tag:theconversation.com,2011:/ca/topics/public-health-crisis-19553/articlesPublic health crisis – The Conversation2024-02-23T13:50:45Ztag:theconversation.com,2011:article/2206352024-02-23T13:50:45Z2024-02-23T13:50:45ZEarly COVID-19 research is riddled with poor methods and low-quality results − a problem for science the pandemic worsened but didn’t create<figure><img src="https://images.theconversation.com/files/577159/original/file-20240221-22-ttfzl.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2070%2C1449&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The pandemic spurred an increase in COVID-19 research, much of it with methodological holes.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/coronavirus-damage-royalty-free-image/1266909460">Andriy Onufriyenko/Moment via Getty Images</a></span></figcaption></figure><p>Early in the COVID-19 pandemic, researchers <a href="https://doi.org/10.1038/d41586-020-03564-y">flooded journals</a> with studies about the then-novel coronavirus. Many publications streamlined the peer-review process for COVID-19 papers while keeping acceptance rates relatively high. The assumption was that policymakers and the public would be able to identify valid and useful research among a very large volume of rapidly disseminated information.</p>
<p>However, in my review of 74 COVID-19 papers published in 2020 in the top 15 generalist public health journals listed in Google Scholar, I found that many of these studies used <a href="https://doi.org/10.1162/qss_a_00257">poor quality methods</a>. <a href="https://doi.org/10.1186/s12874-020-01190-w">Several other</a> <a href="https://doi.org/10.1038/s41467-021-21220-5">reviews of</a> <a href="https://doi.org/10.1371/journal.pone.0241826">studies published</a> in medical journals have also shown that much early COVID-19 research used poor research methods.</p>
<p>Some of these papers have been cited many times. For example, the most highly cited public health publication listed on Google Scholar <a href="https://doi.org/10.3390/ijerph17051729">used data</a> from a sample of 1,120 people, primarily well-educated young women, mostly recruited from social media over three days. Findings based on a small, self-selected convenience sample cannot be generalized to a broader population. And since the researchers ran more than 500 analyses of the data, many of the statistically significant results are likely chance occurrences. However, this study has been cited <a href="https://scholar.google.com/citations?hl=en&vq=med_publichealth&view_op=list_hcore&venue=kEa56xlDDN8J.2023">over 11,000 times</a>.</p>
<p>A highly cited paper means a lot of people have mentioned it in their own work. But a high number of citations is not <a href="https://doi.org/10.1089/ees.2016.0223">strongly linked to research quality</a>, since researchers and journals can game and manipulate these metrics. High citation of low-quality research increases the chance that poor evidence is being used to inform policies, further eroding public confidence in science.</p>
<h2>Methodology matters</h2>
<p>I am a <a href="https://scholar.google.com/citations?user=X1o1PaQAAAAJ&hl=en">public health researcher</a> with a long-standing interest in research quality and integrity. This interest lies in a belief that science has helped solve important social and public health problems. Unlike the anti-science movement <a href="https://theconversation.com/misinformation-is-a-common-thread-between-the-covid-19-and-hiv-aids-pandemics-with-deadly-consequences-187968">spreading misinformation</a> about such successful public health measures as vaccines, I believe rational criticism is fundamental to science.</p>
<p>The quality and integrity of research depends to a considerable extent on its methods. Each type of study design needs to have certain features in order for it to provide valid and useful information. </p>
<p>For example, researchers have <a href="https://www.sfu.ca/%7Epalys/Campbell&Stanley-1959-Exptl&QuasiExptlDesignsForResearch.pdf">known for decades</a> that for studies evaluating the effectiveness of an intervention, a <a href="https://www.britannica.com/science/control-group">control group</a> is needed to know whether any observed effects can be attributed to the intervention. </p>
<p><a href="https://doi.org/10.1111/dmcn.15719">Systematic reviews</a> pulling together data from existing studies should describe how the researchers identified which studies to include, assessed their quality, extracted the data and preregistered their protocols. These features are necessary to ensure the review will cover all the available evidence and tell a reader which is worth attending to and which is not.</p>
<p>Certain types of studies, such as one-time surveys of convenience samples that aren’t representative of the target population, collect and analyze data in a way that does not allow researchers to determine whether one variable <a href="https://doi.org/10.1017/S0033291720005127">caused a particular outcome</a>.</p>
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<figcaption><span class="caption">Systematic reviews involve thoroughly identifying and extracting information from existing research.</span></figcaption>
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<p>All <a href="https://www.equator-network.org/">study designs have standards</a> that researchers can consult. But adhering to standards slows research down. Having a control group doubles the amount of data that needs to be collected, and identifying and thoroughly reviewing every study on a topic takes more time than superficially reviewing some. Representative samples are harder to generate than convenience samples, and collecting data at two points in time is more work than collecting them all at the same time.</p>
<p><a href="https://doi.org/10.1038/s41467-021-21220-5">Studies comparing</a> <a href="https://doi.org/10.1186/s12916-021-01920-x">COVID-19 papers</a> <a href="https://doi.org/10.1371/journal.pone.0241826">with non-COVID-19</a> papers published in the same journals found that COVID-19 papers tended to have lower quality methods and were less likely to adhere to reporting standards than non-COVID-19 papers. COVID-19 papers rarely had predetermined hypotheses and plans for how they would report their findings or analyze their data. This meant there were no safeguards against <a href="https://doi.org/10.1136/bmjebm-2020-111584">dredging the data</a> to find “statistically significant” results that could be selectively reported.</p>
<p>Such methodological problems were likely overlooked in the <a href="https://doi.org/10.1038/s41562-020-0911-0">considerably shortened</a> <a href="https://doi.org/10.1162/qss_a_00076">peer-review process</a> for COVID-19 papers. One study estimated the average time from submission to acceptance of 686 papers on COVID-19 to be <a href="https://doi.org/10.1038/s41467-021-21220-5">13 days, compared with 110 days</a> in 539 pre-pandemic papers from the same journals. In my study, I found that two online journals that published a very high volume of methodologically weak COVID-19 papers had a peer-review process of <a href="https://doi.org/10.1162/qss_a_00257">about three weeks</a>.</p>
<h2>Publish-or-perish culture</h2>
<p>These quality control issues were present before the COVID-19 pandemic. The pandemic simply pushed them into overdrive.</p>
<p>Journals tend to favor <a href="https://doi.org/10.1371/journal.pone.0010068">positive, “novel” findings</a>: that is, results that show a statistical association between variables and supposedly identify something previously unknown. Since the pandemic was in many ways novel, it provided an opportunity for some researchers to make bold claims about how COVID-19 would spread, what its effects on mental health would be, how it could be prevented and how it might be treated.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/577161/original/file-20240221-26-tv7gdq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person with head in hands, elbows planted on stacks of paperwork and books littering a desk, glasses and laptop on the side" src="https://images.theconversation.com/files/577161/original/file-20240221-26-tv7gdq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/577161/original/file-20240221-26-tv7gdq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/577161/original/file-20240221-26-tv7gdq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/577161/original/file-20240221-26-tv7gdq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/577161/original/file-20240221-26-tv7gdq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/577161/original/file-20240221-26-tv7gdq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/577161/original/file-20240221-26-tv7gdq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Many researchers feel pressure to publish papers in order to advance their careers.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/surrounded-by-work-royalty-free-image/637293916">South_agency/E+ via Getty Images</a></span>
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<p>Academics have worked in a <a href="https://doi.org/10.1089/ees.2016.0223">publish-or-perish</a> <a href="https://doi.org/10.1177/1745691612459058">incentive system</a> for decades, where the number of papers they publish is part of the metrics used to evaluate employment, promotion and tenure. The <a href="https://theconversation.com/misinformation-is-a-common-thread-between-the-covid-19-and-hiv-aids-pandemics-with-deadly-consequences-187968">flood of mixed-quality COVID-19 information</a> afforded an opportunity to increase their publication counts and boost citation metrics as journals sought and rapidly reviewed COVID-19 papers, which were more likely to be cited than non-COVID papers.</p>
<p>Online publishing has also contributed to the deterioration in research quality. Traditional academic publishing was limited in the quantity of articles it could generate because journals were packaged in a printed, physical document usually produced only once a month. In contrast, some of <a href="https://doi.org/10.1002/leap.1566">today’s online</a> <a href="https://doi.org/10.1001/jama.2023.3212">mega-journals</a> publish thousands of papers a month. Low-quality studies rejected by reputable journals can still find an outlet happy to publish it for a fee.</p>
<h2>Healthy criticism</h2>
<p>Criticizing the quality of published research is fraught with risk. It can be misinterpreted as throwing fuel on the raging fire of anti-science. My response is that a critical and rational approach to the production of knowledge is, in fact, fundamental to the very practice of science and to the functioning of an <a href="https://doi.org/10.1057/palgrave.jors.2602573">open society</a> capable of solving complex problems such as a worldwide pandemic.</p>
<p>Publishing a large volume of misinformation disguised as science during a pandemic <a href="https://doi.org/10.1073/pnas.1912444117">obscures true and useful knowledge</a>. At worst, this can lead to bad public health practice and policy. </p>
<p>Science done properly produces information that allows researchers and policymakers to better understand the world and test ideas about how to improve it. This involves <a href="https://doi.org/10.1371/journal.pmed.1001747">critically examining the quality</a> of a study’s designs, statistical methods, reproducibility and transparency, not the <a href="https://doi.org/10.1016/j.jclinepi.2021.05.018">number of times it has been cited</a> or tweeted about.</p>
<p>Science depends on a <a href="https://doi.org/10.1007/s10654-023-01049-6">slow, thoughtful and meticulous approach</a> to data collection, analysis and presentation, especially if it intends to provide information to enact effective public health policies. Likewise, thoughtful and meticulous peer review is unlikely with papers that appear in print only three weeks after they were first submitted for review. Disciplines that reward quantity of research over quality are also less likely to protect scientific integrity during crises.</p>
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<a href="https://images.theconversation.com/files/577167/original/file-20240221-22-hmviem.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two scientists pipetting liquids under a fume hood, with another scientist in the background examining a sample" src="https://images.theconversation.com/files/577167/original/file-20240221-22-hmviem.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/577167/original/file-20240221-22-hmviem.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=423&fit=crop&dpr=1 600w, https://images.theconversation.com/files/577167/original/file-20240221-22-hmviem.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=423&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/577167/original/file-20240221-22-hmviem.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=423&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/577167/original/file-20240221-22-hmviem.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=532&fit=crop&dpr=1 754w, https://images.theconversation.com/files/577167/original/file-20240221-22-hmviem.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=532&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/577167/original/file-20240221-22-hmviem.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=532&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Rigorous science requires careful deliberation and attention, not haste.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/female-scientist-drops-liquid-into-test-tube-royalty-free-image/127871289">Assembly/Stone via Getty Images</a></span>
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<p>Public health heavily draws upon disciplines that are <a href="https://doi.org/10.1038/526182a">experiencing</a> <a href="https://doi.org/10.1177/1745691612462588">replication</a> <a href="https://doi.org/10.1371/journal.pmed.0020124">crises</a>, such as psychology, biomedical science and biology. It is similar to these disciplines <a href="https://doi.org/10.1146/annurev-statistics-031219-041104">in terms of its</a> incentive structure, study designs and analytic methods, and its inattention to transparent methods and replication. Much public health research on COVID-19 shows that it suffers from similar poor-quality methods.</p>
<p>Reexamining how the discipline rewards its scholars and assesses their scholarship can help it better prepare for the next public health crisis.</p><img src="https://counter.theconversation.com/content/220635/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dennis M. Gorman does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Pressure to ‘publish or perish’ and get results out as quickly as possible has led to weak study designs and shortened peer-review processes.Dennis M. Gorman, Professor of Epidemiology and Biostatistics, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1797452022-06-02T12:14:38Z2022-06-02T12:14:38ZListening to young people could help reduce pandemic-related harms to children<figure><img src="https://images.theconversation.com/files/456436/original/file-20220405-12-joz1tb.jpg?ixlib=rb-1.1.0&rect=34%2C69%2C7728%2C4667&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kids say they have felt ignored amid policy responses to the COVID-19 pandemic that seemed more focused on the fates of restaurants, bars and entertainment venues than keeping schools open and safe.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/middle-school-students-outdoors-wearing-face-masks-royalty-free-image/1310106559?adppopup=true">kali9/E+ via Getty Images</a></span></figcaption></figure><p>As the COVID-19 pandemic extends into a third year, experts have gained a much better understanding of its consequences for the health and development of children and adolescents. </p>
<p>They range from <a href="https://www.mckinsey.com/industries/education/our-insights/covid-19-and-education-the-lingering-effects-of-unfinished-learning">learning loss</a> to mental health issues to housing and food insecurity to <a href="https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/">contracting the virus</a> itself. </p>
<p>We are a <a href="https://scholar.google.com/citations?user=Ucb8nRwAAAAJ&hl=en">law professor</a> who focuses on children’s rights and well-being and a <a href="https://medicine.umich.edu/dept/family-medicine/tammy-chang-md-mph-ms">practicing family physician</a> who <a href="https://scholar.google.com/citations?user=vTwIjSIAAAAJ&hl=en">researches adolescent health</a>. We and other researchers <a href="https://www.oecd.org/coronavirus/policy-responses/delivering-for-youth-how-governments-can-put-young-people-at-the-centre-of-the-recovery-92c9d060/">have found</a> that over the past two years, governments have missed opportunities to better understand and address what young people have been going through as they navigate the pandemic. </p>
<p>A better understanding of the pandemic’s effects on young people is essential to developing policy responses that can address the breadth of harms children and adolescents are experiencing. </p>
<h2>The pandemic’s impacts on children</h2>
<p>Research has found that, on average, K-12 students <a href="https://www.mckinsey.com/industries/education/our-insights/covid-19-and-education-the-lingering-effects-of-unfinished-learning">fell behind</a> by about five months in mathematics and four months in reading during the 2020-2021 school year compared with students before the pandemic. Many students lost the equivalent of <a href="https://www.nytimes.com/2022/05/05/briefing/school-closures-covid-learning-loss.html">half a year or more</a> of learning, with students in low-income and majority-Black schools being hit hardest. This learning loss puts many students at risk of not finishing high school, and it jeopardizes their chances of attending college, all of which has adverse consequences for <a href="https://www.mckinsey.com/industries/education/our-insights/covid-19-and-education-the-lingering-effects-of-unfinished-learning">lifetime earning potential</a>. </p>
<p>The pandemic has also adversely affected children’s mental health. The Centers for Disease Control and Prevention found that <a href="https://www.cdc.gov/media/releases/2022/p0331-youth-mental-health-covid-19.html">37% of high schoolers</a> reported poor mental health and 44% reported that they “persistently felt sad or hopeless” during the pandemic. <a href="https://theconversation.com/pandemic-related-school-closings-likely-to-have-far-reaching-effects-on-child-well-being-175216">Other research</a>, including a <a href="https://www.hhs.gov/about/news/2021/12/07/us-surgeon-general-issues-advisory-on-youth-mental-health-crisis-further-exposed-by-covid-19-pandemic.html">recent surgeon general’s advisory</a> on young people’s mental health, has found higher rates of depression, anxiety, loneliness and other social-emotional issues among children since the pandemic. </p>
<p><a href="https://doi.org/10.1016/j.jadohealth.2020.07.043">Basic needs</a> including food and housing have also been put at risk by the pandemic. Job losses, disruptions in school-based meal programs and other adverse impacts on families led to an increase in the <a href="https://doi.org/10.1093/cdn/nzab135">number of families experiencing food insecurity</a>, putting children at risk of being unable to get adequate nutrition for healthy development. </p>
<p>In addition, millions of children and their families <a href="https://www.consumerfinance.gov/data-research/research-reports/housing-insecurity-and-the-covid-19-pandemic/">have experienced housing insecurity</a>. The <a href="https://evictionlab.org/eviction-tracking/">Eviction Lab</a>, which tracks evictions in six states and 31 U.S. cities, reports that more than 939,000 evictions have occurred since March 2020. Even when families can stave off eviction, housing insecurity adversely affects children’s <a href="https://doi.org/10.1001/jamapediatrics.2021.1085">educational progress and well-being</a>.</p>
<p>Finally, we know that many children have contracted COVID-19 – <a href="https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/">more than 13 million</a> by official counts – though research suggests the <a href="https://doi.org/10.1038/d41586-022-01231-y">numbers are much higher</a>. </p>
<h2>Children should be seen and heard</h2>
<p>Policymakers frequently <a href="https://doi.org/10.1016/j.childyouth.2016.05.015">dismiss young people as too immature</a> to participate in the “serious business” of policymaking. This attitude has persisted during the pandemic: Young people have seldom been consulted on public health policy changes that affect them directly, from schools to transportation to public parks. </p>
<p>For example, most decisions regarding moves to virtual schooling and back to in-person learning <a href="https://www.washingtonpost.com/education/2022/01/14/students-walkout-covid-safety/">were made without input</a> from children – the very population most affected by these decisions.</p>
<p>This failure to engage young people stems largely from the conventional view that children and adolescents are “<a href="https://doi.org/10.1111/j.1099-0860.2007.00110.x">becomings,” not “beings</a>” – that is, because they are developing, they lack maturity to make important decisions and thus should be “seen and not heard.” </p>
