size × in this case) is constructed using facebook's social connectedness index data. for each country i, i fix w i,i = (the domestic country is not used for the construction of the foreign variable) and i calculate the weights w i,j , i = j , as the social connectedness between countries i and j as a fraction of the sum of connectedness between country i and each country in the sample, sci i,j / n j = sci i,j . therefore, the resulting connectivity matrix has columns that sum to . . country-specific foreign variables are then constructed as x * i,t = n j = w i,j x j,t , using the weights w i,j , for each reference country i. . i estimate conditional varx* (that is, a var with a foreign, weakly exogenous, variable) models, as specified in expression eq. . the models can be estimated separately for each country by ols. i choose lag length also separately for each of them based on schwartz's bayesian information criterion (bic). in most cases, the data select short lag lengths (p and q equal to or ) as optimal. i did not find consistent patterns of seasonality in the data. therefore, we do not perform any seasonal adjustment before the estimation. the benchmark estimation considers varx* models. the robustness section experiments with vecmx* specifications, which allow for cointegrating relationships both within the variables in x i,t and between variables x i,t and x * i,t . in that case, for each domestic vecmx*, the cointegration rank is selected based on johansen's trace statistics. . after being estimated independently, the domestic vars are stacked together as shown in eq. . the global var is "solved" for all the k = n i= k i endogenous variables, as shown in ( )-( ). . i check the moduli for the system eigenvalues and confirm that they are all within the unit circle. . i compute generalized impulse response functions following koop et al. ( ) , as shown in expression ( ) as. the response to a one standard-deviation shock is given, for each, where e j is a selection vector, composed of zeros, except for an element equal to to select the shock of choice. the matrix r h is the matrix of coefficients in the gvar's moving average representation: x t = ε t + r ε t− + r ε t− + .... i use bootstrapping to compute the impulse response error bands. key: cord- -oj v x authors: catala, m.; pino, d.; marchena, m.; palacios, p.; urdiales, t.; cardona, p.-j.; alonso, s.; lopez-codina, d.; prats, c.; alvarez lacalle, e. title: robust estimation of diagnostic rate and real incidence of covid- for european policymakers date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: oj v x policymakers need a clear and fast assessment of the real spread of the epidemic of covid- in each of their respective countries. standard measures of the situation provided by the governments include reported positive cases and total deaths. while total deaths immediately indicate that countries like italy and spain have the worst situation as of mid april , on its own, reported cases do not provide a correct picture of the situation. the reason is that different countries diagnose diversely and present very distinctive reported case fatality rate (cfr). the same levels of reported incidence and mortality might hide a very different underlying picture. here we present a straightforward and robust estimation of the diagnostic rate in each european country. from that estimation we obtain an uniform unbiased incidence of the epidemic. the method to obtain the diagnostic rate is transparent and empiric. the key assumption of the method is that the real cfr in europe of covid- is not strongly country-dependent. we show that this number is not expected to be biased due to demography nor the way total deaths are reported. the estimation protocol has a dynamic nature, and it has been giving converging numbers for diagnostic rates in all european countries as of mid april . from this diagnostic rate, policy makers can obtain an effective potential growth (epg) updated everyday providing an unbiased assessment of the countries with more potential to have an uncontrolled situation. the method developed will be used to track possible improvements on the diagnostic rate in european countries as the epidemic evolves. the evolution of the epidemic in europe has affected spain and italy more strongly than in other countries so far. this is clear from reported cases and fatalities in these however, they lack the recipe-type nature needed sometimes to direct a policy response. the focus of this paper is, thus, to introduce a method to compute the real diagnostic rate and the real incidence of covid- in each european country, testing that the key hypothesis of the method is fulfilled and that, if they were to be slightly off, they would affect all countries in the same direction. in other words, we provide a recipe for policymakers that we have tested to be correct, unbiased across countries and useful to make cross-country comparison provided the evolution and prognosis of the disease in a patient is not strongly dependent on socio-economic factors and only on age, sex and previous clinical history. we must recall here that the ability to determine the diagnostic ratio is essential to evaluate what the real number of infected people is. knowledge of this number is not only useful to visualize the full scope of the epidemic but also to properly estimate the number of people with probable short-term immunity. in this sense, our method can be added as an empirical take of other assessments about the real incidence of the disease and to study the possibility of developing herd immunity. a large number of real infected people would be a positive scenario for policymakers while a low number will be negative. it is thus very important to err on the side of caution in all our estimates giving always the less optimistic take. the basic structure of the paper is the following. first, we give a general overview of our framework in the methods section. then we discuss our key assumption: the real case fatality rate (cfr) in european countries experiencing a significative incidence will be roughly the same, given the similar structure of the population. if the real cfr were to be lower, or higher, it would affect all countries in the same way and would not affect most policy decision-making since it will move all countries in the same direction. we take this real cfr to be % and proceed to test that, effectively, there is a strong correlation between the day of reported deaths with the number of cases taken - days before. once a given value for the real cfr is taken, one must consider that people do not die immediately from the disease, as it takes roughly days after infection [ ] [ ] [ ] . in other words, the present values of the death toll can provide an estimation of the number of infected people days ago. knowing the number of infected people at present, not days in the past, is crucial. we attack this problem considering that people who become infected are usually diagnosed a few days after the onset of the symptoms, which can be to days after infection occurs. by comparing the number of people diagnosed on a certain date with our estimation of the real number of infected people, we can estimate what percentage of the cases are being diagnosed. we can calculate this for different countries and regions and test how this ratio has changed dynamically as the epidemic advanced. in the results section, we provide a full detailed description of how this fraction has become steady in the last weeks. we demonstrate that the percentage of diagnosis throughout the development of the epidemic has taken values that gradually converge for most countries. this gives a final clear picture showing the rate of diagnosis for each country. using this rate is straightforward to give a present-day estimate of the incidence given the number of reported infected people in each country as long as we can observe that the rate of diagnosis remains fairly constant. for policymakers, we have constructed an index named effective potential growth (epg) that combines this information with the growth rate of the epidemic to provide insight regarding which countries are, comparatively and in the short-term, in the most potentially complicated situation [ ] . framework of our methodology our analysis will be applied to european countries with a minimum of deaths on april so that we can guarantee a minimum statistical significance. the analyzed countries are: belgium, france, germany, italy, netherlands, portugal, spain, sweden, switzerlands and united kingdom. our two core assumptions are that the real cfr in all european countries is roughly the same and that reported data of death due covid- is uniform in all european countries under consideration. we will address these two hypothesis in the following sections. with these assumptions we need to carry out four steps, as indicated in fig. , to obtain the percentage of diagnosis. first, using a common reference cfr = % and, given the reported reported death count, we estimate the number of cases days ago. according to medical reports people die between and days after the development of the first symptoms [ ] . this time to death, ttd, after the development of the first symptoms will not be country-specific for demographic reasons. the estimated number of infected people with the disease at time t (see process in fig. this allows us to know to estimate the number of cases days ago. this value can be compared with the number of cases detected days ago, obtaining a diagnostic depending on the availability of tests, saturation of the health system and other external factors, countries have a great variability in the time of diagnosis delay. countries accumulate some delay that may arrive to days in the case that a country detected people as late as they were detected on death. this delay to detection (dd) due to lags in diagnosis corresponds to the time between the patient having the first symptoms and being reported by the health system. in fact, this time in some countries may vary throughout the course of the infection. therefore we cannot assume that the estimated and the reported are comparable and we need to know what the diagnostic time was for each of the countries studied. we can compare the reported deaths with the reported cases to find the maximal correlation, see process in fig. (a) , to estimate the dd, see process in fig. (a) . finally the ratio between reported cases at dd with the estimated cases, see below, provides an estimation for the percentage of diagnosis, see process in fig. (a) . note that the usual development of the reporting of a new case/death, see fig. (b), depends on the particular country under consideration, which determines dd. in fact, dd also includes a delay in reporting the diagnostic to death to official information systems. the cornerstone of our analysis is that the real cfr in all european countries will not be biased against any country in particular. we should point out immediately that we are not arguing that there are not important uncertainties in the real cfr, what we do claim and check in this methodology is that these uncertainties will not generate any biased against particular countries and should not affect policy decision. we take the cfr in of covid- in europe to be between . - % and we assume % to be the benchmark scenario. this value ( %) is the cfr observed in the initial stages of the south korea pandemic and the diamond princess cruise. in both cases, it was found to be around - . % and, in both, error margins came from different sources [ , ] . in south korea, the ability to test all the population in contact with infected people and the tracking of contagious chains was thorough, despite that, the reported cfr increased from initial values around . - . % to higher values around %. in the diamond princess cruise, cfr for confirmed cases was % but estimation of false negatives and the possibility that a fraction of the passengers never developed symptoms and was never tested put the cfr again around %. both south korea and the diamond princess cruise provide complementary evidence, one coming from a natural experiment and another from a country with the ability to perform half a million tests/day from the very beginning of the transmission chain [ ] . if we accept the two measurements of the cfr independent, the most likely interval of real cfr is between . and %. recent experimental results from random testing in the german city of gangelt [ ] and preliminary results from iceland [ , ] indicate the presence of a layer of people fully asymptomatic that are normally not detected. this group of people have passed the disease without any knowledge seems to be larger than previously thought. these preliminary studies point to a cfr of around . % in zones where the epidemics was not fully spread. we cannot disregard the possibility that, just as cfr inceased with time even in south korea, similar studies in countries with more cases, could have a real higher cfr. it is thus reasonable to consider cfr at % as an easy policy guiding principle and not to use the more positive scenario of . %. unbiased nature of cfr in europe there are three sources of possible biased cfr across countries. the disease affects more strongly elder people with comorbidity problems than healthy younger ones, and more men than women. in all european countries the male/female ratio is unbiased except for older people. this is precisely the group with higher mortality rate. it is thus very important to asses how the different demographic structure of european countries could affect our central benchmark [ ] . the same must be said about the relative prevalence of other comorbidity factors. we proceed to show that, with the data we have today: the demographic and comorbidity structure, none of these possible sources of bias can have anything but a small effect. to do so, we will do a comparison with the cfr of south korea on april , . %. table shows the demographic structure of south korea and the corresponding cfr for each analyzed age group reported on april . the first row shows the demographic structure according to eurostat, but the analysis has be performed by using only the three age groups shown in the second row: ≤ , − and ≥ years. this was done because for many countries reported cases and fatalities consider different age groups, and some countries even report this two figures using different age groups. the three age groups considered in the analysis were the only ones that includes all the analyzed countries. as can be observed in the to analyze what is the role played by the differences in demography in europe in the covid- cases and fatalities we have downloaded from eurostat the demographic distribution by age (see table ). we can readily asses that, when comparing with south korea, all the countries have a larger percentage of population above years ( % larger for italy) and larger median age except sweden and united kingdom, but the relative differences in each of the cohorts in between the european countries shown in the table is small. only italy presents a relevant larger than average ratio of people over . using this demographic data and assuming each european country presents the same cfr by age group as south korea on april , we have computed the cfr for each country. table shows the results of this analysis and the officially reported cfr by the different european countries on the same date. both values are presented relative to the cfr reported by south korea on april , . %. as can be observed in the first column, when demography is the only difference between countries, between the worst and best case of the relative cfr the differences april , / . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . having previously a very bad prognosis. we know this group is strongly affected by the virus [ ] . in blunt terms, we must examine the possibility that different countries are counting the raw number of dead people differently. before entering in the detail of the analysis, let us point out that two indications go against this possibility. first, health care systems in europe can have different april , / . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . resources in different countries with different focus and priorities, but they attend there is a single exception that we know of: belgium [ ] . belgium seems to be reporting unconfirmed cases from nursing homes without tests as due to covid- . it is quite clear that this includes a good number of people who, either, did not die from covid- or that covid- was not an important factor in the prognosis. therefore, we will include a reminder that belgium data is biased compared with other countries, being anywhere from % to % lower given the number of reported deaths from nursing homes compared with hospitals. there is a second argument regarding the treatment of the elder population in other countries. if large undercounting woul be the case, it should be noted in the mortality rate for people years and older, which is not observed in the countries where we have data. in this framework, spain becomes a key country. if spain were not to have an important undercounting is highly implausible to think that other countries would. we proceed to analyze the data of the national epidemiology center (instituto de salud march to april for the whole of spain, they see that, as expected, mortality is much higher than in previous years. an increase of % is observed. however, it is interesting to compare this with the data reported for covid- deaths. the reported deaths by covid- are roughly , depending on how you attribute deaths to a particular day in the calendar. on the other hand, the reported excess of deaths by the momo surveillance system is . we think that the assessment of around % underreporting can be taken indeed as a worst-case scenario for a highly impacted country. it seems reasonable to expect other countries to have underreported way below or slightly below this level. all the data point out right now, that the undercounting due to a different treatment of the very fragile population is highly unlikely across europe, and at most introduces changes in cfr around ± %. having shown that the real cfr should not present bias in european countries larger than %, we address now how to deal with the real sources of bias in the diagnostic rate for each country. to estimate dd we look for a correlation between the number of reported cases (see fig. a ) and the number of reported deaths (see fig. b ) [ , ] . to deal with noise effects we put a weighted moving average filter on the data of both cases and deaths. the correlation time between reported cases and reported deaths will be named as time from diagnosis to death (dtd), and: ttd = dd + dtd. ( ) correlation between reported cumulative cases and reported cumulative deaths exploring different delays between diagnose (reported) and death for germany (red), spain (green) and switzerland (green). (d) maximum correlation is marked with a red square for each country. % correlation interval can be seen with black bars. april , / . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . in fig. c we can see the correlation [ ] between reported cases and reported deaths assuming different dtd for germany, spain and switzerland. as you might expect, correlations have values close to . in most cases the correlation has a concave parabolic shape with a clearly defined maximum. we assume this maximum represents dtd for each country. the correlation interval is estimated as the points where the correlation is greater than % of the observed maximum. we decided to set a lower limit of days and a higher limit of days [ ] because we believe that time outside diagnostic rate by country as discussed in the methods, we use the same cfr = % in all european countries instead of making small corrections for demography. the bias due to demography was shown to be around - %, precisely the same order of magnitude we obtain for the possible bias in the counting of reported mortal cases. given that our aim is to provide a clear method for policymakers and that there is no data on how, or even if, both correlate, a common cfr allows us to homogenize the results with the clear limitation that we will obtain reasonable estimations and not exact results. the resulting picture is expected to be closer to reality than using purely reported data, but worse than correcting properly for age and diagnosis if the data of cfr for all age brackets and locations (nursery homes, hospitals, individual homes) were available, which is not the case. the estimation of the diagnostic rate is straightforward. from the cumulative number of deceased each day, and multiplying by ( % cfr) we get the cumulative number of people with symptoms days ago [ ] [ ] [ ] simply by rescaling and displacing backward in time the cumulated death curve of any country. to give an initial realistic and homogenous diagnostic rate we must establish how many days are needed as a bare minimum to be able to detect a patient from the onset of symptoms. first, the patient has to feel sufficiently sick and then contact the health service. from this contact, the doctor needs to be suspicious that the person has the disease and request a test. then, this test must be available, performed and the result received and annotated. it is clear that a bare minimum of one week is needed for this process. we use the name -days . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . symptoms and then days forward to be detectable/diagnosable. from this curve, we can obtain the rate between the cumulated number of people who had symptoms for or more days and the cumulated number of people detected days ago. it is thus clear that this homogenous analysis across countries could be performed assuming d-dr or d-dr and different cfr. it gives a proper first estimation of the situation. we argue, however, that there is indeed bias in the way people deal with the health care system in normal situations and, especially, under an epidemic. different countries and populations are in fact behaving very differently. we have observed that this is the case in the methods section checking the delay between diagnostic and death using time-displaced correlation analysis. this is the reason why we also define the delay to detection diagnostic rate (dd-dr) as the diagnostic rate computed using a time delay between the appearance of symptoms and detectability different for each country. we proceed to use fig. , with spain as an example, to explain the concept behind dd-dr. for spain, the maximum correlation between cumulated death curves and cumulated reported cases appears when cumulated deaths are displaced days backward. this suggests a dd of around two weeks ( − = days). this makes sense in a situation like the one in spain during march . the population receiving news that the health care system is under stress may decide to delay reporting of symptoms unless they are very serious. additionally, there is the possibility that tests are not available to people who report with symptoms to primary health care centers, and that the delay between the test, its positive result, and its record to official information systems is not negligible as well. it is thus important to correct for this bias in the estimation of the diagnostic rate. it is clearly not the same to have a time delay from symptom to the detection of days than . dd-dr can be computed from spain just like we did before for the d-dr using the same rescaling of the cumulated dead curve as before but using a displacement backward of days instead of days. fig. shows how the dd-dr is obtained in different countries depending on the delay between symptoms and detectability. countries with a lower dd, such as germany, have the same d-dr than dd precisely because they diagnose as early as realistically possible. we notice now that both d-dr and dd-dr can be tracked along time, as the epidemic advances we can check how these diagnostic rates changes. each new day we can look days back for the d-dr and compute the diagnostic rate. dd-dr can be tracked similarly. in fig. we show the evolution for both as a function of time for three selected countries. we observe that the dd-dr reaches a steady state after the initial stages of the disease while d-dr seems more affected by trends. this can be expected since dd-dr uses, precisely, the maximum of the correlation delay so it is expected to fluctuate less. the dd-dr is not only more stable but it also allows as to produce a proper assessment of the errors involved. the main one is the fact that the april , / . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . april as above million in spain and close to half million in germany. the table in fig. shows a list of the d-dr as of the beginning of mid-april of , and the dd-dr, which seems stable, together with the associated error. to interpret estimated cumulative cases and estimated attack rate we must take into account detection delay, because they are computed using the reported data. data updated on april . belgium data is biased due to reporting of unconfirmed death cases [ ] . best estimations might shift - % once the diagnostic rate is known, it is straightforward to establish a real incidence no longer affected by the presence of important differences in the time delays to diagnostic in different countries (see the table in fig. ). the level of diagnosis and the real incidence is indeed useful for policymakers since it gives a clear general picture. however, the policy response needed to improve the diagnostic rate is limited, in the short-term, by the ability to increase the production of pcr kits and other diagnostic tools. policymakers have more ability to affect immediately mobility patterns and social contact. in this sense, a key number for policymakers would be to have a reliable and robust estimation of the number of infected people in each country that can propagate the disease. providing an exact number is, right now, impossible. we can, however, produce an index of the effective potential growth using the dd-dr and the guidelines used by the ecdc to track the epidemic. even if the precise number of people with the disease were known, and the distribution of symptoms by sex and age was reported, there is no clear knowledge regarding the level of infectivity of the different type of person and symptoms. for instance, it is not known the days a person with mild symptoms can transmit the disease. the same can be said for people with serious symptoms. virus loads in the throat seem to be rather high across the board [ ] , but data on how this influence contagion is unclear. the only way to assess the situation is to use a general unbiased broad measure, which is indicative of the potential for infection. the ecdc uses the number of newly infected people in the last days [ ] . we use this same criterion. this number can only be obtained properly some days in the past, on the day we have a typical diagnosis. after that, we would need input from new data to properly compute how many people are diagnosed. so the number i is strictly a measure of the recent past, but good enough to give the proper picture that the system will face the following days. april , / . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . fig . schematics of the procedure to obtain incidence a , recovered and estimated cases using germany as an example. incidence of estimated cases (blue), contagious incidence (red) and total estimated recovered cases (green). blue shaded part is the number of cases used to compute the estimated contagious incidence. to interpret final number of total cumulative cases, recovered cumulative cases and estimated attack rate we must take into account detection delay, because they are computed using the reported data. similar figures for all countries are shown in si fig. we also consider those undetected cases which appear earlier than days as recovered r i . notice that here we use the word recovered lousily. it does not mean literally that all of them are fully recovered since most of them never fell ill to begin with, and some of them could not have neutralized tests yet, but that those infected and undetected for more than two weeks ago do not seem to pose a serious risk. a alone, however, does not give a full picture of the situation. it is not the same to have contagious per inhabitants when the number of contacts is high that when the number of contacts is low. it is important to take into account the level of spreading velocity of the epidemic related to the effective reproductive number (r t ). the effective reproductive number depends on multiple factors, from the properties of the virus itself to the number and type of contacts. those, again, depend on different social behavior and structure such as mobility, density or the typical size of the family unit sharing a house, to name a few. the only feasible way to estimate r t is using fits from seir models. complex seir models which include spatial and contact-processes have a large number of parameters which, due to the present lack of knowledge, are ( ) and epg.ρ ( ) is computed using the mean value for the last three days. epg: effective potential growth described in the text. to interpret table data we must take into account detection delay, because they are computed using the reported data. data updated on april . * belgium data is biased due to reporting of unconfirmed death cases [ ] . best estimations might shift - %. given the partial empiric nature of present r t , we prefer to take a fully empiric surrogate as a quantitative evaluation of the level of infections. we define an alternative reproductive number as the number of new cases detected today divided with the number of new cases detected five days ago as n t /n t− . however, the high fluctuations on this quantities imposes the use of averaged values over three days [ ] : where n t stand for new cases reported at day t. this rate is one if the number of new cases is constant. it will be below if new cases are decreasing and larger than if the april , / . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint number of cases is increasing. we take days as the key delay unit since this is roughly the time since infected people develop symptoms if they do develop them. there are still clear fluctuations on a day-to-day basis of this measure ρ t due to common delay and irregularities in reporting. most fluctuations can be eliminated by taking the average of ρ t during three daysρ ( ) which is normally enough to get a rather smooth measure. it is not uncommon to find still some fluctuations and one-week averages can be done if required. we propose the following day-to-day index epg: epg is just the multiplication of the growth rate of the diseaseρ ( cases is biased by diagnosis protocols and ratios in each country, as well as by the pool of asymptomatic cases. moreover, any attempt to improve diagnosis percentage requires an economic, infrastructural and logistical effort that is not always possible. in addition, this health system structure is a strong conditioning that limits the possible actions to carry out in this direction. the reported number of deaths, if uniformly and properly recorded, provides very relevant information as a first general overview. even in countries where there is a bias on death reporting, the effort that should be made to improve these data collection is much lower than the necessary effort to increase data about cases. the assumption of a common lethality, which has been situated around %, allows for using the cfr as an indicator of real incidence. current information on cfr is still not complete, since many countries do not report distribution of deaths by age or sex, neither provide covid- mortality outside hospitals. however, we argue that the kingdom ( , ), france ( , ) and belgium ( , ). if we estimate the cases that should have been diagnosed by that time, the ranking is lead by italy ( , , ) and followed by france ( , , ), spain ( , , ), united kingdom ( , , ), belgium* [ ] ( , ) and germany ( , ). thus, differences in diagnostic rate are absolutely significant when analyzing global situation in europe. countries like germany, portugal and switzerland would be diagnosing around % of cases, while belgium, france, sweden and united kingdom would be in the level of %. assessing the risk of countries to enter or remain in the epidemic growth phase is essential. in this sense, the epg index is a valuable tool for policy makers. a high epg in the situation where there is a high growth rate of the epidemic and large number of active cases is a clear situation of danger, while a very low epg because both the reported epg vs estimated real epg. different european countries in terms of the epg computed using the reported data on the attack rate vs the epg using our estimation of the real attach rate. the order of the different countries should be done from right to left (for the reported state of the index) and from top to bottom (for the estimated value of the index). we observe how the comparative situation of the different countries changes as of april . * belgium data is biased due to reporting of unconfirmed death cases [ ] . best estimations might shift - %. despiteρ ( ) is quite independent of the diagnostic rate, reported i directly depends on the level of diagnosis. thus, if epg is evaluated with reported data, it can provide a wrong picture of the situation. based on reported epg, the worst situation in europe at april would be for belgium, followed by spain, united kingdom, netherlands and portugal. if risk is evaluated with estimated epg, highest value would still correspond to belgium as well, but followed by sweden, united kingdom, spain, netherlands and italy. portugal is in much better position that its reported data suggest. actually, countries with similar reported epg like portugal, and netherlands have, in fact, totally different estimated epg, being the last country at significantly higher risk than the former . we have shown in the methods section that the basis for obtaining estimated i and a is not biased due to demographic differences and, right now, there is no indication that it is biased due to a different way of accounting for the cumulative dead toll of the epidemic. there is also no indication that comorbidity factors are largely different in different countries or that cfr is higher on some countries given that icu units and hospitals are not available for people that would need it, at least so far. if this were the case, under any scenario where the situation occurs, the epidemic in that country will have such a larger number of cases, attack rate and growth that the epg will be extremely high. the only real limitation is that the social and environmental issues could affect the prognosis of the infected. if living in a small house with other people infected could lead to worse prognosis than staying in a large house alone, a new analysis regarding the unbiased nature of the cfr would need to be done. it is important to indicate that not only i is unbiased, as analysed in previous sections, but thatρ ( ) is not biased as well. even though absolute reported cases is biased, as we have shown, ρ t deals with ratios and its evolution. as long as the diagnosis and recording of the people with disease follows roughly the same criteria along time in each country, ρ t is a good measure of the growth the epidemic. indeed, if evaluated diagnosis percentage is more or less constant in time, we can assume that ρ t correctly reveals tendencies in contagiousness. if a change in criteria in reporting the cases occurs (i. e., a large increase in the number of tests per day leading to an increase of cases due to more testing), ρ t will be temporally affected but will go back to be a good measure once the new criteria is established. in this case, epg will provide a wrong picture for a while as well, until stationary conditions in diagnosing and reporting are achieved again. there is another important point to address in order to guarantee that ρ t is a robust measure. as soon as we are estimating real number of cases, we can determine the associated ρ t . it is expected that both ρ t behave similarly but with a certain delay. this delay can be determined by translating both ρ t in time until error between both is minimized. we show this detailed analysis in the supplement material si file where we evaluate that both the reported ρ t and the inferred ρ t are indeed different but that follow the same type of evolution once the proper delay is accounted for si fig. . the third important outcome of this analysis is the estimation of recovered people. this is an important number to assess the possibility of herd immunity discussed as a possible exit strategy. the idea is that those that recover might have immunity and act as barrier in the transmission of the disease. a recent study from the fudan university at shangai [ ] has analyzed antibody titters of adult covid- recovered patients. the study is based in the detection in plasma of spike-binding antibody using rbd, s , and s proteins of sars-cov- using an elisa technique. it is also the first study that looks after neutralizing antibodies (nabs) specific for sars-cov- using a gold standard to evaluate the efficacy of vaccines against smallpox, polio and influenza viruses. the study highlights the correlation between the nab titters and spike-binding antibodies that were detected in patients from day - after the onset of the disease, remaining afterwards. middle and elderly age patients had higher titters compared with young age patients, in which in cases the titters were under the limit of detection. nab titters had a positive and negative correlation with c-reactive protein (crp) levels and lymphocyte counts, respectively. this indicates that the severity of the disease, in terms of inflammatory response (crp levels), usually worse in middle and elderly age, favors the increase of antibody titters. equally, the negative correlation with lymphocyte counts suggests an association between cellular and humoral response. therefore, it is possible that the immunity reached by young people, which were mostly asymptomatic, is residual. in that case, this sub-population would keep being carriers of covid- . serological studies that many countries are designing and carrying out should provide further information on post-infection immunity. even if the entire recovered population acquires middle-term immunity, current incidence situates european countries far from herd immunity. nevertheless, it is feasible that regions with highest affectation were closer to use herd immunity as a strategy for de-confinement. governments might wish to explore the possibility of local deconfinement. there are two possible limitations of this present study. it could be possible, in theory, that some countries present an intrinsically different cfr if they are able to isolate completely and significantly its elder population more than others. the epidemics real cfr is a measure of the case fatalities if all the population, or a representative sample of it, has become infected. if one country would effectively prevent all infections among all its elder population from contagious forever, it will certainly have a different cfr. right now, it is impossible to assess if this is indeed the case in different countries given the lack of reported cases and mortality rates by age and sex. we should notice however that, if this disaggregation were to be provided, we could proceed with exactly the same methodology but instead of using the whole country as a whole we would divide it into different age brackets and treat them separately. the second limitation is related to the first one but coming from a more structural perspective. a clear possibility is that countries under stress could be failing in providing the same medical support changing the cfr. we must notice that health care in european countries, even under stress, has been able to increase dramatically its number of health personnel, of beds and hospitalization in short notice [ , ] . italy and spain present some regions under stress but not the whole country [ ] . finally, one cannot disregard the possibility that complex mechanisms of mutations and repetitive exposure to the virus may change the prognosis depends on the type of residence and, hence on socio-economic factors, which are clearly different across countries. if any proof that a close environment not only increases the level of infections, which they obviously do, but also changes the disease evolution in the patient, one should again test that the uniform/unbiased cfr hypothesis holds with the proper knowledge at hand. to obtain dtd for each country and the corresponding evolution of the diagnostic rate. we also provide fore each country the evolution of recovered and the attack rate in the last days a . we also provide the demonstration thatρ ( ) is also unbiased showing the correlations between real and estimated growth rates. fig. series of figures showing the evolution of the estimated cases for different european countries. in blue, incidence of estimated cumulative cases. in green, estimated incidence of cumulative recovered cases. in red, estimated incidence of attack rate lasts days (a ). day is considered the first day where cumulative cases was over cases, it is different for each country. data extended till april . . cc-by-nc . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . growth rate and, in blue, reported cases growth rate. (b) the gorwth rate of estimated cases is displaced to find better match with the growth rate of reported cases. 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cohort and their implications chain safety and environment belgium government. the covid- figures: collection, verification and publication vigilancia de los excesos de mortalidad por todas las causas. momo world health organization. coronavirus disease (covid- ) situation reports correlation (in statistics virological assessment of hospitalized patients with covid- european centre for disease prevention and control. coronavirus disease (covid- ) in the eu/eea and the uk -eighthupdate el ministerio de sanidad amplía las medidas para el refuerzo de personal sanitario hospital fira salut ja està a disposició del sistema sanitari per si calen llits addicionals incidencia de la covid- en las camas uci en españa key: cord- - w c qr authors: ojong, nathanael title: the covid- pandemic and the pathology of the economic and political architecture in cameroon date: - - journal: healthcare (basel) doi: . /healthcare sha: doc_id: cord_uid: w c qr this article examines the factors restricting an effective response to the covid- pandemic in cameroon. it argues that structural adjustment policies in the s and s as well as corruption and limited investment in recent times have severely weakened the country’s health system. this article also emphasises the interconnection between poverty, slums, and covid- . this interconnection brings to the fore inequality in cameroon. arguably, this inequality could facilitate the spread of covid- in the country. this article draws attention to the political forces shaping the response to the pandemic and contends that in some regions in the country, the lack of an effective response to the pandemic may not necessarily be due to a lack of resources. in so doing, it critiques the covid- orthodoxy that focuses exclusively on the pathology of the disease and advocates “technical” solutions to the pandemic, while ignoring the political and socio-economic forces that shape the fight against the pandemic. at times, medical supplies and other forms of assistance may be available, but structural violence impairs access to these resources. politics must be brought into the covid- discourse, as it shapes the response to the pandemic. the current coronavirus disease (covid- ) pandemic started in december [ ] , and on december , china informed the world health organisation (who) of numerous cases of pneumonia of unknown cause in wuhan, a city of million inhabitants [ ] . initially, a significant proportion of those affected worked at the city's huanan seafood wholesale market. three weeks later, there were confirmed cases in the us, thailand, nepal, france, australia, malaysia, singapore, south korea, vietnam, and taiwan. the who's director-general, dr. tedros adhanom ghebreyesus, declared the novel coronavirus outbreak a public health emergency of international concern on january , after the number of cases increased more than tenfold in a week [ ] . by this time, there were confirmed cases in countries, excluding china. on february , the who announced a name for the new coronavirus disease: covid- . on march , the who's director-general said that the institution was "deeply concerned both by the alarming levels of spread and severity, and by the alarming levels of inaction", and concluded that "we have therefore made the assessment that covid- can be characterised as a pandemic" [ ] . by this time, there were over , cases in countries, with deaths [ ] . by may , there were over three million confirmed cases and over , deaths in countries [ ] . in declaring covid- a pandemic, the who's director-general noted that the "greatest concern is the potential for this virus to spread to countries with weaker health systems which are ill-prepared to deal with it" [ ] . most african countries have weak health systems, including inadequate surveillance and laboratory capacity and limited medical personnel [ ] . as of february , only this review draws on secondary data sources, and the evidence presented is based first on the growing body of literature regarding the covid- pandemic from a variety of institutional fora. a significant proportion of this work has been carried out by people directly or indirectly associated with international institutions (e.g., the world health organisation and world bank), academic institutions, news agencies, national government departments, and non-governmental organisations (ngos). in some cases, data from these sources were readily available online. this paper relies heavily on scholarly and national government literature to historicize the state of the health sector, while some of the evidence supporting the analysis is drawn from local and international news agencies. the evidence provided by these news agencies is current, which explains why they are used to shed light on contemporary issues related to health care, including covid- . additionally, news agencies often bring to the attention of the public issues that governments are not ready to disclose for political reasons, and scholars have endorsed the use of these sources [ , ] . the use of these secondary sources poses some limitations, as local new agencies may be biased regarding reportage [ ] . to minimise this problem, evidence is drawn from a variety of national and international news agencies. additionally, the statistics provided by national government agencies should be considered with caution, as across multiple african countries, there are discrepancies between administrative data and independent household surveys [ ] . several african countries also misreport to foreign donors [ ] . so, these limitations should be taken into consideration when engaging with discussions in this paper. that said, the goal of this review is to provide a deeper understanding of the factors that have contributed to weakening cameroon's health sector over the years and to shed light on socio-economic and political factors that are currently restricting an effective response to the pandemic in the country. coronaviruses are pathogens that primarily target the respiratory system in humans [ ] . the most common symptoms at the onset of covid- are fever, cough, and fatigue, while other symptoms include headache, sputum production, hemoptysis, dyspnoea, diarrhoea, and lymphopenia [ ] [ ] [ ] . the incubation period for covid- , i.e., the time between exposure to the virus and symptom onset, is on average - days, but can be up to days [ ] . however, some people are asymptomatic, meaning that they are infected with covid- but do not develop symptoms. scholars have suggested that a "wet market" in wuhan city where live animals are often sold may be the zoonotic origin of covid- [ ] . the who has classified covid- as a β-coronavirus of group b [ ] , with a genome that is highly similar to bat coronavirus, thus pointing to bats as the natural host [ , ] . research has shown that some bat sarsr-covs have the potential to infect humans [ , ] . it seems that most of the early confirmed cases had a contact history with the original wet market in wuhan [ ] ; however, covid- is currently being transmitted by human-to-human contact. covid- uses the same receptor, angiotensin-converting enzyme (ace ), as that for sars-cov, and spreads principally through the respiratory tract [ ] . human-to-human transmission occurs primarily through direct contact or through droplets spread from an infected person by coughing or sneezing [ ] . human-to-human transmission has accounted for the proliferation of covid- across the globe. a strong health care system is vital in handling confirmed cases and reducing the covid- fatality rate. as was mentioned earlier, cameroon, like other african countries, has a weak health care system. so, what is the state of cameroon's health system, and what factors have contributed to weakening it? the public health sector is considered one of the driving forces of cameroon's health care system due to its core objectives of disease prevention and providing and improving health services to its population. public health facilities are organised into seven categories: general hospitals, central hospitals, regional hospitals, district hospitals, district medical centres, integrated health centres, and ambulatory health centres [ ] . in addition to these seven groups, there are also private clinics, health facilities operated by religious organisations and ngos, and traditional health institutions. quantitatively, in , there were public and private health facilities in the country (table )-of which, . % were private institutions (i.e., for-profit or non-profit institutions) [ ] . some public health institutions are not fully functional due to lack of equipment, and where equipment exists, it is obsolete or of poor quality [ ] . one study identified a lack of delivery kits ( . %), dry-heat sterilization systems ( . %), caesarean section kits ( . %), and functional microscopes ( . %) in health institutions in the country [ ] . the ratio of health personnel (medical doctors, midwives, and nurses) to the regular population is . per inhabitants [ , ] . more precisely, there are . doctors per , people, and hospital beds per , people [ ] . in some administrative regions, the proportion is as low as . doctors per , people ( table ). the government admits that public health institutions are understaffed [ ] . public resources allocated to the health sector in cameroon remain some of the lowest in africa in terms of gdp [ , ] . out of the us$ per cameroonian spent on health care in , the government contributed only us$ , i.e., %-of which, us$ was provided by international donors [ ] . therefore, the cost of health care is largely borne by individuals through out-of-pocket payments. in , out of us$ per person spent on health care in the country, us$ was out-of-pocket spending, us$ was government spending, us$ was development assistance for health, and us$ was prepaid private spending [ ] . the national and international press have reported cases in cities such as douala and yaoundé where people were denied health care or detained because of their inability to pay their health care bills. in , the bbc reported the case of a mother and baby who were detained for months by a hospital in yaoundé due to the mother's inability to pay her medical bill [ ] , and in , the france-based news agency france reported that a hospital in the capital city, yaoundé, detained 'about a dozen mothers and their newborns in a small room for about a month because they were unable to pay the hospital fees for the birth by caesarean section' [ ] . people have also had to rely on out-of-pocket payments to cover health care costs related to covid- . an independent local news agency in the country reported that some public health institutions in douala required covid- patients to cover their health care costs. the news agency interviewed the spouse of a covid- patient who, after spending approximately , fcfa ($ ) on tests and prescription drugs, turned to the use of free herbal medicine provided by the archbishop of the douala metropolitan archdiocese, his lordship samuel kleda [ ] . the country's minister of public health, dr. malachie manaouda, in a press release published on april , declared a ban on the systematic billing for screening tests, hospitalisations, and administration of prescription drugs. however, two weeks after the minister's press statement, people in douala, for example, were still relying on out-of-pocket payments for covid- -related medical expenses [ ] . the confusion surrounding the requirement of covid- patients to cover their medical bills is captured in the following statement by the director of the douala gyneco-obstetric hospital, prof. emile mboudou: "is it possible that the hospital gives you a prescription and also gives you the money to buy the prescribed drugs in a pharmacy? we have not received a drug endowment until now at the douala gyneco-obstetric hospital" [ ] . this case depicts a lack of coordination between the ministries of public health and finance. the former has the technical authority to instruct medical facilities not to charge covid- patients, but for this policy to take effect, the latter must make the funds available to the medical institutions to cover the costs. the covid- pandemic has made manifest cameroon's weak health system. as of april , the country had just four testing laboratories, with three of them in the capital yaoundé [ ] . a medical doctor in douala, the country's economic capital, noted: "there are less than ventilators in the whole city. we are having challenges in treating patients with acute respiratory distress" [ ] . the country's prime minister, joseph dion ngute, announced plans to transform eight venues into makeshift medical facilities to be used for the treatment and follow-up of covid- patients, but the construction of these makeshift medical facilities, as well as equipping them, has been slow [ ] . as of april , none of these makeshift medical facilities was ready to receive covid- cases. cameroon has received external support to fight covid- . the country received medical supplies from unicef and jack ma's alibaba foundation [ ] , vehicles from the who, and financial support from countries such as the united states of america [ ] and switzerland [ ] . the ngo doctors without borders (médecins sans frontières) has also been supporting the country's response to the covid- pandemic. although the humanitarian assistance provided is laudable and timely, it reinforces structures of dependence, and history tells us that the country is likely to continue to depend on external assistance, including foreign experts to tackle future epidemics. scholars have argued that sub-saharan african countries which receive aid are less likely to have incentives to invest in effective public institutions [ ] . therefore, the government may not have the incentives to invest in the health care system, as it is well aware that it can always count on external support in times of emergency. undoubtedly, covid- has exposed cameroon's weak health care system, and to understand the current state of the country's health system, it is important to investigate its roots. put simply, it is important to examine the factors that have contributed to weakening the country's health system. cameroon's weak health system can be traced to the years of structural adjustment which began in the mid- s. after independence, cameroon enjoyed relative economic prosperity until the mid- s. from to , its economy grew annually at approximately % [ ] , which led us president ronald reagan to refer to the country as a 'shining example for africa' [ ] . this growth was mostly due to the boom in exports of cash crops. in , cash crops made up . % of exports, while oil comprised only . % [ ] . the structure of the country's economy changed in the s because of oil exploration. in , oil made up . % of exports and cash crops . %, with the government receiving high royalties from international oil companies developing the field [ ] . according to the world development indicators database, gdp per capita (in us$) increased from $ . in to $ . in . however, cameroon's impressive economic performance was short lived, and in / , a drop-in oil revenue due to a simultaneous reduction in prices and exploitable sites and a decline in the terms of trade for cash crop exports slowed down the economy's growth [ ] . farm prices for cocoa, arabica and robusta coffee, rice, and cotton declined by , , , , and %, respectively [ ] . accompanying the sluggish economy were budget and balance-of-payment deficits, a build-up of internal arrears, a rise in foreign indebtedness, and worsening solvency problems for commercial banks [ ] . external borrowing and reserves held abroad permitted the government to push back any sort of reform until , when president paul biya announced some budget cuts [ ] . however, this measure failed to remedy the situation, and deficits continued to rise. between and , real gdp fell by %, the external deficit averaged % of gdp, foreign debts tripled to over % of gdp, and the debt-service ratio increased to % [ ] . by , the government had no option but to enter into a structural adjustment agreement with the world bank [ ] . structural adjustment policies in cameroon included devaluing the currency, cutting public expenditures, eliminating subsidies, promoting exports, especially agricultural, and liberalising trade [ ] . pay cuts were introduced in ( %) and ( % at first, and later %) [ ] . prior to the pay cuts in , an integrated public employee on index earned a gross salary of , fcfa (us$ ), and after the cuts, their salary decreased to , fcfa (us$ ), i.e., a . % reduction in pay [ , ] . then, in , there was a % devaluation of the fcfa in return for $ million in credit ratified by the international monetary fund [ ] . additionally, as of , public service employees began to experience delays in salary payments which usually exceeded three months [ ] . according to the world development indicators database, per capita gdp (in us$) decreased from $ . in to $ . in . the world bank-and imf-sponsored structural adjustment programmes severely affected the public health sector in the country, and there was no recruitment of people into the public health sector for years [ ] . further, there was little investment in health infrastructure [ ] . paramedical training for laboratory technicians and nurses was suspended for several years, and training schools closed [ ] . low salaries and poor working conditions [ ] led public health personnel to move to the private health sector where salaries were higher [ ] , or to move abroad [ ] . in , public health sector jobs were approximately % unfilled [ ] . unsurprisingly, the structural adjustment policies also directly affected users of public health institutions. government spending on public services was curtailed, and "health became a commodity and an individual responsibility" [ ] . the government implemented a health cost recovery system that required users of public health institutions to cover their health care costs, and this implementation of out-of-pocket payments amid chronic poverty pushed people to turn to alternatives such as self-medication, traditional medicine, and drugs from street vendors [ ] . drugs purchased on the street are often counterfeit or substandard, causing harm to patients as well as failing to treat the diseases for which they are intended. people's decisions to purchase counterfeit or substandard drugs on the street were not solely due to the cost of these products in formal health care institutions. the government's reduction in health spending meant that some public health institutions did not have the medications required by patients, leading the latter to purchase drugs on the street [ ] . unlike the public health institutions, people did not have to travel long distances to purchase counterfeit or substandard drugs, as these were readily available in local communities. put simply, availability and accessibility were and remain key contributory factors to the proliferation of counterfeit or substandard drugs in the country [ ] . the shortage of drugs in public health institutions was also linked to chronic corruption, which remains pervasive in the country. cameroon was ranked the most corrupt country in (out of countries surveyed) and (out of countries surveyed), and in it ranked rd out of countries in the corruption perception index. cameroon's score of out of indicates serious levels of public sector corruption [ ] . regarding judicial independence, in , the country had a value of . out of , indicating that its judicial system is seriously influenced by members of the government as well as private citizens and firms [ ] . in the past, there has been large-scale drug thefts and small-scale pilfering, and the limited drugs that reached public health care institutions due to the reduction in public health expenditures were given to local authorities, family members, and friends before patients could benefit from them [ ] . it is no coincidence that data from the household survey conducted by the government show that approximately % of household heads in urban and semi-urban areas noted the high level of corruption in the public health sector [ ] . a study conducted in the city of douala found that in order to avoid long wait times to see a doctor, people offered bribes in order to enable them to skip the queue [ ] . additionally, some doctors in public hospitals operate private clinics, so when patients go for consultation in public hospitals, these doctors often direct them to their own clinics, where costs are significantly higher [ ] , and this practice also increases the total health care costs borne by patients. funds provided by external partners, intended to help the government strengthen the country's health system, have been misused too. this was the case for funds provided by the gavi alliance, a public-private partnership whose mission is to save children's lives and protect people's health by increasing access to immunisation in the global south. the gavi alliance uncovered massive misuse of its grants in cameroon in , and an investigation led by the alliance revealed that "of us$ . million programme expenditures, us$ . million had been misspent, partly due to fraud. different types of corruption affected this programme" [ ] . the investigation highlighted fraud in purchasing (e.g., non-existent suppliers, order-splitting to avoid tender, fake invoices, over-invoicing of - % higher than market prices, purchase of incompatible supplies, unjustified repairs), fraud in activities (e.g., funding of fictitious activities, funding of activities already funded by other partners, withdrawals for activities not undertaken, payment of unauthorized per diems), and unjustified cash disbursements (e.g., discrepancies between bank withdrawals and the amounts in supporting documentation). in fact, a business address on one of the fake invoices was found to actually be a cemetery, and 'brand new vehicles were allegedly subjected to "repairs" costing thousands of dollars' [ ] . several top government officials have been imprisoned for corruption. for example, in , a former finance and economy minister was sentenced to years in prison for embezzling us$ million [ ] . however, some political analysts contend that the arrest and imprisonment of some high-profile government officials, allegedly for embezzlement of funds, is politically motivated [ ] . the government claims that the country has lost approximately us$ . billion in stolen funds [ ] , but corruption is just one of several factors which have contributed to weakening the country's health system. deepening the problems is the limited state investment in health care, and even after the country entered a period of successive gdp growth, there was no significant increase in health spending as a percentage of government expenditures (figure ). instead of an increase in public health spending as a percentage of general government expenditures, there has been a decrease; e.g., between and , the country recorded an annual gdp growth rate of at least %, but there was a decrease in health expenditure as a percentage of general government spending from % in to . % in , and then to . % in ( figure ) . so, the weak health care system is also due to years of inadequate investment in the public health sector. the point emphasised here and elsewhere is that state institutions shape the response to covid- , and put differently, this trend is indicative of how structural violence hampers the fight against the disease. by structural violence, i refer to the 'way institutions and practices inflict avoidable harm by impairing basic human needs' [ ] . apart from the weak health care system, however, there are several other factors restricting an effective response to the covid- pandemic. so far, i have examined the factors which have contributed to weakening cameroon's health care system. as the fight against the covid- pandemic requires bringing together various vital elements, this section focuses on the socio-economic and political factors currently restricting an effective response to the pandemic. in addition to the weak health care system, other factors such as poverty and a lack of basic amenities are hindering the fight against covid- . according to the country's national institute of statistics, approximately . % of the population lives below the national poverty line of fcfa (us$ . ) per day [ ] . the world bank noted that between and , the number of poor people increased by %, to approximately million. however, these figures should be considered with caution, as there is a consensus among researchers that official statistics in several sub-saharan african (ssa) countries are inadequate and unreliable [ , ] -what shantayanan devarajan refers to as the "statistical strategy" [ ] . unemployment among those aged to is approximately %, but crucially, underemployment is . % at the national level and . % and . % in urban and rural zones, respectively [ ] , while informal employment stands at . % [ ] . the precariousness of everyday life makes it challenging to prevent the spread of covid- . on march , the government announced restrictive measures, including the closure of land, air, and sea borders, closure of schools, a ban on gatherings of more than people, and a restriction of non-essential urban and interurban travel within the country. from the beginning, however, it was clear that it would be difficult to implement these measures. it is challenging to ensure physical distancing and the flow of people in marketplaces which are often overcrowded, especially when a significant proportion of the population is not cooperative. moreover, as earlier mentioned, over % of the population relies on the informal economy for a living, and since the functioning of the informal economy is based on the movement of people, without an outright lockdown, it is almost impossible to prevent the interurban travel of informal workers. as well, the government may not be willing to impose a lockdown since over % of the working population have livelihoods in the informal economy. additionally, the government made it obligatory from april for people to wear face masks whenever appearing in public as part of measures to slow the spread of the disease, but due to the high poverty rate in the country, most people say they cannot afford a mask. so far, i have examined the factors which have contributed to weakening cameroon's health care system. as the fight against the covid- pandemic requires bringing together various vital elements, this section focuses on the socio-economic and political factors currently restricting an effective response to the pandemic. in addition to the weak health care system, other factors such as poverty and a lack of basic amenities are hindering the fight against covid- . according to the country's national institute of statistics, approximately . % of the population lives below the national poverty line of fcfa (us$ . ) per day [ ] . the world bank noted that between and , the number of poor people increased by %, to approximately million. however, these figures should be considered with caution, as there is a consensus among researchers that official statistics in several sub-saharan african (ssa) countries are inadequate and unreliable [ , ] -what shantayanan devarajan refers to as the "statistical strategy" [ ] . unemployment among those aged to is approximately %, but crucially, underemployment is . % at the national level and . % and . % in urban and rural zones, respectively [ ] , while informal employment stands at . % [ ] . the precariousness of everyday life makes it challenging to prevent the spread of covid- . on march , the government announced restrictive measures, including the closure of land, air, and sea borders, closure of schools, a ban on gatherings of more than people, and a restriction of non-essential urban and interurban travel within the country. from the beginning, however, it was clear that it would be difficult to implement these measures. it is challenging to ensure physical distancing and the flow of people in marketplaces which are often overcrowded, especially when a significant proportion of the population is not cooperative. moreover, as earlier mentioned, over % of the population relies on the informal economy for a living, and since the functioning of the informal economy is based on the movement of people, without an outright lockdown, it is almost impossible to prevent the interurban travel of informal workers. as well, the government may not be willing to impose a lockdown since over % of the working population have livelihoods in the informal economy. additionally, the government made it obligatory from april for people to wear face masks whenever appearing in public as part of measures to slow the spread of the disease, but due to the high poverty rate in the country, most people say they cannot afford a mask. a lack of basic amenities is also affecting the fight against the pandemic. frequent power outages in the country render it difficult for people who have food preservation appliances to make use of them, and for low-income populations who cannot afford a power generator, this means they must go out on a regular basis to purchase fresh food. water shortages also plague major cities in the country. the over three million residents in the country's capital, yaoundé, require a daily supply of approximately , cubic meters of clean water, but only % of this is provided [ ] . it is tough persuading someone staying in a one-room unit with family members, without water and power, to stay indoors as much as possible and only go out when necessary. additionally, the closure of schools has simply moved most primary and secondary school students from low-income households from the classroom to the streets. in order to make ends meet in the household, some parents send their children to sell goods in the streets and marketplaces. one student told a local news agency that "we are afraid to contract covid- but we have to sell; we won't have food to eat if we stay home" [ ] . another said that since the schools closed, she had been helping her mother sell goods in the market, adding that they would not have food to eat if they did not perform these activities [ ] . as those who make a living in the informal economy have no income if they do not work, they are forced to continue their activities even at the risk of contracting the disease. crucially, the discussion regarding poverty shows how it causes the spread of covid- , as low-income populations who work in the informal economy are forced to go outside in order to gain income, and as they often work in crowded environments, this exposes them to the virus. when they get the virus, it is likely to spread faster within their households, as they are often overcrowded. different households in the slums often share toilets and bathrooms [ ] , thus facilitating the spread of the virus from one household to another. scholars have documented the complex interconnections between poverty, slums, and disease in africa [ , ] . the interconnections between poverty, slums, and covid- bring to the fore the social inequality in cameroonian society. pandemics rarely affect populations in a uniform way [ ] , and arguably, the experiences with covid- , i.e., the nature of the infection, the rate of spread, and access to medical care, vary according to class. as mentioned earlier, low-income populations are more likely to get infected; the upper class can self-impose lockdowns, as they have food, power generators, access to potable water and the internet, and their households are not overcrowded. their status in everyday life reduces their rates of infection, and those who get infected can afford quality medical care. i do not suggest, however, that the better-off populations constitute a homogenous class. the point emphasised here is the different impacts of covid- on different populations. arguably, if low-income populations are more likely to get infected and spread it to others in their households and communities, one might argue that inequality may facilitate the spread of covid- in the country. scholars have put forward points that seem to support the relationship between inequality and the spread of covid- [ ] . in addition to the issues of poverty and social inequality, weak enforcement mechanisms also restrict effective responses to the pandemic. to prevent the spread of the disease, the government recommended that travellers coming into the country be quarantined for days, and travellers arriving at international airports in douala and yaoundé were taken to hotels in these cities for quarantine. however, some of these people received visits in their hotel rooms from family members, friends, and even prostitutes. a top government official in the administrative division of mfoundi, where yaoundé is located, angrily noted, "we discovered that people put in quarantine were conniving with hotel agents [workers] to smuggle women into the hotel to sleep with them. we have arrested some of them. we have to work together to stop this virus" [ ] . the official added that he ordered the arrest of prostitutes as well as women and six men who had sneaked into hotels to meet their spouses [ ] . moreover, of those quarantined escaped from their hotels, and people who returned to the country from france and italy refused to be isolated [ ] . in cameroon, the locals often say that "money speaks"-in other words, people in a sound financial position can make things happen. most of those who escaped were people who had returned from western countries such as france, italy and belgium, and their social class may have made it easier for them to disregard the guidelines. the violators seem to have exploited the country's weak enforcement mechanisms, as people tend to get different treatment based on their social class. the who has urged national governments to "find, isolate, test and treat every case and trace every contact" [ ], but it is challenging to implement this protocol in an environment where corruption is pervasive and where there are weak law enforcement mechanisms. the current political climate in cameroon is affecting the fight against the covid- pandemic there. as mentioned earlier, there is armed conflict in the far north, northwest, and southwest regions. what began in as a political crisis linked to discrimination against english-speaking regions in the country, i.e., the northwest and southwest regions, became a deteriorating humanitarian emergency. the united nations has noted that the conflict in the northwest and southwest regions has created a humanitarian emergency affecting approximately . million people [ ] . as of august , there were , internally displaced persons in the northwest and southwest regions and , internally displaced persons in the far north region [ ] . for political reasons, the government has repeatedly downplayed the severity of the displacement and the humanitarian need, putting it at odds with aid agencies, including the united nations office in the country. for example, in , the government, through the minister of foreign affairs, said that aid agencies had inflated the number of internally displaced persons in order to receive aid from donors, and noted that only , displaced families have been identified and that the government was already providing humanitarian assistance to , of them [ ] . the government has focused on blocking the delivery of aid to the northwest and southwest regions to show that there is no humanitarian crisis in these regions [ ] , and the government recently suspended flights by aid groups to these regions [ ] . officially, the government claims that this is to prevent the spread of covid- , but the move may have more to do with politics, and seems to be part of a government strategy to restrict aid agencies' access to these regions in order to in turn prevent access to information on the ground and thus impose its narrative. there are confirmed cases in both regions, so by suspending the un humanitarian air service, the government is preventing aid, including medical supplies, from reaching the most vulnerable people. in a news conference, the who's director-general famously said, "do not politicise this virus." it seems that his call was not heeded in cameroon. on april , opposition leader prof. maurice kamto launched the "survie-cameroon-survival initiative" (scsi) in order to raise funds to fight covid- in the country. in response, the country's minister of territorial administration said that any appeal to public generosity, for whatever reason, must be authorized by his ministry, considering the scsi to be "illegal", and ordered banks and mobile phone operators to close accounts linked to scsi. to the government, the launch of scsi was a direct challenge to the solidarity fund set up by the government to fight covid- . on april , a gift of approximately , face masks and test kits from prof. maurice kamto under the banner of scsi was rejected by the minister of public health, and the scsi coordinator was told to take the gift to the ministry of territorial administration [ ] . according to the government, scsi was functioning illegally, as it had not received authorization from the ministry of territorial administration to collect public donations. it is based on this narrative of illegality that the minister of public health said that the gift would have been received if the opposition leader had presented it as an individual and not through scsi, concluding that "just because we are in an epidemic does not mean that we have to set aside our laws and regulations . . . this must be emphasized. we did not refuse to do so [receive the gift], but we simply asked him to get in touch with the ministry of territorial administration which oversees associations" [ ] . based on the aforementioned points, it is clear that some people are not receiving assistance because of politics. on may , six volunteers from scsi were arrested while handing out free protective masks and sanitizing gel to residents of yaoundé, the capital [ ] . some medical facilities are in need of vital supplies, low-income people are in need of masks and hand sanitizer, and communities affected by conflict lack food and other basic necessities, while politicians seem to be focused on scoring political points. this is another manifestation of structural violence. although the focus here has been on cameroon, some of the core issues discussed so far are not unique to the country. corruption is also pervasive in neighbouring countries such as gabon, nigeria, central african republic, chad, republic of congo, and equatorial guinea. according to the corruption perception index, these