<p>However, we have learned through our own research and <a href="https://hearmyvoicenow.org/">engagement with young people</a> – as well as through other youth participation projects <a href="https://issues.org/youth-experts-bcyf-nasem-fox-kahn-battle/">and reports</a> – that this mindset is outdated and fails to recognize the knowledge young people’s lived experience offers. In our research and partnering with youths, we have found consistently that involving young people at all stages – from identifying issues to designing and implementing projects to developing policy recommendations – improves outcomes.</p>
<h2>Why consulting with children matters</h2>
<p>The United Nations Convention on the Rights of the Child recognizes that young people have a <a href="https://www.ohchr.org/en/instruments-mechanisms/instruments/convention-rights-child">right to be heard</a> and to participate <a href="http://dx.doi.org/10.1007/978-3-030-32146-8_2">in decisions that affect their lives</a>. Research shows that that while young people may not want the burden of making the final decision, they do want a say in what happens <a href="https://www.researchgate.net/publication/274411872_Child_Participation_in_the_Family_Courts--Lessons_from_the_Israeli_Pilot_Project">in their lives and their communities</a>. </p>
<figure class="align-center ">
<img alt="Maroon car with a Class of 2020 sign attached, with drawings of toilet paper rolls in place of the zeros." src="https://images.theconversation.com/files/465162/original/file-20220524-12-ef3gw6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/465162/original/file-20220524-12-ef3gw6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/465162/original/file-20220524-12-ef3gw6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/465162/original/file-20220524-12-ef3gw6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/465162/original/file-20220524-12-ef3gw6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=506&fit=crop&dpr=1 754w, https://images.theconversation.com/files/465162/original/file-20220524-12-ef3gw6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=506&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/465162/original/file-20220524-12-ef3gw6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=506&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The effects of school shutdowns on children’s learning is still being researched.</span>
<span class="attribution"><span class="source">Paras Griffin/Contributor via Getty Images North America</span></span>
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</figure>
<p>Research has found that listening to and engaging young people helps adults better understand the <a href="https://www.pewresearch.org/social-trends/2019/02/20/most-u-s-teens-see-anxiety-and-depression-as-a-major-problem-among-their-peers/">challenges children face</a>. Giving young people meaningful opportunities to participate in decisions that affect their lives can lead to <a href="https://childfundalliance.org/resources/publications/4236-children-s-right-to-be-heard-we-re-talking-are-you-listening">important insights</a> about whether particular options will be effective and can help identify <a href="https://pdxscholar.library.pdx.edu/cgi/viewcontent.cgi?article=1230&context=socwork_fac">more promising solutions</a>. </p>
<p>In addition, experience shows that involving youths in the development of policies and programs increases the likelihood of <a href="https://www.urban.org/sites/default/files/publication/103408/youth-engagement-in-collective-impact-initiatives_2.pdf">better buy-in</a> from young people on the final decisions. In turn, buy-in helps improve outcomes. </p>
<p>For example, while children may not be experts on education theory, they are the only ones alive today who have ever navigated school during a global pandemic. Their <a href="https://www.nationalacademies.org/event/11-03-2021/incorporating-youth-voice-and-the-lived-experience-in-research-seminar">lived experience</a> offers expertise that can help <a href="https://www.ojp.gov/ncjrs/virtual-library/abstracts/youth-decision-making-study-impacts-youth-adults-and-organizations">inform and improve policies and outcomes</a>. </p>
<p>Moreover, involving young people now will help them develop the skills they need to <a href="https://bostonbeyond.org/resources/incorporating-youth-voice-into-program-design/">prepare for adulthood</a>.</p>
<h2>Listen, involve and create pathways</h2>
<p>Our work suggests that there are various ways <a href="https://www.advocatesforyouth.org/resources/fact-sheets/building-effective-youth-adult-partnerships/">adults can partner</a> with children on creating policies and programs during this pandemic, as well as in future public health crises. A few of these include:</p>
<p>– Parents, teachers, school administrators and community leaders can simply listen more often to children. This may best be done by “<a href="https://doi.org/10.1111/fcre.12350">meeting them where they are</a>,” which can include paying attention to what youths express on social media to connecting with them through text messages or asking them more often how they are doing. Adults can ask them what they’re concerned about or what they want to see happen, or create supportive in-person and virtual groups.</p>
<p>– Adults can actively involve young people in what is happening in their communities and engage them in responses to the pandemic in age-appropriate ways. There are <a href="https://www.actionnews5.com/2020/07/02/best-life-inspired-by-covid-kids-stepping-up/">good examples</a> of children <a href="https://en.unesco.org/news/youth-strategic-partners-during-covid-19-crisis">having an impact</a> during the pandemic. With ideas originating from youths themselves, young people have taken on leadership roles in their communities, leveraging their skills to do everything from <a href="https://www.mynews13.com/fl/orlando/coronavirus/2020/04/25/face-mask-extenders-for-hospital-workers">producing mask extenders</a> for health care workers to starting a <a href="https://www.actionnews5.com/2020/07/02/best-life-inspired-by-covid-kids-stepping-up/">food delivery business</a> to aid elderly community members.</p>
<p>– Schools, communities and policymakers can create permanent pathways for young people to participate in developing and implementing policies – and don’t have to wait for a pandemic to do it. In Colorado, the <a href="https://www.growingupboulder.org/">Growing Up Boulder</a> initiative has successfully engaged young people on a breadth of policy issues including transportation, urban planning, housing and <a href="https://www.growingupboulder.org/project-list-and-reports1.html">parks-related projects</a>. Other cities, such as Minneapolis and San Francisco, <a href="https://sfgov.org/youthcommission/">have established youth commissions</a> and <a href="https://www.ycb.org/aboutmyc">congresses</a> that provide ongoing ways for young people to have a say in their communities.</p>
<p>All three examples – from regular, informal check-ins with youths to official youth commissions – can enable policymakers, parents, teachers and other adults to learn from young people and partner with them to develop more effective responses to the pandemic or any other issue.</p><img src="https://counter.theconversation.com/content/179745/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Making room for the input of children and adolescents in responses to the next pandemic would help maintain their health, education, well-being and more.Tammy Chang, Associate Professor of Family Medicine, University of MichiganJonathan Todres, Distinguished University Professor and Professor of Law, Georgia State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1769492022-02-25T13:46:16Z2022-02-25T13:46:16ZCan churches be protectors of public health?<figure><img src="https://images.theconversation.com/files/447903/original/file-20220222-21-1ntyhbh.jpg?ixlib=rb-1.1.0&rect=6%2C10%2C1016%2C671&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The relationship between public health and faith is far older than the COVID-19 pandemic.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/bible-in-a-church-with-a-disposable-mask-to-avoid-news-photo/1227371856?adppopup=true">Fred de Noyelle/Godong/Universal Images Group via Getty Images</a></span></figcaption></figure><p>Over the past two years of living with COVID-19, many churches have had to think in new ways. Congregations across the country are experimenting with practices such as virtual worship and Bible study or masking and social distancing – even as others go “back to normal.”</p>
<p>While scholars have studied the relationship between religion and health for decades, the pandemic has put a spotlight on it. Often, this attention emphasizes examples of churches opposing safety recommendations, such as <a href="https://www.cnn.com/2021/04/14/us/covid-vaccine-evangelicals/index.html">vaccines</a> or <a href="https://www.theguardian.com/world/2020/nov/22/let-us-disobey-churches-defy-lockdown-with-secret-meetings">lockdowns</a>, but this misses the complexity and variety of religious responses to public health problems.</p>
<p>As <a href="https://www.hartfordinternational.edu/our-faculty/andrew-gardner">a scholar</a> of Christianity in the United States, I believe understanding how churches have navigated health crises in the past can help us better understand our present. Over the past two years, I have worked with <a href="https://www.covidreligionresearch.org/">an interdisciplinary team of researchers</a> based at the <a href="http://hirr.hartsem.edu/">Hartford Institute for Religion Research</a> to understand how churches are confronting the realities of COVID-19. U.S. history, coupled with <a href="https://www.covidreligionresearch.org/wp-content/uploads/2021/11/Navigating-the-Pandemic_A-First-Look-at-Congregational-Responses_Nov-2021.pdf">our survey of congregations</a>, suggests that a commitment to public health has long been a part of ministry, but there is room to make it stronger.</p>
<h2>A history of protecting health</h2>
<p>Christian leaders have been advocating for public health in the United States since the Colonial period. Historian <a href="https://www.missouristate.edu/relst/PhilippaKoch.aspx">Philippa Koch</a> has <a href="https://books.google.com/books?id=W2wDEAAAQBAJ&newbks=0&printsec=frontcover&hl=en&source=newbks_fb#v=onepage&q&f=false">argued</a> that the religious worldview of American Protestants in the 18th century helped them “accept the new promises and insights of modern medicine.” According to Koch, this unwavering faith in God’s plan for creation helped spur individuals like the Puritan minister <a href="https://doi.org/10.1136/qshc.2003.008797">Cotton Mather</a> to promote inoculation for smallpox as a gift from God.</p>
<figure class="align-right ">
<img alt="A black and white illustration shows a portrait of a man in a large white wig." src="https://images.theconversation.com/files/447902/original/file-20220222-267-1oolmii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/447902/original/file-20220222-267-1oolmii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=770&fit=crop&dpr=1 600w, https://images.theconversation.com/files/447902/original/file-20220222-267-1oolmii.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=770&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/447902/original/file-20220222-267-1oolmii.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=770&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/447902/original/file-20220222-267-1oolmii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=968&fit=crop&dpr=1 754w, https://images.theconversation.com/files/447902/original/file-20220222-267-1oolmii.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=968&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/447902/original/file-20220222-267-1oolmii.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=968&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Cotton Mather, an influential minister in the Massachusetts Bay Colony, supported smallpox vaccines.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/an-engraved-portrait-of-cotton-mather-a-boston-news-photo/517387846?adppopup=true">Bettmann/Bettmann via Getty Images</a></span>
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<p>During the 1918 influenza pandemic, too, congregations were on the front lines of public health. Churches in <a href="https://www.newspapers.com/clip/82848315/the-wilmington-morning-star/">North Carolina</a>, for example, sought to make sure their worship space was “well ventilated” to avoid spreading the virus. They also required members to wear “germ proof” gauze masks. <a href="https://www.newspapers.com/clip/82848809/the-spokesman-review/">Churches in Washington state</a> prohibited public singing and roped off pews to ensure that congregants would be spread out around the sanctuary. </p>
<p>Many churches also canceled in-person worship gatherings and turned to the technology of the day: newspapers. In Los Angeles, ministers encouraged their congregants to “<a href="https://www.newspapers.com/clip/55370413/go-to-church-in-your-home-today/">go to church in your own home today</a>” with sermons printed in the paper. In Indianapolis, the newspaper printed an <a href="https://www.newspapers.com/clip/95484327/the-indianapolis-star/">order of worship</a> with hymns, Scripture and prayers. The paper also included sermons from local congregations, including Episcopalian, Catholic, Baptist and Jewish. </p>
<p>Presbyterian minister Francis Grimke later reflected on his church’s decision to close, <a href="https://babel.hathitrust.org/cgi/pt?id=emu.010002585873&view=1up&seq=1&skin=2021">stating</a>, “If avoiding crowds lessens the danger of being infected, it was wise to take the precaution and not needlessly run in danger and expect God to protect us.”</p>
<p>Not all churches responded to the health precautions with enthusiasm. Many ministers <a href="https://www.newspapers.com/clip/72471253/the-washington-times/">insisted</a> that communal prayers were necessary to get the country through the sickness. Others blatantly disobeyed public health orders. In Harrison, Ohio, the Rev. George Cocks of Trinity Methodist Church and 16 members of his congregation were <a href="https://www.newspapers.com/clip/78666410/the-cincinnati-enquirer/">arrested and jailed</a> for a staged protest. After being locked up, he preached through the window of his jail cell to approximately 500 individuals who had gathered to hear him. </p>
<p>Over the past few decades, more recent church practices that intersect with health include holding <a href="https://www.redcrossblood.org/donate-blood/how-to-donate/how-blood-donations-help.html">blood drives</a>, hosting 12-step programs for addiction, <a href="https://theconversation.com/nearly-half-of-all-churches-and-other-faith-institutions-help-people-get-enough-to-eat-170074">running soup kitchens</a> and providing basic <a href="https://theconversation.com/americans-are-in-a-mental-health-crisis-especially-african-americans-can-churches-help-167871">mental health counseling</a>.</p>
<h2>Churches and COVID-19</h2>
<p>The past two years have been difficult on churches. Our team at the <a href="https://www.covidreligionresearch.org/">Exploring the Pandemic Impact on Congregations</a> project <a href="https://www.covidreligionresearch.org/wp-content/uploads/2021/11/Navigating-the-Pandemic_A-First-Look-at-Congregational-Responses_Nov-2021.pdf">surveyed more than 2,000 churches</a> and found that the vast majority – 83% of those surveyed – reported that a member had tested positive for the virus. Thirty-seven percent had a staff member who had tested positive.</p>
<p>While our data shows that nearly all churches in the United States have been affected by COVID-19, not all of them have responded to the pandemic in the same way. Political polarization around public health measures has only complicated how congregations have responded to COVID-19. </p>
<p>Twenty-eight percent of the 2,074 churches we surveyed invited a medical professional to speak to their membership about the pandemic. Evangelical Christian <a href="https://www.nih.gov/farewell-dr-francis-collins">Francis Collins</a> – who recently stepped down as director of the National Institutes of Health and is now <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/16/president-biden-announces-ostp-leadership/">acting science adviser</a> to President Joe Biden – has modeled how the science of public health can be <a href="https://religionnews.com/2021/04/27/francis-collins-urges-evangelicals-love-your-neighbor-get-covid-19-vaccine/">framed in religious terms</a>, such as loving one’s neighbor. </p>
<p>Just 8% of churches volunteered to serve as <a href="https://religionnews.com/2021/01/29/black-clergy-offer-churches-as-covid-19-vaccination-sites-roll-up-their-sleeves/">a testing or vaccination location</a>. These churches were more likely to have more than 250 members, have been founded recently, and be racially diverse.</p>
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<img alt="Masked workers in safety vests walk between cars in a parking lot by a sign reading COVID vaccine, appointments only." src="https://images.theconversation.com/files/447904/original/file-20220222-17-185ptz4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/447904/original/file-20220222-17-185ptz4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/447904/original/file-20220222-17-185ptz4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/447904/original/file-20220222-17-185ptz4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/447904/original/file-20220222-17-185ptz4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=423&fit=crop&dpr=1 754w, https://images.theconversation.com/files/447904/original/file-20220222-17-185ptz4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=423&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/447904/original/file-20220222-17-185ptz4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=423&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Health care workers greet people at a drive-thru vaccination site at St. Patrick’s Catholic Church in Mount Dora, Fla.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/health-care-workers-greet-people-as-they-arrive-in-cars-to-news-photo/1230810750?adppopup=true">Paul Hennessy/NurPhoto via Getty Images</a></span>
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<p>Before the pandemic, many clergy had a <a href="https://doi.org/10.1080/21645515.2020.1736451">positive attitude toward vaccinations</a> but did not see them as particularly relevant to their faith communities. There is reason to believe that this is changing. <a href="https://www.covidreligionresearch.org/wp-content/uploads/2021/11/Navigating-the-Pandemic_A-First-Look-at-Congregational-Responses_Nov-2021.pdf">Our survey</a> found the majority of clergy across the country, 62%, have encouraged their congregants to be vaccinated against COVID-19.</p>
<p>This varies significantly across different segments of Christianity in the U.S., however. Of <a href="https://www.covidreligionresearch.org/wp-content/uploads/2021/11/Navigating-the-Pandemic_A-First-Look-at-Congregational-Responses_Nov-2021.pdf">clergy surveyed</a> from historically Black denominations, 100% had encouraged their congregations to get vaccinated. Over three-quarters of mainline Protestant congregations and nearly two-thirds of Latino churches had clergy publicly encouraging members to take the vaccine. Half of Roman Catholic and Orthodox clergy advocated for their congregants to take the vaccine, and among white Evangelicals, only 29% of clergy offered similar advice.</p>
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<p>Among churches with a senior woman clergy leader, 82% encouraged their members to get vaccinated, as compared with 58% of those with senior male leaders. Small churches were also more likely to recommend the vaccine to their congregants.</p>
<p>Our project has also conducted <a href="https://www.covidreligionresearch.org/research/national-survey-research/extraordinary-social-outreach-in-a-time-of-crisis/">a survey on how churches have adapted social outreach programs during COVID-19</a> and is currently fielding a survey about the pandemic’s effect on Christian education.</p>
<p>Given the results of our first survey, there is significant room for U.S. congregations to think more deeply about how their work intersects with public health. But before taxing clergy with something else to add to their already overburdened schedules, we believe it’s worth encouraging congregational leaders to consider their churches as institutions of public health: places that can promote the physical, spiritual and emotional health of both their members and the local community.</p>
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<p class="fine-print"><em><span>Andrew Gardner does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Responses to COVID-19 health guidelines have been polarized, including in churches. But religious communities have a long history of involvement in public health.Andrew Gardner, Visiting Faculty Associate of American Religious History, Hartford International University for Religion and PeaceLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1737272021-12-14T19:15:10Z2021-12-14T19:15:10ZMourning after mass shootings isn’t enough – a sociologist argues that society’s messages about masculinity need to change<figure><img src="https://images.theconversation.com/files/437374/original/file-20211213-21-iiq3v1.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5173%2C3371&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People attend a vigil for the victims of a school shooting that occurred in Oxford, Michigan, on Nov. 30, 2021. </span> <span class="attribution"><span class="source">AP Photo/Paul Sancya</span></span></figcaption></figure><p>This week Americans marked the anniversary of <a href="http://www.nydailynews.com/news/sandy-hook-elementary-school-shooting-victims-gallery-1.1221180">the tragic loss of children and teachers</a> at Sandy Hook. </p>
<p>After any mass shooting, Americans hear politicians make the ritualistic call for “thoughts and prayers.” Yet years after the killing of these 20 elementary students and six staff, school shootings continue to frequently claim young lives, most recently in Oxford, Michigan. There have been <a href="https://www.edweek.org/leadership/school-shootings-this-year-how-many-and-where/2021/03">more than 30</a> in the U.S. during 2021 alone – and <a href="https://www.gunviolencearchive.org/">more than 600 mass shootings</a> of any kind, according to the Gun Violence Archive. The archive defines a mass shooting as an incident with four or more people injured or killed, not including the perpetrator. </p>
<p>Thoughts and prayers are not enough. As someone <a href="https://drake.academia.edu/DarcieVandegrift/CurriculumVitae">who specializes in youth studies</a>, I would argue for a deeper exploration of the problem. A social-contextual analysis would examine how shooters’ shared characteristics interact with their surroundings to make them capable of the unimaginable acts they committed. </p>
<p>The Sandy Hook tragedy was part of a venomous chain: Aurora, Charleston, Orlando, Las Vegas, and other public mass killings. These repeated mass shooting-suicides that occur when troubled boys and men turn to guns are far too similar to one another.</p>
<p>After Sandy Hook, too many explanations described these horrible events as peculiar to a deranged individual or due to the sole factor of mental illness. An overly simplistic explanation of <a href="http://www.economist.com/blogs/lexington/2013/03/guns-and-mentally-ill">shooters as mentally ill is used as a diversionary political tactic against gun reform</a>. This explanation is both terrifying – because the actions of someone like this killer can come out of nowhere – and comforting, in that we do not hold any obligation or responsibility. </p>
<h2>Buried problems, buried people</h2>
<p>These shooters have common factors. They were all men. In the case of <a href="http://www.usatoday.com/story/news/nation/2014/11/21/sandy-hook-massacre-newtown-connecticut-adam-lanza/19343223/">Sandy Hook</a>, <a href="http://abcnews.go.com/US/accused-charleston-church-shooter-dylann-roof-handwritten-note/story?id=44138508">Charleston</a> and <a href="http://www.desmoinesregister.com/story/news/crime-and-courts/2016/11/02/scott-michael-greene-convicted-combative-2014-encounters/93157528/">Des Moines</a>, the shooters were white.</p>
<p>They apparently experienced a life of intense emotional pain. They demonstrated signs of a traumatic life, like severe social isolation, school or job failure or family estrangement.</p>
<p>But these shootings are symptoms of a deeper public health crisis that we are not talking about. Scholarship on mass shootings <a href="https://doi.org/10.5172/hesr.2010.19.4.451">demonstrates a pattern</a> for school shooters, in particular, in which the <a href="https://doi.org/10.1177/0002764203046010010">predominant understanding of masculinity</a> combines with the <a href="https://doi.org/10.5172/hesr.2010.19.4.451">cultural script of spectacular mass violence</a>.</p>
<p>As <a href="https://books.google.com/books?id=CY8TAAAAQBAJ&printsec=frontcover&dq=violence+white+masculinity&hl=en&sa=X&ved=0ahUKEwjMsoa-5vHQAhUnBMAKHcSGBY0Q6AEIKzAC#v=onepage&q=school%20shooter%20white&f=false">sociologist Michael Kimmel found</a>, most school suicide-murder shootings after 1990 have been carried out by white boys. Instead of <a href="https://theconversation.com/black-americans-may-be-more-resilient-to-stress-than-white-americans-62338">exhibiting resilience</a> or asking for help, some white boys who are bullied, under threat or disrespected turn to aggression and revenge as a toxic salve, using prior accounts of past shootings as a script for their own acts of suicidal mass violence.</p>
<p>This way of imagining manhood amplifies the worst messages our culture offers – that <a href="https://doi.org/10.1186/1471-2458-10-712">men should not demonstrate pain and vulnerability</a> or <a href="http://www.apa.org/monitor/jun05/helping.aspx">seek help</a>. Instead, a toxic masculinity emerges to put forth the idea that when white men are hurting, they are entitled to <a href="https://books.google.com/books?id=uiPvCgAAQBAJ&pg=PT109&dq=douglas+kellner+guns+vulnerability&hl=en&sa=X&ved=0ahUKEwj3-dqI5vHQAhULBcAKHbLpB2kQ6AEIITAB#v=onepage&q=douglas%20kellner%20guns%20vulnerability&f=false">act violently against others to cover feelings of vulnerability</a>. </p>
<p>The link between the taboo on white male vulnerability and toxic white male violence permeates everyday life. Boys are <a href="https://books.google.com/books?id=CY8TAAAAQBAJ&printsec=frontcover&dq=violence+white+masculinity&hl=en&sa=X&ved=0ahUKEwjMsoa-5vHQAhUnBMAKHcSGBY0Q6AEIKzAC#v=onepage&q=fighting%20is%20appropriate&f=false">four times as likely</a> as girls to think that everyday aggression, like cutting in line or fighting, is acceptable. </p>
<p>Often, debasing others’ humanity involves not guns but racist, sexist or homophobic components that are not seen as violent. The worst insults lobbed at vulnerable men are that they are feminine or gay. These ideas reside in the cultural ether, occasionally emerging in the form of <a href="https://theconversation.com/its-just-a-joke-the-subtle-effects-of-offensive-language-62440">ugly jokes</a>, unwanted gropes or racist cartoons. Other men may inflict these values in ways that create pain but are not immediately lethal – think about sexual harassment or emotional abuse of wives or children.</p>
<p>Everyone is exposed to this cultural smog that sends men messages of unearned entitlement and superiority. Some damaging elements of white masculinity even feel normal and unremarkable, such as when a parent tells a boy child to stop “crying like a girl.” Many men live with this smog or actively resist it. But when mixed with pain or mental illness, these toxic elements can take a devastating turn. </p>
<h2>A public health crisis</h2>
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<img alt="" src="https://images.theconversation.com/files/149983/original/image-20161213-1625-1vq5m8w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/149983/original/image-20161213-1625-1vq5m8w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=432&fit=crop&dpr=1 600w, https://images.theconversation.com/files/149983/original/image-20161213-1625-1vq5m8w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=432&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/149983/original/image-20161213-1625-1vq5m8w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=432&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/149983/original/image-20161213-1625-1vq5m8w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=543&fit=crop&dpr=1 754w, https://images.theconversation.com/files/149983/original/image-20161213-1625-1vq5m8w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=543&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/149983/original/image-20161213-1625-1vq5m8w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=543&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Parents of Ana Marquez-Greene, killed at Sandy Hook, hold a photo of their child.</span>
<span class="attribution"><span class="source">Jessica Hill/AP</span></span>
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</figure>
<p>Americans have repeatedly seen instances in which white boys who feel vulnerable descend into a horrific sequence of practices that look eerily familiar. The Sandy Hook shooter <a href="http://www.cnn.com/2013/11/25/justice/sandy-hook-shooting-report/">painstakingly collected stories of other mass shootings as he planned</a>. The cultural script of committing violence against vulnerable others becomes a <a href="https://books.google.com/books?hl=en&lr=&id=CSseCwAAQBAJ&oi=fnd&pg=PP1&dq=douglas+kellner+guns&ots=2nH337Ulmr&sig=uEPPpJixKHJpPyWUNTZqqkYOUFA#v=onepage&q=script&f=false">blueprint for boys to regain respectable masculinity</a>. </p>
<p>This argument isn’t about condemning white men, or any men. Instead, I suggest that a public health crisis exists in which men suffer from <a href="https://www.google.com/books/edition/The_Pain_Behind_the_Mask/ey1mAgAAQBAJ?hl=en&gbpv=1&dq=white+masculinity+hurts&pg=PP1&printsec=frontcover#v=onepage&q&f=false">undiagnosed depression and a lack of social connection, which are embedded in toxic masculinity</a>. It’s about eliminating a cultural contaminant that provides terrible options for men to fall back on in tough times when they need to be able to treat their pain.</p>
<p>In acknowledging mass shootings as a cultural script and the limits of how we construct masculinity, we can begin to consider how to change it. Ideas about masculinity are transmitted through multiple channels – the family, media, entertainment, schools, college campuses, politics and the military – and we can interrupt it in these channels, too. White parents, for examples, can teach boys other definitions of how to “be a man,” ones that don’t see aggression as “natural.”</p>
<p>If we want to actually change the climate that is enabling these horrors, mourning rituals are not enough. We can push back at empty “thoughts and prayers” sentiments and support public figures who take responsibility for changing how we teach white boys what it means to be men. </p>
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<p>Public health interventions against violence rightfully advocate <a href="http://www.latimes.com/nation/la-oe-hemenway-guns-20150423-story.html">tighter gun control</a> and gender-conscious <a href="http://www.counseling.org/Publications/FrontMatter/78086-FM.PDF">mental health care for white men</a>. We can think nondefensively about how dominant constructions of white masculinity in everyday life provide fodder for feelings of entitlement present in suicide mass shootings. </p>
<p>While talking about how entitlement, racism and violence contaminate masculinity is a tough conversation, continuing to endure the consequences is even worse.</p>
<p><em>This is an updated version of <a href="https://theconversation.com/why-thoughts-and-prayers-after-mass-shootings-fall-short-70306">an article</a> originally published on Dec. 14, 2016.</em></p><img src="https://counter.theconversation.com/content/173727/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Darcie Vandegrift is affiliated with Vandegrift Huting Consulting LLC, Drake University, and the Metropolitan Council. The ideas expressed in this essay do not necessarily reflect those of her affiliations.</span></em></p>Years after the Sandy Hook massacre, school shootings are still frequent. Addressing the problem head-on takes more than ‘thoughts and prayers.’Darcie Vandegrift, Researcher, consultant, lecturing professor, Drake UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1683182021-09-23T20:25:14Z2021-09-23T20:25:14ZHow Covid-19 upended our understanding of migration, citizenship and inequality<p>The Covid-19 pandemic has shown that the global system governing migration may not be sustainable. Temporary migration schemes including those for seasonal agriculture workers or those allowing for construction and care work no longer function when people’s mobility is hampered because of a rapidly circulating and dangerous virus.</p>
<p>We have also seen that migrants, refugees and immigrant minorities have been <a href="https://www.migrationdataportal.org/themes/migration-data-relevant-covid-19-pandemic">more severely affected</a> by the virus and have had poorer access to treatments and <a href="https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(21)00124-1/fulltext">vaccinations</a>.</p>
<p>So should we reconsider the rights of citizens versus the rights of residents or temporary workers? The pandemic has exposed several of the contradictions of our domestic and global migration governance as well as the limitations of integration policies.</p>
<h2>In or out?</h2>
<p>Covid-19 has raised important questions about the many different ways of belonging to a country: where does the boundary between insiders and outsiders lie and who should be in or out?</p>
<p>We can imagine the effective population of a country <a href="https://journals.sagepub.com/doi/10.1177/1468796802002002656">as a set of concentric circles</a>: the inner group includes citizens, then come permanent residents (in the case of the Europe, EU citizens too), then temporary residents, who have been admitted to a country for a specific period; and then come those seeking entry, asylum-seekers, for protection purposes and general aliens.</p>
<p>Covid-19 pushed this outer circle of transient members of the community into the inner circle of those who effectively live in the country by forcing the closure of borders. At the same time, these transient members were still often internally excluded in some countries if they did not have access to emergency unemployment or family benefits.</p>
<p>This forced countries to consider what <a href="https://www.canada.ca/en/immigration-refugees-citizenship/services/coronavirus-covid19.html">Canada has termed the “effective residence”</a> of temporary migrants. It pushed governments to ask where people live habitually, where they send their kids to school, where they pay taxes or have health coverage.</p>
<p>In Belgium, 400 temporary migrants recently <a href="https://www.aljazeera.com/features/2021/9/19/why-undocumented-migrants-went-on-hunger-strike-in-belgium">went on hunger strike</a> to demand the right to remain in the country and are now in negotiations with authorities.</p>
<p>This shows that while effective membership of a country may still seem tentative, the pandemic has raised the question of whether this notion of effective residence can be codified into law.</p>
<p>For instance, it could include consular protection for someone found temporarily abroad due to a sudden border closure, or the right to re-unite with second-degree family members such as elderly parents or adult children who may find themselves cut off from extended family during the pandemic restrictions.</p>
<h2>Pandemic inequalities</h2>
<p>In Belgium, we are part of an ongoing research program between the Université Libre de Bruxelles and the Université de Liège focuses on the social disparities in exposure to the Covid-19 virus, illness and death in the French speaking part of the country. It also examines to what extent previously existing social and health inequalities have grown during the early waves of the pandemics.</p>
<p>Since the research is still being conducted, no final conclusions can be presented. However, some observations have already emerged.</p>
<p>First, it appears that people’s living conditions have had an impact on their exposure to the virus, on the development of the illness and eventually on the probability of death. Three factors are particularly relevant: the density of the neighbourhood and the size of housing, family structure and community life. These living conditions often characterise immigrants and their families in Belgian cities.</p>
<p>Clearly, living in a dense neighbourhood and in small apartments with an intergenerational family has increased exposure to the virus, which in turn has raised the probability of developing a severe or fatal case of Covid-19, especially among the elderly.</p>
<p>The study seems to confirm that unequal access to health care and social services has also had a negative effect on the health of vulnerable people in general and immigrants in particular.</p>
<p>Finally, access to relevant information has been crucial. Not all residents have equal access to information about how to protect themselves and the others, and on what to do in case of illness. This an important factor explaining why immigrants have often been particularly hit by the virus.</p>
<h2>An opportunity to change</h2>
<p>Even in a welfare state like Belgium, the pandemic has revealed the weakness of immigrant membership and social citizenship.</p>
<p>While the pandemic pushed people with temporary status toward the inner circle of belonging, albeit temporarily, it also exposed the significant structural inequalities that migrants suffer and the gaps that exist in our welfare systems.</p>
<p>But a crisis brings with it the seeds of change. We can treat the pandemic as an opportunity to reconsider the importance of essential workers, to address shortcomings in housing and healthcare, to strengthen the cohesion of our societies and our solidarity toward those members who may at times find themselves pushed to the margins.</p><img src="https://counter.theconversation.com/content/168318/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marco Martiniello a reçu des financements du FRS-FNRS</span></em></p><p class="fine-print"><em><span>Anna Triandafyllidou a reçu des financements de recherche de la part du Social Sciences and Humanities Research Council (SSHRC) du Canada; de l' IRCC (Immigration, Refugees, Citizenship Canada); de la Commission Européenne programme Horizon et plusieurs programmes cadre de recherche en Europe, la European Science Foundation, l'Open Society Institute, entre autres. Aucun de ces financements n'est lié directement avec cet article. </span></em></p>Covid-19 has raised important questions about the many different ways of belonging to a country: where does the boundary between insiders and outsiders lie and who should be in or out?Marco Martiniello, Research Director FNRS Director, Centre d’Etude et des Migrations (CEDEM) Directeur de l'IRSS,Faculté des Sciences Sociales, Université de Liège, Université de LiègeAnna Triandafyllidou, Canada Research Excellence Chair in Migration and Integration, Toronto Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1409622020-06-24T16:50:23Z2020-06-24T16:50:23ZNon-medical use of prescription drugs among skilled workers: a pilot study in Nigeria<figure><img src="https://images.theconversation.com/files/343198/original/file-20200622-55021-wqrrxh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A pharmacy store in Ogun State, southwest Nigeria. </span> <span class="attribution"><span class="source">Photo by Pius Utomi Ekpei /AFP via Getty Images</span></span></figcaption></figure><p>More than ever, the world is facing a challenge of non-medical use of prescription drugs among people of all ages, genders and occupations. <a href="https://pubmed.ncbi.nlm.nih.gov/24654550/">Evidence shows</a> that pharmaceutical opioids (tramadol, codeine, or morphine), barbiturates such as pentobarbital sodium, benzodiazepines (diazepam and alprazolam), and amphetamines are the most common types of prescription medication used in a non-medical context. </p>
<p>According to the International Narcotics Control Board there was a <a href="https://www.incb.org/incb/en/publications/annual-reports/annual-report-supplement-2018.html">tripling</a> in the consumption of pharmaceutical opioids between 2014 and 2016. </p>
<p>Unfortunately, abuse of pharmaceutical drugs is as <a href="http://www.ulifeline.org/articles/390-the-dangers-of-misused-prescription-drugs">dangerous and deadly</a> as any other psychoactive substance. And the chemical components and effects of many pharmaceutical drugs make them particularly addictive. </p>
<p>In Nigeria, we conducted <a href="https://www.tandfonline.com/doi/full/10.1080/14659891.2020.1760375">research</a> into the non-medical use of pharmaceutical drugs among hairstylists and mechanics in Osogbo, a southwest region of the country. </p>
<p>My findings showed that tramadol and codeine were the most common drugs used for non-medical purposes. They also showed that prevalence was higher than the 4.7% use of non-medical drugs among adult Nigerians as reported in a nationwide survey on drug use by <a href="http://www.unodc.org/documents/data-and-analysis/statistics/Drugs/Drug_Use_Survey_Nigeria_2019_BOOK.pdf">the United Nations Office on Drugs and Crime</a> in 2018.</p>
<p>For <a href="https://www.samhsa.gov/data/sites/default/files/report_3210/ShortReport-3210.html">many reasons</a> more people are shifting from the use of conventional psychoactive drugs such as cannabis, cocaine and heroin to pharmaceutical drugs for a non-medical purpose. These reasons include sensation seeking, energy boost, to feel better and to cope with stress, frustration and unpleasant life events. </p>