countries occupied the rd, th, rd, nd, th, and rd positions out of countries, respectively, thus indicating very high levels of corruption [ ] . based on these rankings, these countries are worse off compared to other african countries such as botswana (which ranked ), rwanda (ranked ), and mauritius (ranked ). in comparison, nigeria and chad were the most corrupt countries in and , with rankings of and , respectively [ , ] . similar to cameroon, investment in the public health system has also been limited in neighbouring countries. based on data from the world bank's world development indicators and stockholm international peace research institute (sipri), in chad, for example, while military spending increased when the country started receiving oil revenues in , except for and , there has been a decrease in health expenditures as a percentage of government spending. according to data from the world bank's world development indicators, health expenditures in chad as a percentage of government spending decreased from . % in to . % in , and then to . % in . in the republic of congo, another oil-exporting country, data from the world bank's world development indicators show that since , health expenditures as a percentage of general government expenditure have been below %. unsurprisingly, these countries have weak health care systems. the health system is even worse in the central african republic, which has been ravaged by a protracted civil war. as of april , the un's office for the coordination of humanitarian affairs (ocha) noted that there were only three ventilation kits, one oxygen concentrator, and one covid- treatment centre with beds in that country [ ] . as in cameroon, the pandemic has been politicised in neighbouring countries. the government of equatorial guinea recently expelled the country's who representative based on a claim that the representative had falsified the country's tally of covid- cases [ ] , since figures published by the who have sometimes been higher than those put forward by the country's government. additionally, equatorial guinea's official tally of covid- cases had been being updated daily, but the practice ceased on april [ ] . this case corroborates the point mentioned earlier regarding the political economy of data in african countries. the point emphasised here is that cameroon's economic, social, and political issues are not unique to that country. although there are differences in terms of specifics, there is a general pattern noticeable in cameroon and its neighbour countries, and moreover, covid- has equally exposed the weak health care systems in those countries. the covid- pandemic has exposed weak health systems in several countries, especially those in the global south. medical experts are currently focused on the epidemiology of the disease, and rightly so, due to its high fatality rate, as the disease has so far claimed the lives of over , people. so, scientists are racing to develop a vaccine, and in the meantime governments around the world have implemented restrictive measures aimed at containing the spread of the disease. although these efforts are laudable, i argue that it is important to examine the political economy of covid- , as political and economic forces influence the fight against the disease. using cameroon as a case study, i have examined the economic, political, and social forces that negatively affect the fight against covid- , and argue that the country's weak health care system makes it challenging to tackle the disease there as well as in other countries. a combination of structural adjustment policies in the s and s as well as corruption and limited investment in recent times have severely weakened the country's health system, causing poor and vulnerable populations to suffer the most. additionally, politicians are using the pandemic to score political points, as, for political reasons, the government has prevented aid, including medical supplies, from humanitarian organisations from reaching vulnerable populations in certain regions. based on the foregoing, i contend that the inability to tackle the covid- disease may not always be due to a lack of medical supplies or other forms of assistance. as i have shown, aid is at times available, but some people are not able to access it. put differently, political forces are thwarting the response to covid- in cameroon, so politics must be brought into the discourse. the response to covid- in cameroon is a political process, and strategies produced by various actors in the development community cannot be effective if the complexity of local politics is not taken seriously. it is also worth noting that the pandemic has also brought to the fore the weaknesses of health-systems in western countries, as several countries in the west have also been facing challenges in tackling the pandemic due to years of budget cuts that have weakened their health care systems. the major difference between african countries and western countries is that in most cases, the latter have the capacity to mobilise resources needed by health care systems at short notice, while the former often do not have that capacity. the apc was partially funded by york university. a pneumonia outbreak associated with a new coronavirus of probable bat origin looming threat of covid- infection in africa: act collectively, and fast africa is woefully ill-equipped to cope with covid- that's only part of the problem msf supports covid- response in cameroon cameroon: allow aid access amid pandemic covid- ) epidemics, the newest and biggest global health threats: what lessons have we learned? he deadly coronaviruses: the sars pandemic and the novel coronavirus epidemic in china epidemiology of coronavirus covid- : forecasting the 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des dépenses publiques et le niveau de satisfaction des bénéficiaires dans les secteurs de l'éducation et de la santé au cameroun (pets ): rapport principal; volet santé health care systems (primasys): case study from cameroon ministry of public health. cameroon health workforce census cameroon economic update. towards greater equity healthcare financing in rural cameroon institute for health metrics and evaluation. financing global health; institute for health metrics and evaluation detained in cameroon's hospitals. available online: www cameroon hospital detains new mothers over unpaid fees Équinoxe tv-journal h du lundi cameroonian president hails china's jack ma over support in fighting covid- united states department of state. the united states is leading the humanitarian and health assistance response to covid- cameroon coronavirus: swiss govt donates $ m, health workers agitate an aid-institutions paradox? a review essay on aid dependency and state building; cgd working paper 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[crossref] . national institute of statistics. perception de la gouvernance et de l'intégrité au cameroun: une Étude quantitative basée sur les résultats d'enquêtes statistiques auprès des ménages corruption and discrimination in douala metropolis public hospitals of cameroon implementing a transparency and account-ability policy to reduce corruption: the gavi alliance in cameroon cameroon court jails ex-finance minister for years for corruption arrests in cameroon for corruption, or challenges to biya? available online poor numbers: how we are misled by african development statistics and what to do about it africa's statistical tragedy african economic outlook : promoting youth employment; afdb: tunis presentation of the first results of the fourth cameroon household survey (ecam) of water shortages plague major cameroon cities health, wealth and poverty in developing countries: beyond the state, market and civil society why inequality could spread covid- violating covid- restrictions can get you arrested. voa news nearly two million cameroonians face humanitarian emergency: unicef crise anglophone: la guerre des chiffres entre le gourvernement et les ong covid- brings out government's ugly side in cameroon humanitarian response plan covid- equatorial guinea accuses who official of falsifying covid- data acknowledgments: i am grateful to the anonymous reviewers for their constructive feedback and insightful comments as this article gradually came to fruition. the usual disclaimer applies. the authors declare no conflict of interest. key: cord- -tchu av authors: shahzad, naeem; abid, irfan; mirza, wajahat javed; iqbal, muhammad mazhar title: rapid assessment of covid- suspected cases: a community based approach for developing countries like pakistan date: - - journal: journal of global health doi: . /jogh. . sha: doc_id: cord_uid: tchu av nan t he coronavirus pandemic started in late december , when an unexplained case of mass pneumonia occurred in wuhan, china raising concern of the responsible health department of the city. the chinese government notified the who of the epidemic situation in the first week of january and subsequently, the causative agent was identified as a new coronavirus ( -ncov), followed by genetic sequence analysis and the development of a detection method [ ] . in the second week of january, the new coronavirus pneumonia was included in the management of class b infectious diseases by the national health and health commission china on the approval of the state council. city went under lockdown and the chinese government made the highest-level commitment to mobilize every effort to stop the epidemic. understanding the epidemiological characteristics of corona virus ( -ncov) transmission is critical to developing and implementing effective control strategies. this virus spread rapidly affecting provinces (autonomous regions / municipalities) from days after the first reported case, the epidemic reached its first peak on january - , , and an unusually high incidence of single-day event on february , , and then gradually decreased till china was able to contain this virus to its track [ ]. covid- has become one of the largest spreading diseases on the global front in the recent times after spanish flu in early th century. current globalized environment and rapid modes of transportation have helped spreading this virus at an enormous rate, which is unprecedented. the non-availability of cure for the disease and rapid transfer rate has brought the world to a halt. there is also a deficiency of testing kits on the global front coupled with the capacity of available health facilities to test and treat the patients, especially in the under developed world. this required a scientific approach to shortlist the case requiring medical attention for testing and treatment. another important factor raising red flag for the spread is a period of days inactivity of the virus, which may lead to a wrong diagnostic, resulting into spread of the disease. photo: nurse wearing locally produced low cost covid- kit and filling the score card from a suspected patient for initial screening and triage at the emergency control room (from the collection of dr naeem shahzad, used with permission). inclusion of epidemics and pandemics amongst biological hazards by the sendai framework for disaster risk reduction (unisdr, ) and other related frameworks and conventions, the corona virus outbreak has exposed the loop holes which many countries are struggling to respond and manage, as their health care systems have been overwhelmed by exponential increase in cases with every passing day. it is worth mentioning that notwithstanding all odds, countries like china, south korea and singapore have effectively controlled the spread of this pandemic while us is managing huge number of patients with considerable fatalities. by observing the response of the us and most european countries to covid- , it is apparent that the developing countries and countries with poor economic infrastructure will not be able to cope up with this health emergency. it is contingent that countries with low gdps are already over burdened due to number of factors including overwhelmed health care systems and different underlying co-morbidities. therefore, it is imperative to infer that risks posed by covid- in countries with poor economies will be entirely different as compared to us, china and europe. the average household in low-income countries is on higher side as compared to middle and high-income countries thereby highlighting the vulnerabilities of these countries to rapid spread of covid- [ ] . for this reason depending on the existing health care systems in countries with low gdps will be unrealistic to contain and stop the covid- transmission. different strategies for suppression of the covid- are being practiced globally ranging from lockdown of cities to isolation of cases, in order to prevent the number of cases having severe illness requiring icu [ ] . different countries are resorting to massive lock down and social distancing to manage and contain the covid- . this is more critical in the case of developing countries like pakistan to avoid stretching of its already weak health care facilities by resorting to excessive testing, contact tracing, isolation and quarantine of the suspected cases to circumvent health care system overload [ ] . aggressive testing of the individuals becomes tiring and cumbersome in the absence of covid- testing kits. therefore, this study has made an effort to design a rapid assessment score card using bottom up approach starting from community level which will help the low-income and developing countries to ascertain the suspected covid- cases at community level. this will be quite beneficial for rapid triage especially for the countries like pakistan where the suspected cases of covid- are likely to be under-detected due to low testing capabilities [ ] . based on different research findings [ ] [ ] [ ] [ ] [ ] [ ] , a score card has been developed encompassing maximum possible/ probable causes of covid- suspicion among the community. to develop an effective tool for patient screening without overburdening the health care infrastructure while still not compromising the control over the spread of the disease and preventive measures, an effective score card has been developed covering numerous effective parameters for rapid assessment of the probable coivd- cases, as shown in figure . for this purpose the trends and effects of spread rate, age factor, previous health history, travel history, isolation period, appearance of the symptoms and contact with the suspected or confirmed patients has been taken into consideration. this score card has been designed for low income countries with no or limited testing capabilities of covid- tests. it is perceived that countries like pakistan, could resort to this score card at community level to triage the suspected patients and may adopt testing of only basing on the discussed factors, the over burdening of the health system can be controlled with a systematic filtering and triage of the suspect cases using the proposed score card, where the parameters discussed have been given due weight to assess the total score of the suspect to filter him/her for a probable test case or otherwise. those patients who have higher scores (ie, ˃ ). this will help lessen the burden of already limited laboratory testing facilities available in the country. the method will also be helpful for low-income countries like afghanistan, bangladesh, chad etc., which are vulnerable to exponential outbreak of this virus due to their in-capacity to detect covid- patients and availability of the testing kits is badly hampering and overburdening the who efforts to fight this pandemic. the score card has been tested on a small community of risalpur cantonment ( . latitude, . longitude) which is an enclosed community consisting of a population of around . the demographic distribution of this community cannot be shared due to security issues as it is housed in a cantonment. this score card was tested for its effectiveness after the area was under complete lock down since march , and limited entrance and exit was allowed to this community. an emergency control room has been developed in the community to deal with the covid- situation. this room is manned / and any person entering risalpur cantonment was sent here in order to screen the individual for covid- suspicion. besides, any individual complaining or expecting probable symptoms of covid- was first screened at this centre and was then further referred to the hospital if required. until april , , persons were screened at the control room. these results show that persons were suspected and their scores suggested that they were required to be tested on priority, while others were immediately hospitalized. since the burden of patients was not much at the health facility available in the area, which is class 'c' hospital, so tests of all the suspected patients ie, were sent to islamabad and peshawar and all tested negative. however, these patients were isolated and quarantined for days. it can be easily inferred that instead of testing all the individuals who reported to the control room for suspicion of covid- , only persons required covid- tests which accounts for % only. low-income countries with limited health facilities may resort to this technique to reduce the burden on their testing facilities. it is pertinent to mention that this is not an ide- covid- : extending or relaxing distancing control measures using observational data to quantify bias of traveller-derived covid- prevalence estimates in wuhan, china time course of lung changes on chest ct during recovery from novel coronavirus (covid- ) pneumonia clinical characteristics and intrauterine vertical transmission potential of covid- infection in nine pregnant women: a retrospective review of medical records coronavirus disease (covid- ): situation report covid- and the cardiovascular system severe acute respiratory syndrome coronavirus (sars-cov- ) and corona virus disease- (covid- ): the epidemic and the challenges pathological findings of covid- associated with acute respiratory distress syndrome covid- ): a perspective from china korea' s response to covid- : early lessons in tackling the pandemic the authors hereby acknowledge the risalpur cantonment authorities for sharing the data regarding persons reporting the control room. no funding was available for this study.authorship contributions: ns was involved in data gathering and preparing of initial draft. ia was involved in preparing part of the paper and reviewing and improving the initial draft. wjm was involved in developing the score card and assisting in data gathering. mmi reviewed the final draft. the authors completed the icmje competing interests form (available upon request from the corresponding author) and declare no conflict of interests. al way of tracing the covid- suspected patients but can be an alternative to no testing at all due to minimal or low testing capacities.besides findings highlighted above, following deductions have been made for the observed statistics. . for a country where the disease has been imported after february , , the rate of spread has been lower while still being on the exponential scale, as the preventive model of isolation and lockdown of the society was already inferred basing on the initial devastation of the disease. . poor health facilities result in better immunity of the people to fight against the illness but the same also results in a less average age due to a fatigued life, there by having significantly less people with age over years in the under developed world. . previous health history is associated to age, health infrastructure, trends in the society, and to some extent geographical location. this also contributes significantly to the potential proneness for disease adaptability and seriousness. . nevertheless, travel history is also a significant parameter. although most of the countries have started to exercise the travel ban internationally, but the ghost phenomenon of the disease for a period of days and local mobility within the country or affected region can still affect the patient count dramatically (both for confirmed and non-confirmed cases). . an already exiting mechanism evolved over the experience of last few weeks to deal with the spread, prevention, and cure of this disease has shown the efficacy of the isolation period and appearance of the symptoms of the disease. this is helpful in eliminating the disease and its spread in a locality or a region. the two successful strategies to contain and control corona virus have been adopted by china and korea [ , ] . for countries like pakistan, korea' s strategy to trace, test and treat is difficult to adopt due to limited testing capabilities. similarly, owing to the poor economic conditions of the country, complete lock down will lead to economic crisis especially for small businesses and daily wagers. in addition to enhancing the country' s testing capabilities by importing test kits, it is imperative to adopt suggested score card based assessment, to reduce the load on the testing centers all across the country. this will be very beneficial in small villages and towns to adopt a bottom up approach and ease the already over stretched testing facilities for management, treatment and care of the suspected covid- patients. basing on the above mentioned factors, the over burdening of the health system can be controlled with a systematic filtering of the suspect cases, where the parameters discussed have been given due weightage to assess the total score of the suspect to filter him/her for a probable test case or otherwise. key: cord- -m v q gk authors: bidaisee, satesh; macpherson, calum n. l. title: zoonoses and one health: a review of the literature date: - - journal: j parasitol res doi: . / / sha: doc_id: cord_uid: m v q gk background. one health is a concept that was officially adopted by international organizations and scholarly bodies in . it is the notion of combining human, animal, and environmental components to address global health challenges that have an ecological interconnectedness. methods. a cross-sectional study of the available literature cited was conducted from january when the one health concept was adopted till december to examine the role of the one health approach towards zoonoses. inclusion criteria included publications, professional presentations, funding allocations, official documentation books, and book chapters, and exclusion criteria included those citations written outside the period of review. results. a total of resources met the inclusion criteria and were considered in this review. resources showed a continuous upward trend for the years from to . the predominant resources were journal publications with environmental health as the significant scope focus for one health. there was also an emphasis on the distribution of the work from developed countries. all categories of years, resources, scopes, and country locale differed from the means (p = . ). year of initiative, scope, and country locale showed a dependent relationship (p = . , p = . , and p = . , resp.). conclusion. our findings demonstrate the rapid growth in embracing the concept of one health, particularly in developed countries over the past six years. the advantages and benefits of this approach in tackling zoonoses are manifold, yet they are still not seemingly being embraced in developing countries where zoonoses have the greatest impact. one health is a concept that aims to bring together human, animal, and environmental health. researchers including louis pasteur and robert koch and physicians such as william osler and rudolph virchow demonstrated the collaborative links between animal and human health. more recently, calvin schwabe revived the concept of one medicine [ ] . as the traditional boundaries between medical and veterinary practice continue to pervade society there is a need for the practical application of one health. one health is defined by the one health commission [ ] as "the collaborative effort of multiple disciplines to obtain optimal health for people, animals, and our environment. " in another definition, the one health initiative task force (ohitf) [ ] defines one health as "the promotion, improvement, and defense for the health and well-being of all species by enhancing cooperation and collaboration between physicians, veterinarians, and other scientific health professionals and by promoting strengths in leadership and management to achieve these goals. " the one health approach plays a significant role in the prevention and control of zoonoses. it has been noted by the world health organization (who) [ ] and graham et al. [ ] that approximately % of new emerging human infectious diseases are defined as zoonotic, meaning that they may be naturally transmitted from vertebrate animals to humans. new and reemerging zoonoses have evolved throughout the last three decades partly as a consequence of the increasing interdependence of humans on animals and their products and our close association with companion animals. zoonoses should therefore be considered the single most critical risk factor to human health and well-being, with regard to infectious diseases. of the , infectious diseases journal of parasitology research recognized to occur in humans by the national academy of sciences, institute of medicine [ ] , approximately % are caused by multihost pathogens, characterized by their movement across various species. this gives significant credence to the importance of examining health effects across species, in order to fully understand the public health and economic impact of such diseases and to help implement treatment and preventive programs. the one health concept is a broad term that covers a variety of subcategories identified as bioterrorism, animals as predictors for disease, and the psychological bonds that can exist between an animal and a human [ ] . zoonoses comprised the primary focus for this review with the overall objective to determine the status of the one health approach and its applications to zoonoses, using scholarly peer-reviewed literature that has been published since the global adoption of the concept in (for study purposes, january , , until december , . four subobjectives were considered. the first assessed scholarly resources on the one health approach published works between january , , and december , . one health scholarly resources were classified as peer-reviewed publications, professional presentations, grants or funding allocations, reports from the who, and books or book chapters. the second objective examined the preferred scope of one health published works within the period of study. scopes of one health subject categorizations were, namely, zoonoses, food safety, agriculture, environmental health and global health. the third objective analyzed the geographic distribution of scholarly one health resources, whether they were in developed nations or developing nations listed by the international monetary fund (imf). the final objective reviewed trends in the application of the one health concept. a cross-sectional study using internet resources was carried out to analyze one health applications to zoonoses in scholarly resources from to , representing a -year review. before conducting the internet search, clear definitions were made of the one health resources. scholarly material was distinguished as eligible and ineligible using the following criteria which were found on google scholar and ebscohost. ( ) peer-reviewed publications were classified as scientific journals and literature reviews of the pertinent subject matter (human, animal, and environmental health) that had been published in peer-reviewed journals. ( ) professional presentations were represented by formal presentations made by organizations and other professionals on the subject matter of human, animal, and environmental health, presenting research material, policy developments, or promotional activities in support of one health. ( ) grants and funding allocations were characterized as proposals for funding research, policy development, and so forth in the collaborative subject matter of humans, animals, and the environment accessed from reviewing all professional publications available from the systematic search conducted. ( ) who-related reporting included updates from the website that involved relevant health issues, specifically reflecting the one health approach. ( ) book and book chapters were qualified as books or selections involving the subject matter. the target population included all published studies that addressed the one health philosophy and which met the inclusion criteria. the documentation review included resources found on the internet through the search engines and databases identified, which fit into the criteria of a one health approach and which took place from the concept's adoption of january , . excluded from this study were studies that were not found on the internet databases, those that did not involve the one health concept, or fit the criteria of a one health approach, or those that were reported outside the period of study. database searches were conducted from may to july . in the search fields for google scholar and ebscohost, the terms "one health, " "health, " "human, " "animal, " and "zoonoses" were typed in. the first result that appeared from the database was reviewed and then assessed, using the definitions, to determine whether it fits into one of the one health approach criteria. every fifth search result was examined and after reaching results on both databases numbered onward, every second result was then considered. for every result that did not meet the inclusion criteria, the very next result was examined, and so forth, until a result did meet the criteria. after a result met the criteria, the fifth result from the last selected result was examined to be included in the review. each scholarly initiative that met the inclusion criteria was separated into its initiative category as well as into its year of publication. in addition, each resulting initiative was further categorized by the subject matter covered in the scholarly work. considering one health scopes, these were the common subject areas covered: zoonoses, agriculture, food safety, environmental health, and global health. these categories were condensed from a larger, more complex list provided by the one health initiative task force [ ] . for resources that contributed to more than one scope, such as agriculture and food safety, the final determination was made on the emphasis of one of the scopes from within the contents of the title. finally, each initiative was also categorized into being conducted in, or having an analysis on, either a developed or developing nation based on a country's gross domestic product (gdp). all the results were then categorized by their year of publication, the initiative that was represented, scope covered within the work, and the geographic distribution of where the initiative was conducted or what area was analyzed. spss statistical software package version . was used to analyze the frequencies of the years of scholarly resources, the initiative types, scopes categories, and geographic distribution. all years for the review were represented, except for , , and as there were no publications that were sourced for these three years. there were a total of resources in ( %) and in ( . %). the year began a continuous presence of one health resources annually. the year began a continued increase in one health resources for the period of review. the years to were the most productive for publications on one health as % of publications occurred during this period of time. an overall increase in the number of published one health scholarly works was found for the review with a marked increase in the most recent years ( figure ). journal articles, presentations, who reports, and books or book chapters were included in the analysis. grants and funding allocations were not represented in the data gathering process. of the resulting resources, peer-reviewed journal articles took precedence ( %) of all publications, while presentations and books accounted for . % and . %, respectively; only one who report was recorded. evaluation of scopes, covered in the scholarly resources (figure ), revealed that the predominant topics were global health, with scopes ( . %), and environmental health, with total scopes ( . %). in terms of geographic distribution of the scholarly resources, most of the resources focused their objectives within or towards countries that were already developed ( %) (figure ). an assessment on how one health initiatives were distributed by country size and gdp was achieved by mapping and measuring the burden of zoonoses and its distribution across the world ( table ) . events of zoonoses were found to be disproportionately distributed as a result of the poverty and emerging market interface. outbreaks or epidemics of emerging zoonoses were also noted to be sporadic in temporal and spatial distribution and appeared in developed countries where emerging zoonoses had not previously been reported but are increasing in incidence or geographical range. data on zoonoses extracted from the global burden of diseases noted that endemic zoonoses were concentrated among the developing countries of india, nigeria, democratic republic of congo, china, ethiopia, and bangladesh, whereas emerging zoonoses events were reported in the developed countries of the united states, united kingdom, australia, france, brazil, canada, germany, and japan (table ) [ ] . for data analysis, chi-square was conducted to determine if, in the resulting reviewed years, one health resources themselves, scopes, and country locale differed significantly from the averages expected. analysis revealed values of less than . ( < . ), meaning that the resources, scopes, and country locale were all statistically different ( table ) . further analysis employed linear regression, using each focus, year, one health resource, scope, and country as the dependent variables and comparing them against independent variables of themselves. this showed whether the relationship between the independent and dependent variables was predictive or dependent on one another [ ] . in the case of using year as the dependent variable, the regression shows that it was dependent on the initiative ( = . ), scope ( = . ) and the country locale ( = . ) ( table ) . since all the values were < . , the null hypothesis was rejected and it was concluded that the years selected for the study showed a dependent relationship on the one health approach conducted, the scope topic areas and the represented country in the scholarly work. the same linear regression was performed, this time using the initiative as a dependent variable against the other variables (table ) . for this analysis, the initiative showed it to be dependent on the year ( = . ), as also noted in table , but not dependant on scope ( = . ) nor on the country's locale ( = . ). the null hypothesis failed to be rejected because no complete dependency relationships were formed between all the variables from the regression test that was conducted, as compared to the regression testing done with year. next, scope was selected as the dependent variable against the year, initiative, and country. the linear regression showed that the scope was dependent on the year, as seen before ( = . ), but not dependent on the initiative ( = . ) nor on the country ( = . ) ( table ). the null hypothesis thus failed to be rejected. the country locale was used as the dependent variable against the others in the last linear regression. it was demonstrated that the country, whether developed or developing, was dependent on the year ( = . ) but not on the initiative ( = . ) nor the scope ( = . ) ( table ) . again, the null hypothesis failed to be rejected for the whole dependency of scope on all other variables. the only rejected null was the dependency displayed between the year of the initiative and the initiative itself, its scope, and the country covered from within the initiative. many of the results of this study could be attributed to the occurrences in the world during the time period of the study. when observing the trend of the one health approach over time, there was a minimal spike in , an increased output from , and marked increase from to . four [ , ] and also to the passing of the one health initiative task force in [ ] . two ( . %) of the defined resources in involved agriculture, eight involved environmental health ( . %), were on zoonoses ( . %), were on global health ( . %), and four were on food safety ( . %). the marked increase since may have resulted from the developments since which continued into which allowed for the one health approach to be placed on the research and scholarly agenda. ( %) of the recorded resources in involved agriculture, ( %) involved environmental health, ( . %) were on zoonoses, ( . %) were on global health, and ( %) were on food safety. the distribution of the years of the one health approach, the scholarly resources, the scopes, and the countries' locale were not equally represented. for the one health concept to be appropriately beneficial to the global population, it would be necessary for a significant equal distribution of scholarly works to exist. the data, suggesting that the scopes of global health ( . %) and environmental health ( . %) dominated the others, including the zoonoses, produces an area of concern. the issues relating to one health, while in their genesis involved zoonoses and food safety, were identified as environmental and global health issues in the reporting and publications. while this shows evidence of the profound efforts to boost environmental and global knowledge about one health, it also demonstrated the limited body of knowledge of zoonoses, agriculture, and food safety. zoonoses, agriculture, and food safety are all interconnected topics in that they all directly impact the health of humans. in the last years, there has been an average of one newly discovered emerging infectious disease every year [ ] . a total of emerging infectious diseases were identified between and [ ] . considering that more than % of infectious diseases are zoonotic, they have an important and increasing impact on human health. agriculture, livestock production, and food safety practices are intimately linked with the prevention and control of zoonoses through the one health approach [ ] . considering the significance of agriculture and food safety, it was surprising that these scopes did not have a greater representation in the literature reviewed. developed countries, by virtue of their greater institutional facilities, trained personnel and financial resources are able to address the issues of one health approach. this is extremely beneficial as it enables developed nations to gain an awareness of one health initiatives and the added synergistic value of this approach. the one health initiative task force [ ] has reported that while the developed countries prevail in making one health discoveries, it is the developing countries that suffer the most from the effects of zoonoses. it has been estimated that % of the reasons for poverty in africa can be attributed to poor livestock production practices [ ] . zoonotic infections significantly impact animal production in this region further jeopardizing human and animal livelihoods. the dependency of the initiative year, initiative, scope, and country locale on one another revealed that the incidence of the scope or country location is somewhat dependent on the year. in other words, it can be argued that the scope or country locale was represented due to that particular year, namely, due to the associated events during that year. immediate action and scholarly resources are commonly implemented after a devastating event occurs [ ] , proving that the publishing of a particular one health topic may not be due to chance during that specific year. it is important to note that the general availability of one health resources is likely to be higher in the more recent years than in the s, as the internet was still in its evolutionary stage and not yet a global