<h2>Findings</h2>
<p>The study population for the research was made up of 64 hairstylists and 54 mechanics. Ninety four were males and 24 females. Their ages ranged between 18 and 45 years.</p>
<p>About 20% of the participants reported non-medical use of tramadol in the previous 12 months, 18% used codeine, 10.1% used other unnamed painkillers, and 1.7% used Rohypnol. A further 3.2% reported the use of other tranquilisers for a non-medical purpose within a one year period.</p>
<p>The results also showed that the non-medical use of pharmaceutical drugs was more prevalent among mechanics. For instance, 10.2% of the mechanics compared to 6.6% of the hair stylists reported non-medical use of tramadol within a period of one month. </p>
<p>We found that participants’ level of education and living situation was associated with their non-medical use of pharmaceutical drugs. This usage was most prevalent among participants who had received formal education at a higher level. These were participants with either complete or incomplete tertiary education (55.6%).</p>
<p>And we found that drug use was more prominent among persons living with friends (66.7%). We recorded 54.1% among people living alone and 50% of those living with their children alone, compared to people living with spouse and children, parents, and other relatives. </p>
<p>Our <a href="https://www.tandfonline.com/doi/full/10.1080/14659891.2020.1760375">research</a> was a pilot study. We intend to conduct a follow-up study with wider coverage among the target population to reinforce the findings of the present study.</p>
<h2>Solutions</h2>
<p>Drug abuse, including the non-medical use of pharmaceutical drugs at the workplace, exacts a <a href="https://www.verywellmind.com/substance-abuse-in-the-workplace-63807">heavy price</a>. </p>
<p>As a result a <a href="https://www.shrm.org/resourcesandtools/hr-topics/risk-management/pages/nsc-prescription-drug-abuse-at-work.aspx">lot of effort</a> has been put into reducing drug abuse. </p>
<p>Over time different solutions have been proposed. </p>
<p>Based on experience garnered from my clinical practice and research, I would recommend three solutions.</p>
<p>The first is primary intervention. This involves effort aimed at protecting an individual from becoming exposed and vulnerable to drug use. Activities at this level also include reducing environmental stressors and building people’s abilities to cope with life events that may particularly make them susceptible to drug use. </p>
<p>The main aim of the primary intervention is, therefore, to prevent drug use from occurring. For instance, we found that among the hairstylists and mechanics we studied, their work, leisure and other activities are not well balanced. </p>
<p>Intervention at the secondary level involves putting in place a functioning system that can assist individuals who are already using drugs to cut down and eventually quit. </p>
<p>The secondary intervention also involves preventing drug users from progressing to a harmful level of use which compromises or impairs their health, relationships, finance, academics or work and overall mental well-being. </p>
<p>At a secondary level of intervention, institutions and organisations are encouraged to provide an environment that enables well-being and discourages drug use. </p>
<p>Irrespective of the preventive or intervention measure put in place for any problem behaviour such as drug abuse, it is evident that some people will always be caught up in the web. </p>
<p>At this level, the aim is to minimise the impact of drug use on an individual and organisation. </p>
<p>Lastly, there is relapse prevention. People who have been to treatment are assisted not to return to drug use. Several forms of rehabilitating strategies are also employed at this level to help people regain their well-being and possibly become optimally productive at work again.</p><img src="https://counter.theconversation.com/content/140962/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samson Femi Agberotimi does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>For many reasons, drug users are shifting from the use of conventional psychoactive drugs such as cannabis, cocaine and heroin to pharmaceutical drugs for non-medical purposes.Samson Femi Agberotimi, Postdoctoral Research Fellow, North-West UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1398342020-06-18T17:50:14Z2020-06-18T17:50:14ZDomestic abusers use tech that connects as a weapon during coronavirus lockdowns<figure><img src="https://images.theconversation.com/files/342546/original/file-20200617-94066-1sp2h7b.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C5751%2C3811&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Technology plays a major role in violence against women and girls.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/sad-teen-with-a-phone-in-her-bedroom-royalty-free-image/820379104">AntonioGuillem/iStock via Getty Images</a></span></figcaption></figure><p>The coronavirus pandemic has driven much of daily life – work, school, socializing – online. Unfortunately, perpetrators of violence against women and girls are also increasingly turning to technology in response to the pandemic.</p>
<p>Globally, violence against women and girls is a problem of pandemic proportions, with <a href="https://news.un.org/en/story/2019/11/1052041">one in three</a> experiencing an act of physical or sexual violence in her <a href="https://www.who.int/reproductivehealth/publications/violence/9789241564625/en/">lifetime</a>. Most of these acts of violence are perpetrated by intimate partners and family. In the United States, women are at increased risk of <a href="https://www.ncjrs.gov/pdffiles1/nij/183781.pdf">violence from a current or former intimate partner</a>, and they are more likely than men to <a href="https://www.ncjrs.gov/pdffiles1/nij/183781.pdf">suffer injuries</a>, <a href="https://www.prisonpolicy.org/scans/bjs/vrithed.pdf">be treated in emergency rooms</a> and <a href="https://www.nytimes.com/2019/04/12/us/domestic-violence-victims.html">be killed</a> as a result of intimate partner violence. </p>
<p><a href="https://eige.europa.eu/gender-based-violence/estimating-costs-in-european-union">Violence against women and girls is costly</a> for victims and their families, communities and society. The problem is complicated by new technologies, and now COVID-19. </p>
<p>Left unchecked, violence against women and girls can increase in <a href="https://www.ncbi.nlm.nih.gov/books/NBK499891/">frequency and severity</a> and damage victims’ <a href="https://doi.org/10.1016/S0140-6736(02)08336-8">physical and mental health</a>. It can also place children who are exposed to the violence at risk for behavioral issues, including <a href="https://www.ncjrs.gov/pdffiles1/nij/184894.pdf">delinquency and violence</a>. And it can be lethal, as highlighted by <a href="https://vawnet.org/sc/scope-problem-intimate-partner-homicide-statistics">homicide by intimate partners</a>, <a href="https://www.nytimes.com/2019/11/27/us/chicago-college-student-killed-catcall.html">homicide by strangers</a> and even <a href="https://doi.org/10.1111/soc4.12730">mass murders</a>. </p>
<h2>Technology and violence</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/342547/original/file-20200617-94066-1vdf93q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/342547/original/file-20200617-94066-1vdf93q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=840&fit=crop&dpr=1 600w, https://images.theconversation.com/files/342547/original/file-20200617-94066-1vdf93q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=840&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/342547/original/file-20200617-94066-1vdf93q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=840&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/342547/original/file-20200617-94066-1vdf93q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1055&fit=crop&dpr=1 754w, https://images.theconversation.com/files/342547/original/file-20200617-94066-1vdf93q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1055&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/342547/original/file-20200617-94066-1vdf93q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1055&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">U.S. Rep. Katherine Clark, D-Mass., is the sponsor of a bill aimed at curbing online harassment and abuse.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Battling-Online-Abuse/4dbd34b7b0c44768a0f5af4a7e7dd26b/40/0">AP Photo/Stephan Savoia</a></span>
</figcaption>
</figure>
<p>Pre-COVID-19 research shows that approximately 75% of women and girls experience <a href="https://www.unwomen.org/%7E/media/headquarters/attachments/sections/library/publications/2015/cyber_violence_gender%20report.pdf?v=1&d=20150924T154259">cyber or technology-facilitated violence,</a> which is often misogynistic, hostile or both in nature. </p>
<p>Recipients of <a href="https://www.bbc.com/news/magazine-35600228">online harassment</a>, image-based abuse such as “<a href="https://scholarship.law.bu.edu/cgi/viewcontent.cgi?article=1643&context=faculty_scholarship">revenge pornography</a>” and <a href="https://genderit.org/onlinevaw/faq/">other digital transgressions</a> experience them not only on <a href="https://www.amnesty.org/en/latest/research/2018/03/online-violence-against-women-chapter-3/">social media</a> platforms but also in the home. These experiences include <a href="https://www.daily-jeff.com/news/20191210/threatening-text-messages-result-in-warrant-request-by-police">text message</a> or online threats of death or rape, harassment, monitoring and <a href="https://www.justice.gov/usao/file/851856/download">stalking</a> by a current or <a href="https://www.npr.org/2014/12/01/366534452/is-a-threat-posted-on-facebook-really-a-threat">former intimate partner</a>. </p>
<p>Technology-facilitated violence is the <a href="https://doi.org/10.1177/0886260515614283">most common type of intimate partner victimization</a>, and it accompanies in-person psychological, physical and sexual violence. It’s also linked to physical, psychosocial and <a href="https://doi.org/10.5817/CP2020-1-1">behavioral problems</a>. </p>
<h2>The COVID-19 factor</h2>
<p>Since COVID-19, reports of <a href="https://www.dallasnews.com/news/crime/2020/05/19/ut-dallas-study-finds-family-violence-increased-125-during-shelter-at-home-orders/">intimate partner violence</a>, <a href="https://www.equalitynow.org/covid_19_online_exploitation">child sexual exploitation</a> and other serious crimes suggest a <a href="https://www.cnn.com/2020/04/04/us/domestic-violence-coronavirus-calls-cases-increase-invs/index.html">surge</a> in offenses.</p>
<p>Public health officials are asking people to socially distance and stay at home. These policies isolate women and girls from sources of support and place them in contact with abusers for extended periods of time without reprieve, which worsens control and <a href="https://www.nbcnews.com/health/health-care/it-s-hard-flee-your-domestic-abuser-during-coronavirus-lockdown-n1205641">abuse</a>. </p>
<p>Technology-facilitated forms of control and abuse, like disabling phone or internet services and monitoring electronic communications, are particularly damaging during pandemic lockdowns. Many other <a href="https://www.apc.org/sites/default/files/APCSubmission_UNSR_VAW_GBV_0_0.pdf">digital transgressions</a> including <a href="https://www.npr.org/sections/coronavirus-live-updates/2020/04/08/828827926/child-sex-abuse-livestreams-increase-during-coronavirus-lockdowns">livestreaming child sexual abuse</a>, nonconsensual photo sharing and forced pornographic consumption, are exacerbated by the combination of technology, time and isolation. </p>
<p>Abusers have also used technology and the pandemic in efforts to cover up their crimes. In one case, <a href="https://www.nbcmiami.com/news/local/jupiter-man-kidnaps-and-kills-wife-tells-family-she-had-coronavirus-police/2233379/">a man disabled location services on his wife’s phone and used her text messaging services</a> in an unsuccessful attempt to fool her family into thinking she was alive. He was ultimately arrested for her kidnapping and murder. </p>
<p>Additionally, there are countless <a href="https://www.bwjp.org/news/coercive-control-covid-19.html">nonlethal acts of partner violence relating to COVID-19</a>, including <a href="https://www.theguardian.com/us-news/2020/apr/03/coronavirus-quarantine-abuse-domestic-violence">threats of eviction for coughing</a>, forced physical contact during times of isolation and refusal to share soap or hand sanitizer, among other behaviors designed to gain power and control. </p>
<p>Adults aren’t the only victims during the pandemic. As children stay home from school and spend more time online, they may fall victim to predatory loved ones and online strangers. Reports of <a href="https://ktla.com/news/local-news/online-child-sex-abuse-reports-surge-as-kids-spend-more-time-on-computers-amid-coronavirus/">online child sexual abuse</a> are on the rise. </p>
<h2>The system comes up short</h2>
<p>There are few resources to keep women and girls safe, and those that exist are commonly <a href="https://genderit.org/onlinevaw/faq/">plagued with problems</a>. Police, courts and corrections officials historically have failed survivors by blaming the victim, dropping charges and not attempting to rehabilitate offenders. They have also <a href="https://thewebindex.org/wp-content/uploads/2014/12/Web_Index_24pp_November2014.pdf">failed to take appropriate action</a> in most cases of cyber violence against women and girls. </p>
<p>Budget cuts are creeping into already underfunded homeless shelters, domestic and sexual violence hotlines, community outreach and related human services in some of the most populous states, including <a href="https://www.syracuse.com/news/2020/06/onondaga-county-cuts-45m-from-nonprofits-amid-coronavirus-budget-crisis.html">New York</a> and <a href="https://chronicleofsocialchange.org/news-2/california-budget-calls-for-90-million-cuts-child-welfare-services/43352">California</a>. </p>
<p>Technological solutions like improved digital device security, <a href="http://nixdell.com/papers/stalkers-paradise-intimate.pdf">abuse-aware technology design</a> that distinguish users from others based on <a href="https://lifehacker.com/how-to-keep-someone-from-unlocking-your-pixel-4-when-yo-1839235867">visual or behavioral cues</a> and two-factor authentication to online services are not yet widespread. At the same time, online providers <a href="https://research-repository.griffith.edu.au/bitstream/handle/10072/388941/Draghiewicz263291Published.pdf?sequence=5&isAllowed=y">have not done enough to curb harassing behaviors</a>. All of this is detrimental to public health, especially for vulnerable populations.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/342549/original/file-20200617-94086-zab1cx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/342549/original/file-20200617-94086-zab1cx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=395&fit=crop&dpr=1 600w, https://images.theconversation.com/files/342549/original/file-20200617-94086-zab1cx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=395&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/342549/original/file-20200617-94086-zab1cx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=395&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/342549/original/file-20200617-94086-zab1cx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=497&fit=crop&dpr=1 754w, https://images.theconversation.com/files/342549/original/file-20200617-94086-zab1cx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=497&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/342549/original/file-20200617-94086-zab1cx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=497&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">An advocate works in the National Domestic Violence Hotline center’s facility in Austin, Texas.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Domestic-Violence-Hotline/d9825b895a8a44f7a3947240ce69d7fd/9/0">AP Photo/Eric Gay</a></span>
</figcaption>
</figure>
<h2>How to respond</h2>
<p>There are several ways to address COVID-19, technology and interpersonal violence. </p>
<p>Domestic violence agencies need to reach people at home. Local and national <a href="https://nnedv.org/%20https:/www.thehotline.org/%20https:/www.thehotline.org/help/deaf-services/%20https:/www.bwjp.org/">domestic violence hotlines</a> and online chat services can promote their services via Hulu and Facebook ads, Roku background screens, Google homepages and local news. Agencies can also conduct surveys to learn about vulnerable people’s communication preferences. Insurance companies and local and state governments can offer telehealth visits, and social service agencies can reach people in crisis online.</p>
<p>Access to technologies like domestic violence apps <a href="https://probonoaustralia.com.au/news/2016/06/family-violence-app-wins-inaugural-premiers-iaward/">SmartSafe+</a> and <a href="https://www.circleof6app.com/">Circle of 6</a> can help victims with collecting and storing evidence that can be used in later criminal justice proceedings. They can also provide immediate access to local and national rape crisis hotlines and resources. Also, tools like <a href="https://www.takebackthetech.net/mapit/main">Take Back the Tech!</a> map instances of violence against women and girls worldwide as a way for survivors to have their stories heard and call on others to take action.</p>
<p>Social media platforms can find innovative ways to connect users with key resources and services, as Twitter has done with its new search prompt (<a href="https://www.wionews.com/technology/as-cases-of-domestic-violence-shoot-up-amid-covid-19-pandemic-twitter-launches-dedicated-tool-to-help-people-combat-the-menace-306527">#ThereIsHelp</a>). They can also make it <a href="https://www.wired.com/2015/06/abused-emoji/">easier</a> to communicate difficult experiences while also reducing <a href="https://www.cnn.com/2013/08/09/us/florida-facebook-confession/index.html">traumatizing images</a> that may harm survivors, family members, friends and others. </p>
<h2>Technology by and for women</h2>
<p>Developing <a href="https://www.scientificamerican.com/article/the-technology-of-kindness">regenerative technologies</a>, which foster online kindness and empathy, and diversifying the tech field with women who research or are survivors of violence against women and girls could make a meaningful difference. It’s important to <a href="https://theconversation.com/the-lack-of-women-in-cybersecurity-leaves-the-online-world-at-greater-risk-136654">incorporate women</a> and their perspectives in technological work. It’s also important to find ways for women and girls to maintain connections and interact safely online while social distancing. </p>
<p>Considering the possibility for continued and future outbreaks, it’s imperative that women and girls have access to services and strategies – in person and through technology – at local, regional and national levels. By reimagining approaches to violence and safety, the health and social services systems can reduce violence against women and girls. They can also better support those who find themselves in peril as they navigate life during and after trauma in ways that are safest for them.</p>
<p>[<em>You need to understand the coronavirus pandemic, and we can help.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-help">Read The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/139834/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Stay-at-home orders and social distancing make technology all the more important for maintaining human connections. They also make it easier for abusers to use technology against their victims.Alison J. Marganski, Associate Professor & Director of Criminology, Le Moyne CollegeLisa Melander, Associate Professor of Sociology, Kansas State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1355152020-04-08T20:47:16Z2020-04-08T20:47:16ZQAnon conspiracy theories about the coronavirus pandemic are a public health threat<figure><img src="https://images.theconversation.com/files/326309/original/file-20200408-108576-1xk1gch.jpg?ixlib=rb-1.1.0&rect=15%2C75%2C4977%2C3111&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Followers of the QAnon movement, shown here at a 2018 rally in Pennsylvania for President Donald Trump, use social platforms to spread conspiracy theories. False information from the QAnon community about the coronavirus pandemic is a public health hazard.</span> <span class="attribution"><span class="source">(AP Photo/Matt Rourke)</span></span></figcaption></figure><p>First there was the pandemic, <a href="https://www.weforum.org/agenda/2020/03/how-experts-are-fighting-the-coronavirus-infodemic/">then came the “infodemic”</a> — a term the head of the World Health Organization defines as the spread of false information about COVID-19.</p>
<p>The most dangerous conspiracy theories about the coronavirus are now part of the <a href="https://www.thedailybeast.com/what-is-qanon-the-craziest-theory-of-the-trump-era-explained">QAnon phenomenon</a>. For months now, actors in QAnon have downplayed the severity of the crisis, amplified medical disinformation and have been originators of hoaxes.</p>
<p>The QAnon movement started in 2017 after someone using an anonymous account known only as Q posted wild conspiracy theories about U.S. President Donald Trump on the internet forum 4chan.</p>
<p><a href="https://www.thedailybeast.com/what-is-qanon-the-craziest-theory-of-the-trump-era-explained">QAnon</a> conspiracy theorists believe a deep state cabal of global elites is responsible for all the evil in the world. They also believe those same elites are seeking to bring down Trump, whom they see as the world’s only hope to defeat the deep state. QAnon has now brought the same conspiracy mentality to the coronavirus crisis.</p>
<p>As a researcher of online movements like QAnon, I use a combination of data science and digital ethnography to research how extremist movements use technology to create propaganda, recruit members to ideological causes, inspire acts of violence or impact democratic institutions.</p>
<h2>Bottom-up approach</h2>
<p>A central component of QAnon is the crowdsourcing of narratives. This bottom-up approach provides a fluid and ever changing ideology. My analysis of Twitter shows from January to March, there was a 21 per cent increase (a total of 7,683,414 posts) in hashtags used by the QAnon community. This means the misinformation they spread has the capacity to reach a wider audience.</p>
<p>For instance, <a href="https://www.thedailybeast.com/qanon-conspiracy-theorists-magic-cure-for-coronavirus-is-drinking-lethal-bleach">QAnon community influencers on Twitter promoted Miracle Mineral Supplement</a> as a way of preventing COVID-19. The toxic product was sold by the Texas-based Genesis II Church of Health and Healing for US$45. The U.S. Food and Drug Administration <a href="https://www.fda.gov/news-events/press-announcements/fda-warns-consumers-about-dangerous-and-potentially-life-threatening-side-effects-miracle-mineral">had previously issued a warning</a> about the dangerous and potentially life threatening side effects of the supplement.</p>
<p>In <a href="https://twitter.com/4ngl3rf1sh/status/1238537196841426944">January</a>, QAnon was amplifying narratives on 8kun (<a href="https://www.cnet.com/news/8chan-rebranded-8kun-site-taken-offline-days-after-launch/">the internet forum formally known as 8chan</a>), Facebook and Telegram (an encrypted instant messaging plaform) about a false theory that Asians were more susceptible to the coronavirus and that white people were immune to COVID-19. Not only are there racist undertones associated with this disinformation, it minimizes the threat posed by the virus.</p>
<h2>Downplayed threat</h2>
<p>From February until the second week of March, QAnon followed the lead of Trump in downplaying the threat of the virus and calling it a hoax. They believed the virus was a deep state plot to damage the president’s chance at re-election. The QAnon community said those warning about the pandemic threat were trying to detract from U.S. domestic politics, stop Trump rallies and remove all the economic gains they contended had occurred during the Trump presidency.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/326312/original/file-20200408-134345-bzlidk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/326312/original/file-20200408-134345-bzlidk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/326312/original/file-20200408-134345-bzlidk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/326312/original/file-20200408-134345-bzlidk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/326312/original/file-20200408-134345-bzlidk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/326312/original/file-20200408-134345-bzlidk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/326312/original/file-20200408-134345-bzlidk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">After Trump initially said COVID-19 posed no threat to the United States, the QAnon community reinforced that message by spreading disinformation about the disease.</span>
<span class="attribution"><span class="source">(AP Photo/Alex Brandon)</span></span>
</figcaption>
</figure>
<p>After the WHO upgraded COVID-19 to pandemic status and the U.S. announced it was closing its borders to <a href="https://www.bloomberg.com/news/articles/2020-03-12/trump-says-he-s-suspending-all-travel-from-europe-for-30-days">most people from Europe for 30 days</a>, QAnon changed the narrative again. Suddenly, QAnon thought the pandemic was something to celebrate because it was a cover for the Trump administration’s secret plan <a href="https://vimeo.com/396698839">to arrest deep state agents</a>.</p>
<p>Evangelicals within the the QAnon movement viewed the pandemic as the promised coming of the Kingdom of God on Earth. David Hayes, <a href="https://www.rightwingwatch.org/post/dave-hayes-trump-is-locked-in-a-literal-fight-to-the-death-with-the-deep-state/">who is better known as the Praying Medic</a> and an influencer in the QAnon community with 300,000 YouTube subscribers, said in a March 14 livestream that there was no reason to be concerned about COVID-19. Hayes reassured his viewers that they may not be affected by the disease because this was “spiritual warfare” — only those who have not been chosen by God will be affected by the disease.</p>
<p>The person known as Q, who spawned the QAnon movement, didn’t post anything online about COVID-19 until March 23. Up until then, all of the medical disinformation, hoaxes and downplaying of the pandemic had been sourced from QAnon influencers and community.</p>
<h2>Public health threat</h2>
<p>In his first post on the topic of COVID-19, Q pushed a conspiracy theory with racial undertones about COVID-19 being <a href="https://www.forbes.com/sites/brucelee/2020/03/17/covid-19-coronavirus-did-not-come-from-a-lab-study-shows-natural-origins/#591269013728">a Chinese bioweapon</a> and that the virus release was a joint venture between China and the Democrats to stop Trump’s re-election by destroying the economy.</p>
<p>The QAnon conspiracies have created an environment of complacency among its followers who aren’t taking the risks posed by the virus seriously.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/326599/original/file-20200408-156807-1ubjz2n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/326599/original/file-20200408-156807-1ubjz2n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/326599/original/file-20200408-156807-1ubjz2n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=752&fit=crop&dpr=1 600w, https://images.theconversation.com/files/326599/original/file-20200408-156807-1ubjz2n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=752&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/326599/original/file-20200408-156807-1ubjz2n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=752&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/326599/original/file-20200408-156807-1ubjz2n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=945&fit=crop&dpr=1 754w, https://images.theconversation.com/files/326599/original/file-20200408-156807-1ubjz2n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=945&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/326599/original/file-20200408-156807-1ubjz2n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=945&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Rodney Howard-Browne, pastor of The River Church in Florida , was charged on March 30 with violating a safer-at-home order intended to limit the spread of the coronavirus. His megachurch held two Sunday services with hundreds of people after the order was issued.</span>
<span class="attribution"><span class="source">(Hernando County Jail via AP)</span></span>
</figcaption>
</figure>
<p>Florida pastor Rodney Howard-Browne, who has <a href="https://web.archive.org/web/20200403142722/https:/twitter.com/rhowardbrowne/status/947885030315057152">given credence to QAnon in the past</a> and has preached that the coronavirus was planned by the Bill and Melinda Gates Foundation, <a href="https://www.nbcnews.com/news/us-news/florida-pastor-arrested-after-holding-church-services-despite-coronavirus-orders-n1172276">was arrested</a> after holding Sunday services and disregarding federal, state and county orders to limit gatherings to less than 10 people. His conspiratorial beliefs led to his negligent actions, which put hundreds of people from his congregation at risk.</p>
<p>In another instance, right-wing media figures were spreading an “empty hospital” conspiracy, downplaying the pandemic and its death toll. </p>
<p><a href="https://www.thedailybeast.com/naturally-we-now-have-a-cottage-industry-of-coronavirus-truther-assholes">A QAnon account originally launched the #FilmYourHospital hashtag</a>. This was amplified by QAnon influencers such as former California congressional candidate DeAnna Lorraine Tesoriero and QAnon influencer <a href="https://www.rightwingwatch.org/people/liz-crokin/">Liz Crokin</a>. This hoax was then picked up by mainstream right-wing media figures promoting COVID trutherism to a wider audience.</p>
<p>The FBI once called conspiracy theories spread by QAnon and others a “potential domestic terrorism threat.” It’s time to call the infodemic a public health threat.</p><img src="https://counter.theconversation.com/content/135515/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marc-André Argentino receives funding from Concordia University. </span></em></p>QAnon refers to the online community that believes in conspiracy theories about Donald Trump and the so-called deep state, and is spreading harmful misinformation about COVID-19.Marc-André Argentino, PhD candidate Individualized Program, 2020-2021 Public Scholar, Concordia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1342392020-03-28T05:14:27Z2020-03-28T05:14:27ZWithout major intervention, Indonesia could have 71,000 COVID-19 cases by April’s end<p>Transmission of COVID-19 in Indonesia, a country with more than a quarter-billion people, may <a href="https://www.forbes.com/sites/startswithabang/2020/03/17/why-exponential-growth-is-so-scary-for-the-covid-19-coronavirus/#65d402fb4e9b">increase exponentially</a> if the government makes no immediate effort to reduce the spread.</p>
<p>Using exponential function analysis, we estimate – with data gathered since March 2 and assuming the doubling times are similar as <a href="https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200317-sitrep-57-covid-19.pdf?sfvrsn=a26922f2_4">Iran’s</a> and <a href="https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930627-9">Italy’s</a> – that at the end of April 2020, there may be 11,000-71,000 COVID-19 cases in Indonesia. </p>
<p>Indonesia might hit those numbers if the country’s handling of the coronavirus outbreak doesn’t change. Currently, there is scarce information on the location of infected patients, the number of tests carried out and areas to avoid. There is still a lack of awareness and compliance among the public about social distancing measures. There is also a lack of sanctions against self-quarantine violations.</p>
<p>President Joko Widodo announced Indonesia’s first two COVID-19 cases on <a href="https://www.thejakartapost.com/news/2020/03/02/breaking-jokowi-announces-indonesias-first-two-confirmed-covid-19-cases.html">March 2</a>. In the following days, the number of new cases has continued to increase rapidly. As of <a href="https://www.covid19.go.id/situasi-virus-corona/">March 27</a>, the total number of cases nationwide is <a href="https://www.thejakartapost.com/news/2020/03/27/indonesian-covid-19-cases-top-1000.html">1046</a>, it increased 523 times from the first day cases were announced. And there is still a high possibility of undetected infections in the community.</p>
<iframe title="The trend of total number and new cases of COVID-19 in Indonesia&nbsp;" aria-label="Interactive line chart" src="https://datawrapper.dwcdn.net/HgLiw/3/" scrolling="no" frameborder="0" style="border: none;" width="100%" height="500"></iframe>
<p>The Indonesian government has put in a disaster emergency plan for COVID-19 outbreak up to <a href="https://jakartaglobe.id/news/indonesia-extends-covid19-emergency-to-may-29-as-cases-rise-to-172/">May 29, 2020</a>. Since <a href="https://www.thejakartapost.com/news/2020/03/20/indonesia-starts-rapid-tests-imports-medicines-to-cure-covid-19-jokowi-says.html">March 20 the first rapid tests has been conducted</a> in South Jakarta and the government <a href="https://www.thejakartapost.com/news/2020/03/23/jakartas-emergency-hospital-for-covid-19-open-for-business.html">has converted four apartment towers of the Kemayoran Athletes Village in Jakarta as a new emergency hospital to handle COVID-19 patients</a>. </p>
<p>Campaign for <a href="https://www.thejakartapost.com/news/2020/03/15/jokowi-calls-for-social-distancing-to-stem-virus-spread.html">social distancing</a> also <a href="https://www.thejakartapost.com/news/2020/03/24/no-lockdown-for-indonesia-jokowi-insists-as-covid-19-cases-continue-to-rise.html">continues</a>. However, many still criticise the scale and effectiveness of these initiatives.</p>
<p>It’s important to note that at the end of April, the Islamic fasting month Ramadan starts. During this time, Muslims, that make up the majority of Indonesia’s population, commonly hold many activities together that involve close contact, such as breaking the fast in the evening and the following congregational prayer at mosques. </p>
<p>In late May, <a href="https://www.thejakartapost.com/news/2020/03/26/indonesia-may-ban-idul-fitri-exodus-to-stop-covid-19-transmission.html">Eid al-Fitr holidays will mark</a> the end of Ramadan. <a href="https://bisnis.tempo.co/read/1193980/survei-separuh-penduduk-jakarta-mudik-saat-lebaran-2019/full&view=ok">Nearly 15 million people</a> usually leave Jakarta during this time to travel to West Java, Central Java, East Java and other provinces to celebrate the Islamic holiday.</p>
<p>Indonesia should learn from the <a href="https://www.ft.com/content/b257738e-3da7-11ea-b232-000f4477fbca">mass meeting over 40,000 families ahead of the Lunar New Year in the Baibuting District, Wuhan, China</a> on January 18. The meeting is thought to be the initial medium of the mass spread of the disease throughout mainland China, which <a href="https://www.worldometers.info/coronavirus/countries-where-coronavirus-has-spread/">then spread into 198 countries and territories</a>.</p>
<h2>A terrifying exponential growth</h2>
<p>Theoretically, interventions such as <a href="https://theconversation.com/kasus-covid-19-di-indonesia-naik-4-hal-penting-untuk-menghindari-penularan-baru-132602">limiting social gatherings</a>, <a href="https://theconversation.com/cara-menilai-level-bencana-covid-19-di-indonesia-segera-tes-massal-dan-perbanyak-lab-133628">mass testing</a> and <a href="https://theconversation.com/how-do-we-detect-if-coronavirus-is-spreading-in-the-community-132349">isolation of positive cases</a> should slow the number of new cases down.</p>
<p>Without these strict restrictions, the growth in the number of COVID-19 patients will be exponential. This means that for every similar period, the number of patients multiplies by the number of patients before. </p>
<p>For example, if the number of patients increases by two every day, each patient transmits to two people per day. So, the number of patients on the first day to the 7th day would be: 1, 2, 4, 8, 16, 32 and 64.</p>
<p>In this first week, medical staff would still be able to handle the number of patients they need to treat. But if the <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)30260-9.pdf">doubling</a> continues, at the end of the second week, the number of patients will be 8,192. By the end of the third week, it will pass the one million mark.</p>
<p>By the end of the fourth week, the number will break past 10 million and be at 13,421,728.</p>
<p>This rate of increase is dynamic, depending on the period analysed and interventions conducted to slow the spread of the virus. </p>
<p>To prevent the health system from being overwhelmed with patients, the doubling must be stopped as soon as possible, at the beginning of the outbreak, when the number of patients is still small.</p>
<h1>The four phases of the outbreak</h1>
<p>In general, an infectious disease outbreak has four periods: the delay phase, the exponential phase, the static phase and the decline phase.</p>
<p><strong>The delay phase</strong></p>
<p>The delay phase is the initial phase when there are only a few people coming to medical facilities with complaints.</p>
<p><a href="https://www.medrxiv.org/content/10.1101/2020.02.06.20020974v1.full.pdf">The incubation period for coronavirus is 1 to 24 days</a>. This incubation period provides an opportunity for the virus to multiply and spread from one person to another.</p>
<p>Some people who have COVID-19 <a href="https://tekno.tempo.co/read/1312293/studi-virus-corona-wanita-tanpa-gejala-menginfeksi-5-orang/full&view=ok">do not show symptoms</a>. Without testing, they may not realise they are carriers of the virus.</p>
<p>In this phase, most health authorities and the community tend to be ignorant and in some cases in denial of a looming problem.</p>
<p>South Korea, for example, reported its first case <a href="https://www.cdc.go.kr/board/board.es?mid=a30402000000&bid=0030">on January 20, 2020</a>. Four weeks later, the number of new cases only reached 30. On February 18, a COVID-19 confirmed patient attended a routine religious event at a church <a href="https://jkms.org/DOIx.php?id=10.3346/jkms.2020.35.e112">which was also attended by many other people</a>. Two days after that, the number of cases <a href="https://www.cdc.go.kr/board/board.es?mid=a30402000000&bid=0030&tag=&act=view&list_no=366296">exploded to 346</a>. </p>
<p>There was <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7045878/pdf/ophrp-11-8.pdf">a delay phase of four weeks</a> during which health authorities were only tracing contacts of positive cases and not putting in place drastic interventions. After that, there was an exponential growth of cases. As of March 18, almost four weeks after the exponential phase began, <a href="https://www.cdc.go.kr/board/board.es?mid=a30402000000&bid=0030">South Korea reported</a> 8,413 cases and 81 deaths.</p>
<p><strong>The exponential phase</strong></p>
<p>A protracted delay in detecting infections is usually followed by an explosion of cases. In this phase, health authorities and most people only just begin to realise the danger.</p>
<p>They start to panic and immediately act to control the situation. Unfortunately, health services are already being overwhelmed. </p>
<p>Italy is an example of a more severe exponential growth rate. The country reported its <a href="https://www.ijidonline.com/article/S1201-9712(20)30101-6/fulltext">first case</a> at the end of January 2020. Then it started to report some positive cases from Italian citizens returning from China.</p>
<p>But suddenly, on February 20 (three weeks after the first case), <a href="https://time.com/5788661/italy-coronavirus-cases/">an Italian citizen</a> who had reportedly never travelled to China or had contact with anyone who came from Asia, tested positive, confirming <a href="https://jamanetwork.com/journals/jama/fullarticle/2763401">local transmission has started</a>.</p>
<p>Since then, cases have exploded and followed an <a href="https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930627-9">exponential</a> growth pattern. About six weeks after the first case, at March 18, the SARS-CoV-2 virus had infected <a href="https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200317-sitrep-57-covid-19.pdf?sfvrsn=a26922f2_2">31,506 people and caused more than 2,500 deaths</a>.</p>
<p>Iran is an example of exponential growth rates higher than Italy’s and in a shorter period. The first case in Iran was found and reported more slowly compared to Italy and South Korea, on <a href="https://annals.org/aim/fullarticle/2763328/estimation-coronavirus-disease-2019-covid-19-burden-potential-international-dissemination">February 19, 2020</a>.</p>
<p>Elections and political pressure there <a href="https://www.tehrantimes.com/news/445074/Iran-denies-first-case-of-coronavirus-death">delayed</a> the examination of infected patients. The government punished those spreading <a href="https://www.tehrantimes.com/news/445586/Anybody-who-spreads-fake-news-about-coronavirus-will-get-3-year">rumours</a> about the outbreak, like <a href="https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/protecting-chinese-healthcare-workers-while-combating-the-2019-novel-coronavirus/03DEB8D3BF68A674ADAB3FC4EF245E40">what the Wuhan local government did in early January 2020</a>.</p>
<p>In less than two weeks, the Iranian Ministry of Health reported <a href="https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200301-sitrep-41-covid-19.pdf?sfvrsn=6768306d_2">593 cases</a> and the number continues to rise. Only one month since the first case, on March 18 in Iran, there were <a href="https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200317-sitrep-57-covid-19.pdf?sfvrsn=a26922f2_2">almost 16,200 cases and 988 deaths</a>.</p>