resource, as it is today [ ] . the free availability of scholarly information on the internet is evolving rapidly which will equalize the field. it will then be a matter of trained personnel and resources to make appropriate advances. many of the classifications which determined the scope of an initiative were subjective. even though many of them clearly fit into their appropriate scope, some were hard to decipher, as some titles could have easily been included in more than one scope. as a result, one author's classification of an initiative could differ from another's opinion, resulting in interobserver bias. some resources truly belonged in their own category; however, for the purposes of this study, only five scopes were included. this resulted in many resources being placed in the global health scope, as it is a category that could be applied to all one health approaches. subjectivity was also a limitation in classifying the country locale. in some cases, resources' locations were clear from the article's title or content, and others were not. some scholarly resources covered subject matter concerning a developing country, yet the actual work was conducted in a developed country. the one health approach, according to the one health initiative, has been utilized to accelerate biomedical research discoveries, enhance public health efficacy, expeditiously expand the scientific knowledge base, and improve medical education and clinical care [ ] . the increasing encroachment of people and livestock into wildlife habitats provided a multifaceted need to study bats and offer understanding for study at the human-wildlife interface [ ] . bats are an important reservoir and vector for spread of a number of emerging infectious diseases and they are associated with zoonoses with global public health significance such as lyssa, hendra and nipah viruses, severe acute respiratory syndrome (sars) like coronaviruses, and ebola and marburg viruses. the importance of wildlife as reservoirs of human diseases has also been widely recognized for most of the parasitic zoonoses, including american and african trypanosomiasis, leishmaniasis, giardiasis, cryptosporidiosis, balantidiasis, fascioliasis, opisthorchiasis, clonorchiasis, paragonimiasis, schistosomiasis, echinococcosis, taeniasis, diphyllobothriasis, sparganosis, dipylidiasis, trichinellosis, toxocariasis, strongyloidiasis, and ancylostoma caninum and a. braziliense infections. molecular phylogenetic methods used to examine the genetic diversity and species composition of these parasites in humans and their domestic and wild reservoir, paratenic, definitive, and intermediate host species have shown that they are in many instances identical. for example, african trypanosomes identified in wildlife in the serengeti in tanzania and the luangwa valley in zambia which harbour a wide range of trypanosomes are the same species which infect humans and livestock [ ] . the one health concept has successfully replaced the disease centered approach to zoonoses with a system based approach that aligns multiple disciplines, working locally, nationally, and globally, to attain optimal health for people, domestic, and wild animals and the environment. zoonotic diseases pose both major health threats and complex scientific and policy challenges, to which the social, cultural, and political norms and values are essential to address successful control outcomes [ ] . the need to employ one health is illustrated in the cases of h n avian influenza in which control failed due to the lack of addressing the complex dynamics of zoonotic diseases. rapid response briefing [ ] produced a report on the ebola haemorrhagic fever outbreak which occurred in kibaale and kampala in uganda in . the number of deaths in kibaale was at least ; the outbreak was spread miles away to kampala four months later. these two outbreaks demonstrated the continuing existence of ebola in uganda which recorded an earlier outbreak in and led to cases; more than half of the cases died. the one health approach, employing disease surveillance, management, and eradication through collaboration between veterinarians dealing with livestock and wild animal populations and ecologists examining ecosystem biodiversity and public health experts, may have yielded a more rapid resolution to the outbreak the application of the one health approach has been recognized as a critical need by international organizations as well as the preferred approach to address global health issues. the grand challenges in global health [ ] is based on the theme "the "one health" concept: bringing together human and animal health for new solutions. " the recent call for proposals for funding recognizes the lack of knowledge sharing and an artificial barrier that separates the fields of human and animal health. the grand challenges in global health specifically identified that advances in drug and vaccine discoveries for human diseases can be applied to provide tools and approaches for animal diseases that still plague developing countries. it is also noted that knowledge in veterinary medicine and animal nutrition and husbandry could provide insights into human nutrition and growth. one health has gained momentum and now encompasses zoonotic infections, food safety, and even health delivery systems [ ] . there is also an integrated epidemiological and economic framework for assessing zoonoses using a "one health" concept building on the medical focus of zoonoses [ ] . in recent times the one health concept has been expanded to encompass the health and sustainability of the world's ecosystems [ ] . based on complex ecological thinking that goes beyond humans and animals, these approaches consider inextricable linkages beyond the human, animal, and environmental interface. collaboration between veterinary, medical, and public health professionals to understand the ecological interactions and reactions to flux in a system can facilitate a clearer understanding of climate change impacts on environmental, animal, and human health. climate change adds complexity and uncertainty to human health issues, such as emerging infectious diseases, food security, and national sustainability planning [ ] . these issues intensify the importance of interdisciplinary and collaborative research. evidence for expanded application of one health compared to separate sectoral thinking is growing [ ] and this integrative thinking is increasingly being considered in academic curricula in schools of medicine, veterinary medicine and public health [ ] , clinical practice, ministries of health and livestock/agriculture, and international organizations [ ] . the one health approach to zoonoses however remains an average priority for health care professionals. the impact of zoonoses on animal health has been largely neglected but the effects on public health usually drive control initiatives on zoonoses and are much better defined by the use of disability adjusted life years (dalys) [ ] . the first zoonoses prioritization exercise involving health professionals in north america who had a limited knowledge of infectious diseases identified zoonoses as an area of priority [ ] . another study reported that local public health agencies in north america were not prepared and potentially unaware of their responsibility to be the initiator of the work on zoonotic disease information intelligence [ ] . the advancement of the one health approach has increased the discussion and reporting on the topic. there remains a lack of knowledge and application of the integrated approach to health care by the health care professionals. reaching the goal of control, and elimination and/or ultimate eradication of zoonoses pose a significant challenge for the future. standardized interlaboratory test validation, intersectoral collaboration and establishment of an international one health diagnostic platform are considered to be important strategies [ ] . the sharing of best practices on diagnosis of zoonoses and the further refinement of new, cheaper, multispecies tests which can be interpreted by minimally trained individuals could contribute to a greater level of intersectoral integration, control, and elimination of zoonoses. the projection from one health may eventually lead to a one system approach based on the inherent challenges to intersect disciplines that belong to different systems. one health approaches applied across international boundaries that share the same challenges are required to create sustainable and coordinated control. the one system approach focusing on the strengthening of the community model health system as a whole as well as developing effective and novel tools to be applied across all aspects of health, is fundamental of a one world one health approach [ ] . the future of one health is a one world approach with the continued effort towards integration of the contributing parts that form the whole which is health. the one health approach continues to be a highly investigated concept, via the pursuit of scholarly resources involving the health of humans, animals, and the environment. there is a need to increase research on zoonoses, food safety, and agriculture and to improve the understanding of the one health concept. this could be achieved by introducing more scholarly resources in developing countries by the further development of the internet and the free availability of online information on one health. the use of massive open online courses (mooc) available to developing countries is now being offered to deliver courses on the approach and applications of one health [ ] . this is critical because most of the public health and economic impacts that occur within the concept of one health occur in developing nations. the lack of basic health infrastructure in developing countries means that everything else suffers as a result, namely, the environment, human, and animal health and well-being. the future of one health is at a crossroad; there is a need to more clearly define its boundaries and demonstrate its benefits. the greatest acceptance of one health is seen where it is having significant impacts on control of infectious diseases. there is also a continuing need for further efforts towards integration with the global community serving as the unit of a one system approach. one health: its origins and future. current topics in microbiology and immunology one health. 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zenchenko, t. a. title: rhythmic components of covid- daily cases in various countries date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: qooax xc not only does covid- pandemic encourage scientists to look for remedies and treatment schemes, but also identify the drivers of pathogenicity and spread of the virus. the scope of this research consisted in identifying recurrence patterns and comparing the number of daily cases between various countries. data for countries where at least daily cases were recorded at least once ( in europe, in north america, in south america, in central america, in asia and in africa). according to our evaluation, the dynamics recorded for countries includes a -day statistically significant component. this statistically significant weekly component has been identified in % of the countries examined in europe, % in north america, % in south america, and % in asia. the range of this rhythmic component is low at the growth stage and increases at the stabilization and decrease stages. the weekly phases feature shifting peaks depending on the country. in some cases, the phases shift, i.e. they are not limited strictly to certain days of the week. due to range and phase variation, its explanation cannot be limited to strictly medical and social factors. in some cases, national incidence dynamics includes , , , and -day periods. understanding the factors of recurrence patterns in covid- incidence dynamics may help in the pandemic response. studying covid- behaviour in various countries and identifying its rate and spread drivers are among the most relevant tasks. the solution of these challenges is necessary both for proper prediction at the practical level and for identifying disease origin and spread patterns at the fundamental level. pandemic response decision-making is frequently related to predictions produced using various computing models. such models are based on specific input. the authors of some recent publications have made attempts to identify covid- drivers [ , ] . for example, study [ ] offers a statistical analysis of weather-related increase in daily cases. the authors conclude that disease rate is related to average temperature. the scope of this study consisted in assessment of covid- daily case increment dynamics in various countries in order to identify rhythmic components. identification of general and specific features in disease dynamics is expected to further insight into the internal logic of the pandemic spread. this will make prediction, i.e. assessment of peaks, stabilization and case rate decrease, possible. daily covid- case data were obtained from the web site of center for systems science and engineering (csse) at johns hopkins university (jhu) (https://systems.jhu.edu/research/public-health/ncov/) and from google database of national agency data ("coronavirus statistics by country" search query). data verification for each country was performed through matching data from both sources. the shortlisting criterion required at least a single daily case rate increment equal to or exceeding at least once within the review period ( . . - . . , days), and the number of zero case days in the above databases not exceeding . this allowed shortlisting the countries where the statistical spread of data did not have significant impact on the daily increment rates. hence, countries with relatively equal distribution across europe, america and asia were included in the sample. the full list of countries is provided in table . for rhythmical component identification spectrography, wavelet transform and periodogram method were used. for lf trend trimming the signal was pre-filtered using a band-pass filter with a blackman-harris window the lower and upper cutoff bandwidth set at . and . nyquist bandwidth respectively. for comparing results obtained using different tools, the scale parameters obtained through wavelet transform were converted to temporal characteristics similar to oscillation periods in spectrography. in the periodogram analysis, statistical significance of the reviewed periods was assessed using wilcoxon distribution-free test. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint figure shows the global dynamics of covid- daily case increment and the results of the time series analysis using three approaches: periodogram ( fig. b) all three rhythmic component tests demonstrate the presence of a solid -day period. nd and rd order harmonic components are also evident in the periodogram. wavelet and fourier analysis also reveal periods of about and days. it is arguable that it is autonomous, rather than a nd order harmonic of the weekly period by periodicity, . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint since the wavelet transform, contrarily to fourier analysis, has not revealed any multiple harmonics. a comparison of figures a and c reveals that any periodicity is absent in period , where the absolute values are low, with gradual spectral power increase at interval , and is even stronger at intervals and , with a slight boundary decrease of the power. similar behaviour has been recorded for the -day period, despite being much lower in power. at stage a -day period arises and gradually acquires power. as can be seen from figure c, the three and seven day periods have been constant for two months. their stability in the dynamics of the global incidence time series, which is the sum of national autonomous series, is indicative of its existence and need for an advanced analysis. in the periodicity analysis of incidence series for countries, we used the level of its statistical significance in the periodogram method with the boundary value of p< . (-lg(p)> . , fig. b) . table represents country samples by continent and shows the statistical significance of the -day period as k=-lg(p). hence, in the countries included in the analysis, statistically significant -day periods were recorded in , including countries ( %) in europe, countries ( %) in asia, countries ( %) in americas, and in africa. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint one of the most likely explanations of the -day period could have a social nature, i.e. inconsistent reporting of new cases on weekdays versus weekends. this hypothesis was tested by plotting the phases of this period at the global level and for countries with the most evident weekly period ( fig. ) . since the beginning of the review interval falls on march (sunday) and the source data reflect incidence increment reported for the previous hours, the first two points on the x-line correspond to weekend days in figure distribution as follows from figure , phasal dips and peaks occur on different days of the weekly period depending on the country. the hypothesis related to -day period formation due to decrease in case reporting on weekends can substantiate the dynamics only for some countries, e.g. usa, sweden, brazil and uk. for the rest of the countries this hypothesis does not provide sufficient substantiation. for example, it does not match the global weekly periodicity with dips on thursdays. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint another argument against the medical and social nature of weekly periodicity consists in comparing the dynamics between various countries. figure shows the comparison between two countries with strongly manifested weekly periods, i.e. the netherlands and spain. this chart includes: (a) superposition of raw time series, (b) superposition of filtered time series, (c) cross correlation between them, (d) sliding window correlation by points, (e) and (f) wavelet and fourier images of the filtered series for spain, (g) and (h) equivalent images for the netherlands. the superposed time series are shifted against each other by days in figures a and b. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint as follows from figure , the pandemic spread phases almost coincide in these two countries. the curves in figures a and b are shifted against each other by days in order to better demonstrate the similarity of the weekly phases through the shift. the existence of the shift is evidenced by cross-correlation, where the peak value of the function corresponds to - days (fig. c) . figure d shows a point sliding window correlation between the two filtered series. here one can see that there is virtually no correlation between the series during the first days, or that it is rather negative due to the phasal differences. however, the correlation ratio increases significantly at the end of the observation period. this occurs when the oscillations in these two series synchronize. hence, even in incidence time series where the weekly period is the sole and highly statistically significant one, its phase does not remain constant in some cases. it is notable that phase periodicity does not depend on the national quarantine policy, since similar oscillation phases have been recorded for sweden and germany, although not special quarantine restrictions have been introduced in sweden, by contrast with germany. similar findings have been recorded in the comparison of other countries differing both in terms of quarantine restrictions and socio-cultural features. despite the fact that the -day period has been recorded in % of the countries included in the sample, presence of other stable periods has been recorded in some . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . the examples in figure show an -day period in poland that has been lasting for . months since the outbreak (early april), and another, less intensive, -day period. in ireland, where the incidence growth period was rather short and occurred between april and early may, -day and -day periods have been recorded throughout the entire increment interval. chile and bangladesh are among the countries with current rapid increase in daily incidence. bangladesh dynamics features and day periods, while chile - and day periods. an advanced study of the dynamics and identification of the factors related to such periodicity should become the focus of further exploration. a strong weekly period has been identified in countries from the included in the sample, such weekly period manifesting more evidently at the incidence peak and decline phases. the weekly period has been identified primarily in european countries ( % of the countries included in the sample), as well as in north america ( %) and south america ( %), yet seldom in asia ( % of the countries included in the sample). drawing any conclusions about africa is difficult, since only three african counties met the sampling criteria. the most simple and convincing explanation of the origin of the weekly period in the incidence dynamics seems to be related to varying levels of epidemiological activity and admission to hospital over weekdays versus weekends. to some extent it can be recorded for the relevant structures of all countries included in the sample. furthermore, other social or economic factors related to irregularity of case reporting . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted july , . . https://doi.org/ . / . . . doi: medrxiv preprint over the weekly period may exist. however, the factors of phase consistency may only partially explain the effect, while the rest of it does match this hypothesis. . for example, in case of inconsistent intensity of medico-social service activity, the phase of the effect should remain constant throughout the entire observation period, with the dip occurring on saturdays and sundays. as follows from figures and , this is not true in many cases. weekly period phase shifts over the observation period have been recorded in some cases. . the weekly period begins to manifest consistently closer to incidence peak and generally does not manifest at the initial stage. were this caused by diagnosing irregularity, periodic existence would not be related to the pandemic phase in a given country. . the weekly period has been detected in the incidence dynamics of countries with various health care systems and various pandemic response strategies, including both quarantine-based and quarantine-free (see table ). . in the incidence dynamics of some countries consistent and statistically significant periods other than weekly have been recorded, i.e. , or days. hence, the identified periodicity patterns are not accounted for solely by the investigated medico-social factors. one could presume that some less obvious medicobiological aspects related to the viral spread underly the observed periodicity patterns. this problem deserves advanced investigation, since the findings of such investigation could help to explain the specifics of viral spread in various countries. association between climate variables and global transmission of sars-cov- correlation between weather and covid- pandemic in jakarta key: cord- -vhuw gwn authors: demertzis, nicolas; eyerman, ron title: covid- as cultural trauma date: - - journal: am j cult sociol doi: . /s - - -z sha: doc_id: cord_uid: vhuw gwn this paper has two aims. the first is to introduce the concept of compressed cultural trauma, and the second is to apply the theory of cultural trauma in two case studies of the current covid- pandemic, greece and sweden. our central question is whether the pandemic will evolve into a cultural trauma in these two countries. we believe the pandemic presents a challenge to cultural trauma theory, which the idea of compressed trauma is meant to address. we conclude that, while the ongoing covid- pandemic has had traumatic consequences in sweden and greece, it has not evolved into cultural trauma in either country. this paper has two aims. the first is to introduce the concept of compressed cultural trauma and the second is apply the theory of cultural trauma in two case studies of the current covid- pandemic, greece and sweden. our central question is whether the pandemic will evolve into a cultural trauma in these two countries. we believe the pandemic presents a challenge to cultural trauma theory, which the idea of compressed trauma is meant to address. we begin with a short presentation of cultural trauma theory, and then discuss the idea of a compressed cultural trauma before moving into our two cases. there can be little doubt that the ongoing covid- pandemic poses a global threat that has created crisis on many levels, from local communities to states and nations. as eric woods et al. ( ) puts it, 'it has significant potential to trigger multiple, cascading crises in nearly every aspect of our lives. in addition to the presence of a threat, crises typically involve systemic disruption, uncertainty and stress'. a cultural trauma is a form of crisis, a crisis of identity that affects individuals and collectives. both greece and sweden experienced severe crisis during the first stages of the pandemic yet neither, to this point, have developed into cultural traumas. no matter how severe, not all crises become cultural traumas and the point of our comparison is to explain why. a cultural trauma occurs as the taken-for-granted foundations of individual and collective identity are shattered, setting in motion a discursive process to understand what happened, assign blame, and find pathways to repair an interpreted situation. in this ensuing meaning struggle various actors propose answers to these questions, articulating trauma narratives that compete for attention and acceptance. cultural traumas are not the aggregate of individual traumas, nor are they determined by gradations of suffering. cultural trauma is a specific form of collective trauma, affecting collective identity, where groups of individuals feel similarly affected by a fracturing of the existential security that a firm sense of identity affords. a step towards regaining that security, a human requirement, is to understand what happened and who or what was responsible, and then to act accordingly. cultural traumas imply anxiety and suffering, but also opportunity. the latter stems from the human capacity to learn and adjust to new conditions, to remake the world as well as to live in it. cultural traumas are usually studied in retrospect from a distant point in time, allowing one to isolate a point of origin, often a cataclysmic incident, and then trace the ensuing meaning struggle through a range of forums and media, toward memorialization and the impact with regard to collective memory. it is also possible, though more speculative, to study cultural trauma as it is occurring. an example is neil smelser's essay on / that appeared as an epilogue in cultural trauma and collective identity (alexander et al. ) . written just months after the event, smelser ( , p. ) suggests that the distinctive culture of the united states shaped the cultural trauma process in a way that was 'fused, telescoped and undifferentiated'. explaining this, smelser writes: 'with respect to the dimension of time alone, the traumatic process was truncated… the moment of the attacks to the recognition that they constituted a national trauma was a matter of short days, if not hours…the scope of the trauma and the identity of the victims were established immediately… there was an instant consensus that it was a trauma for everybody, for the nation… there was no significant divergence in the reactions of government and community leaders, the media, and the public in assigning meaning to the events as a national tragedy and outrage…there was little evidence of social division around the trauma' (smelser , p. ) . in this article, we look at the ongoing covid- pandemic through the lens of cultural trauma theory, asking what kind of trauma is this, for whom, and what are the possible outcomes? we will illustrate this further through the examples of greece and sweden, addressing the issue raised by smelser about how national cultures and a compressed time/space postmodern condition shape the trauma process. heuristically speaking, the pandemic covid- erupted as a total social fact manifested as an unexpected chain of ruptures (kasuga ) in all socioeconomic, political and cultural institutions and every aspect of everyday life at local, national and international levels. millions are experiencing the greatest disruption of their lifetimes. even during wwii businesses and schools remained open, restaurants served customers, major cultural and sporting events took place and life went on. there has never been anything affecting modern daily life as the current pandemic. it is imposing itself physically and virtually, as an image, with unprecedented and expanding force, condensing time and space worldwide in the most critical way, a phenomenon known as 'time-space compression' (harvey ) . some historians assure us that the coronavirus is a juncture where the river of history changes direction that could lead to the best of times or to the worst of times (macmillan ; garton ash ). as total social fact, the pandemic forces itself into existence in at least four interrelated ways: (a) it is global: it encompasses almost half of the world's population since trillion people are under lockdown as we write. due to international transportation and trading this virus has been transmitted with unusual speed in all continents causing very serious damage to most national economies and world finance markets. also, it deepened the antagonism between the usa and china with regards to g technology, the discovery of the vaccine, and the blame game over the cause of the pandemic. (b) it is risky and uncertain: the pandemic instantiates the quintessence of risk society; a hazardous situation systematically spread through global interconnectivity. it is individually experienced as an anticipated threat to be realized or not, eliciting negative and positive emotionality: anxiety, fear, sadness, and grief, for one's own vulnerability. at the same time, it evokes a sense of loss and anger; feelings of resentment, hope, confidence and trust in a government's efficiency or its opposite. for the time being, insofar as the genomic attributes of the virus are not fully discovered, we claim that the pandemic generates an emotional climate of uncertainty, not as in 'we know that we don't know', but as in 'we don't know what we don't know'. (c) it is highly mediatized: in variable proportions, individuals form a synthetic experience of the pandemic; either as infected or as locked down at home. they live the pandemic through firsthand experience and through the information disseminated by the communications media. the aesthetics of media coverage (dramatization, personalization, fragmentation) are likely to affect the way viewers perceive the health crisis and the concomitant risks. with a lack of effective medical care and the much sought-after vaccine, an individual's need for orientation increases all the more. this need for orientation is contingent upon the relevance of an issue for that individuals' life interests, and the degree of certainty they have concerning their knowledge about it. whenever an issue is highly relevant to one's personal agenda and one's information and knowledge about it is limited, the need for orientation increases. therefore, a person's media dependency increases and the media agenda setting effect rises with conspiracy theories being a possible side effect. with both the radical diversity in media access and representation, the conflict over what happened and who is responsible intensifies, adding more uncertainty with regard to orientation. who is one to believe? (d) it is traumatic: several hundreds of thousands of people around the world are grieving due to the unexpected and sudden loss of loved ones. those deaths often occurred under dire circumstances, in poorly equipped and crowded hospitals, or isolated and abandoned in caretaking facilities. in many countries, normal grieving rituals are prohibited for fear of further contagion. millions of middle aged or elderly people infected by the coronavirus are at home, vulnerable, insecure and isolated, while many others, tired of 'social distancing', harbor anxiety about the upcoming months and an uncertain future. photographs of empty and unpopulated metropolitan areas, in new york, london or paris, may be comprehensible, yet also inconceivable. this is certainly a situation full of traumatic potential. who could imagine the long lines of trucks carrying coffins in italy or the innumerable makeshift caskets stored in refrigerated vehicles outside new york hospitals, or the unclaimed victims buried in mass graves? one can rightly ask, is this europe? is this america? as we noted at the outset, studies of cultural trauma are carried out in retrospect, at the end of a process where discursive themes and central actors can be identified and studied over time. the covid- pandemic is ongoing, but as a total event, it already has many of the characteristics that circumscribe cultural trauma. these include a fundamental disruption of the taken for granted in daily life, a potential loss of trust in leaders and social institutions, negative attribution in the media, a contentious meaning struggle to determine what happened and who is responsible, with many competing accounts aired in various forums. there is constant reference to collective memory, the search for comparable historical incidents, as grounds for understanding, and various carrier groups have formed to articulate and defend their interpretation. this is certainly a collectively aggregated trauma: innumerable people are experiencing the pandemic as traumatic, characterized by a loss of existential security, a biopolitical condition that can potentially create new modalities of subjection and subjectivation, shaping both collective and individual subjectivities. the global dimensions of a public health crisis, its rapid expansion, and the instant circulation of images depicting deep human tragedy have already initiated a trauma drama process. the public discourse about the coronavirus and its effects is multifaceted, antagonistic, and replete with emotionality; it revolves around the meaning of normality, discipline, and self-discipline, trust, confidence and distrust toward institutions and political authority. in many countries, the covid- trauma drama has triggered new forms of artistic expression, such as online concerts, musical and theatrical performances, humorous offline and online creations, the production of books about pandemics throughout the centuries, novels and poetry. blame attribution and the politics of fear through the designation of the virus as 'invisible enemy' and bellicose metaphors of the efforts to cope with it as 'war', permeate public discourse in the same way warfare language was used to tame tb and cancer in the nineteenth and twentieth century. globalization and the accompanying ubiquitous presence of the internet and digital social media have contributed to an intensified time-space compression, whereby the trauma drama that is the core of cultural trauma phenomenon is deepened. in previous theorizing and comparative analysis, cultural trauma studies have noted a belated reaction to a triggering incident or series of incidents that leave indelible marks on collective memory and group identity. as with / and hurricane katrina, this seems no longer the case with regard to covid- , should this be generalized it would expand the trauma potential of related incidents. in many places, a sense of crisis, with a trauma potential, began immediately. under what is identified as time-space compression, some-if not all-elements of the tenets of cultural trauma are visibly present at once: (a) emotionality (mostly negative); (b) blame attribution (carrier groups, media claims etc.); (c) identity formation processes; (d) defense mechanisms (artistic creation). if the indelible marks on social body (i.e. change in personal and group identity, alteration in value priorities) are always noted at a later time, then the coronavirus crisis is not a cultural trauma proper. the 'period effect ' inglehart , pp. - ; norris and inglehart , p. ) of the health crisis has to be traced retroactively, not in anticipation. another issue to cope with is the distribution of the disease and its trauma potential. at first glance, the pandemic seems to be inherently universal because it threatens everyone, irrespective of class, ethnicity and religion. it might also be possible to be perceived differently from the way individuals perceive existential threats, war and terrorism for example, which are unambiguously anthropogenic and particularistic. however, the extant differences in death rates and different patterns of the disease dispersal inevitably poses once more the question 'trauma for whom?' and at what level. as already mentioned, the pandemic reveals the dynamics of risk society. yet, we should take heed of the fact that despite the genomic indeterminacy of the sarscov- there is a background assumption and a reasonable expectation about the upcoming cure and protection after a vaccine becomes readily available. the current pandemic is encountered by disease-experienced lay people and a knowledgeable community of experts. as a species, we are more or less confident that this is not a repetition of the black death. the covid- is not entirely surrounded with horrible and unsolvable mystery and it is not regarded as a totally intractable and capricious disease like tb or cancer before finding their cure (sontag , pp. - ) . this might mitigate the prospect of the pandemic to become a future point of reference for collective and/or global memory. not infrequently, harsh pandemics leave no trace in social memory. although the pandemic influenza virus identified in hong kong in caused one million casualties, it passed almost unnoticed, since people in many countries had other priorities (keck ; keck and lachenal ) . on the other hand, it might be plausible to argue that even if the number of deaths will not be comparable at all, for example, that of the great influenza or aids, it will mark collective memory and identities because it forcefully damaged the illusion of invulnerability modern science can confer. by turning a spotlight on the dark sides of the present-day technocracy and technopoly (postman ) , this pandemic may point to a threshold in the 'imaginary institution of society' creating an anticipation of human extinction. building up a 'pandemic imaginary' drawn from the 'apocalyptic catastrophism' of risk society, people are seen as unable to selfcreate as before (lynteris , pp. , ) ; as a total social fact, this pandemic like other pandemics and epidemics in the past, instills a feeling of being 'lost in the world' and as such is deeply traumatic. a pertinent question is whether we should think of the pandemic not only as a total social fact, but also in terms of a trauma-ridden 'historical event'; namely, as a ramified sequence of rupturing occurrences that is recognized as notable by contemporaries, and that results in a durable transformation of structures (sewell ) . currently, at least as far as most of the eu countries and the usa are concerned, it seems that the pandemic meets most of the criteria sewell ( , p. ff) identified as relevant in the conceptualization of historical events: dislocation and re-articulation of socioeconomic structures; cultural-aesthetic transformation; heightened emotionality; institution of rituals; conducive 'structure of the conjunction'. these are traits to be found in the accelerated trauma drama already unfolding in terms of time-space compression and ensuing presentism. the case in point, however, is not only the pace but also the depth and the possible duration of these traits, as we will discuss in our case studies. how then does this compression affect an unfolding trauma drama? eyerman ( , p. ) identified several factors that influence the development of a cultural trauma: timing, political context, performance of authority, mass-mediated representations, carrier groups, and collective memory. the relative weight of these factors is determinant in the appearance of cultural trauma. refers to the relative proximity of triggering incidents, the closer in time the more chance of a cumulative collective emotional response. under the conditions of compressed trauma, the triggering responses are continuous, with local, national and international reports of cases and deaths flowing together, intensifying anxiety and fear. everything seems to be happening at once and threats everywhere, undermining the existential security of individuals. the very air breathed cannot be trusted, turning family members and neighbors, as well as strangers, into potential carriers. basic notions of humanity, morality, and empathy are undermined; all that's solid melts into air. one of the first casualties of the pandemic was the cooperative relations between nations. if by globalization, one refers to the systematic interconnectedness and indepth interdependency of nations, the pandemic revived the nation-state as the natural site of collective reference. similar to the way the outbreak of the first world war fragmented the international socialist movement in a wave of emotional nationalism, the first response to the pandemic was to withdraw behind national boarders, to turn inward for protection. this was especially prominent in the european union, where borders were shuttered and international travelers looked upon with suspicion. like city walls built to keep out the plague, airports and train stations were manned with border guards. as the enemy was invisible, national identification became the main means of determining purity from danger. nevertheless, the cunning of history herein consists in the extant global cooperation between bio-laboratories and pharmaceutic big companies for the production of a vaccine, on the one side, and, on the other, the instant global transmission of news items about the disease which leaves room for empathetic feeling and acting towards distant others. in polarized political contexts, such as the u.s. the possibility of radically different accounts is more likely to appear. this is aided by the presence of alternative means of communication to distribute such accounts. as a rule, whenever there is dispute among elites over a public issue the media are prone to disseminate divergent accounts of it. central to the pandemic are public health authorities, usually medical professionals and epidemiologists who, more often than not, are represented as professional heroes. how well they argued for various control measures and how they interact with political authorities is crucial; as is the quality and availability of health care systems. in antagonistic political cultural contexts and discordant public spheres, the performance of national authorities and the relative strength of traditions of confidence in the institutions they represent call for more attention as drivers of cultural trauma. there is frequent use of war metaphors, bombast and fear mongering on the one side and cold, factual, scientific representations on the other. the general public is dependent on media for information and on authorities for dealing with an invisible and unknown enemy. it is through such means that what is happening and who is responsible is articulated and transmitted. the mass media create story lines, highlight victims and heroes and generally construct meaningful accounts of what is happening. articulate the alternative narratives, to interpret what is happening, who is responsible and what is to be done. besides the authorities mentioned above and those working in the mass media, important actors here are professional organizations, trade unions and other interest organizations that speak in the name of their members. in polarized contexts, the relative strength of these carrier groups, their access to mass media, and their support from political and religious authorities is crucial. those nations that have experienced trauma appear to be better prepared, provided with a memory and a means to deal with crisis (keck and lachenal , pp. , ) . 'this' is like 'that', we survived that and can survive this. in the process, various historical instances are recalled through previous trauma, from earlier pandemics to aids. such associations are meant to offer hope as well understanding. we can illustrate the interplay of these factors under the intense conditions of ongoing compressed cultural trauma through two short case studies. we chose these countries for practical reasons, from firsthand knowledge and because they represent varied responses to the pandemic. both countries had the advantage of some advance knowledge of the virus and the means of its spread. sweden has been held up as a unique approach, for some exemplary, for others dangerous. however, despite initial high levels of anxiety the pandemic did not evolve into cultural trauma in either, even with an exceptionally high death rate in sweden and the great difference in trust in authority that distinguishes the two countries. we hope to explain why. like many south and east european countries, greece was much less exposed to global transactions during the - winter and that might be a reason why the disease spread and the death toll remained at quite low levels compared to other eu countries. the first covid- case was diagnosed in greece on february th. the virus came through those returning from travel to holy sites in jerusalem and from a group of fur trade businessmen who visited milan a few days before. contact tracing was initiated on the first and all subsequent confirmed cases, with all contacts being tested and isolated. on february th, the annual carnival in patra (an event which draws large crowds from all over the country) was cancelled. on march th, with officially cases and deaths, all schools and universities across the country were closed. on march th, libraries, movie theaters, gyms and courtrooms were closed. on march th, with confirmed cases and death, malls, cafés, restaurants, bars, beauty parlors, museums and archaeological sites were closed. on march th, supervised beaches and ski resorts were also closed. all stores but big food markets were closed four days later and on march rd, a nation-wide lockdown was enforced, whereby citizens could leave their house only for specific reasons and with a special permit and under strict time limits. as we write confirmed cases amount to since the start of the outbreak with the death toll at . as a country that was pulling out of a decade-long financial crisis, greece is considered surprisingly successful in containing the pandemic. with its national health care system weakened by the crisis and with one of the oldest populations in the eu the outbreak of the disease alarmed the authorities and the majority of the people to the extent that greece would be the next italy or spain. at the outset, a gloomy atmosphere of fear and anxiety was documented in numerous opinion polls. soon after the curve began to flatten, hope, pride and confidence improved in the emotional agenda of the public sphere. since may th the lockdown measures are gradually loosening in view of approaching the greek summer. to avoid overcrowded hospitals with a limited number of intense care units, public authorities acted in a very cautious and unusually efficient way. mobilization had to be very fast because the health care system could not have otherwise handled the outbreak. the government has been strictly following the strategic directions given by a committee of experts in public health, composed of prestigious professors of epidemiology and other disciplines. the pandemic has been handled by a rather strong center-right government that took office in july , with a good number of technocratic members. in a polity traditionally permeated by fierce antagonism, apart from minor reservations opposition parties raised no substantive objections to the lockdown measures. there were however disputes and skirmishes on resource allocation policies, especially in view of the expected economic fallout caused by the pandemic. however, there has been consensus over the need to keep tourism alive during the summer in order to shield the per cent drop in gdp, a dire prospect that would make the greek economy the hardest hit across the entire eurozone. the necessity of the lockdown measures was also reinforced by the extremely poor reserves of test kits for the general population. until substantive amounts of kits were imported, less than one percent of the population had been tested for the virus. testing was focused on people admitted to hospitals with symptoms and those closely connected to confirmed cases, as well on all those returning from abroad. this raised concerns about the accuracy of the case numbers announced during briefings held by sotiris tsiodras, the president of the experts committee, a soft-spoken, infectious disease specialist at the university of athens, and nicholas hardalias, the deputy minister for civil protection. since the death toll was small, concerns were alleviated and these two became the most trusted authorities and their briefing became a sort of news event, thus crediting television with a trace of its old rhapsodic fun action (fiske and hartley ) . consecutive opinion polls during the spring of indicated an impressive increase in public confidence towards most social and political institutions of the country, as well as the raising popularity of political figures. for a good many years-if not decades-political institutions and the political authorities in greece were much discredited and this change in public mood might be taken as a signal of the remaking public trust in the face of a collective trauma. yet, that upswing was brought about more because of an ensuing 'rally round the flag' reaction, and was not a sign of a regained and restored institutional credibility. if anything, as documented by a social attitude research directed by nicolas demertzis in may , the covariance between institutional credibility and social trust was limited (r = . ), which means that amidst the trauma drama there was a paradox of trustworthy institutions and a misanthropic-like attitude. this paradox is contingent upon the duration of the rally round the flag effect. in this respect, if a deep recession is imminent, much of the confidence in political and social institutions will evaporate and the trauma drama will deepen, especially because any new economic crisis will overlap with the previous one, occurring no more than a year ago. after the crash test of the gradual removal of restrictions in may , the 'stay home' message of authorities was replaced by a 'stay safe' logo. yet, in many instances social distancing and other safety measures were not observed. in some cases where young people from extremist social networks initiated festive gatherings in public spaces violating any precaution, police had to intervene. in greece's over-politicized public culture, these incidents were enough to trigger grievances and controversy. more or less, however, they sprung more from spontaneous reactions to stringency and not as organized massive protest like the mobilizations in the usa, australia, poland, and germany, where lockdown is viewed as an unjustified tyrannical policy. it is striking that due to the customarily weak civil society in greece (demertzis ) , organizations representing the elderly and pensioners haven't been given (or taken) the opportunity to get involved in the debate concerning the repercussions of social distancing. after all, the chief objective of the entire strategy was to avoid a massive loss of older people who, nevertheless, in greece are not placed in care homes due to strong family ties. national and international ngos are at pains to warn authorities about the risk of the disease spreading among the overcrowded clusters of asylum seekers in identification and reception centers. although the living conditions in these camps are unacceptable, according to official sources only a few tested positive. yet, right-wing voices often decry them as 'health-bombs'. apart from the community of doctors and experts whose voice are respectfully heard, other carrier groups include think tanks organizing webinars on the socioeconomic impact of the pandemic, major cultural organizations like the national theater, the national opera, the onassis foundation and the stavros niarchos cultural center delivering a vast number of artistic creations and performances online. another influential carrier group has been the greek orthodox church. drawing from the byzantine tradition of lesser caesaropapism and its legendary role as the only religious and juridical-political institutional mediation of the orthodox populations under the ottoman rule, the orthodox church accommodated itself to the greek nation-state as a claimant of the national identity. we cannot delve into its impact and to greek religiosity except to stress its perpetual stronghold on public life to roughly understand the fierce dispute between political parties, secularized civil society groups, health experts groups, and religious cycles when the greek orthodox church announced on march that coronavirus could not be transmitted by communion wine or water. as the greek easter approached, a dispute grew with the government hesitant to ban public rituals due to its political cost, especially when orthodox hardliners and rogue bishops made public declarations and followed practices undercutting government efforts to come to grip with the pandemic through social distancing in the first crucial weeks in march. eventually, the government regulated the issue and easter church services were held without the participation of parishioners. after the gradual loosening of restrictions on may, church attendance was permitted as long as social distancing was observed. however, despite its marginal and grotesque character, it is striking that on may a media-based former bishop excommunicated the prime minister, the minister of education, and the deputy minister for civil protection. although this would have been much more serious if that gesture was undertaken by an ordinary bishop or the archbishop himself, it is indicative of the spiritual and political power the church entertains during the pandemic trauma drama. sweden's current statistics as of july , were , tested positive, deaths, of a population of . million. sweden's death toll, with . deaths per , , remains among the worlds highest. most of these deaths, %, were persons over years of age, many living in state run care facilitates. by comparison, greece's population is . million, cases and deaths, or . deaths per , . sweden has experienced few traumas of national proportion. it remained neutral during the two world wars and, as opposed to scandinavian neighbors, avoided the trauma of occupation and as opposed to greece its handling of recent financial crises has been exemplary. the two political assassinations that rocked the nation in and did not shake the foundations of collective identity as similar events did in the us and the netherlands (eyerman ) . the virus came to sweden through those returning from travel (over million returned to sweden during these early weeks), many from ski vacations in italy and other parts of europe, as this was winter sport vocation for students, and from china. the news of the treat however preceded the arrival. once the source was identified, identification, tracking of contacts and isolation was put in place. sweden's landbased access to the european continent closed when denmark shut its borders on march , setting up roadblocks on the bridge made famous by a television show. international rail and air traffic shut down for all travel deemed 'unnecessary'. the many swedes who commuted to work in denmark were forced to show proof of the necessity of their daily commute. the same was true for truckers carting food and other goods into sweden. effectively cut off from the rest of the world, swedish authorities designed their own path of response to the internal spread of the virus, though communication with other members of the european union continued. close contact with other scandinavian countries was also maintained. at the center of this strategic planning was the national public health authority (folkhalsomyndighten) working in close contact with elected political authorities. as distinctive from other countries, even its nordic neighbors, these exists a very tight institutional connection between heath and political authorities in sweden. however, there also exists distinctive regional autonomy. through its daily press conferences, anders tegnell, the 'state epidemiologist', became the public face of this strategy. at these televised press conferences, tegnell and other authorities offered statistics over the 'state of the cov- virus' in sweden and the rest of the world. interviewed for the journal nature, tegnell described the daily planning sessions and meetings with regional authorities that lay the foundation for the swedish response to the pandemic. at this point (april ) he noted that the death rates amongst older swedes was not yet 'traumatic', indicating that there was some critical threshold, presumably connected to public sensitivity, where a response by the authorities would become necessary. sweden is unique in the sense that officials held fast with this strategy of containment, with a minimum of enforced restrictions. the idea of managing the spread of the virus and 'flattening the curve' so that hospitals never became overwhelmed was generally discussed, including in the united states. however, most countries changed to much stricter restrictions after death rates in italy and spain climbed seemingly out of control. along with strict restriction of movement, germany and other countries began general testing in order to identify new cases and then trace contact networks in order to isolate those infected. such measures were accompanied by strict hygiene measures, such as wearing masks in public places. what was (perhaps wrongly) called the 'south korea solution' was followed by many european countries. sweden did not waiver however; it followed the original strategy of minimal restriction to manage the spread without overwhelming the health care system to reach 'herd immunity'. at the same time, after considering who was dying in other countries recommendations were made to protect those over the age of . defined as a risk group, those over were cautioned to stay at home, with food shopping and other essential activities suggested for special hours of the day. these were recommendations however, with no enforced restrictions or penalties, as in other parts of europe. this stems in part from the stipulations of the swedish constitution, which prohibit restrictions on mobility, but primarily on the belief that citizens would follow the stipulations, especially social distancing, on their own. as the very young appeared the least at risk, day care centers and grade schools remained open. an additional rationale was that those who worked in the vital health care system, doctors, nurses and others, were likely to have young children and in need of child care. high schools, colleges and universities shut down and their activities shifted to the internet. stores and restaurants stayed open, with social distancing requirements put in place. several restaurants were temporarily closed for not following social distancing recommendations. crowds of over persons were banned, thus cancelling sporting events, though teams were permitted to practice and, later, to play to empty stadiums. people were encouraged to exercise, especially outdoors, gyms, voluntarily closed at first, soon re-opened. as death rates climbed to alarming proportions compared to neighboring countries, it became clear those working in care facilities as well as those they cared for were especially vulnerable and visitors were forbidden. the specificity of the death rates, especially in care facilities, remains unclear and a matter of concern. a formal inquiry is now ongoing. as for testing, sweden began by opening public booths to administer tests, but soon abandoned this policy in favor of testing only those displaying specific symptoms, as well as professionals working in the care sector. there is no general testing policy or program, in part because general testing was deemed unreliable, as well as costly. anyone showing symptoms was advised to call a hot line and to stay at in an op-ed in the major national newspaper dagens nyheter in april signed by researchers with the headline 'the national board of public health has failed, now it time for politicians to step in' (https ://www.dn.se/debat t/folkh alsom yndig heten -har-missl yckat s-nu-maste -polit ikern a-gripa -in/), it was argued that the strategy being followed was not working and that elected officials ought to step in to change it. the authors pointed to italy as evidence, arguing that sweden should follow other european countries in imposing stronger restrictions. the public health authorities met this criticism by denying that reaching 'herd immunity' through such callous means was their strategy, rather the aim was to flatten the curve, to slow the spread of the virus but not eliminate it. the issue of herd immunity was the subject of another article in dagens nyheter on may . the paper's science editor defined herd immunity as a state where a sufficient number of a community is immune to an illness to prevent further spread. this can be reached, she pointed out, by vaccination or immunity from having the illness and carrying antibodies. the issue with covid- is twofold, one that it remains uncertain if one can become immune through having the virus and ) even if the body does produce antibodies, it is still uncertain how long they last. the article points out that the price of achieving this state too quickly is the death of many elderly. home until symptoms became acute. the population was told that the vast majority of those who fall ill with the virus will have only mild symptoms, and that the real danger is infecting others. sweden's death rate is significantly higher than its scandinavian neighbors and they have been some of its most vocal critics. the alleged 'herd immunity' policies were called immoral and utilitarian. while opening its boarder to germany, denmark has refused to do the same with sweden; greece announced an opening to european tourists, but excluded sweden as well. in defense, swedish authorities have publicly acknowledged failures with regard to elderly care facilities and new policies and finances are promised. the swedish prime minister explained the high death rate as 'communications problem' within the care sector, rather than a problem stemming from the overall strategy (interview in sydsvenska dagbladet july : a ). public debate has begun addressing this issue, though at this point relative political unity prevails even with a weak coalition government in place. all parties remain united behind the leadership, even the anti-immigrant party (though its leader has called the death rates among the elderly a 'massacre'). trust remains high and the daily press conferences of the public authorities are exemplary in their fact-based seriousness. these civil servants and the science-based expertise they represent continue to be held in high regard (though polls noted a % drop in approval between april and june), and the approval ratings given the social democratic prime minister have been rising, with an . % increase since the last survey in november . if the death rates continue to rise however, how long this trust in leadership and collective solidarity will last is an open question. at this point the feared 'second wave' has not occurred. even at this date, one can identify stages in an ongoing trauma drama. concerning the question of who is to blame: there was first denial, the hope that the virus could be contained in asia or other parts of the world. with the sudden rise in italy, there was the recognition that it could come to sweden. the presumptive early carriers were swedes returning from vacations and business travel; thus, they could not be outwardly blamed or stigmatized as outside carriers, however there were a few reported incidents of harassed asian travelers and immigrants as outside carriers. the right-wing internet has focused on immigrants as carriers and what they consider their 'over representation' in the number of cases. another form of denial, with the fact of rising death rates in sweden, is the claim that other countries are less accurate in their reporting, or that they are 'at a different place in the curve' and will soon catch up. both such claims have been made by swedish health authorities. following denial came acceptance. swedish authorities turned to modeling science and to managing the spread of the virus from that standpoint. it is a form of bargaining with natural forces and predicting that most of the cases will be mild, that primarily only the elderly are seriously at risk. this freed most of the population from some anxiety, but could induce guilt or worry about older relatives, who were being 'sacrificed for the herd', which is to say, the nation. the greater good for the greatest number. given these assumptions, daily life proceeded almost normally for a good portion of the population. there are several features of the swedish national culture that have influenced this strategy and its general acceptance. the first is a tradition of identification and trust in government and representative authorities in general. sweden lacks the strong opposition between the people and the state that exists in some other countries. there is also an underlying faith in science and technology and a good health care system available to all. all of which have contributed to a general following of the suggested regulations. the regulations are viewed as rational responses to an exceptional incident, not as restrictions imposed by an alien authority over the natural rights of individuals. swedish political life builds around consent and consensus and the general populace has been willing to give up some of the most basic human interactions, including the possibility to grieve their dead. survey results concerning trust in the authorities (https ://www.msb.se/conte ntass ets/ f a c fa c b e d / -msb_resul tat-coron aunde rsokn ng_ .pdf) with the highest ranked being the health care system ( % positive), the national public health authority ( %) the police %) lower down the government at %. one exception that became apparent during the pandemic can be found in some immigrant communities, where there remain traces of different social traditions of communication and interaction. an example is that of the tightly knit somali community in stockholm that was overrepresented among those infected, that either did not receive or ignored the imposed regulations. there is also evidence that trust in political authority is lower in immigrant communities. all this has been fodder for the extreme right and their anti-immigrant rhetoric, at least behind the scenes, on the internet, and on social media. the problem of social segregation has been further illuminated through the pandemic; one recent study revealed that death rates among middle-aged and older immigrants from syria, iraq and somalia were % higher for the months during the pandemic than for the same period last year. the differences for ethnic swedes for the same period was very much less (cited in sydsvenska dagbladet july a: ). in answering the question 'trauma for whom?', one would look to immigrant communities and minority groups, both for their being stigmatized as well as being disproportionally impacted by the virus itself. as in many parts of europe, immigrant groups and minorities work in some of the most vulnerable and exposed occupations, under the most precarious conditions. like the elderly, they are a group at risk, but unlike the elderly (an abstract category), they, as a stigmatized and stereotyped group, are not as respected. there are also specific demographic factors that have affected the levels of contagion in sweden, including the countries low population density, high share of single person households (not the cross generation extended family of italy or greece for example), generally high life expectancy, low level of chronic illness, low levels of obesity ( % as compared to % in the us, and low rates of diabetes ( . % as compared to . in the us). the high death rate however remains to be explained and public debate has begun. faith in the system and its representatives remains high, for covid- to lead to cultural trauma the sense of existential security in the general populace would have to be fractured. for the moment, the pandemic is viewed as a public health crisis, not a threat to basic values or collective identity(/ies). for that to happen trust in leadership and institutions and faith in science-based medicine would have to be broken. foundational issues, such as what it means to be a swedish citizen and the relationship between individual freedom and responsibility to the collective have been opened by the pandemic. an example being the need to follow directives that restrict individual mobility for the collective good. also being debated is the question of who should bear for the extra (financial, political, and moral) burden in a health care in a system where there are wide differences between regions affected by the virus; are localities where there are few cases of the virus responsible for those where there are many; should those living in southern sweden where there have been relatively few deaths be held accountable (by other countries) for those in other regions where there have been many? sweden is a nation very much aware of how it is viewed by the rest of the world. with its handling of the pandemic now the subject of global discussion and the resulting stigmatizing of swedish citizens as dangerous, potential carriers, strikes at the heart of the basic trust in political and expert authority and the relationship between state and citizen. if trusting authority leads to others distrusting swedish citizens, what then? with the proviso that the pandemic crisis and responses to it continue to change from day to day, we argue that the covid- pandemic can be usefully studied as a cultural trauma, but with modifications. previous studies have been retrospective accounts of the cultural trauma process, while here we offer a means to use the framework for a trauma that is ongoing. in this final section, we summarize these modifications, ending with comments on the outcome. in retrospective studies, timing has to do with the sequence of incidents that initiate and propel the trauma process. the flow of information is constant and confusing but the distance of time (and theory) one knows what to look for. in studying the trauma process as it occurs one does not have a clear notion of an underlying logic or an end in sight. in the current pandemic, nations face the future with uncertainly. there is no surety concerning the immunity of those who have been ill and no sure knowledge with regard to the availability of a vaccine. strategies of containment have had relative and varied success, but deciding when to end restrictions, to open borders and permit international travel is a guessing game, with frightening consequences. the fear of new waves of infection and rising death rates is real and most be included in all proposals. as in war, one needs exit strategies. all this increases uncertainly and anxiety amongst leaders and within the general population bringing to the fore a painful interplay between normality and exceptional. added to this is the prospect of future pandemics of similar consequence though with different cause, raising the possibility of cumulative affect with regard to collective trauma. retrospective studies can isolate relatively distinct incidents; compressed trauma faces the simultaneity of incidents without clear order or value. it is not only the fear of infection and death; there is also the collapsing economies and rising rates of unemployment that create another level of fear and anxiety within a population. these fears must be balanced in the strategies formulated by elites and is conditioned not only by levels of trust and faith in leadership but also by the type of rule. authoritarian or competitive authoritarian systems have a different relation to those they represent than democracies, where election cycles are an important rhythm and consideration in the choices made by those holding power. sitting leaders do not have the luxury of trial and error to the dimensions available in authoritarian systems, adding to the pressure imposed by time. in the midst of the pandemic, many countries have experienced collective solidarity and political unity, a real question is how long this will prevail? as a global historical event, the covid- pandemic appears as facilitator and accelerator of structural calibrations and cultural shifts. in all likelihood, it condenses social time and identity formation processes within the terms of late modern time-space compression. as with / and hurricane katrina, it triggered a trauma process from the very beginning giving us the opportunity to comparatively study it in vivo with the aid of cultural trauma theory. yet, a caveat to keep in mind is necessary at this point; time-space compression is both a result of technological and informational globalization and a globalizing driver of shifting our sense of time towards presentism. it brings about a 'nowist culture' (bertman ) , the 'tyranny of the moment' (eriksen ) , and an experience of a 'continuous present' in the sense that, severing the present from history. one lives in a 'flat collection and arbitrary sequence of present moments' (bauman , p. ) . therefore, it is not only a pandemic induced trauma that is deeply inscribed in the time-space compression, but also those commentators (like ourselves) who are hermeneutically dealing with it. this might express itself in hasty postures like those of giorgio agamben who, on february , , denounced the measures taken by the italian government as 'absolutely unwarranted', as a pretext to the imposition of a state of exception. to avoid the error of theorizing too quickly under the pressure of presentism, it is better to consider the pandemic as cultural trauma in the making. the lure of presentism can cause one to jump to conclusions, even if all the components of cultural trauma-with the possible exception of collective memoryappear at hand. a possible conceptual means to avoid hasty theorizing is to look at the pandemic not only as compressed, but also as virtual cultural trauma. as long as it 'is not the result of an event but the effect of a sociocultural process … the result of an exercise of human agency' (alexander , p. ), cultural trauma is not meant to be historically realized, but rather socially constructed. ontologically it is understood as a status nascendi, the specificity of which is conditioned by the interplay between virtuality and actuality (lévy ) . contrary to the predetermined correspondence of potentiality to reality, where all possible attributes of the real are already inherent in the potential, virtuality is replete with openness and contingency so that the actual outcome of an historical event emerges from unpredictable agentic action. as historical constructs cultural traumas may or may not emerge out of the discursive mediation of abrupt fractures of the societal fabric, and in this respect, as a compressed shocking experience, the pandemic trauma process signals a virtual cultural trauma. relatedly, as customarily held, traumas break and remake societal bonds regarding in-group and out-group relations. among others, the social marketing campaign for diminishing the pandemic in greece was a first-class opportunity for the restitution of the damaged national pride driven by the debt crisis. for nearly ten years greece was depicted in the international media as the black sheep of europe but now, with the successful handling of the first wave of the pandemic and employing an 'we and them' schema, a repetitive message campaign claims that 'this time others can learn from us'. in a retroactive way, the present trauma drama presents an opportunity to symbolically heal the past trauma of economic collapse. the greek government and the party in power are doing their best to regain trust through this success, however as mentioned above, this is a precarious and ephemeral enterprise due to the long-standing distrust of the greek public with regard to political institutions. if anything, according to certain estimations, implemented policies against the pandemic were more successful in low-trust societies than in high-trust nations. although efficient coping with the pandemic is a multi-variable task, the cases of greece and sweden seem to support this estimation. in the main, greeks complied with the stringency rules because they were afraid that a discredited political and administrative system would be unable to protect them. ultimately, greeks began feeling confident in the system as soon as it worked efficiently. this resulted from elites addressing the public in a convincing manner and keeping the death toll at a relatively low level. to the contrary, the allegiance of the swedish populace to the loose restrictions was premised on their prior well-established confidence in political institutions and scientific discourse. should the death toll continue to rise dramatically, the likelihood is that distrust will increase in sweden, as well as instigate a contentious political debate; yet this short-term entropic tendency will likely be counterbalanced by the long-term culture of trust in national institutions. as explained above, quite the opposite could be expected in greece. comparatively speaking the countries are almost entirely different: high trust versus low trust tradition; economic success and security versus the opposite; rational and secular value orientations versus traditional and religious. there is also a sharp contrast in their death and infection rates, with greece incredibly low and sweden the reverse. unless major upheavals in public trust, economic performance, and the number of deaths occur, the likelihood of a cultural trauma unfolding in either country is small for however different reasons. the compressed condition stemming from covid- is unlikely to end up doing serious harm to habitual value patterns and collective identification in either these two countries. how do we explain this? with regard to sweden, one can point once again to long-standing traditions of trust in national authorities and institutions. the performance of these authorities in articulating and managing the crisis potential was swift and transparent. with the pandemic framed and understood as a public health emergency, not a political crisis, the management of the threat was turned over to non-partisan health authorities. their televised press conferences, organized around factual presentations and preventive recommendations, were models of authoritative representation in their non-dramatic tone and format. these daily performances had a large and receptive audience. those entrusted the public good spoke with one voice. that the policy recommendations were minimally invasive and appeared to work was essential to their being followed. as the unusually high death rates became apparent, these were acknowledged as policy failures, with accompanying explanation and the promise of reparation. that these deaths could be explained as largely restricted to identifiable groups, the elderly and ethnic minorities, also freed the majority of the population from a degree of anxiety. that all political parties and mass media outlets accepted this definition of the situation is also an important factor in explaining the absence of collective trauma. had there been political contestation and mass-mediated rhetorical challenges to the prevailing framing, the trust in