<iframe title="The total number and exponential growth of COVID-19 cases in Italy, Iran and South Korea" aria-label="Interactive line chart" src="https://datawrapper.dwcdn.net/jyawM/1/" scrolling="no" frameborder="0" style="border: none;" width="100%" height="400"></iframe>
<p><strong>The static phase</strong></p>
<p>In this phase, cases have increased to a point from which they start to decrease. And the addition of new cases is no longer as fast as in the exponential phase. New cases still appear, but the number is relatively stable.</p>
<p>Several factors may cause a decrease in this phase. First, the infection growth decreases due to interventions that reduce transmission. Second, the community has developed immunity and is resistant to the infection. Third, there is a reduction in people vulnerable to infection (in other words, many people have died).</p>
<p><strong>The decline phase</strong></p>
<p>The last phase is when the infection rate shows a negative trend, and the number of new cases is on a downward trend (period of decline).</p>
<p>The length of the period of each phase is difficult to predict. But certainly, the exponential phase will happen soon after the delay phase.</p>
<h2>How about the doubling time in Indonesia?</h2>
<p>The site of <a href="https://ourworldindata.org/coronavirus-source-data">Our World in Data</a> calculates the rate of growth of new cases for various countries. </p>
<p>For South Korea, the number of new cases doubles every 13 days. Iran and Italy are worse, doubling every seven and five days respectively. China, in March, doubled its cases every 33 days.</p>
<iframe title="New COVID-19 cases in Italy, Iran and South Korea&nbsp;" aria-label="Interactive line chart" src="https://datawrapper.dwcdn.net/ypxyg/4/" scrolling="no" frameborder="0" style="border: none;" width="100%" height="500"></iframe>
<p>Indonesia’s doubling time is two days. In other words, the number of Indonesian cases will double every two days. If we refer to this figure, it is estimated that by the end of March 2020, Indonesia will report more than 20,000 cases.</p>
<p>This is a very large number and can paralyse the Indonesian health system.</p>
<p>But let’s assume the doubling time of Indonesia is the same as Iran (seven days) or Italy (five days), then we get a picture of cases piling up in April. Assuming exponential growth similar to Iran and Italy, then at the end of March, Indonesia will report between 600-1,000 cases and by the end of April, there will be between 11,000-71,000 coronavirus cases.</p>
<iframe title="Predicted exponential growth of COVID-19 cases in Indonesia till the end of April" aria-label="Interactive line chart" src="https://datawrapper.dwcdn.net/qeXkz/4/" scrolling="no" frameborder="0" style="border: none;" width="100%" height="600"></iframe>
<p>We should note that the reported cases are people who came to a medical facility on their own. These people come after recognising symptoms resembling COVID-19 or people tracked from contact tracing of previous positive patients.</p>
<p>We still don’t know how many people who have COVID-19 have not, or do not want to, come for testing because <a href="https://www.thejakartapost.com/news/2020/03/20/indonesia-starts-rapid-tests-imports-medicines-to-cure-covid-19-jokowi-says.html">almost three weeks after first case detected</a> there is no mass testing as in <a href="https://www.worldometers.info/coronavirus/covid-19-testing/">South Korea and Italy</a>. </p>
<p>Massive COVID-19 <a href="https://www.thejakartapost.com/news/2020/03/20/govt-says-rapid-covid-19-testing-kits-can-return-results-in-two-minutes.html">rapid testing</a> with 125,000 COVID-19 antibody-based rapid testing kits is starting this week in the several cities and regencies of coronavirus hot spot of <a href="https://www.thejakartapost.com/news/2020/03/24/as-contagion-spreads-indonesia-focuses-covid-19-tests-in-three-worst-hit-provinces.html">Jakarta, West Java and Banten provinces</a> focusing on vulnerable groups including medical workers. </p>
<h2>Interventions to prevent exponential growth</h2>
<p>Indonesia has just entered the exponential phase. The government must take immediate action to slow down the doubling of cases, by: </p>
<ol>
<li><p>increasing examinations of people at risk in areas where an infected case occurred or areas that have an indication of transmission. Utilise rapid and high detection performance tests to differentiate accurately between infected and non-infected individuals. </p></li>
<li><p>provide data on patient location at the sub-district level so the public can take part in examining themselves and avoid contact with these areas </p></li>
<li><p>raise public awareness and encourage the community to <a href="https://theconversation.com/social-distancing-what-it-is-and-why-its-the-best-tool-we-have-to-fight-the-coronavirus-133581">minimise contact with each other, or social distancing</a>. For example, restrict mobility between contaminated districts or cities, implement strict migration surveillance to individuals returning home from contaminated areas, and apply sanctions to violations on mass gathering ban.</p></li>
</ol>
<p>With more intensive use of science and technology and improved coordination between local institutions and also cooperation between organisations at regional and international levels, we believe this pandemic can be controlled.</p><img src="https://counter.theconversation.com/content/134239/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Para penulis tidak bekerja, menjadi konsultan, memiliki saham atau menerima dana dari perusahaan atau organisasi mana pun yang akan mengambil untung dari artikel ini, dan telah mengungkapkan bahwa ia tidak memiliki afiliasi di luar afiliasi akademis yang telah disebut di atas.</span></em></p>Massive COVID-19 rapid testing is starting this week in the several cities and regencies of coronavirus hot spot of Jakarta, West Java and Banten focusing on vulnerable groups.Iqbal Elyazar, Researcher in disease surveillance and biostatistics, Eijkman-Oxford Clinical Research Unit (EOCRU)Sudirman Nasir, Senior lecturer and researcher at the Faculty of Public Health, Universitas HasanuddinSuharyo Sumowidagdo, Physicist, Indonesian Institute of Sciences (LIPI)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1313412020-02-19T15:43:48Z2020-02-19T15:43:48ZObesity is more common than you think – here’s why<figure><img src="https://images.theconversation.com/files/316177/original/file-20200219-11044-1n4wp7d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/little-happy-cute-boy-eating-donut-632097332">Shutterstock</a></span></figcaption></figure><p>The World Health Organization has <a href="https://www.who.int/nutrition/topics/obesity/en/">described</a> obesity as a global epidemic and one of today’s “most blatantly visible yet neglected public health problems”. In the last few years <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1614362">reports</a> on the rise of this life-threatening condition among children and adults across the globe have been <a href="https://www.ncbi.nlm.nih.gov/pubmed/29029897">alarming</a>. </p>
<p>A total of 107.7 million children and 603.7 million adults were considered to be obese in 2015. But now our <a href="https://www.who.int/bulletin/volumes/96/11/17-205948/en/">research</a> shows that obesity is even more common than these reports suggest, and that in many countries most people are now living with obesity. </p>
<p>Obesity is a disease in which the amount of body fat is too high – high enough to harm health. It can increase the risk of diabetes, high blood pressure, heart problems, stroke and some cancers. But measuring body fatness accurately is difficult – and so most scientific studies and national surveys do not measure it, but use instead the weight-to-height <a href="https://www.nhs.uk/common-health-questions/lifestyle/what-is-the-body-mass-index-bmi/">body mass index</a> (BMI) as a simple proxy for body fatness.</p>
<p>But the issue here is that the BMI can be a misleading proxy for high body fatness in both children and adults – and even more so in particular ethnic groups. This means that many people with apparently healthy BMI will actually be living with high body fatness without being aware of it, and so be at risk of the serious health consequences without realising it. Our research aimed to assess how problematic BMI is when used as a proxy for high body fatness in African children.</p>
<h2>The problem with body-mass index</h2>
<p>A high BMI or BMI-for-age – in children and adolescents BMI has to be adjusted for age because it increases with growth and maturation – is usually taken to represent high body fatness. The problem is that while almost all <a href="https://www.ncbi.nlm.nih.gov/pubmed/20125098">adults</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/24961794">children</a> who have a high BMI will have a high level of body fat, many people with an apparently healthy BMI will also have a high level of body fat.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/mjR6KRMPQGw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>It is well known that BMI misclassifies the body fatness of athletes, bodybuilders and sportsmen and women, because a high muscle mass produces a high BMI. Only a small proportion of the population are athletic though, and the far more common problem with BMI is that it misclassifies body fatness of this much larger, non-athletic portion of the population – but in the opposite direction, meaning it downplays its extent.</p>
<p>The extent of the misclassifying of body fatness by BMI matters. Most studies which have measured both body fatness and BMI have taken place in Europe and North America – and in these studies the prevalence of high body fatness has been as much as two to three times greater than the prevalence of high BMI. In <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0033308">one example</a>
26% of US adults were obese according to their BMI, while 64% of the same adults were obese according to a more accurate measure which images the amount of fat in the body directly using X-rays. </p>
<h2>Obesity and ethnicity</h2>
<p>The problem of underestimating obesity is even worse in some population groups. The extent to which the BMI misclassifies the body fatness of people <a href="https://www.ncbi.nlm.nih.gov/pubmed/27383689">depends on their ethnicity</a>. It is well established, but not well known, that BMI misclassifies children and adults in south and east Asia even more than Europeans.</p>
<p>There is emerging evidence that this problem extends to using BMI in other population groups too. In our <a href="https://www.who.int/bulletin/volumes/96/11/17-205948/en/">recent study</a> of children living in eight cities across Africa from Windhoek in the south to Tunis in the north, we found that 9% were obese according to their BMI-for-age, but 29% had high body fat according to a <a href="https://humanhealth.iaea.org/HHW/Nutrition/BodyComposition/RefsBodyComp/TBW_2015.pdf">stable isotope technique</a> designed for measuring body fatness.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/316189/original/file-20200219-11023-rvefcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/316189/original/file-20200219-11023-rvefcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=378&fit=crop&dpr=1 600w, https://images.theconversation.com/files/316189/original/file-20200219-11023-rvefcw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=378&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/316189/original/file-20200219-11023-rvefcw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=378&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/316189/original/file-20200219-11023-rvefcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=475&fit=crop&dpr=1 754w, https://images.theconversation.com/files/316189/original/file-20200219-11023-rvefcw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=475&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/316189/original/file-20200219-11023-rvefcw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=475&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People in south Asia are more likely to misclassified according to the BMI measure of fatness than Europeans.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/obese-brother-sister-eating-box-lunch-697576930">Shutterstock</a></span>
</figcaption>
</figure>
<p>By underestimating the prevalence of obesity because of reliance on BMI in clinics, research studies and national health surveys, we also underestimate the need for action to prevent and treat obesity. To use our African study as an example, the case for action at a 29% prevalence of obesity is much stronger than at a prevalence of 9%. Obesity is far more common than it seems, and it requires much greater effort and more urgent attention than it is currently receiving. </p>
<p>As we enter a new decade it is time for national resolutions that are more ambitious. The main drivers of the global obesity epidemic are well known: excessive fat and sugar intake, lack of sleep, too much screen time, insufficient physical activity. We need global measures across all age groups to address these elements and we need them now.</p><img src="https://counter.theconversation.com/content/131341/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John J Reilly receives funding from the Scottish Funding Council, Scottish Government Chief Scientist Office, Hannah Research Foundation, Cunningham Trust, World Health Organisation.. </span></em></p>The problematical body-mass index method of measuring fatness means the number of people who are obese has been seriously underestimated.John J Reilly, Professor of Physical Activity and Public Health Science, University of Strathclyde Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1315712020-02-13T08:59:32Z2020-02-13T08:59:32ZLassa fever: why there’s a call to declare a health emergency in Nigeria<figure><img src="https://images.theconversation.com/files/315042/original/file-20200212-61935-6wbvv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Alarmed by a rapid spread of Lassa fever, the Nigerian Academy of Science is calling on government to declare a health emergency. </span> <span class="attribution"><span class="source">Pius Utomi Ekpei/AFP via Getty Images</span></span></figcaption></figure><p><em>The Nigerian Academy of Science <a href="https://guardian.ng/news/declare-lassa-fever-national-emergency-says-academy-of-science/">has called</a> for the current outbreak of Lassa fever in Africa’s most populous nation to be declared a national health emergency because of its severity. Adejuwon Soyinka asked Dr Doyin Odubanjo to unpack the background.</em></p>
<p><strong>How serious is the current Lassa fever outbreak in Nigeria?</strong></p>
<p>It is serious enough given the worsening trend. It has spread from just two states when it was first diagnosed in 1969 to <a href="http://www.xinhuanet.com/english/2020-02/10/c_138769873.htm">23 states in 2019</a>. The situation has increasingly got worse over the years. In 2018, the Nigerian Centre for Disease Control <a href="https://ncdc.gov.ng/diseases/info/L">reported</a> the largest ever number of cases in Nigeria, with over 600 confirmed cases and over 170 deaths. </p>
<p>And the numbers have continued to rise. An alarm was raised over the tripling of the number of suspected cases between 2017 and 2018 only for the reported number of suspected cases <a href="http://www.xinhuanet.com/english/2020-02/10/c_138769873.htm">to rise in 2019</a>. </p>
<p>Outbreaks have historically occurred during the dry season – November to April. But in recent years there have also been cases during the rainy season. Fatality rates are also <a href="https://ncdc.gov.ng/diseases/info/L">unacceptably high</a>. Over the last few years they have remained between 20% and 25%. This is particularly bad given that there is an effective treatment for the disease if it’s detected early and patients are presented at the hospital.</p>
<p><strong>How do people get infected and why has it been persistent?</strong></p>
<p>Lassa fever <a href="https://theconversation.com/lassa-fever-will-keep-ravaging-nigeria-unless-better-surveillance-is-put-in-place-83847">is a viral haemorrhagic disease</a> caused by the Lassa virus which naturally infects the widely distributed house rat. It’s transmitted through the urine and droppings of infected rats found in most tropical and subtropical countries in Africa. They are able to contaminate anything they come in contact with. The Lassa virus spreads through human to human contact with tissue, blood, body fluids, secretions or excretions. This includes coughing, sneezing, kissing, sexual intercourse and breastfeeding. In hospitals the disease is spread through contaminated equipment.</p>
<p>People become ill six to 21 days after they are infected. A fever is usually the first symptom followed by headaches and coughing, nausea and vomiting, diarrhoea, mouth ulcers and swollen lymph glands. Some patients also complain of muscle, abdomen and chest pains. And later, patients’ necks and faces swell and they bleed from their orifices and into their internal organs. Lassa fever can be fatal, but it can be treated if diagnosed early.</p>
<p><a href="https://www.cdc.gov/vhf/lassa/treatment/index.html">A drug</a> does exist for the treatment of the disease. But its efficacy is affected by the fact that Nigeria has inefficient laboratory diagnosis and patients are admitted late to hospital. </p>
<p>The spread of the disease throughout the country may also have resulted from increased contact between humans and rodents. This has happened as populations of rodents have grown, encouraged by a pervasively poor environmental sanitation. </p>
<p>Another factor is that inadequate attention has been paid to the disease. This has led to poor funding for research into drugs, including vaccination, and compounded by a weak disease surveillance and response system and a relatively weak health system.</p>
<p><strong>What needs to be done?</strong></p>
<p>To successfully turn the tide, governments at state and federal level need to mount an extensive and sustained public Lassa fever prevention and control awareness programme.</p>
<p>States of the federation also need to establish functional isolation wards for the treatment of Lassa fever patients. </p>
<p>It is also important to set up a mechanism for improving environmental sanitation in a sustained way throughout the country to reduce rodent population as well as rodent – human contact.</p>
<p>Funds should also be provided for research into finding new drugs for Lassa fever treatment and the development of a Lassa fever vaccine.</p>
<p><strong>What difference would a public health emergency make?</strong></p>
<p>A recent, and good example, of the difference this can make was the <a href="https://www.bbc.com/news/world-africa-28715939">announcement</a> of a public health emergency in 2014 to tackle the Ebola virus outbreak.</p>
<p>The announcement led to an emergency mode being activated with the attendant political will and funding which <a href="https://theconversation.com/how-nigeria-beat-the-ebola-virus-in-three-months-41372">ultimately stopped</a> the spread of the disease within 93 days.</p>
<p>This is why the Nigerian Academy of Science is calling for more action. In particular, we are recommending that an interdisciplinary committee be set up comprising medical and veterinary specialists, epidemiologists, social scientists, media practitioners, community representatives. This would be along the lines of an approach known as One Health. This is rooted in the understanding that human health is affected by interactions between people, the environment and animals. </p>
<p>Equally important is the need for the government to enhance the capacity of the national laboratory network for reliable and efficient diagnosis of suspected cases. This is because only about 20% of suspected Lassa fever cases are usually <a href="https://www.frontiersin.org/articles/10.3389/fpubh.2019.00170/full">diagnosed</a>.</p>
<p>Government should also provide adequate funds for a sensitive disease surveillance and response system. This is a system that ensures disease outbreaks (not just Lassa fever) are quickly noticed, diagnosed, and appropriate responses or containment measures are started in the shortest possible time.</p><img src="https://counter.theconversation.com/content/131571/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Doyin Odubanjo does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Concerned about rising cases and spread of Lassa fever, the Nigerian Academy of Science has called on government to declare it a national health emergency.Doyin Odubanjo, Executive Secretary, Nigerian Academy of ScienceLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1304882020-01-28T12:27:28Z2020-01-28T12:27:28ZPerspectives from Kenya and Ghana on coronavirus preparations<figure><img src="https://images.theconversation.com/files/311605/original/file-20200123-162232-1gij0ys.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kenyan health workers from port health services screen inbound travelers for temperatures at Nairobi's Jomo Kenyatta International Airport.