leadership and the management of the threat would have been more difficult. this is to speak of cultural trauma at the national level. there is greater potential for such trauma at the group level, most particularly amongst the elderly, immigrant groups and minorities, those, that is, that bear the statistical brunt of the virus. the isolation felt by the elderly, especially those in care facilities, has not been remedied and a sense of uncertainly remains as restrictions have not been lifted, nor has any time frame been noted. this, however, is largely a group without voice and representation, a statistical rather than social or political group. it is also a fleeting group, with little possibility for narrative collective identification or collective memory formation. this is not the case for ethnic minority groups, where the impact of the virus is great and where marginalization and stigmatization are prevalent. here there is more potential for individual trauma to find collective voice and representation. finally, with regard to collective memory, one can ask if the pandemic will leave an indelible mark on collective memory. the spanish flu left little or none. the theory of cultural trauma is a heuristic framework that offers little grounds for prediction. that said, given the secular nature of swedish society and the absence of strong commemorative traditions, there mostly likely will not be any collective memorialization for those who died of the coronavirus. a recent national recognition of the dead occurred after the tsunami, where over swedish tourists died. in , the swedish church and embassy organized a th anniversary ceremony and a memorial has been erected in stockholm. at a ceremony marking the th anniversary of the estonia ferry disaster of , the swedish prime minister called it 'a trauma for the entire nation' and representatives of the swedish royal family offered flowers during the memorial ceremony. the individualized deaths resulting from the covid- pandemic, visible primarily through statistics, do not appear to lend themselves to collective commemoration in the same way. against this however, one should point out that in both the other cases initiative for the memorial celebrations and national recognition of the victims came from the bottom up, from survivors and family members. the emergence of such carrier groups cannot be excluded in the covid- case. as for greece, the low death toll is unlikely to make a traumatic impact on public memory since it is represented as a mark of elite success, to further boost the rebound of the economy predicted for . most probably, any traumatic memory will be set aside in public discourse and mourning made a private matter, as is the case with the people who suffered to death amidst a wild fire in attica on july after a blatant failure of civil protection. albeit in that incident, there was clearly someone to blame for the hecatomb of burn victims, yet no indelible mark was left on social identity or public memory; this time there is virtually nowhere to place blame. insofar as losses remain low, individual family tragedies will not turn into a collectively shared suffering that could initiate a cultural trauma. a collective trauma might virtually arise if families were to lose the grandparents living at home. as family ties remain very strong in greece, living in care facilities or on their own is the exception, not the rule as it is in sweden and other countries. in a country with a shame-oriented culture, the mass loss of generational predecessors would inflict painful shame and guilt, strong emotions that when shared shatter individuals and collectives alike. such might be sufficient cause for the unfolding of a cultural trauma, especially if a reform in the protection measures was not forthcoming. for the time being however, in greece as in sweden, there has been a basic consensus among the elites regarding the handling of covid- ; therefore, the mainstream media were unable to amplify strategic differences and polarize public opinion. in greece however, this served to regain national pride, while it sweden it preserved it. we are not claiming an absence of trauma in these countries. as we indicated, despite great differences in the number of cases and the death tolls, both countries have their victims and large segments of the population that face the future with great anxiety. these are troubles confined and maintained in the private sphere. by and large, albeit references to 'trauma' are made in both countries, on a societal level the covid- is perceived and framed in terms of crisis and crisis management, rather than a traumatic catastrophe that fractures value priorities and collective representations. compressed cultural trauma means that the trauma drama begins immediately, but makes not prediction that it will result in indelible marks on the social body. if anything, the core idea of compressed cultural trauma idea is its virtuality, implying that the constellation of meaning making processes will shift when and if societal variables change. trauma. a social theory cultural trauma and collective identity berkeley from pilgrim to tourist-or a short history of identity hyperculture: the human cost of speed the political sociology of emotions. essays on trauma and ressentiment greece german cinema-terror and trauma: cultural memory since tyranny of the moment: fast and slow time in the information age the cultural sociology of political assassination a better world can emerge after coronavirus. or a much worse one the condition of postmodernity hegel's logic (trans: wallace, w.) total social fact: structuring, partially connecting, and reassembling the new emerging viruses are unpredictable. kathmerini simulations of epidemics: techniques of global health and neo-liberal government qu' est-e que le virtuel human extinction and the pandemic imaginary the world after covid- social capital. summing up the debate on a conceptual tool of comparative politics and public policy technolopy. the surrender of culture to technology logics of history. social theory and social transformation cultural trauma and collective identity illness as metaphor covid- as cultural trauma covid- , nationalism, and the politics of crisis: a scholarly exchange publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations nicolas demertzis is professor at the department of communications and media studies at the university of athens. since , he has been director and president of the board of administrators of the national centre for social research (ekke) we thank the editors for the opportunity to approach this subject and especially jeffrey alexander for the constructive criticism he offered. key: cord- -u s uzp authors: bamgboye, ebun l.; omiye, jesutofunmi a.; afolaranmi, oluwasegun j.; davids, mogamat razeen; tannor, elliot koranteng; wadee, shoyab; niang, abdou; were, anthony; naicker, saraladevi title: covid- pandemic: is africa different? date: - - journal: j natl med assoc doi: . /j.jnma. . . sha: doc_id: cord_uid: u s uzp covid- has now spread to all the continents of the world with the possible exception of antarctica. however, africa appears different when compared with all the other continents. the absence of exponential growth and the low mortality rates contrary to that experienced in other continents, and contrary to the projections for africa by various agencies, including the world health organization (who) has been a puzzle to many. although africa is the second most populous continent with an estimated . % of the world's population, the continent accounts for only % of the total cases and % of the mortality. mortality for the whole of africa remains at a reported , as at august , . the onset of the pandemic was later, the rate of rise has been slower and the severity of illness and case fatality rates have been lower in comparison to other continents. in addition, contrary to what had been documented in other continents, the occurrence of the renal complications in these patients also appeared to be much lower. this report documents the striking differences between the continents and within the continent of africa itself and then attempts to explain the reasons for these differences. it is hoped that information presented in this review will help policymakers in the fight to contain the pandemic, particularly within africa with its resource-constrained health care systems. introduction c ovid- , a novel disease caused by the sars-cov- virus was declared by the world health organization (who) as a public health emergency of international concern on january , and as a global pandemic on the march , . first noted in wuhan in the hubei province of china in december , it has now spread to all the continents except antarctica. every country in the world, with the possible exception of north korea and turkmenistan, has documented confirmed cases with a spiraling increase in covid- related mortality and an excess of overall mortality compared to previous years. although covid- manifests primarily as a respiratory tract infection, there have been many reports of renal involvement, more so in the severe forms of the disease. , patients with chronic kidney disease (ckd) are amongst those at the highest risk for developing severe disease. this is over and above other recognized risk factors like hypertension, diabetes, chronic lung disease, and cancers,which are common comorbidities and often coexist with ckd. patients on maintenance haemodialysis (hd) are at particular risk, given the need to come into dialysis centres for their treatment sessions. the enclosed spaces of most dialysis units with centralized, recycled air-conditioning and the length of time necessary for haemodialysis further compounds this risk. patients with kidney transplants need to use immunosuppressive agents which increases their risk of acquiring the illness and of progression to severe disease. acute kidney injury (aki) is one of the more common complications of severe covid- and studies have reported an incidence as high as % amongst hospitalized patients, with it being one of the major reasons for mortality in these patients. recent reports have also suggested a possible association between high-risk apol genotype, common in peoples of african descent, and the increased risk of kidney disease in covid- . reports of collapsing glomerulopathy associated with covid- in patients of african ancestry who are carriers of apol risk variants have also been described and the name covid- -associated nephropathy (covan) for the condition has been proposed. these challenges are superimposed on nephrology practice in a continent that has limited resources and capacities to deal with renal patients even preceding the ongoing pandemic. africa is the world region with the lowest density of nephrologists at . per million population (pmp), and nine of the ten countries with the lowest nephrologist densities are from the africa region. many countries have no trained nephrologists and many that do, have very low numbers with few dialysis units often restricted to the urban centres. peritoneal dialysis is not widely available as the fluids are not manufactured locally and the cost of importation puts this beyond the reach of most patients as costs are often borne out-of-pocket by the patients themselves. [ ] [ ] [ ] [ ] [ ] against this background, the african association of nephrology (afran), developed covid- guidelines to guide nephrologists in the continent on measures to be taken by nephrology practitioners in the care of our regular patients during this pandemic and also in the management of patients developing the renal complications of covid- . during the discussions leading to the production of the guidelines, local experiences and insights were shared by members of the expert committee from the different countries represented on the committee. these discussions prompted afran to conduct a more formal survey to document the experience of covid- in different member countries. this report also summarizes the results of the survey and reflects on the reasons for some of the apparent differences in the pandemic between african countries and those in other parts of the world. two sets of data were collected for this study. the first included data to allow comparisons between africa and other regions as well as comparisons within africa itself. we also collected data on variables that could explain the apparent differences in covid- case numbers, mortality, and tests in africa, compared to other parts of the world. for all data sets, publicly available data was gathered up until august , . data on covid- cases, mortality, and test was retrieved from the worldometer website (http://www.worldometers.info/coronavirus/), worldometer is a trusted data aggregator site that retrieves timely data from official websites and social media accounts of ministries of health, government institutions, and official press briefings. the african data was augmented with information from the african centres for disease control (http://africacdc.org/covid- /) and official reports from the disease control centres of various african countries. data on environmental variables i.e. humidity, temperature, and uv index was obtained from weather online (https://www.weatheronline.co.uk/), a site that provides global meteorological data. this source has also been used in previous studies on temperature and coronavirus cases. , the human development index (hdi) data was retrieved from the united nations development program (undp) human development report. flights data was accessed from the international civil aviation organization, which publishes civil aviation statistics on air transport. additionally, data on healthcare access and quality index (haqi) was sourced from the lancet global burden of disease study. furthermore, data on population density and diabetes prevalence was accessed from worldometer and the international diabetes federation (idf). , the second set of data was collected via a survey amongst physicians in various countries in africa in the process of developing the afran covid- guidelines. an electronic (google forms) questionnaire was sent out on a whatsapp forum populated by nephrologists from different countries in africa. questions focused on the availability of nephrology resources in the countries of the various respondents and on their experience with managing cases of covid- with particular focus on the renal complications of the disease. case numbers, mortality, number of tests performed, and demographic data were summarized and compared by continents, regions, and countries within the continent of africa. also, we compared all african countries to the top worst-hit covid- countries. scatter plots were used to visualize the data and correlation coefficients were calculated to identify the strengths of the relationships between variables. the data analysis tool on the google forms platform was used to summarize the survey responses. africa accounts for . % of the world's population, but only about % of the total covid- cases diagnosed and % of the related mortality ( figure ). the number of cases per million population (pmp) globally is , , with south america ( pmp), north america ( , ) and europe ( , ) the most affected regions, while africa has a lower rate of pmp ( figure ). the case fatality rates have been . % worldwide, . % in europe, . % in north america, . % in south america and . % in africa. furthermore, as shown in figure , the values also vary considerably within the various countries in the african continent, although this might be related to differences in the number of tests performed (table ) . south africa and egypt have reported the most cases. importantly, these countries are amongst the countries at the top of tests done which is a critical factor in determining the number of confirmed cases. all the countries surveyed employed the rt-pcr method for diagnosis and many have experienced constraints with obtaining the necessary reagents. south africa, morocco, ethiopia and ghana however stand out prominently in terms of the number of tests done thus far. ghana has used pooled samples for screening suspected cases with separate tests done for only the positive pooled samples. the experience shared by african nephrologists has revealed that most of the cases have been completely covid- pandemic: is africa different? asymptomatic or mildly symptomatic, with very few patients requiring intensive care. the first set of patients managed in nigeria were mostly asymptomatic and none required intensive care. this has also reflected in the prevalence of the renal complications of covid- and the need for renal replacement therapy (rrt). the responses from the survey have indicated a paucity of cases requiring rrt, with % of respondents having no cases in their country requiring rrt. countries with more developed healthcare systems like egypt and south africa had a greater number of cases. approximately % of respondents noted that haemodialysis was available as a means of rrt. the survey also confirmed the poor state of nephrology care in the continent with many countries having limited numbers of nephrologists, few dialysis centres and very few dialysis machines. the median number of dialysis centres and nephrologists among the respondents were and respectively. the public health response of several countries consisted of a containment policy involving the isolation of all positively diagnosed cases at isolation centres. unfortunately, quite a number of these isolation centres lacked the capacity to perform dialysis as indicated by % of the survey respondents, with the consequences of avoidable mortality. some centres with limited capacity had only a single dialysis unit. there are regional differences within the continent as regards the severity of cases and the outcomes, with the countries in north africa having the worst outcomes. the case fatality rate is . % for north africa, . % for west africa, . % for south africa, . % for east africa and . % for central africa. south africa and egypt account for % of all african cases and for % of the mortality. these two countries along with nigeria, the third ranked in terms of numbers, are also the three strongest economies on the continent. north africa particularly appears to have the worst statistics in africa, even though their numbers represent % of total cases, they constitute % of mortality. several reasons have been adduced for this unexpected pattern of illness being seen in africa. given that covid- reached countries in africa by importation from asia, europe, and america, the onset of the disease in most countries was much later than was experienced in other continents. of the countries in africa, reported their first case in february, in march, in april, and in may. this of course suggests that many of these countries are still experiencing the early stages of the pandemic. the number of cases in the early stages of the pandemic was directly proportional to the number of international flights into african countries. the busiest international airports in the continent are located in south africa which also has the highest numbers on the continent, followed by egypt which is also second in case numbers ( figure a ). countries with infrequent business and tourism contacts with other continents are those with the lowest numbers ( figure b ). the few countries to buck this trend were countries like kenya and ethiopia whose airports serve as hubs for several countries on the continent and many international travelers pass through their airports and not actually into these countries. many african countries with previous experience of managing other epidemic infectious diseases like ebola, tuberculosis, and lassa fever closed down their airports to international travels much earlier than had been done in other continents. prior to the closure, many commenced disease surveillance activities and contact tracing at the airports, again much earlier than was done in many other countries outside the continent. all of these factors limited the number of cases "seeded" into african countries delaying the outset and the subsequent growth in numbers thereby "flattening the curve" in many of these countries. this is another major potential reason for the relatively lower numbers of cases on the continent. the number of positive cases reported is driven by the number of rt-pcr tests performed. the top five testing countries in the world (as of august , ) were china À million, the usa- million, russia- million, india- million, and the uk- million. in contrast, the top four countries in africa were south africa with . million tests, morocco with . million, ethiopia with , , and ghana with , tests done as at the same date. within the continent, the top testing countries were also the countries with the highest number of cases. many countries have been limited by the costs of these tests and the non-availability of the necessary equipment, reagents, and trained personnel. ghana notably has done many more tests per million of its population by pooling samples, thus testing more patients with each kit deployed. antibody testing in several countries suggests that many cases might have been missed by the paucity of tests carried out in the continent. many of these tests suggest that as much as %- % of the population in some of these countries might have already contracted and recovered from the disease. in fact, preliminary results from a study from the western cape in south africa revealed a seroprevalence of antibodies in % of antenatal screening specimens and routine monitoring blood tests covid- pandemic: is africa different? done for hiv positive ante-natal clinic patients. it is also possible that many deaths attributed to other reasons in the absence of testing might have been due to covid- . the population density in africa is much lower than many of the countries in other continents. the disease spreads quicker and more easily in crowded, enclosed, and noisy spaces. many communities on the continent are rural and widely dispersed, which slows the spread of the virus. the "hotspots" in most countries are the crowded major cities like lagos in nigeria (responsible for over % of cases), johannesburg and cape town in south africa, nairobi in kenya, and cairo in egypt. within these cities, the greatest numbers are seen in crowded communities such as kosofe and alimosho in lagos. the institution of lockdown measures early in the pandemic has also served to limit the spread of the disease. countries like rwanda and senegal which implemented strict and efficient measures were able to limit the spread even better than surrounding countries in their sub-regions. many of these countries, following the economic distress caused by these lockdown measures, have had to relax some of these measures with the consequence of, in some cases, rising numbers. africa is the youngest continent on the planet; the median age of the countries in sub-saharan africa is years. this is in comparison to europe for instance where the median age is years. individuals in europe over the age of years constitute . % of the population, whilst that of sub-saharan africa is %. younger individuals are times less likely to acquire the illness and when they do, they seldom develop severe symptoms or die from the illness. within the continent as well, countries with slightly older populations like egypt and south africa are also the ones with the highest numbers and the greater case fatality rates ( figure ). older individuals are also the ones more likely to have the various co-morbidities that have been associated with severe disease and the risk of mortality. these include obesity, type diabetes, and malignancies. the prevalence of these conditions is greatest in the countries of the maghreb and south africa all of which have the highest case numbers and the worst cfr on the continent (figures and ) . in nigeria, % of patients admitted at the isolation centres had no comorbidities whilst in south africa, % had at least one comorbidity. this could partly explain the larger numbers and higher mortality observed in south africa. the cultural practice of caring for elderly relatives at home as opposed to using care facilities may also be a major factor. in europe and the usa, these care homes were major centres for transmission of covid- with the resultant heightened mortality. age might also be relevant in the vitamin d related factor as younger individuals are more efficient in the production of vitamin d from sunlight and are more likely to be ambulant and exposed to the sun for this to happen. people living near the equator get more uvb light from the sun and thus generally have higher serum vitamin d levels than those living farther away. healthy levels of vitamin d give patients with covid- a survival advantage by helping them avoid the cytokine storm. some preliminary studies have demonstrated that vitamin d status and sun exposure are important factors to consider for reducing the rates of transmission, infection, and severity of illness. , exposure to previous infections there are speculations of the possible relative resistance to the virus with resultant milder presentation and much lower mortality being observed on the continent. there is a hypothesis that exposure to similar coronaviruses in the past may have conferred relative immunity to patients on the continent. coronavirus cross-reactive antibodies may contribute to a low transmission rate and reduced severity of disease associated with sars-cov- through crossneutralization and rapid clearance. the heightened immunity obtained from exposure to previous infections like malaria and other ongoing endemic infections, like tuberculosis and hiv, has been speculated as a possible reason for the milder presentation of the covid- in africa. ongoing vaccination for tuberculosis using the bcg vaccine has also been speculated to be a factor in protecting vaccinated individuals from acquiring the illness and when they do, from the severity of disease and mortality. most countries in africa continue to vaccinate their citizens against pulmonary tuberculosis with bcg, as the disease remains endemic in various countries on the continent. countries in europe with later discontinuation of bcg vaccination also all seem to have relatively fewer cases and milder illness than their surrounding neighbours. although we could not find a correlation with bcg vaccination and the number of coronavirus cases, some studies have shown bcg to be protective against severe cases of the illness. , human development and healthcare quality a correlation has been observed between the human development index (hdi) and the numbers of cases and case fatality rate. countries with higher hdi have higher numbers and worse outcomes ( figure a ). another surrogate of healthcare development, the healthcare access and quality (haq) index showed quite a similar pattern ( figure b ). the pearson correlation coefficients for hdi and haq, against covid- cases pmp were noted to be . and . respectively. some studies have suggested that temperatures in excess of c, ultra-violet rays associated with sunlight and humidity all tend to have negative effects on the survival of the virus. we could not demonstrate this for african countries. however, the rise in numbers in the southern part of the continent currently experiencing their winter season and the relatively lower numbers and mortality in countries closer to the equator with higher temperatures and higher intensity of uv-light might be in keeping with these speculations. despite weaker health care facilities and systems, the growth of cases in africa has defied most predictions and has remained geometric and not exponential. available data and statistics continue to reflect consistently lower numbers than those in other continents except for oceania. the severity of presentation has also remained relatively mild and the anticipated overwhelming of the health systems, including the renal services of the various countries on the continent has not been seen. mortality and case fatality rates have been a fraction of what had been predicted. this is however not a reason to be complacent as for many african countries, these are still early days in the pandemic and a change in the pattern may yet occur as the numbers continue to rise. it has taken six months to reach the first , cases but less than two months to cross the million cases mark on the continent. a novel coronavirus from patients with pneumonia in china, j nejm who director-general's opening remarks at the media briefing on covid- - who coronavirus disease (covid- ) dashboard excess deaths associated with covid- clinical features of patients infected with novel coronavirus in wuhan kidney disease is associated with in-hospital death of patients with covid- collapsing glomerulopathy in a patient with covid- covan is the new hivan: the re-emergence of collapsing glomerulopathy with covid- outcomes in adults and children with end-stage kidney disease requiring dialysis in sub-saharan africa: a systematic review global dialysis perspective: senegal isn global kidney health atlas global nephrology opinion paper workforce: gaps and opportunities toward a sustainable kidney care system the challenges of esrd care in developing economies: sub-saharan african opportunities for significant improvement guidelines for the prevention, detection and management of the renal complications of covid- in africa coronavirus update (live): , , cases and , deaths from covid- virus pandemic -worldometer world weather j world weather online impact of weather conditions on atopic dermatitis prevalence in abuja, nigeria on the global trends and spread of the covid- outbreak: preliminary assessment of the potential relation between locationspecific temperature and uv index healthcare access and quality index based on mortality from causes amenable to personal health care in countries and territories, e : a novel analysis from the global burden of disease study global diabetes data report maverick citizen: spotlight: covid- : high prevalence found in cape town antibody study the possible role of vitamin d in suppressing cytokine storm and associated mortality in covid- patients vitamin d insufficiency is prevalent in severe covid- lessons for covid- immunity from other coronavirus infections bcg vaccine protection from severe coronavirus disease (covid- ) is global bcg vaccination coverage relevant to the progression of sars-cov- pandemic? med hypotheses covid- pandemic: is africa different? key: cord- -baqbxez authors: kobayashi, yoshiharu; heinrich, tobias; bryant, kristin a. title: public support for development aid during the covid- pandemic date: - - journal: world dev doi: . /j.worlddev. . sha: doc_id: cord_uid: baqbxez global pandemics are a serious concern for developing countries, perhaps particularly when the same pandemic also affects donors of development aid. during crises at home, donors often cut aid, which would have grave ramifications for developing countries with poor public health capacity during a time of increased demand for health care. because the major donors are democracies, whether they renege on promises would depend intimately on how donor citizens respond to the specific crisis. we conduct two survey experiments with u.s. residents to examine how the covid- pandemic influences their attitudes toward aid. we demonstrate that citizens’ concern about the impact of covid- on their country’s financial situation reduces their support for aid. if they think that aid can help curb the next wave of the disease at home by first alleviating its impact in developing countries, they become substantially more supportive of giving aid. in contrast, merely stressing how covid- might ravage developing countries barely changes their aid attitudes. our findings have implications for what to expect from donors during global pandemics as well as how advocates may prevent aid from being cut. which covid- may bring about the grim scenario in which scarcer development aid generates detrimental outcomes in developing countries. however, the looming impact of covid- on developing countries may also make people in donor countries acutely aware of how dire the pandemic can be in developing countries. this perception of increased need might activate a sense of greater empathy, which may lead (some) people to be more supportive of aid (bayram & holmes ) . moreover, a particularly widespread outbreak of covid- in poorer countries might lead to a worse second wave of cases in donor countries months later. aid to fight covid- abroad could also have tangible health benefits at home. realizing that donor and recipient countries are entangled via the high transmissibility of covid- , voters may favor assisting poorer countries in order to dampen the impact of a second wave (steele ), a rationale for development assistance called "targeted development" (bermeo ) . if activists, politicians, or public health officials can generate such beliefs about increased need or the "targeted development" idea, then support for aid might actually increase during the covid- crisis. in this paper, we develop and analyze two experiments in order to examine the different channels through which covid- may shift attitudes toward foreign aid. the experiments were carried out on april / , using u.s.-based respondents. in the first experiment, we investigate how concerns about the economic impact of the pandemic influence individual attitudes towards aid. we assess two different types of concerns about the economic impact of covid- , personal and sociotropic economic concerns. we experimentally induce worry about each by asking respondents to write down what makes them worried about either personal or national (sociotropic) financial situations (albertson & gadarian ) . we find that worries about the impact of covid- on the national financial situation cause a decrease in support for aid by . % [ . , . ] (compared to a neutral control condition). in contrast, worries about one's personal financial situation are not significantly associated with support for aid ( . % [- . , . ] ). the second experiment exposes respondents to a message linking covid- to increased hardships for people in poorer countries or to a message suggesting aid that helps african countries deal with covid- will also have public health benefits at home in several months. these messages mimic arguments by pro-development activists that wish to increase support for aid. the results demonstrate that messages that convey anticipated detrimental health consequences in developing countries barely move aid support. the changes compared to a control condition are around zero with wide uncertainty ( . [- . , . ] ). in contrast, messages emphasizing that helping african countries in order to weaken the next wave of the pandemic at home generate a sizable increase in aid support. the probability of a respondent "strongly" favoring aid increases by . % [ . , . ] compared to a control condition. our study has implications and guidance for those who wish to see both public support and aid commitments be sustained. our findings imply that if policies related to covid- keep stunting economy activity in affluent countries, opposition to development aid is likely to grow (see also dolan & nguyen ( ) ). our study suggests that this would happen because of a greater concern about the finances of one's own country. this is not good news for global health or aid activists because assuaging worries about one's own country's financial circumstances is not an easy task, particularly in countries politically polarized or that lack trust in elites (green, edgerton, naftel, shoub & cranmer ). on a more positive note, beliefs over what aid spending might effect are more malleable. however, according to our results, focusing on messages of need and the deservingness of the recipient is not an effective method. rather, activists need to make a more instrumental case for aid to donor voters, which some have already done. the german development agency managed to increase funding for global health projects by e . billion despite job loss and massive government spending on domestic matters. echoing our findings, the accompanying press release states that it is in germany's "interest that we combat the virus globally. if not, it will return to us in germany and europe in waves." the uk international development secretary has also adopted this strategy when discussing uk aid with the public in many occasions. for example, alongside the uk prime minister's announcement of £ million aid commitment to fight the pandemic, the international development secretary was quoted in major newspapers as stating "[b]y strengthening developing countries' health systems ..., the uk is playing its part in stopping the global spread of coronavirus to save lives everywhere and protect our nhs." our findings have implications for the broader literature on aid allocation and aid effectiveness. ours is the first experimental evidence to provide a micro-foundation for "targeted development," an allocation strategy increasingly pursued by aid donors since the end of the cold war (bermeo ) , and one that has been shown to be in play for health-related aid (steele ) . in an increasingly interconnected world where plenty of negative externalities emanate from poorer and poorly governed countries, donor governments allocate aid to places where the potential externalities are high. however, such a strategy is only sustainable if the public consents to the provision of foreign aid. our second experiment shows that this can be the case. these findings also provide further evidence to support the broader idea that donors' citizens can see foreign aid instrumentally (heinrich, kobayashi & long , kohno, montinola, winters & kato . we will discuss additional implications for the literatures on aid allocation, aid effectiveness, and aid opinions in the conclusion. in the next section, we develop our theoretical arguments about the different mechanisms through which a global pandemic such as covid- may affect attitudes toward development aid spending. subsequently, we introduce and examine the two experiments. then, we conclude by discussing the policy implications and contributions of our study to different strands of aid research. for decades, scholars have analyzed the provision of foreign aid. recently, health has become a focus. not only have researchers examined how health conditions in recipient countries affect aid flows as a whole, but also (even more recently) how health-targeted aid is allocated. crucially, in line with the broader literature on aid allocation, this body of work quickly recognized and now fully embraces the idea that (even) health aid is intrinsically shaped by the domestic politics of donors (lee & lim , stepping , steele , suzuki . however, the research on health-centric foreign aid has not embraced two crucial aspects of global public health crises, both of which are manifested in the covid- pandemic. for one, health issues have mostly, but not exclusively (steele ) , focused on health crises in recipient countries. for example, studies have examined whether donors' funding for some diseases in a recipient country is commensurate with the burden of the diseases in that country. however, in an increasingly globalized world, many health crises cross borders and can easily become global issues, as evidenced by the covid- pandemic. if the goal is to understand the effect of such crises on aid policy, it would be useful to treat such crises as donor-side crises as well and examine them as such. for the other, a growing strand in the literature has convincingly demonstrated that public opinion can play a crucial role in shaping the aid policies of traditional (democratic) donors, especially when public attention is heightened (van belle , milner , eisensee & strömberg , nielsen , heinrich et al. , abbott & jones . therefore, we ask how a global pandemic like covid- may affect donor citizens' attitudes towards foreign aid, particularly when donor and recipient citizens are enmeshed in the same pandemic. to our knowledge, only one study has tackled this