</span> <span class="attribution"><span class="source">EPA/Daniel Irungu</span></span></figcaption></figure><p><em>Chinese officials have <a href="https://www.who.int/health-topics/coronavirus">identified</a> a novel coronavirus which belongs <a href="https://theconversation.com/what-the-latest-coronavirus-tells-us-about-emerging-new-infections-130623">to a family of viruses</a> that cause illnesses ranging from the common cold to more severe diseases. Countries across the world have heightened their disease surveillance systems and, in some cases, issued travel advisories. The Conversation Africa asked experts from Ghana and Kenya about their preparedness.</em> </p>
<hr>
<p><strong>What measures need to be put in place to contain the virus?</strong></p>
<p><strong><em>Abdhalah Ziraba, Kenya:</em></strong> Public health education, particularly for travellers and airport public health staff, is critical. National newspapers and broadcast channels, as well as various social media outlets, should be used. People in all countries, not just Kenya, need to be made aware of the symptoms which include fever, cough, difficulty breathing, sneezing, and body aches.</p>
<p>The other important intervention is to maintain vigilance at entry ports to screen for fever and vet travel histories, particularly incoming flights from China and the region. Kenya has <a href="https://mobile.nation.co.ke/news/Kenya-issues-alert-on-Coronavirus/1950946-5427668-1597ihgz/index.html">announced</a> that it will screen all passengers arriving from China and increased the levels of vigilance at all entry points. </p>
<p>All suspected cases need to be assessed further. A major consideration will be whether someone has a history of travelling from Wuhan, the Chinese epicentre of the outbreak, and other cities that have reported cases or being in contact with a person suspected of having the disease. </p>
<p>After being assessed, any suspected cases should be reported to the country’s health authorities immediately, and the subjects isolated and managed as per protocol.</p>
<p><strong><em>Peter Kojo Quashie, Ghana</em>:</strong> A number of measures need to be put in place. Due of the previous and ongoing response to Ebola, some measures are already in place.</p>
<ul>
<li><p>Arriving passengers need to be screened for elevated temperatures. Those with high ones need to be quarantined</p></li>
<li><p>travel history needs to be established</p></li>
<li><p>Secure quarantine areas at airports and selected hospitals</p></li>
<li><p>Rapid testing protocols must be put in place</p></li>
<li><p>Port and airport health officials and everyone who will get in contact with travellers should be properly educated on how to behave and what personal protective equipment (PPE) is required. </p></li>
</ul>
<p>On top of these, additional steps should include:</p>
<ul>
<li><p>Routing passengers arriving from China and other South East Asian countries to another terminal or section, and screening them individually. </p></li>
<li><p>Continuous monitoring of passengers from China and South East Asia for at least a month as was done in some countries for people who returned from Ebola endemic regions. These travellers should be counselled on the need to avoid large crowds and non-essential contact with people.</p></li>
</ul>
<p>It is important to establish health support for Ghanaians in China, especially in Wuhan. It is also imperative to keep track of Ghanaians in China, providing them support as well as knowing when they return.</p>
<p><strong>What systems, already in place to deal with Ebola, will come in handy? What more needs to be done?</strong></p>
<p><strong><em>Abdhalah Ziraba, Kenya:</em></strong> Airport public health officials have got better at screening at ports of entry, especially for international arrivals. Basic screening is done using thermal cameras to detect fever. Kenyan officials have the equipment in hand and the trained personnel to swing into action fast.</p>
<p>Public health officials need to vigilant and have a high index of suspicion to be able to identify potential cases. They will then be able to flag travellers who seem unwell, more so if they have a matching travel history. </p>
<p>To support their work, public health authorities also need to mobilise a rapid surveillance and response team so that they can manage any suspected cases- including taking samples, isolation and reporting on developments.</p>
<p><strong><em>Peter Kojo Quashie, Ghana</em>:</strong> <a href="https://www.newsghana.com.gh/ghanas-main-airport-on-high-alert-over-coronavirus-outbreak/">Temperature</a> screening protocols have been in place since the onset of the 2014 Ebola crisis. I believe they need to be revisited to screen at a lower threshold (for example temperature > 37.5C) to avoid missing patients who are just beginning to show signs of the disease. </p>
<p>Scientists in the national influenza control lab at the University of Ghana have written standard operating procedures and testing protocols to allow for rapid laboratory detection of this new virus. This effort, in collaboration with Ghana Health Service, the <a href="http://www.africacdc.org/">Africa Centres for Disease Control and Prevention</a> and the West African Health Organisation, has been ongoing since the virus was first detected. </p>
<p>Steps that were effective during the Ebola crisis and helped reduce the spread of the virus included hand washing, as well as educating the public about what precautions they have to take for their personal and public health. </p>
<p><strong>What lessons can African countries bring to bear given their experience of handling outbreaks like Ebola?</strong></p>
<p><strong><em>Abdhalah Ziraba, Kenya</em>:</strong> Many countries are now readying themselves to mount a response bringing together specialists and other players from different sectors with centralised coordinating. Several countries also have epidemic outbreak response plans in place, as well as resources and facilities to deal with situations like this. But the comprehensiveness of these varies greatly. </p>
<p>Finally, with lessons from the Ebola, SAR and MERS outbreaks, there is a greater ability to coordinate a response and to keep the public accurately informed. This prevents a panic situation that often fuels the spread of outbreaks. Public health authorities are now more likely to avoid knee jerk interventions not supported by evidence. These can often be counterproductive, as was the case with the <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61412-4/fulltext">Ebola outbreak in West Africa</a>.</p>
<p><strong><em>Peter Kojo Quashie, Ghana</em>:</strong> There are significant differences between the Ebola virus and this coronavirus. First, the spread of Ebola was limited to villagers who crossed border freely, health workers, and a few immigrants who visited their villages and then returned. Second, it is transmissible by bodily fluids, and requires direct contact with an infected individual or surface.</p>
<p>If the latest coronavirus virus is transmitted like MERS or SARS, then it transmits like a <a href="https://foreignpolicy.com/2020/01/26/2019-ncov-china-epidemic-pandemic-the-wuhan-coronavirus-a-tentative-clinical-profile/">the common cold</a>. It is therefore likely to be much more <a href="https://foreignpolicy.com/2020/01/26/2019-ncov-china-epidemic-pandemic-the-wuhan-coronavirus-a-tentative-clinical-profile/a">infectious than Ebola</a>. </p>
<p>Fortunately, the preparedness of most African countries were not tested during the West African Ebola epidemic. Unfortunately, that means infection control protocols were never challenged. </p>
<p>In terms of a rapid laboratory diagnosis, we have protocols in place and skilled laboratory personnel. But we have to effectively isolate the risk. That’s the part that must continuously be worked on and reworked. </p>
<p>We should look at how countries like Canada managed to <a href="https://www.ncbi.nlm.nih.gov/books/NBK92467/">track down infected people</a> and keep the SARS epidemic in check in 2003. In addition, the WHO protocols published <a href="https://www.who.int/csr/resources/publications/WHO_CDS_CSR_ARO_2004_1/en/">in 2004 for SARS</a> will be more effective than protocols for Ebola. Lessons learned from the still ongoing <a href="https://www.who.int/emergencies/mers-cov/en/">MERS epidemic</a> would be useful, as well as understanding the issues of stigma and cultural issues that are the main challenges of the response to Ebola in Africa.</p>
<p>Other things to consider are the fact that, unlike SARS and unlike Ebola, there are <a href="https://www.sciencemediacentre.org/expert-reaction-to-news-reports-that-the-china-coronavirus-may-spread-before-symptoms-show/">reports</a> that patients infected with 2019-nCoV are infectious even during the incubation period, before they get a fever. This would mean that temperature screening won’t work. What would be required is stronger, and different, terminal and individualised screening.</p>
<p>But there are a few recommendations for personal safety that were effective during the SARS and Ebola outbreak. These included avoiding large crowds and stuffy areas as well as not shaking hands. Health sector workers should used enhanced personal protective equipment and change gloves regularly. Finally, masks can help. But they should be changed regularly and disposed of safely.</p>
<p>Lastly, if you have cold or flu-like symptoms and have been in contact with travellers from China, alert public health officials and avoid non-essential contact with others.</p><img src="https://counter.theconversation.com/content/130488/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Airport public health officials have got better at screening at ports of entry especially for international arrivals.Abdhalah Ziraba, Research Scientist, African Population and Health Research CenterPeter Kojo Quashie, Senior Research Fellow, West African Institute for Cell Biology of Infectious Pathogens, University of GhanaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1283652019-12-12T08:34:06Z2019-12-12T08:34:06ZIs it Ebola, or just a drill? How to test a public health crisis response<figure><img src="https://images.theconversation.com/files/305855/original/file-20191209-90574-1u9tekw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Hugh Kinsella Cunningham/ EPA-EFE</span></span></figcaption></figure><p>There wasn’t an Ebola outbreak in Lesotho – but for a few hours in November 2019, you may have heard that there was.</p>
<p>On <a href="https://ewn.co.za/2019/11/14/lesotho-confirms-first-ebola-case">November 14</a>, Lesotho public health authorities conducted a simulation exercise involving a woman who was rushed to hospital and tested positive for Ebola after crossing the border from South Africa. Media picked up on this event and reported it as if it were true. But a few hours later it was revealed that there had been no Ebola case in Lesotho, and this event was only a drill.</p>
<p>The Lesotho government was conducting a public health simulation exercise. When done properly, a simulation exercise is a useful tool for evaluating preparedness for a public health emergency. When done poorly, a simulation exercise can cause unnecessary panic in local or international communities. Here, we’ve drawn on our <a href="https://bushchicken.com/ebola-simulation-in-three-counties-gives-liberias-health-system-a-failing-grade/">experience in Liberia</a> to outline how to properly plan and execute a simulation exercise.</p>
<h2>What is a simulation exercise?</h2>
<p>A public health simulation exercise is a test of an emergency response system. Simulation exercises are used to develop emergency response protocols, train staff, and monitor and evaluate the capability of the public health system to respond to emergencies. Regular exercises make it possible to identify areas for improvement and ensure that a health system will be able to respond appropriately to a true crisis.</p>
<p>The World Health Organisation (WHO) lays out <a href="https://www.who.int/ihr/publications/WHO-WHE-CPI-2017.10/en/">guidelines</a> for planning various types of simulation exercises. Simulation exercises can range from tabletop discussions to partial tests to full-scale field exercises.</p>
<p>The simulation in Lesotho was a full-scale exercise. This is the most complex type, intended to mirror real-life emergency situations as closely as possible. It tests many components of an emergency plan and may involve many organisations and multiple countries. Full-scale exercises are immensely valuable for testing emergency management plans under close-to-real conditions. But they are difficult to plan and can cause alarm in the wider community if not executed thoughtfully and deliberately.</p>
<h2>Planning a simulation</h2>
<p>Planning a simulation exercise should involve discussions with key stakeholders about the purpose, scope and objectives of the exercise. An exercise management team should be created to develop and conduct the exercise. This will typically include a project management plan, identification of participants and logistics management.</p>
<p>The people being tested – such as local health workers – should not be told that they are undergoing a simulation exercise. After all, the purpose is to assess what would occur in a true emergency. That said, key stakeholders who are not being tested should be made aware that a simulation exercise is under way. Otherwise they may respond as if there were a real crisis, leading to unnecessary mobilisation.</p>
<p>Key stakeholders may include the leaders of ministries such as health, information and internal affairs; members of the media; and leaders of partner organisations who may be involved in a public health response. If the simulation involves multiple countries, stakeholders in each country should be informed.</p>
<p>Stakeholders should be informed in advance and updated while the simulation exercise is under way. It is very important that the word “simulation” or “exercise” is displayed prominently in all communication. </p>
<p>Media organisations should be informed ahead of time. If news media outlets hear about the event but are unaware that it is a simulation, they may report it as if it were true. This can cause unnecessary panic.</p>
<p>WHO <a href="https://www.who.int/ihr/publications/WHO-WHE-CPI-2017.10/en/">guidelines</a> for simulation exercises recommend creating a strategy to communicate with media, local communities and the public. There should be a designated media point person and clear lines of communication should be publicised. News outlets should be able to contact the exercise management team and receive reliable information.</p>
<p>The exercise management team should anticipate potential media and public relations issues and help prevent misinformation from spreading.</p>
<h2>Running the exercise effectively</h2>
<p>The exercise will begin with a message sent containing the prompt. In a full-scale exercise, teams of health workers are physically deployed to the location to respond as they would in an actual emergency. Actors may play the role of patients – for example, in a simulation exercise testing infection prevention control and management, an actor may play a person who is exhibiting Ebola symptoms. The exercise management team will observe and evaluate the emergency response.</p>
<p>If the initial team of health workers fails to respond appropriately, the exercise management team will escalate the response to the next level. For example, if health workers at a village clinic fail to properly isolate a suspected Ebola case, the management team may call an ambulance, and then test how the ambulance workers respond. Eventually, the response could grow to the national or international level.</p>
<p>A full-scale simulation exercise will last for at least one day and up to four or five days. At the end, the project management team will review what happened and whether the response was appropriate. Findings are used to improve emergency protocols, train staff and solve other problems that arose. </p>
<h2>Lessons</h2>
<p>A simulation exercise strengthens health systems – and helps countries prepare for real public health emergencies.</p>
<p>It’s difficult to determine if Lesotho’s public health simulation exercise was a success because lessons about emergency preparedness were overshadowed by panic. With proper planning and management, Lesotho and other countries can conduct future simulation exercises without making headlines.</p><img src="https://counter.theconversation.com/content/128365/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mosoka Fallah consults for MERCK/MSD as an expert from Africa on the process of the Ebola vaccine licensing.</span></em></p><p class="fine-print"><em><span>Lucy Tantum does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When done properly, a simulation exercise is a useful tool for evaluating preparedness for a public health emergency.Mosoka Fallah, Part-time lecturer at the Global Health & Social Medicine, Harvard University, and Lecturer at the School of Public Health, College of Health Sciences, University of LiberiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1246172019-10-04T13:05:30Z2019-10-04T13:05:30ZWhy it’s dangerous for Tanzania to withhold information about Ebola fears<figure><img src="https://images.theconversation.com/files/295272/original/file-20191002-49383-wa3s2a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tedros Adhanom Ghebreyesus, World Health Organisation Director-General, speaking on Ebola at the UN's Geneva headquarters. </span> <span class="attribution"><span class="source">EPA/Martial Trezzinni</span></span></figcaption></figure><p>In the past few weeks there have been unofficial reports that some people in Tanzania, including one in Dar es Salaam, had <a href="https://www.theguardian.com/global-development/2019/sep/23/alarm-over-cases-of-disease-with-ebola-like-symptoms-in-tanzania">died</a> of what was suspected to be Ebola virus disease. As we know, there is an ongoing outbreak in eastern Democratic Republic of Congo (DRC) in which <a href="https://www.who.int/emergencies/diseases/ebola/drc-2019">thousands have died</a>. </p>
<p>The World Health Organisation (WHO) <a href="https://www.washingtonpost.com/world/tanzanias-refusal-to-acknowledge-possible-ebola-casesrepresents-a-challenge-who/2019/09/22/70bf9a80-dd19-11e9-be96-6adb81821e90_story.html">has criticised</a> Tanzania for failing to provide details about suspected cases of Ebola in the country. While Tanzania insisted it had no confirmed or suspected cases of Ebola, it did not directly address the case of the woman mentioned by the WHO and provided no further information. </p>
<p>The reports are a cause for concern because they followed earlier cross-border Ebola cases and fatalities in neighbouring Uganda which were clearly linked to <a href="https://theconversation.com/ebola-one-year-on-the-wins-the-setbacks-and-the-way-forward-124292">the DRC outbreak</a>. The ongoing concern is that the disease might spread in the region, and potentially even globally.</p>
<p>The DRC outbreak <a href="https://theconversation.com/why-declaring-ebola-a-public-health-emergency-isnt-a-silver-bullet-120685">was declared a global public health emergency</a> in July and regional countries were advised to proactively monitor the situation and report any suspected cases of Ebola. </p>
<p>The cases in Tanzania, if confirmed, are also highly likely to be related to the ongoing outbreak in the DRC. </p>
<p>What is different and a departure from international norms in Tanzania’s case is the lack of transparency, and information sharing. No clinical data, investigation results, contact tracing and laboratory tests performed have been shared by the government. </p>
<p>Why the government has taken this route is unclear and some observers are alleging a <a href="https://www.bbc.com/news/world-africa-49786823">cover-up</a> in which for whatever reason, the authorities in Tanzania seem deliberate about not providing the information that have been requested for by WHO. <a href="https://www.africanews.com/2019/10/02/there-is-no-ebola-in-tanzania-minister/">Fear</a> and concerns among international <a href="https://www.statnews.com/2019/09/27/ebola-tanzania-travelers-alerted-to-possible-unreported-cases/">travellers</a> are <a href="https://www.vox.com/science-and-health/2019/9/23/20879869/ebola-2019-outbreak-tanzania">spreading fast</a>. </p>
<p>One possible explanation might be that the government is reluctant to give out details for fear of alarming the public and the international community. Providing information could spread panic while also affecting international travel, tourism and business. </p>
<p>The problem with this thinking is that it means missing the opportunity to contain the outbreak before more people are exposed. When this happens, a much better response is needed. And panic, as well as travel and business disruptions, may end up being even greater. </p>
<h2>Why information matters</h2>
<p>The importance of sharing information cannot be over-estimated. Ebola can spread at a phenomenal speed – as was shown in the 2014-2016 outbreak in West Africa. The only way to ensure this doesn’t happen is to provide information to the public, stakeholders, put service providers on high alert, provide necessary suppliers, and ensure a functional laboratory capacity is in place. Those who have come in contact with people who have contracted the virus need to be isolated while the infected need supportive care. </p>
<p>Getting all stakeholders on board lessens the burden of containing an outbreak. For example, in Ebola outbreak situations we have seen before, the WHO is often willing and ready to provide technical capacity where these are lacking. These include personnel, laboratory and supplies. No such requests have been made in this case. </p>
<p>The WHO provides<a href="https://www.who.int/ebola/publications/en/"> extensive guidance</a> on a range of issues. These include definitions of suspected Ebola virus disease cases, setting up surveillance systems, contact tracing, infection prevention among health care providers and handling deaths. Under the International Health Regulations, Ebola is classified as a notifiable disease. This means that countries are <a href="https://www.who.int/ihr/publications/9789241596664/en/">obligated</a> to report suspected and confirmed Ebola cases. </p>
<p>The first action on any suspected case of Ebola is to isolate the person and to provide supportive treatment. At this stage, samples are taken to a reference laboratory for testing. The next step is to trace all the people with whom the person had contact with and to try and establish whether they are showing symptoms or not. </p>
<p>Most of the outbreaks that have caused lots of infections and deaths have been as a result of a poor response in identifying and isolated early cases. For example in Guinea it took about <a href="https://www.who.int/csr/disease/ebola/one-year-report/factors/en/">three months to establish Ebola as the cause of the epidemic</a>. This usually happens where health systems are weak, as was the case with the west Africa outbreak and in the DRC. Insecurity is an <a href="http://www.cidrap.umn.edu/news-perspective/2019/05/experts-drc-ebola-outbreak-fueled-attacks">additional layer</a> to the challenges of containing the outbreak in the DRC. </p>
<p>The Ebola virus is transmitted through body fluids. Risk of exposure is high in particular settings. These include health facilities such as laboratories, during burial rituals involving the washing of corpses, and other intimate acts such having sex with an infected person. The web or network of exposed people can grow quickly from one case if steps aren’t taken early on to avoid further onward transmission. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/15178190/">Research</a> has shown that the number of new cases generated from a single case in the absence of control measures can be as high as two. Given the <a href="https://www.cdc.gov/vhf/ebola/pdf/what-need-to-know-ebola.pdf">relatively short incubation period</a> of two to 21 days, several new cases can develop and a full blown outbreak may manifest. </p>
<h2>Next steps</h2>
<p>In the event that Ebola cases are confirmed in Tanzania, the logical thing to do is to act fast to stem further spread. Isolation of infected people and their contacts is critical. </p>
<p>New <a href="https://theconversation.com/the-uganda-vaccine-trial-how-african-researchers-are-tackling-ebola-121517">vaccines are being tried</a> in the DRC and Uganda especially among front line health workers who are more likely exposed to virus through attending to patients. This could also be considered to protect those at the highest risk of exposure.</p>