question. dolan & nguyen ( ) ask how personal financial circumstances and partisanship affect u.s. voters' willingness to give aid bilaterally. their results indicate that personal exposure to covid- and job loss are negatively related to aid support. our study differs from theirs in crucial yet complementary ways. first, we focus more on the worries that dire economic circumstances might produce and less on the (objective) event giving rise to such worries. with that, we are examining one channel connecting the economy to aid attitudes. second, we examine personal and sociotropic worries, recognizing the force that sociotropic attitudes often have. third, we proceed experimentally, alleviating the usual concerns about omitted variables and selection effects. we begin our study by first establishing a theoretical framework under which we can examine the questions of interest to us. as it is rooted in existing research, we ensure that knowledge can accumulate across different fields of study in foreign aid. two specific mechanisms emerge from our framework. first, covid- may impact the financial livelihood of one's household (heinrich et al. , dolan & nguyen and of the country. second, a looming pandemic in developing countries can spur perceptions of deservingness and the need of recipients (bayram & holmes ) , but it can also be the source of a negative externality for one's own country down the road (steele , bermeo ). our analytical framework of aid attitudes builds on recent work which emphasizes moral concerns, material interests, beliefs over the costliness of aid, and available financial resources as sources of aid attitudes. first, donor citizens care about the moral consequences of their government's aid policy. they are more supportive of giving aid to recipients that are economically poorer and demonstrate greater respect for human rights (allendoerfer , blackman . second, they are also appreciative of the material benefits that foreign aid brings (heinrich et al. ). for example, citizens express greater support for aid that generates easier access to natural resources and greater counterterrorism cooperation. third, when deciding whether or not to support aid, they consider how costly aid is and how many resources are available to the government to spend on policies, including foreign aid (heinrich et al. , abbott & jones . while citizens generally do not have a good idea of how large their government's budget is, how the economy is actually faring, or what the size of their government's aid spending is, they still hold beliefs over these quantities, which in turn influence their policy preferences (stevenson & duch , gilens , scotto, reifler, hudson & vanheerde hudson . we first focus on citizens' concerns about the economic impact of the covid- pandemic as a channel through which aid attitudes are shaped. while the health impact of covid- is serious in many developed countries, economic disruptions caused by covid- and government responses to it have been severe, far-reaching, and widely felt by many people. we argue that economic concerns about covid- affect aid support by shifting a person's belief over how many government resources are available to spend on policies. citizens do not typically learn about the size of the government budget directly from government reports. instead, they rely on information from the mass media and elites or on their own personal economic circumstances. we differentiate between two types of economic concerns, personal and sociotropic. first, donor citizens may rely on their personal financial situations to update their beliefs about how well the economy is doing and how much budget is available. a past study by heinrich et al. ( ) makes a similar argument and finds survey evidence that personal economic downturns are systematically related to opposition to aid. in a similar vein, we expect that personal economic concerns about covid- will lead to a decrease in aid support. second, we also consider citizens' concerns about the effects of covid- on the national economy. plenty of evidence from various literatures suggests that when deciding whether or not to support national policies, sociotropic considerations motivate citizens to make judgements, but the effects of personal considerations are highly circumscribed. we argue that sociotropic concerns inform and update one's belief about the economy and therefore influence one's support for aid. we expect that concerns about the national economy will lead to reduced support for foreign aid. the second channel stresses the effects of covid- on people in recipient countries and how news, arguments, and messages about them influence donor-side public attitudes. previous findings demonstrate that aid opinions are malleable-new information, and how the information is presented, strongly influence attitudes towards aid (scotto et al. , hurst, tidwell & hawkins , baker . we focus on two types of messages that closely mirror the dominant arguments in the mass media, elite messaging, and academic writing: one emphasizing recipient needs and the other focusing on the benefits of helping developing countries for their own country. commentary about covid- in developing countries emphasizes pre-existing issues such as the lack of health personnel and budgets, inadequate medical facilities, and existing health problems (e.g., aids and malaria). those wishing to shape aid opinions combine such descriptions with a call for financial assistance to help these countries during the covid- pandemic. these messages are designed to raise awareness and moral concerns in the audience (bayram & holmes ) , which is an important driver of aid support in our analytical framework. if such messages are effective, we would expect that exposure to these messages will increase citizens' support for aid. another type of message argues that rich countries should provide aid to help developing countries because doing so also benefits themselves. the potential emergence of a second wave of covid- infections has been a serious concern, especially after seeing them in places like singapore and japan. stemming outbreaks in developing countries can be framed as a powerful way to prevent a second wave of infections at home. for example, abiy ahmad, the president of ethiopia, wrote in march , "[i]f the virus is not defeated in africa, it will only bounce back to the rest of the world ... momentary victory by a rich country in controlling the virus at a national level ... may give a semblance of accomplishment. but we all know this is a stopgap. only global victory can bring this pandemic to an end." messages like this frame the health problems in developing countries as also the donors' own problems by emphasizing the negative spillover and contagion effects of covid- . indeed, as globalization has increased and strengthened connections between rich and poor countries, the ability of developed countries to insulate themselves from problems originating outside their borders has become weaker. bermeo ( ) argues that in an interconnected world, donor countries use foreign aid to mitigate negative effects resulting from problems associated with underdevelopment, such as the spread of infectious diseases. in the same spirit, steele ( ) argues that donors give health-related aid funds to countries combating diseases that could also threaten the donor country. we argue that this type of message can enhance public support for aid by appealing to the material concerns of donor citizens, in addition to their moral concerns. we expect that messages with an emphasis on the benefits of addressing the problems in developing countries will increase aid support. in short, our framework allows us to examine two broad mechanisms that connect covid- to attitudes toward foreign aid, leading to four specific hypotheses: • as worries about the household financial situation increase, support for aid declines [tested in experiment ]. • as worries about the country's financial situation increase, support for aid declines [tested in experiment ]. • when people in developing countries are seen as suffering from covid- , support for aid increases [tested in experiment ]. • when the provision of aid is seen as helping with one's own country's covid- health situation, support for aid increases [tested in experiment ]. in the first experiment, we use a bottom-up, self-directed generation of worry about the current financial situation, an approach that is commonly used in psychology (small, lerner & fischhoff , lerner, gonzalez, small & fischhoff and political science (albertson & gadarian , valentino, banks, hutchings & davis ). respondents were randomly assigned to one of three conditions: household-worry, country-worry, and control. in the household-worry condition, respondents were asked "to take a moment to think about the financial situation of your household and your family. when you think about it, what makes you worried? please describe the biggest worries that come to mind." in the country-worry condition, we replaced "your household and your family" with "your country." the control condition prompts people to write about the weather. the act of writing down worries induces the specified concerns directed toward the object (here, either financial situation) (albertson & gadarian ) . feelings are intended to stay neutral in the control condition as attention is directed at the weather. following the experimental manipulation, each respondent answered the often-used question of whether, "on the whole, do you favor or oppose the u.s. government giving foreign aid to poor countries for purposes of economic development and technical assistance?" the answer options are a -point likert scale with "strongly oppose," "oppose," "favor,", and "strongly favor." we recruited u.s. residents through an online survey-taking platform, prolific (palan & schitter , peer, brandimarte, samat & acquisti . the oxford-based service lets researchers post ads for surveys, which the eligible subset of the , + active members can see. participants are paid by researchers for their participation. those that took our job to participate in a short survey were randomized with equal probability into the six conditions-three for this experiment and three for the next experiment, respectively. people participated in the first experiment. we approach the analysis of the two treatments and the control in two different ways. first, we estimate the "intent-to-treat" (itt) effect, comparing aid support for those treated with support from those in the control condition. the itt estimates are useful if we are only interested in the effect of the act of inducing subjects to worry about the financial situations. however, itt estimates may fail to measure the effect of actual worries if there is an issue of non-compliance. indeed, a casual inspection indicates that some participants asked to list worries actually wrote that they were content and not worried whereas others asked about the weather mentioned worries about the covid- pandemic. as a result, the itt estimates may be compromised by subjects' non-compliance. in our context, we can use randomized treatment assignment as an instrumental variable (iv) to adjust for all the confounding (gerber & green ) stemming from propensities to not comply with the treatment status. although the treatment non-compliance issue seems minor in our data (as we show later), we also conduct a separate analysis using the iv approach. first, we estimate the itt effect by comparing the expressed aid support under the treatment about household financial worries against the control condition. we examine analogously the support under the country-worry condition against the control. we do this by pooling the observations and using dummy variables capturing the treatment status of each respondent. the statistical model we use is a robust ordinal model that includes a conventional set of control variables. , the first column in table gives the itt estimates. respondents who were asked to worry about their own household's financial situation are less supportive of aid compared to those in the control condition, but this difference is not statistically significant. the % confidence interval, which we present below the coefficient, contains the value of zero. in contrast, comparing aid support among those asked to think about the country's financial situation to those prompted to consider the weather, we find that the difference is negative and statistically significant with the entirety of the % confidence interval lying below zero. prompting respondents to worry about the country's financial situation causes them to be less supportive of foreign aid, while asking them to consider their own household finances does little to their aid opinions. before we discuss the magnitudes of these effects, we will show the results from our iv analysis. we have so far focused on the itt estimates that measure the effect of treatment assignment on those we intended to treat, but not the effect of actual worries. we use randomized treatment assignment as an iv to adjust for the impact of treatment non-compliance. to conduct the iv analysis, we need to assess and score the extent of expressed worries about either the household's or the country's financial situation. we hired four reliable coders via amazon's mechanicalturk to code the expressed worries of (almost) all respondents. two of the authors also coded a random subset of more than responses each. the hired coders and the authors performed the coding without knowledge of the treatment status or the level of support for aid of the respondent. additionally, the hired coders were unaware of the content of the research project as a whole. a total of , evaluations of the statements were generated. we instructed coders to read each description of worries from each treatment condition and determine the extent to which it expresses worry about the household's and the country's financial situation, respectively. they then assigned one of the following worry levels: "positive", "neutral", "minor worries," "some worries," "big worries," and "extreme worries." we combined these , codings from the six coders through two confirmatory ordinal factor models that account for the coders' coding differences (quinn ) , one for household worries and another for country finance worries. (the full set of details is in section iii in the appendix.) the resulting measures are two latent variables-one for the household and one for the country-scaled to the standard gaussian distribution, with higher values indicating greater worries about the respective financial situation. for the iv analysis, we split the data set into those treated to worry about their household's finances and those asked to write about the weather to examine the iv estimates for the effect of expressed household worries on support for aid. analogously, we pool the weather and country-worry treatment observations to study the effect of country-finance worries on attitudes toward aid. in the first stage for each, we regress the respective estimated worry on the appropriate treatment indicator while including the same set of covariates used before. the statistical model is a linear regression. in the second stage for each, we model support for aid as a function of the predicted worry from the first stage and the same covariates (without the treatment indicator, of course), again using the robust ordinal model. columns - in table give the iv results. we first check whether the treatment assignments actually increase worries. columns and give the results from the first stages. the respective treatment assignments increase worries about the finances of the household (column ) and of the country (country ). the effects are sizable. as each outcome is scaled to a standard normal distribution, we can interpret the coefficients of about . in each case as showing that assignment to the treatment leads to about a . standard deviation increase in the latent worry. we now consider columns and to see if the instrumented worries are systematically related to support for foreign aid. in column , we find that the instrumented household-finance worries are not statistically significantly associated with aid support. the coefficient of − . is small in magnitude with the length of the % confidence interval being almost eight times the magnitude of the point estimate. therefore, we have little evidence that greater worries about the household's financial situation lead to a reduction in aid support. this corroborates the null results from the itt analysis. in contrast, the fifth column shows that increased worries about the country's finances significantly reduce the extent to which citizens support foreign aid. the point estimate is almost four times as big as the one for the household worries, but the confidence interval is entirely above the value of zero. therefore, in line with the itt estimate, we find that increased worries about the financial situation of the country lead to less support for the provision of aid. the signs and significance of these effects speak directly to our hypotheses. however, we would also like to present simulated effects that show not only the magnitudes of the effects but also changes in patterns on the ordinal scale of the aid support variable. we first describe our simulation approach and then discuss the results. each panel gives along the x-axis the potential levels of support for aid and along the y-axis the difference in probability of observing the level when subtracting the corresponding probability in the control condition. the gray dots and lines give the itt estimates, the black counterparts the iv estimates. dots give the mean probabilities, the thin (thick) lines the % ( %) confidence intervals. the left-hand and right-hand panel give the results for the country and household financial worries, respectively. the y-axis gives the post-stratified probability that each level of aid support is picked under the panel's treatment condition minus the respective probability under the control condition. the black dots and thick (thin) lines denote the mean estimates and the % ( %) confidence intervals from the iv results; the light gray ones denote the itt estimates. starting with the left-hand side panel, we see that both opposition answer options become more popular when respondents are prompted to think about the country's finances (gray) or express greater worries about them (black). moreover, we find an interesting pattern in how worries about the country's finances shift aid support across levels. substantial increases in aid opposition due to sociotropic worries occur at the "oppose" level but are not that sizable at the "strongly oppose" level. reductions in aid support occur at both the "favor" and "strongly favor" levels. this means that worries about national finances cause both enthusiastic and moderate supporters to become moderately opposed to aid. finally, consistent with the earlier results, the magnitudes of the effects under both approaches in the household-worry setting are smaller and are all statistically insignificant. the second experiment shifts the focus to arguments for the provision of aid that people may encounter. we designed two short news articles to convey arguments that covid- may affect african countries such that the need for foreign aid is high and that rampant spread in africa might make the second wave of infections in the united states particularly harsh. additionally, we wrote a control article mimicking self-help articles to cope with stress. our story introduced "stress-baking" to join the ranks of anti-anxiety activities, like meditation and shinrin-yoku (forest bathing). the full news stories are in section ii in the appendix. the "need"-based news story highlights how covid- might cause a humanitarian disaster in africa. the story begins by drawing a parallel with the dire situation in new york city, but suggests the situation might be worse in african cities that lack health equipment. the article's kicker and conclusion include appeals for increased foreign aid by the united states. the fictitious author is listed as a "global affairs columnist." the "targeted development" article presents the same basic facts but adds and emphasizes the argument that u.s. aid to africa will bring about the advantage that the anticipated fall second wave of covid- in the united states would be weaker. it is worth noting that these treatments are not designed just to frame the issue (i.e., emphasize different aspects), but rather to change beliefs about the moral and material implications of providing financial assistance to africa. for this experiment, we only proceed with the intent-to-treat analysis as we did not ask people to express their thoughts about any of the news stories. for the analysis, we pool all observations in the second experiment and define two dummy variables which denote whether one was assigned to the "need" or "targeted development" group; the baking story is the omitted category. we use the same control variables, outcome variable, and statistical model as before. the sixth (last) column in table presents the results. the coefficient on the "need" story is small, the smallest of all binary treatment coefficients across the two experiments. compared to the control condition, emphasizing how covid- might ravage people in africa hardly affects support for foreign aid. this is a surprising finding in light of the pervasive use of such messages by aid agencies and the existing evidence that arguments emphasizing the need for aid strongly increase aid support , baker . during a global pandemic like covid- , when donor countries are also in need, the effectiveness of a need-based story in shoring up support appears to be fairly limited. by contrast, we find the biggest magnitude of a binary treatment indicator for the "targeted development" narrative. compared to the control condition, support for aid is higher when aid is given to shore up health capacities in african countries to weaken a potential second wave of the covid- in the united states. the mean estimate is ten times bigger than the one for the "need" story, and the % confidence interval does not include zero. we also show simulated substantive effects, following the same approach as before. figure shows in the right-hand panel that the results for the "need" treatment show people's inclinations to support or oppose foreign aid barely change. all changes in probability compared to the control condition hover around zero. in the left-hand panel, the results show not only that the effect size is large but also that the change happens at the highest level of support. the probability of people "strongly" favoring aid increases by . when they are shown a story emphasizing their own benefit of addressing the problem in africa. our study generates several results that challenge existing knowledge and suggest directions for future research. first, our experimental results show that concerns about national finances and the economy during a pandemic cause a substantial reduction in support for aid. however, we also find that personal economic worries do not appear to cause a sizable reduction in aid support. this latter result is in some tension with the existing survey evidence that personal financial downturns are associated with lower support for aid (heinrich et al. , dolan & nguyen . we have some ideas that could reconcile these results. first, given that personal and sociotropic issues are certainly positively correlated, the results by heinrich et al. ( ) and dolan & nguyen ( ) may be capturing the effect of sociotropic, not household, economic concerns on aid support. second, perhaps financial worries from covid- were so severe and widespread during the time of the survey that they were somewhat on people's minds even when asked to write about the weather in the control condition. this would explain the null results from our experiment. finally, personal economic hardship may influence aid attitudes through channels other than through worry. our results rule out the worry-mechanism and raises the question of which other emotions job loss might evoke here. of course, these ideas should be examined in future research. second, we also find that merely stressing the need of people in africa is not enough to shift opinion in favor of aid on average. this is somewhat surprising in light of the existing work that reports that invoking moral considerations such as needs in poor countries increase support for foreign aid ) and charity donations (bekkers & wiepking ) . while this is outside of the scope of our paper, we speculate that in times of crises affecting both recipient and donor countries, the public may place a greater emphasis on their own country's welfare and less weight on moral considerations for distant others. this implies a more complex mechanism linking crises like pandemics to public support for aid, suggesting possible interactions between different elements in our analytical model of public support. we hope future research explores this area further. finally, we find experimental evidence that when people are made aware that helping poor countries deal with a pandemic is beneficial for their own health situation, support for aid increases substantially. this provides the first direct, individual-level evidence for the targeted development argument proposed by bermeo ( ) broadly and for the self-interested addressing of disease burdens elsewhere that might also matter at home (steele ) . while their respective arguments treat donor states as unitary actors and are largely silent on the domestic political base for the strategy of targeted development, it stands to reason that the strategy is only sustainable if citizens give support, or at least do not strongly oppose it. the observed increasing use of this strategy implies that the rationale for the strategy resonates with the public at large. our evidence indeed provides strong support for this implication in the context of a global pandemic. we hope future research examines the micro-foundation of targeted development in areas beyond pandemics. our basic experimental design can be easily adapted to examine how well the idea of targeted development fares with the donor public in other areas such as immigration and refugee issues. while our results have provided new insights, they are based on the u.s. sample. while citizens of other donor countries may differ significantly in preferences, existing multi-country studies do not suggest different individual-level patterns across countries. multi-country non-experimental surveys (prather , heinrich, kobayashi & lawson jr and survey experiments (scotto et al. , prather ) about foreign aid attitudes do not suggest noticeable heterogeneity in aid preferences (former) or responses to experimental treatments (latter). while the scant number of multi-country studies of aid attitudes suggests that transportability may not be an issue, we think future research should replicate our findings outside the united states. the covid- pandemic has generated great concern about its likely devastating effects in developing countries as well as aid donors' willingness to sustain their aid commitments. in this paper, we focus on domestic politics within donor countries-in particular, the donor public-as a source of change in aid policy (eisensee & strömberg , heinrich et al. , van belle . we develop and study several causal channels through which the covid- pandemic may shift attitudes of the public toward aid. the results from two experiments demonstrate that voters' worry about the financial impact of covid- on their own country reduces their support for aid and that their awareness of the benefits of assisting developing countries in curbing the second wave of outbreak at home substantially increase support. we also report that their own personal financial concerns and the awareness of the dire situations in developing countries cause little change in their aid attitudes. these findings have implications for what to expect from donors during global pandemics as well as how advocates may prevent aid from being cut. while we have yet to see what donors will do with foreign aid spending, broader implications of our findings are that it will likely depend on which course the spread of covid- takes and how governments across the world respond to it. to the extent that public opinion matters for governments' decisions, donors' future commitments to foreign aid would depend on the effects of covid- on the donor countries and less on what will actually unfold in developing countries. foreign aid becomes less popular and is likely to become a target of spending cuts when the concern about the covid- 's negative impact on the national economy and finances heightens. while the hope may be that dire situations in developing countries would boost public support and prevent donor governments from cutting aid, the public is less sensitive to adverse effects on people in developing countries. however, our results also imply that the extent to which covid- would eventually affect donors' willingness to engage in international efforts are likely to hinge on how well donor citizens are able to see the increasing global connectivity and vulnerability to infectious diseases like covid- . cases in point are the germany' and uk's increase in aid funding while the countries were undergoing a lockdown. our results suggest it was prudent that they justified the increases by emphasizing interconnectedness between covid- (and other health issues) in developing countries on the one side and in germany, the uk, and europe on the other side, something that the responsible minister and secretary emphasized. that said, exactly how a change in public opinion would manifest itself in aid policy is likely to be more nuanced. first, we would expect politicians to respond to changes in public opinion when they anticipate public attention and thus accountability for their policy decisions. in the domain of foreign aid, existing evidence corroborates this by showing the link between public opinion and aid policy when the media attention is high (nielsen , eisensee & strömberg , van belle , heinrich et al. . in economic downturns, citizens pay far more attention to government spending and place higher priority on domestic current government spending (abbott & jones ) . if opposition to aid increases due to increased concerns about the country's finance, then the reelection-seeking government is likely to cut aid. but, public attention also depends in part on the mass media and elite messaging. as health situations in developing countries worsen, media and elite attention to these countries and foreign aid increases in donor countries precisely because of their health implications for donor countries and citizens. if media and elite messages focus on the connections between rich and poor countries, we would expect increased public support for aid, which we expect the donor government to reflect on aid policy. second, it is also possible that public opinion may change the way donor governments give aid. for example, when opposition to aid increases, donor governments might not reduce their total aid but channel more of it through multilateral organizations to pursue their foreign policy goals, a general pattern found by (milner ) . we might also expect that opinion changes may shift where it goes. in particular, if support for aid increase due to people's appreciation of what aid does for their country, the government may allocate more of its aid to health-related projects and countries that are more connected to the country (e.g. those that are geographically close, trade more) (bermeo ) . our study also presents implications for aid effectiveness. our results imply that global pandemics have the potential to shift donors' emphasis toward targeted development and health-related projects, something that could be considered bad news for aid effectiveness. evidence indicates that when aid is undergirded by donors' (selfish) interests, which is close to the case under consideration, it is not only less effective but might produce undesirable effects in recipient countries. however, a desire to curb the second wave of outbreaks is not the same as the type of interests and motives that scholars traditionally consider (bermeo ) . after all, it would be in donors' interest to use aid to assist developing countries to deal with the pandemic. thus, there is a possibility that aid could be effective in addressing underdevelopment and potentially health crises precise because donors want aid to succeed due to selfish reasons. of course, this clearly requires further research. notes bbc, "coronavirus: africa could be next epicentre, who warns," url: https://bbc.in/ z yl, april , . for example, the executive vice-president of the center for global development, amanda glassman, writes, "[e]conomies worldwide will be substantially weakened, so the evolution of low-income to middleincome country status will slow down or reverse, and-even while more is needed-broader development assistance will be at risk." similarly, madhukar pai, the director of global south and the mcgill international tuberculosis centre, writes, "the pandemic could deplete the economies of lmics, and make them more dependent on international aid. hics, having suffered huge economic losses, could use covid- as an excuse to cut development assistance for health, and recast global health as a narrow mandate focused on 'national security'" for these quotes, see: michael igoe and vince chadwick, "after the pandemic: how will covid- transform global health and development?," devex, url: https://bit.ly/ z wg, april , ; madhukar pai, "can we reimagine global health in the post-pandemic world?", forbes, url: https://bit.ly/ zdxsmt, april , . for example, frot ( ) shows that donors that experienced financial crises reduced aid budgets by % compared to those that did not and that this effect of crises is long-lasting. dang et al. ( ) see also folch, hernandez, barragan & franco-paredes ( ) . this is from an instrumental variable analysis, as we explain later. all estimates in the text rely on reweighting the sample to the u.s. population by age, gender, and ideology, as we also discuss in detail later. translated from german by the authors. the original text is: "es liegt in unserem eigenen interesse, dass wir das virus weltweit bekämpfen. sonst wird es in wellen zu uns nach deutschland und europa zurückkehren." see bundesministerium für wirtschaftliche zusammenarbeit und entwicklung, "entwicklungsministerium legt 'corona-sofortprogramm' vor", april , . url: http://www.bmz.de/ the question is preceded by a short introduction and clarification about the term, foreign aid. this was important, as the survey was executed when the u.s. federal government was providing "aid" to citizens during the covid- lockdown in april . the statement reads: "we would like for you to consider u.s. foreign aid spending. these are funds that the u.s government gives in order to address poverty in poor countries, like those in sub-saharan africa." the experiment was inserted into a larger survey with unrelated content. as is often the case with samples recruited via online crowd-sourcing websites, our sample skews younger (sample mean is . versus . in cces), more male ( . % versus . %), less conservative than the u.s. population ( . % versus . %), more university educated ( . % versus . %), slightly less white ( . % versus . %), slightly less likely to have a very low last year's income ($ , or less) ( . % versus . %), and slightly more likely to have an income of $ , or more ( . % versus . %). therefore, we adjust all effect estimates via post-stratification (park et al. ) by relying on data from the cooperative congressional election survey (vavreck & rivers ) . for example, respondents wrote "generally, my family has a solid base financially so luckily for me there isn't too big of a worry if something were to go wrong", "i am not worried about my household's financial situation", or "i am a happy man". for example, some write "due to the crazy things that are going on right now, i haven't been really paying much attention to it, i would say it feels the same as last year.", "i really don't know how the weather has been due to this covid situation", or "[...] it's hard to have many thoughts about the weather when i'm worried about paying for groceries and such, especially since i'm not going outside too often because of my immuno-compromised roommates." specifically, these are age (years); a dummy variable for whether the respondent is female; dummies for whether she or he is liberal/very liberal, conservative/very conservative, or "not sure" (moderate is the omitted category); a dummy for whether she or he is white; a dummy for completed university education; and dummies for household income levels from last year (less $ , ; $ , - , ; $ , - , ; $ , - , ) with the omitted category being income of $ , or greater. the full texts of the survey questions and answer options are given in the appendix. the data has a very minor missing data issue from respondents' non-responses. we use multiple imputation to fill these gaps and average across the imputations in all analyses (honaker & king ) . we use a robust model to reduce issues of functional form mis-specifications and outliers. our robust model is akin to the familiar ordinal probit or ordinal logit, however it uses the cumulative density function (cdf) of the cauchy distribution as the link function instead of the standard normal cdf or the logistic function. see koenker & yoon ( ) and reuning, kenwick & fariss ( ) for recent discussions and uses of robust models. specifically, let the probability that respondent i chooses level k be pr(y i = k) = f c (ζ k − x i β) − f c (ζ k− − x i β) with f c (·) being the cdf of the cauchy distribution,ζ k a cut point for the ordinal model, x i β the linear predictor for response i. see gelman & hill ( ) . they were deemed "reliable" because of their performance on coding tasks for an unrelated previous research project. see sumner, farris & holman ( ) . to assist coding, we provided guidance and examples for each of these levels via a codebook, which is available from the authors. this approach uses two estimated quantities (worry score, prediction from first stage) which contain measurement errors. as per usual, we account for this feature via a non-parametric bootstrap. we randomly pick one of the imputed data sets and take a random draw (with replacement) from the data, inserting a random posterior draw of the respective worry estimate, and then estimate the first and second stage. we repeat this process , time. as a robustness check, we also estimated a joint bayesian model of the endogenous regressor (either worry score), the instrument (treatment assignments), and the outcome (aid attitude) as the aforementioned plug-in estimator is not guaranteed to produce uncorrelated residuals when the outcome is non-linear (like our ordered outcome). the results look qualitatively the same as below-significant effect for country worries, insignificant for household worries-and are available from the authors upon request. the survey was run in late april . during that time, public and media attention in the united states about the impact of covid- in developing countries was low. searches on google for "covid in africa", "coronavirus in africa" and "pandemic in africa" trended downward from a -day peak in early march ; see google trends. the basic idea and some texts for the story came from actual stories. for example, ian goldin, "coronavirus is the biggest disaster for developing nations in our lifetime," the guardian, url: https://bit. ly/ xizva , april , ; abiy ahmad, "if covid- is not beaten in africa it will return to haunt us all." financial times. url: https://bit.ly/ z jnwu, march , . prior to the news stories, we state that the articles are fictitious but closely reflect real-life facts. the interest in such a second wave, measured by google searches, had its -month peak a week prior to our survey taking place. however, to reinforce the treatments, we asked respondents to summarize what the articles stated. these results are in line with the findings in the literatures on economic voting, terrorism, and immigration that sociotropic concerns tend to be a more important source of opinions about national policies than personal/pocketbook considerations , kinder & kiewiet . url: https:// bbc.in/ dttdue, april , ; department for international development pm urges countries to pull together in coronavirus battle boris johnson: covid vaccine hunt is 'most urgent endeavor of our lives mansfield & mutz they also examine effects on people's willingness to give funds to international organizations. they find that exposure to covid- , either by contracting covid- themselves or knowing a loved one who has, and losing their jobs are positively associated with higher support for u.s. financial contributions to international institutions like who the context of foreign aid former oxfam international interim executive director, made a needbased argument for increased aid to developing countries by stating, "[i]n many poor countries, which face high levels of poverty and inequality, the challenges are even greater. the central african republic for example has only three ventilators, which are vital to treat covid- patients... [d]onors should now prioritize emergency support to the under-funded and ill-equipped public health systems in poor countries protecting the developing world is not a matter of charity or generosity but a question of enlightened self-interest. the global north cannot defeat covid- unless the global south defeats it at the same time spiegel we thank the anonymous reviewer for bringing up this point minoiu & reddy the cyclicality of government foreign-aid expenditure: voter awareness in "good" times and in "bad did that scare you? tips on creating emotion in experimental subjects who cares about human rights? public opinion about human rights foreign policy race, paternalism, and foreign aid: evidence from us public opinion feeling their pain: affective empathy and public preferences for foreign development aid foreign aid effectiveness and the strategic goals of donor governments a literature review of empirical studies of philanthropy: eight mechanisms that drive charitable giving, nonprofit and voluntary sector quarterly aid allocation and targeted development in an increasingly connected world religion and foreign aid a political economy of aid the pernicious consequences of un security council membership from mass preferences to policy business cycle fluctuations, large macroeconomic shocks, and development aid international aid and financial crises in donor countries mutual gain or resource drain? attitudes toward international financial assistance during the early covid- pandemic geopolitics, aid, and growth: the impact of un security council membership on the effectiveness of aid news droughts, news floods, and us disaster relief infectious diseases, non-zero-sum thinking, and the developing world aid and the financial crisis: shall we expect development aid to fall? working paper determinants of donor generosity: a survey of the aid budget literature data analysis using regression and multilevel/hierarchical models the effects of canvassing, telephone calls, and direct mail on voter turnout: a field experiment political ignorance and collective policy preferences effective foreign aid following civil war: the nonstrategicdesperation hypothesis how aid supply responds to economic crises: a panel var approach elusive consensus: polarization in elite communication on the covid- pandemic public attitudes toward immigration when is foreign aid selfish, when is it selfless? how do people evaluate foreign aid to nastyregimes? public opinion and foreign aid cuts in economic crises populism and foreign aid voters get what they want (when they pay attention): human rights, policy benefits, and foreign aid foreign policy as pork-barrel spending: incentives for legislator credit claiming on foreign aid what to do about missing values in time-series crosssection data the consequences of terrorism: disentangling the effects of personal and national threat making and unmaking cosmopolitans: an experimental test of the mediating role of emotions in international development appeals down the rathole? public support for us foreign aid the impact of aid on growth revisited: do donor motives matter? sociotropic politics: the american case parametric links for binary choice models: a fisherianbayesian colloquy donor competition and public support for foreign aid sanctions does international health aid follow recipients needs? extensive and intensive margins of health aid allocation effects of fear and anger on perceived risks of terrorism: a national field experiment economic determinants of electoral outcomes support for free trade: self-interest, sociotropic politics, and out-group anxiety will the global financial crisis lead to lower foreign aid? a first look at united states oda why multilateralism? foreign aid and domestic principal-agent problems the political economy of us foreign aid: american legislators and the domestic politics of aid development aid and economic growth: a positive long-run relation rewarding human rights? selective aid sanctions against repressive states prolific. a subject pool for online experiments bayesian multilevel estimation with poststratification: state-level estimates from national polls beyond the turk: alternative platforms for crowdsourcing behavioral research values at the water's edge: social welfare values and foreign aid transnational ties and support for foreign aid bayesian factor analysis for mixed ordinal and continuous responses exploring the dynamics of latent variable models history says financial crisis will suppress aid, global development: views from the center we spend how much? misperceptions, innumeracy, and support for the foreign aid in the united states and great britain emotion priming and attributions for terrorism: americans' reactions in a national field experiment degrees of democracy: politics, public opinion, and policy public goods and donor priorities: the political economy of development aid for infectious disease control do health conditions determine the flow of external health resources? evidence from panel data the meaning and use of subjective perceptions in studies of economic voting crowdsourcing reliable local data profits before patients? analyzing donors economic motives for foreign aid in the health sector the microfoundations of territorial disputes: evidence from a survey experiment in japan selective exposure in the internet age: the interaction between anxiety and information utility media, bureaucracies, and foreign aid: a comparative analysis of the united states, the united kingdom where the financial and economic crisis does bite: impact on the least developed countries the cooperative congressional election study public ignorance or elitist jargon? reconsidering americans' overestimates of government waste and foreign aid can information change public support for aid? key: cord- - x idzn authors: ibrahim, mohamed izham mohamed; wertheimer, albert i. title: introduction: discovering issues and challenges in low- and middle-income countries date: - - journal: social and administrative aspects of pharmacy in low- and middle-income countries doi: . /b - - - - . - sha: doc_id: cord_uid: x idzn there are gaps and challenges in pharmacy practice in developing countries and possible solutions for various pharmacy stakeholders. health and public health are essentials for development. the weak global economy has hindered progress toward the sustainable development goals. many people are still living in poverty with poor health status and inadequate healthcare. poor health and pharmaceutical sectors in a country will increase the vulnerability of the country and leaves the society at risk. effective public health interventions can save hundreds of millions of lives. pharmacy system is one of the core components in a healthcare system, and pharmacists play a very important role. this book sheds light on various topics that individually and in combination determine the status of pharmacy practice in individual countries. this book incorporates multiple data sources and when outliers are discovered, that may be called to the attention of the reader. this book also provides knowledge and understanding about social and administrative aspects of pharmacy in healthcare in low- and middle-income countries. reminded us that the major obstacle to the establishment of pharmacy administration is due to the negative attitudes and imbalanced focus and emphasis between professionalism versus business orientation that are inherent in pharmacy practice. the book that was edited by fathelrahman, mohamed ibrahim, and wertheimer ( ) , explored the pharmacy practice in developing countries in asia, africa and latin america and provided an excellent overview of pharmacy practice. the book also provides us with gaps, challenges and possible solutions for various pharmacy stakeholders in the developing countries. there is a great deal of work that needs to be done by the pharmacy stakeholders in order to improve the pharmaceutical health services for fulfilling the needs of the society. it is understood that under the sustainable development goals (sdgs), every country is in need for development (united nations, ). yet unfortunately, the weak global economy has hindered progress toward the sdgs, especially for countries with lower economic level. development is everyone's problem and everyone's dream. there is no clear definition of the terms "developed and developing countries" or no consensus on how to categorize these countries. developing countries include, in decreasing order of economic growth or size of the capital market: newly industrialized countries, emerging markets, frontier markets, and least developed countries. list of developing countries according to the united nations ( ) can be classified into three categories: developed economies, economies in transition, and developing economies. geographical regions for developing economies are as follows: africa, east asia, south asia, western asia, and latin america and the caribbean. according to the o' sullivan and sheffrin ( , p. ) , a developing country is a country with a relatively low standard of living, undeveloped industrial base, and moderate to low human development index. this index is a comparative measure of poverty, literacy, education, life expectancy, and other factors for countries worldwide. for the sake of the discussion, the book will consider the classification of countries based on per capita gross national income (i.e., low-and middle-income countries (lmics)). the political, economic, and pharmaceutical sector conditions differ between the countries; some have to do much more and work harder to improve their situations than others. there are significant social and economic differences between developed countries and lmics. many of the underlying causes of these differences are rooted in the long history of the development of such nations and include social, cultural, and economic variables; historical, political, and geographical factors; as well as international relations. furthermore, it is not the intention of the book to indicate the level of the inferiority of an lmic or an undeveloped country compared with a developed country or between east and west, but rather to trigger and stimulate the mind of the people in the lmics about the challenges and problems the societies are facing for decades. no country in this world is free from problems and challenges, but people in the developing world suffer relatively more. the focus of this book is to highlight, discuss, and document policy issues in lmics and about having best practices in the pharmaceutical sector. so far, to what extent is the contribution of pharmacists to this matter? health and public health are essentials for development. around % of the world's population are residing in lmics and they are still living in poverty with poor health status and inadequate healthcare. in any healthcare system, pharmacy system is one of the core components and pharmacists play a very important role. with the dynamic changes happening in healthcare, disease, information communication technology and regulations, and the roles and responsibilities of pharmacists are becoming more important than before. the expectations on the pharmacists are changing; the societal needs and demands are much greater compared with several decades ago. on the other hand, there are growing problems with medicines, the health system, and human resources, especially in the lmics. there are countries with high prices of medicines, a wide prevalence of nonquality medicines (i.e., substandard and counterfeit), lack of access to medicines, and absence of a national medicines policy (nmp) even with strong encouragement from world health organization (who). poor health and pharmaceutical sectors in a country will increase the vulnerability of the country toward several critical problems at micro-and macrolevels and leaves the society at risk. in the medicines supply system, to ensure access to medicines, the following aspects are critical: • reliable health and supply systems; • sustainable financing; • rational selection; and • affordable prices of medicines. the importance of a healthcare system must be looked from three angles: the institutions, organizations, and resources; resources include workforce, financial, and infrastructure. to achieve universal health coverage, the system must function well. the three elements, i.e., institutions, organizations, and resources must be brought together to deliver quality health services to meet the demands of the society. unfortunately, according to mills ( ) , the goals of universal health coverage in lmics could not be achieved, child and maternal deaths are still high, financial protection is lacking, and people do not seek care because of lack of financial support. even though the rational use and quality use of medicines are worldwide issues, but they are particularly pertinent to lmics. access to medicines is still crucial, as children suffering from tuberculosis worldwide die daily, largely because of low access to appropriate treatment (who, a (who, , b . ranganathan and gazarian ( ) reported that there are several key challenges for delivering rational use of medicines (rum) to children in the developing countries. among the problems are as follows: • lack of coordinated nmp to support rum; • availability, affordability, and accessibility to medicines' issues; • inappropriate standards of quality, safe, and efficacy of medicines; • lack of independent, unbiased, and evidence-based information; • lack of information, knowledge, and skills among healthcare practitioners who are dealing with medication use process among children; • lack of proper devices and tools (e.g., calculator and weighing machine) used when deciding on the appropriate dosage for the children; and • retailers selling prescription medicines extensively over the counter. dowse ( ) reported that the likelihood of poor health literacy in developing countries is prevalent. health literacy is fundamental to the effectiveness of health programs and improvement to the quality of life. the united nations educational, scientific and cultural organization institute for statistics found that around % of countries ( / ) indicate an adult literacy rate below %. all these countries are from sub-saharan africa, and the lowest adult literacy rate is in mali with a . % (united nations, ). another issue is corruption. corruption (e.g., misinformation, bribery, theft, and bureaucratic corruption) is a global problem and negatively affects the medicines supply chain and the overall healthcare system. the backbone of the health system is formed by well-functioning supply chains that deliver various pharmaceutical products (yadav, ) . the corruption perception index illustrated that none of the lmics listed top of the transparent (i.e., clean) ranking. on the scale of (highly corrupt) to (very clean), over two-thirds of the countries and territories in this index fall below the midpoint (transparency international, ). people also faced with issues related to substandard medicines, counterfeit drugs, nutrition, tobacco consumption, maternal and child health, and environmental hazards (who, ) . who ( ) reported that the environmental hazards such air pollution caused around million premature deaths a year. most areas affected were densely populated lmics. the conditions in the developing countries become worse when people suffer from various turmoil conditions such as war, humanitarian conflict, and public health crisis, which further collapse completely the healthcare system. these aspects make working in the healthcare system and the practice of pharmacists more challenging. in short, the lmics are facing social, economic, environmental, human capital, political, and infrastructure issues that directly or indirectly affecting the health and pharmaceutical health services. much needs to be done in lmics. the following are important elements for functioning global supply systems and availability of safe and effective medical products at prices equitable to all: effective and innovative health and medicines policies, coordinated approaches, international cooperation, and effective oversight. especially for the pharmacy regulators, policy makers, and practitioners, they must appreciate the complexity of the healthcare system and human life. what is considered fine or rational in one country and society might not be fine or considered irrational among other societies with different cultures, beliefs, and backgrounds. regulators, policy makers, and practitioners in countries of the developing world should evaluate thoroughly health-and pharmaceutical-related issues in their country and find solutions that are appropriate and relevant according to the environment. there are several significant initiatives to ensure health for all and rum in lmics that were advocated by organizations such as health action international asia pacific (haiap), people health movement (phm), third world network (twn), international network for rational use of drugs (inrud) and who, just to name a few. chowdhury ( ) noted that "since the nairobi conference on the rational use of drugs, for every two steps we have advanced we have gone one step backward. a progressive agenda for people-centred, rational and affordable healthcare continues to be undermined by powerful vested interests." we are getting closer and closer, but are not there yet. the phm's member developed the people's charter for health in . it was established after realizing that vision and goals of alma-ata declaration that was established in failed to ensure "health for all by the year ." phm felt that the health status of the lmics has not improved as aimed, but instead worsened further. health crisis happened everywhere, especially in the lmics. there are significant inequalities between and within countries. new threats to health are continually developing (phm, n.d.) . according to international monetary fund (imf) ( ), "the world is a healthier place today but major issues continue to confront humanity." the world has improved greatly with eliminating and controlling few of the communicable diseases such as smallpox and polio. quality and better medicines have been produced to improve the health conditions. people have better sanitation and accessible to clean water. even with the innovations and cost-effective interventions in healthcare, individuals continue to experience and suffer from health threats such as malaria, dengue, typhoid, chikungunya, severe acute respiratory syndrome, middle east respiratory syndrome-related coronavirus, ebola virus crisis. in addition, the prevalence of mental disorders and noncommunicable diseases continues to increase. chronic diseases such as cancer, cardiovascular diseases, and diabetes cause serious ill health and millions of premature death. it is reported that % of them are in lmics. all these threats and disorders negatively affect the public health system and infrastructure, cause disability, and ruin businesses, workforce, and productivity of the affected country (imf, ; who, ) . thanks to pharmaceutical industries, which have produced antibiotics to fight against infectious diseases. the practice of medicine has been transformed. but, unfortunately due to the irresponsible and irrational used of antibiotics by healthcare providers and public, it has resulted in an increase in resistance and caused a worldwide decline in antibiotic effectiveness. the primary healthcare sectors failed to play their roles in containing these threats. the primary healthcare providers failed to perform their responsibilities. pharmacists have a responsibility regarding antibiotic stewardship to help contain or reduce amount of unnecessary antibiotic use especially against viruses and in trivial diseases. we need cost-effective, affordable, and practical interventions. the use of health technology assessment tools becomes helpful at this point. where are the pharmacists when the nations are crippled by these threats? do the pharmaceutical policies fail to curb these problems? the lack of adequate, resilient public health surveillance systems, infrastructure to effectively deploy resources, and a health workforce to provide accessible, quality care where needed leaves us vulnerable to regional and global spread. despite the progress that has been made in the last two decades, more needs to be done to create enabling regulatory environments. understanding the social and cultural contexts that may contribute to these problems, plus effective solutions, is also crucial. health communication often receives less attention and fewer resources than medical, scientific, or policy areas. there is an urgent need for society to value and invest more in evidence-informed public health strategies. the multifactorial nature of broader global health issues poses an enormous challenge to all stakeholders (who, b). effective public health action depends on understanding the scale and nature of threats to health (who, ) . according to the ottawa patient charter, the public health community has a duty to make the invisible visible. they must measure and assess the burden of diseases, health status, and risk factors including the protection factors. the public health community must make the best use of data to promote health. public health interventions should be evaluated, using rigorous research methods, and the results disseminated. the public health community must ensure that evidence is used to give voice to those who would otherwise be unheard. research findings must be disseminated effectively to the different stakeholders in the health sectors, including public, policy makers, practitioners, and (social) media. findings at times are complex and this information should be delivered in ways that are comprehensible and in a timely manner (lomazzi, ) . effective public health interventions can save hundreds of millions of lives in lmics, as well as create broad social and economic benefits. according to frieden and henning ( ) , it is often assumed that public health interventions applied in developed countries are not appropriate in developing countries. main public health functions are similar regardless of a country's income level. many basic public health measures achieved decades ago in developed countries are urgently needed, highly appropriate, extremely cost-effective, and eminently attainable in lmics today. further according to frieden and henning ( ) , a progress of public health in developing countries is possible but will require sufficient funding and human resources; improved physical infrastructure and information systems; effective program implementation and regulatory capacity; and, most importantly, political will at the highest levels of government. most change is due to money. for instance, robotics, automation, and technicians are widely used to save money. in the hospital setting, unit dose, unit-of-use, etc. are done to save cost. similarly, medication therapy management is done to save money and that is why most other changes are accepted, provided if they are cost-effective. pharmacists are dedicated and in a strategic position to preserve and advance public health. their efforts enhance the quality of individual's lives by helping people to live as free as possible from disease, pain, and suffering (jandovitz & brygider, ) . with respect to their relationship with the public, pharmacists are often portrayed as an underused resource for health-and medicines-related advice and information. furthermore, the practice of pharmacy involves both pharmacist and public and can be conceptualized as a social process (harding & taylor, , p. ) . don't we need something about the efforts to locate new pharmacy roles, e.g., in relation to immunizations, patient advisor, educator and advocator for wellness, screening and prevention activities, birth control promotions, and other population health initiatives? pharmacists have an obligation to educate the public in lmics, for example, teaching poor rural women about birth control and safe sex especially if their partner has hiv, etc. the other one is to encourage immunizations. in certain places, some cult leader and religious groups discourage their followers not to be immunized and then we end up with local epidemics of preventable conditions such as polio. hence, understanding the concepts and principles behind social pharmacy disciplines is important and useful. there is a need to apply a socioecological model to public health issues that are impacting the health of the population. what is social pharmacy? social pharmacy is a discipline driven by social needs (fukushima, ) and more focus on the society at large. it is interdisciplinary subject, which helps to understand the interaction between drugs and society. experts have defined social pharmacy as a discipline concerned with the behavioral sciences relevant to the utilization of medicine by both consumers and healthcare professionals (wertheimer, ) . sørensen, mount, and christensen ( ) defined social pharmacy as studying "…the drug/medicine sector… from the social scientific and humanistic perspectives. topics relevant to social pharmacy consist of all the social factors that influence medicine use, such as medicine-and health-related beliefs, attitudes, rules, relationships, and processes." almarsdottir and granas ( ) also agree that social pharmacy is a discipline where there is use of the social sciences in pharmacy to add its usefulness to the society. it is also known as "pharmacy administration" or "social and administrative pharmacy." it has two components: the social sciences and the administrative sciences. the social sciences component includes demography, anthropology, psychology, social psychology, sociology, political sciences, and geography (mount, ) , while the administrative sciences component includes areas such as management, marketing, finance, economics, organizational behavior, law, policy, ethics, information technology, and statistics. social and administrative pharmacy is the integration and application of the social and administrative sciences disciplines in pharmacy, i.e., education and practice. social pharmacy scientists utilize both sciences to improve clinical practice, enhance the effectiveness of pharmaceutical regulations and policy, advocate political awareness, and promote improvements in pharmaceutical health services and healthcare delivery. social pharmacy applied a biopsychosocial or socioenvironmental method to understand health and illness conditions (claire, ) . many types of research use either the quantitative or qualitative or a mixed method approach, from simple to complex statistical methods and modeling in pharmacy practice to make changes and improvement in the healthcare system, quality of care, and patient's quality of life. in addition, there are many useful tools from the social and behavioral sciences literature that researchers could use, for example, in helping with patient-pharmacist communication and compliance enhancement efforts. according to wertheimer ( ) , "there are very few similarities in the education and practice of pharmacy around the world." many individuals have an ethnocentric, regiocentric, or geocentric approach in which they believe. for example, pharmacy colleges in a country might be reluctant to accept improvement in the curriculum. the pharmacy educators think that they are superior, and the curriculum developed and used, for example, in the last decades was excellent. in some cases, there is an imbalance of focus between the pharmaceutical sciences courses and the pharmacy practice and administration courses. they consider teaching more of the basic pharmaceutical sciences subjects to the undergraduate students or just offering pharmaceutical sciences-related research (i.e., lab-based research) at the msc and phd level is adequate to provide the pharmacy graduates knowledge and skill to practice. the regiocentric or geocentric phenomenon in pharmacy practice is quite common and could be observed in the middle east region, for example. further, political struggle and lack of leadership could hurt the dynamic and mission of the pharmacy profession. according to morgall and almarsdóttir ( ) , the pharmacy profession could lose its monopoly and become weak due to the internal conflicts. pharmacists need to advocate locally to upgrade the quality of pharmacy education away from massive amounts of chemistry to applied patient care science and practice and to upgrade the level of standards in each country to work with legislators to ban pharmacies not operated by qualified, licensed personnel. when wertheimer and smith ( ) published the first edition of their book in , social pharmacy or social and administrative pharmacy was a very new discipline and possibly not known in the lmics. the book includes topics such as the contribution of the social sciences; pharmacy, pharmacist, and the professions; the contribution of psychosocial aspects; the contribution of sociology; and behavioral aspects of drugs and medication use, ethics, pharmacist and public health and the future of pharmacists. in the united kingdom, according to harding and taylor ( ) , social pharmacy was introduced in the pharmacy curriculum of uk colleges sometime in the early . the mills commission report in recognized the importance to develop the behavioral and social sciences aspects in pharmacy (study commission on pharmacy, ) . but, actually, the social pharmacy components were first experienced in the united states in the s (wertheimer, ) . then later, the uk and european colleges of pharmacy introduced social pharmacy into their curriculum (claire, ) . it is doubtful if pharmacy colleges in the lmics have successfully introduced this discipline in their pharmacy curriculum. most of the times, the internal politics and a lack of understanding limit or even counteract the collaboration of clinical and social pharmacy, thus weakening both fields (almarsdottir & granas, ) . however, there are cases, to name a few, which had reported positive experience such as in malaysia. school of pharmaceutical sciences, universiti sains malaysia that was established in , first introduced a course "drugs in developing countries" (mohamed izham, awang, & abdul razak, ) in the early s. after a long struggle, the discipline was established in (school of pharmaceutical sciences, n.d.) . several important courses (e.g., drug and society, social and public health pharmacy, pharmaceutical management and marketing, and pharmacoeconomics) managed to be included in the pharmacy curriculum. these additions offer a perspective on the pharmacy that balances and complements the behavioral and natural/physical sciences component of the pharmacy curriculum (hassali et al., ) to produce well-rounded graduates. in addition, the department has also produced hundreds pieces of social and administrative pharmacy-related research generated from more than msc and phd students from around lmics. kostriba, alwarafi, and vlcek ( ) identified large differences in approach and scope of teaching social pharmacy courses as a field of study in the undergraduate pharmacy education worldwide. they also identified regional trends connected with the political, economic, and social aspects of particular regions. basak ( ) expressed concern with the recent changes in the indian pharmacy education. according to the author, in the introduction of the pharmd program (pharmacy council of india, n.d.), social pharmacy is the least developed discipline in the curriculum. it called for cooperation in an attempt to develop social pharmacy components in teaching and research in india. there is a drive to incorporate the social pharmacy topics in the yemeni pharmacy education even with all the challenges and limitations that the country is experiencing nowadays (alshakka, aldubhani, basaleem, hassali, & mohamed ibrahim, ) . in libya, according to abrika, hassali, and abduelkarem ( ) , the pharmacy practitioners were supportive with the ideas of inclusion of social pharmacy subjects in the curriculum because it will enhance the pharmacists' professional roles. in contrast, in the united states, zorek, lambert, and popovich ( ) noted that even though the basic and clinical sciences provide a critical scientific foundation for direct patient care, pharmacists are likely to flounder in the face of social and behavioral challenges without a practical mastery of the relevant principles of modern social and behavioral science. according to the authors, pharmacy education and practice must require greater mastery of social and behavioral science. in the united kingdom, the incorporation of social and behavioral sciences into the curricula of all schools of pharmacy, reflecting a broad recognition that pharmacy practice does not simply involve supplying medicines and advice to a passive public who take their medicines and follow expert advice without question (harding & taylor, , p. ). we know a great deal about pharmacy in the developed world but we know very little about pharmacy practice, education, and science in the lesser developed countries. that is unfortunate because if we in the developed countries understood what the major problems and impediments were in the lesser developed countries, we could be in a better situation to offer advice and aid. very little has been published in the main stream, international literature about the status of pharmacy in the lesser developed countries. it is possible that some more is published in local journals in local languages that may be of limited help to others outside of that country. there are other problems as well. one is that accurate and timely vital health statistics may not be available for any of many possible reasons, such as budget restrictions, and shame in reporting accurate and precise reports that are not flattering to that country's leaders in the healthcare area. this book sheds light on various topics that individually and in combination determine the status of pharmacy practice in individual countries. the nature of pharmacy characteristics in a country has a great deal to do with traditions and characteristics from colonial times, the wealth of the country, its political and economic systems, the level of capital available for investment, the extent of technical education among the population, the presence of a middle class and the size of an upper class, if there is one, and the extent of a culture of corruption. there is one other reason why we need this book. when resources are constrained, sometimes clever persons devise exceptional strategies and schemes that require minimal resources. we are never so good that we cannot learn from our less fortunate colleagues, nor should we be too proud to borrow ideas and systems from nonindustrialized countries. if one of us wanted to learn about some aspects of pharmacy practice, education, or research in jordan, for example, it would be a time-consuming, complicated task, extracting various parts of our goal from a large array of journals, textbooks, and websites, and often a doomed task since some of the references importance of social pharmacy education in libyan pharmacy schools: perspectives from pharmacy practitioners social pharmacy and clinical pharmacy-joining forces importance of incorporating social pharmacy education in yemeni pharmacy school's curriculum social pharmacy concept in pharmacy education social pharmacy-the current scenario the limitations of current health literacy measures for use in developing countries the history of pharmacy pharmacy practice in developing countries: achievements and challenges public health requirements for rapid progress in global health social pharmacy: its performance and promise social dimensions of pharmacy: the social context of pharmacy teaching social pharmacy: the uk experience. pharmacy education social pharmacy as a field of study: the needs and challenges in global pharmacy education pharmacists: unsung heroes. wliw (television station social pharmacy as a field of study in undergraduate pharmacy education global charter for the public's health-the public health system: role, functions, competencies and education requirements health care systems in low-and middle-income countries introducing social pharmacy courses to pharmacy students in malaysia no struggle, no strength: how pharmacists lost their monopoly contributions of the social sciences economics: principles in action people health movement (phm) rational use of medicines (rum) for children in the developing world: current status, key challenges and potential solutions the concept of social pharmacy corruption perceptions index world economic situation and prospects country classification world economic situation and prospects international comparisons social/behavioural pharmacy: the minnesota experience pharmacy practice: social and behavioral aspects ottawa charter for health promotion from burden to 'best buys': reducing the economic impact of non-communicable diseases in low-and middle-income countries public health, environmental and social determinants of health who essential medicines and health products global disease outbreaks world health organization (who) health product supply chains in developing countries: diagnosis of the root causes of underperformance and an agenda for reform the -year evolution of a social and behavioral pharmacy course will be missing, unavailable, obsolete, or in foreign languages. some citations may only be available through the interlibrary loan organization, requiring several weeks.one may realize immediately that having all or nearly all of the desired data and information in one, easy-to-use source makes data collection and subsequent analysis far easier, and the work may be performed in a fraction of the time required to search here and there. in addition, relying on a single source for primary data can be dangerous. governmental statistics offices often spin data-related reports to underreport communicable diseases so as not to discourage tourism or so as not to put a country behind its neighboring nations in its effectiveness in combating health problems, childhood immunizations, etc.this book incorporates multiple data sources and when outliers are discovered, which may be called to the attention of the reader. this book also provides knowledge and understanding about social and administrative aspects of pharmacy in healthcare in lmics. it also creates awareness among readers, providing ideas and possible solutions to these obstacles. it is hoped that the pharmacists and other stakeholders will be better equipped to tackle any problems and challenges facing them in practice.if i had one hour to save the world, i would spend the first fifty-five minutes defining the problem and the last five minutes solving it. the world bank. world bank country and lending groups. https://datahelpdesk.worldbank.org/knowledgebase/ articles/ -world-bank-country-and-lending-groups.