<p>The WHO and other UN agencies discourage countries from imposing travel bans. The WHO argues that <a href="https://www.who.int/mediacentre/commentaries/ebola-travel/en/">travel bans</a> are detrimental and ineffective in the control of Ebola outbreaks. Nevertheless, there is usually nervousness among potential travellers which ultimately affects businesses and normal life.</p><img src="https://counter.theconversation.com/content/124617/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Abdhalah Ziraba does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The web or network of exposed people can quickly grow from one case if steps aren’t taken early to avoid further onward transmission.Abdhalah Ziraba, Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1206852019-07-19T12:49:48Z2019-07-19T12:49:48ZWhy declaring Ebola a public health emergency isn’t a silver bullet<figure><img src="https://images.theconversation.com/files/284958/original/file-20190719-116562-1t5i1dz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health officer on the front-line in the DRC</span> <span class="attribution"><span class="source">Flickr</span></span></figcaption></figure><p>The World Health Organisation (WHO) has declared the Ebola outbreak in the Democratic Republic of the Congo (DRC) a <a href="https://www.who.int/ihr/procedures/pheic/en/">Public Health Emergency of International Concern</a>. It took the decision based on International Health Regulations agreed in 2005. These require the WHO to declare an emergency when a public health event, such as an outbreak, becomes extraordinary because it constitutes a risk to other countries, and when a coordinated international response is required. </p>
<p>The emergency committee from the WHO – which is responsible for taking this decision – has met four times since the outbreak was declared in the DRC’s North Kivu region on <a href="https://www.who.int/ebola/situation-reports/drc-2018/en/">1 August 2018</a>. During the last meeting in June the committee decided that the outbreak didn’t constitute a public health emergency of international concern. </p>
<p>A month later the committee <a href="https://www.who.int/ihr/procedures/statement-emergency-committee-ebola-drc-july-2019.pdf">changed its mind</a>. Its reasons for doing so were that the number of cases had increased from 2071 to 2522. Even though the mortality rate had remained at 67%, three new cases were detected in Uganda. In addition, a case of Ebola was diagnosed in Goma, a city of almost 2 million that is a busy entry point for the DRC. The town sits on the Rwandan border.</p>
<p>The expected impact of the decision is that more funding will be raised for the response teams in the field as international support is stepped up. It will also give the DRC’s Ministry of Health more flexibility to ensure response teams reach even the remotest areas. More means are needed to ensure that teams are able to engage communities. Part of this is ensuring they have the logistics to access them, especially in the most remote places. </p>
<p>The decision is significant and should have a critical affect on the response. It will provide a second breath to address the new phase of the outbreak, hopefully ensuring that it is ended. </p>
<p>But the decision is not a silver bullet. The outbreak of a deadly disease within a conflict zone – and now in a major city – cannot be solved with a technical solution, such as more funding. </p>
<h2>What’s working, what’s not</h2>
<p>The Ebola response have not been enough to stop the spread of the outbreak. This is despite major efforts by the tireless Ebola response teams, community engagement, surveillance, vaccination and communication.</p>
<p>The number of cases and deaths have not declined. This suggests that people are still avoiding going to Ebola treatment centres to get care. This is despite the fact that new therapeutics are now being made available through a randomised clinical trial.</p>
<p>More than 100 000 people have been vaccinated. The vaccine hasn’t stopped the spread of the disease, although it has contributed to controlling it. The introduction of a second vaccine through a clinical trial would support the response, especially in the neighbouring regions of North Kivu, where no cases have been reported.</p>
<p>The other factor holding back efforts to eliminate the outbreak has been the increasing number of attacks on personnel in the area. Dr Richard Mouzoko, an epidemiologist working for the WHO, was <a href="https://www.who.int/news-room/detail/19-04-2019-who-ebola-responder-killed-in-attack-on-the-butembo-hospital">killed in April</a> and <a href="https://www.theguardian.com/global-development/2019/feb/28/arsonists-attack-ebola-clinics-in-drc-as-climate-of-distrust-grows">clinics have been torched</a>. The attacks highlight the complexity of responding to the already complicated outbreak in a conflict zone. </p>
<p>The violence is also getting in the way of engaging with communities, a major part of any Ebola response.</p>
<p>The DRC has also been facing challenges in getting the funds it needs to manage the response efficiently.</p>
<p>The Public Health Emergency of International Concern announcement is a call to the international community for action. But extra funds won’t be enough. the issue of unrest in North Kivu needs to be solved as it remains one of the major catalysts of this outbreak. Solving the outbreak requires a peaceful environment, wherein the community trusts the Ebola response team, and therefore, increase its engagement. Without a higher community awareness and engagement, it is difficult to see the end of Ebola outbreak in the DRC.</p><img src="https://counter.theconversation.com/content/120685/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yap Boum is the regional representative for Epicenter Africa, the research arm of Médecins sans Frontières. He is involved in the Ebola outbreak and the use of the Ebola vaccine for MSF/Epicenter. </span></em></p>The Ebola outbreak in the DRC has been declared a Public Health Emergency of International Concern. What does this mean for the outbreak response?Yap Boum, Professor in the faculty of Medicine, Mbarara University of Science and TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1196722019-07-07T09:03:30Z2019-07-07T09:03:30ZSharing data can help prevent public health emergencies in Africa<figure><img src="https://images.theconversation.com/files/282471/original/file-20190703-126360-6ijqvb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Countries can be better prepared and respond faster to disease outbreaks if public health data is shared more freely.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Global collaboration and sharing data on public health emergencies is important to fight the spread of infectious diseases. If scientists and health workers can openly share their data across regions and organisations, countries can be better prepared and respond faster to disease outbreaks.</p>
<p>This was the case in with the <a href="https://www.ncbi.nlm.nih.gov/pubmed/28405027">2014 Ebola outbreak in West Africa</a>. Close to 100 scientists, clinicians, health workers and data analysts from around the world worked together to help contain the spread of the disease. </p>
<p>But there’s a lack of trust when it comes to sharing data in north-south collaborations. African researchers are suspicious that their northern partners could publish data without acknowledging the input from the less resourced southern institutions where the data was first generated. Until recently, the authorship of key scientific publications, based on collaborative work in Africa, was dominated by scientists from outside Africa. </p>
<p>The Global Research Collaboration for Infectious Disease Preparedness, an international network of major research funding organisations, recently published a <a href="http://www.glopid-r.org/new-release-roadmap-to-data-sharing/">roadmap to data sharing</a>. This may go some way to address the data sharing challenges. Members of the network are expected to encourage their grantees to be inclusive and publish their results in open access journals. The network includes major funders of research in Africa like the European Commission, Bill & Melinda Gates Foundation and Wellcome Trust. </p>
<p>The roadmap provides a guide on how funders can accelerate research data sharing by the scientists they fund. It recommends that research funding institutions make real-time, external data sharing a requirement. And that research needs to be part of a multi-disciplinary disease network to advance public health emergencies responses. </p>
<p>In addition, funding should focus on strengthening institutions’ capacity on a number of fronts. This includes data management, improving data policies, building trust and aligning tools for data sharing.</p>
<p>Allowing researchers to freely access data generated by global academic counterparts is critical for rapidly informing disease control strategies in public health emergencies. </p>
<h2>Why share data</h2>
<p>Mounting appropriate and timely responses to emerging and re-emerging infectious diseases requires global cooperation on data analysis across disciplines. Examples include Ebola, Lassa fever and Yellow fever.</p>
<p>During the <a href="https://www.cdc.gov/vhf/ebola/history/2014-2016-outbreak/index.html">2014 Ebola outbreak in West Africa</a>, field and laboratory data collected in real-time were shared between scientists from different countries. These data revealed how the Ebola virus was evolving and spreading in the region. The information was then used to contain the spread of the virus in Guinea, Liberia and Sierra Leone.</p>
<p>Ninety-six individual investigators, including clinicians and scientists, from 60 institutions in 18 countries worked together. They collected and analysed data by sequencing 1,610 Ebola virus genomes. The data informed policy decisions in West Africa because government ministers from Sierra Leone and Liberia were part of the investigators. </p>
<p>The work done in West Africa shows that global data sharing can work.</p>
<p>This north-south collaboration is the research partnership model that the <a href="https://theconversation.com/how-a-partnership-is-closing-the-door-on-parachute-research-in-africa-102217">European and Developing Countries Clinical Trials Partnership</a> uses on the continent. </p>
<p>This is a partnership between the European Union and national institutions in Europe and sub-Saharan Africa. It was initially created in response to the global health crisis caused by HIV/AIDS, tuberculosis and malaria. Now it includes research and responses to neglected and emerging infections. </p>
<p>It currently supports several institutions that were involved in the West African study. As the regional director for Africa, I promote global collaborations that acknowledge inputs from Africa researchers and institutions. </p>
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Read more:
<a href="https://theconversation.com/how-a-partnership-is-closing-the-door-on-parachute-research-in-africa-102217">How a partnership is closing the door on "parachute" research in Africa</a>
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<h2>Collaborations</h2>
<p>Our north-south partnership is also making strides to improve the capacity for collaboration and data sharing. </p>
<p>The global research collaboration includes a number of members such as the African Academy of Sciences, the Academy of Scientific Research and Technology in Egypt and the South African Medical Research Council.</p>
<p>There are several initiatives under way. </p>
<p>For one, the African Academy of Sciences is in the early stages of building a <a href="https://aesa.ac.ke/cari/coalition-for-african-research-and-innovation/">Coalition for African Research and Innovation</a>. This platform will foster collaboration on research and innovation in Africa. It will also address the under investment in scientific talent and research infrastructure.</p>
<p>Another example is the <a href="https://pactr.samrc.ac.za/">Pan African Clinical Trials Registry</a>. This is hosted by the South Africa Medical Research Council. The registry provides access to contacts for researchers as well as trial sites. It also provides information on which organisation or institution funds various research projects. This data can be used to map clinical trial activity in several disease conditions relevant to the continent such as Ebola. </p>
<p>In 2017, for example, two public health emergencies networks and four regional networks of excellence were funded. This was to ensure that African countries are better prepared to prevent, respond to and minimise the impact of infectious disease outbreaks. </p>
<h2>Building partnerships</h2>
<p>Collaboration and data sharing has become a serious focus in the fight against public health emergencies. </p>
<p>Funding agencies, ethics and regulatory bodies in Africa, reviewers and grant recipients have been looking for ways to consolidate a efforts for collaboration and data sharing. </p>
<p>Among the issues that need to be addressed are big data, the way that databases can be managed and the implementation of systemic reviews. This is critical to prevent the next epidemic.</p>
<p>What the Ebola crisis in West Africa has shown us is that wide scale collaboration is helpful and works. The Global Research Collaboration roadmap instils confidence for such inclusiveness.</p><img src="https://counter.theconversation.com/content/119672/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Moses John Bockarie works for EDCTP which is funded by the European Commission. In addition to his honorary appointment at the South African Medical Research Council, he is also a honorary professor in the Department of Medicine, University of Cape Town, South Africa. He previously received funding from the UK Department for International Development</span></em></p>Sharing data openly across regions and organisations can help to accelerate preparedness and responses to public health emergencies.Moses John Bockarie, Honorary Chief Specialist Scientist, South African Medical Research CouncilLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1054052018-10-25T13:42:41Z2018-10-25T13:42:41ZWhy eradicating polio everywhere has been so hard to crack<figure><img src="https://images.theconversation.com/files/241603/original/file-20181022-105776-b5dnwy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nigerian children receiving the polio vaccine in Lagos. </span> <span class="attribution"><span class="source">EPA</span></span></figcaption></figure><p>Polio is a disease that struck fear into the hearts of parents just a generation ago.</p>
<p><a href="http://www.who.int/topics/poliomyelitis/en/">Poliomyelitis</a>, known as polio, is a viral illness which spreads through faeces and respiratory secretions. Polio causes sudden onset of weakness, often permanent paralysis, in otherwise healthy individuals. One arm or leg can become useless, or the whole body from the neck down can be paralysed. Often multiple children in the same household would die of the disease, with survivors left in wheelchairs. South Africa still had polio cases well into the 1980’s, with the last case of wild poliovirus in 1989.</p>
<p>The <a href="http://polioeradication.org/">Global Polio Eradication Initiative</a> has not gone according to plan. The first eradication target date of 2000 was missed. 2018 is the latest target that we are about to <a href="http://polioeradication.org/polio-today/polio-now/this-week/">miss</a>. This is due to hard-to-reach areas of instability, unrest and fundamentalism in Nigeria, Pakistan and Afghanistan where it’s a struggle to achieve the high vaccination coverage required to eliminate the disease. Health workers in these areas risk their lives to conduct vaccination programmes amid hostile communities. </p>
<p>Unfortunately, pockets of polio transmission provide reservoirs for resurgence at any time, with even one traveller able to bring polio back to a polio-free country.</p>
<p>Polio is targeted to be the second human disease ever eradicated through vaccination. <a href="http://www.who.int/csr/disease/smallpox/faq/en/">Smallpox</a> was the first success story in 1974. Other diseases, like measles, wait in the wings to be selected for third place. Eradication initiatives are too labour intensive for the world to commit to more than one at any given time. </p>
<p>In South Africa, the <a href="http://www.nicd.ac.za/">National Institute for Communicable Diseases</a> investigates every child with sudden neurological weakness for polio – processing hundreds of samples from South African children annually, despite not having a wild polio case for almost thirty years. Such a situation is unsustainable for more than one disease at a time.</p>
<p>The poliovirus has biological characteristics which have proven harder to combat than smallpox. Polio is a tough and hardy organism that can survive in the environment even when not carried by a human host. It’s stealthy, and can infect a hundred individuals silently before resulting in even one case of paralysis. This makes it difficult to trace and contain.</p>
<h2>The big successes</h2>
<p>Despite the setbacks, triumphs of the programme have been notable. Globally, polio caused more than <a href="http://www.who.int/features/factfiles/polio/en/">350 000</a> cases of paralysis in 1988 when the global polio eradication initiative was launched. In comparison, in 2017, there were <a href="http://polioeradication.org/news-post/a-career-spent-chasing-down-polio/">only 21</a> people paralysed by wild poliovirus. Of three viral strains, poliovirus type 2 has been eradicated, with wild poliovirus types 1 and 3 remaining.</p>
<p>But it’s too early to celebrate. Hotspots of wild poliovirus and related strains remain detectable. For this reason, a <a href="http://www.who.int/mediacentre/news/statements/2018/16th-ihr-polio/en/">global public health emergency of international concern</a> was declared for polio in 2014, the same level of threat given to the <a href="http://www.who.int/mediacentre/news/statements/2014/ebola-20140808/en/">Ebola</a> crisis the same year.</p>
<p>Ebola eclipsed polio in public perception. Despite the fear that strikes parents when hearing of Ebola, we have forgotten the potential devastation wreaked by polio. Unlike the gusto with which novel Ebola vaccines were embraced for Ebola epidemics, vaccination for polio has become “bread and butter”. Mothers take their children for vaccination with a sense of duty and purpose, hardly realising that they are participating in the largest social movement in the history of mankind.</p>
<p>Vaccination is a powerful example of social change; demonstrating impact of purpose united across geography and sustained through multiple generations. Every caregiver is participating in the most ambitious social endeavour in human history – to systematically eradicate dreaded diseases through immunisation.</p>
<p>What happens to the diseases waiting in the wings if the polio programme fails?</p>
<p>Cynics will ask if the smallpox success was merely a lucky break. Critics will query whether systematic disease eradication is an attainable human goal. The global polio eradication initiative comprises billions of dollars, hundreds of millions of children, millions of health workers and 30 years of work in hundreds of countries. We have gone too far to go back. It has been said that the global polio eradication initiative will be either a spectacular success or a spectacular failure.</p>
<p>Failure is unthinkable.</p><img src="https://counter.theconversation.com/content/105405/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Suchard discloses having received funding, administered through her university, for speaker honoraria and consultancy work from Aspen GSK, Prepex Circ Med Tech ltd and Paediatric Management Group. She has administered conference funding sponsored by Sanofi Pasteur and been a sponsored delegate to Vaccinology congresses. As part of her responsibilities at the National Institute for Communicable Diseases, she engages regularly with the World Health Organisation and the National Department of heath regarding issues related to the Expanded Programme on Immunization and is a member of the National Advisory Group on Immunization.. </span></em></p>The global target to eradicate polio is being missed because a number of countries are struggling to reach high vaccine coverage.Melinda Suchard, Head, Centre for Vaccines and Immunology, National Institute for Communicable DiseasesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/920612018-02-20T13:55:00Z2018-02-20T13:55:00ZGrowing up in poverty weakens later health – even if you escape it<p>Poverty remains a widespread problem. In the UK, <a href="http://www.cpag.org.uk/child-poverty-facts-and-figures">30% of children</a> are growing up in poverty. More than half of these children are in <a href="http://www.independent.co.uk/news/uk/home-news/british-poverty-60-per-cent-working-families-uk-jobs-employed-study-tax-credits-housing-university-a7751201.html">working households</a>, and poverty is on the rise even for children whose parents work in <a href="http://www.independent.co.uk/news/uk/home-news/surge-in-poverty-rates-among-children-of-public-sector-worker-parents-a8211166.html">government-funded jobs</a>.</p>
<p>According to <a href="https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afy003">new research</a> from the University of Geneva, these children may be at risk of poorer health in adulthood – even if they escape poverty later in life. This suggests that childhood adversity doesn’t just affect our choices, but also directly compromises the biological ability of our bodies to stay healthy. </p>
<p>Our childhood affects our health across the course of our lives. Stress, it seems, is a major contributor. While a life lived with financial, educational and social security and stability may not be free of worries, a disadvantaged childhood means <a href="http://onlinelibrary.wiley.com/doi/10.1111/1467-8624.00469/full">more exposure to a number of difficult circumstances and events</a>. These may include social tensions, domestic abuse, neglect, food and fuel poverty, unsafe or poor quality housing, and separation from caregivers.</p>
<p>These life events understandably cause stress. Most of us will have personal experience of responding to pressure at work or a relationship breakdown with ice cream, cigarettes or alcohol, or giving the gym a miss. When facing financial troubles, the health benefits of vegetables can seem trivial to parents in the face of the time- and money-saving virtues of junk food. Feeling like you do not have enough food, money, time, or friends <a href="http://science.sciencemag.org/content/338/6107/682">occupies the mind</a> so that there is less space to focus on decisions with long-term pay-offs.</p>
<p>Experiencing these feelings over a long period of time (rather than the shorter-term stress experienced when applying for a job or studying for an exam) can make it increasingly difficult to make healthy choices. Over a lifetime, choices add up. But this latest research suggests that chronic stress impacts more than just our choices.</p>
<h2>What doesn’t kill you makes you weaker</h2>
<p>In the new study of over 24,000 people across 14 countries, <a href="https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afy003">researchers</a> found that individuals, particularly women, of lower socioeconomic status in childhood had lower hand grip strength in older adulthood – a reliable health indicator, predicting the risk of <a href="https://academic.oup.com/ageing/article/32/6/650/13078">frailty</a>, <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2010.03145.x/full">disability</a>, and death from <a href="https://academic.oup.com/ije/article/36/1/228/665601">cardiovascular disease and cancer</a> in older age.</p>
<p>While health-related behaviours such as exercise, nutrition, smoking and alcohol consumption were partially responsible for this link, adults from poorer backgrounds had weaker grip strength even if their socio-economic status improved later in life. This suggests that a tougher start in life has a direct, biological and lasting effect on an individual’s ability to stay healthy.</p>
<p>We already know that children suffering from long-term stress build up <a href="https://www.sciencedirect.com/science/article/pii/S0301051107002013">higher levels of the stress hormone cortisol</a>, making the body’s response to threats from the outside world change. Chronic stress in childhood is related to <a href="http://pediatrics.aappublications.org/content/131/2/319">a host of diseases</a> through mechanisms such as poorer mental health, changes in the body’s <a href="https://www.sciencedirect.com/science/article/pii/S0889159112001821">immune response</a> to infection and injury, and increased blood pressure. </p>
<p>Now, we have evidence that growing up in poverty has a cumulative wear-and-tear effect on the physiological systems that govern how our bodies respond to our environment, permanently disrupting the ability of affected individuals to maintain good health in old age.</p>
<p>While more work is still needed to understand how early adversity affects our immune system and other physiological systems in later life, one thing is already clear. To make our society less stressed, happier and healthier, we need to recognise just how crucial a role hardship in childhood plays in determining an individual’s long-term health.</p>
<p>The argument that poverty and poor health are <a href="https://www.sciencedirect.com/science/article/pii/S0277953696001918">down to laziness or lack of willpower</a> is itself lazy and too often thrown around. Poverty in early life affects not only how capable the mind is of making the right choices, but also how the body responds to adversity at a fundamental level. Far from being a resource drain, investing money in improving children’s quality of life could improve a <a href="http://pediatrics.aappublications.org/content/131/2/319">range of health outcomes</a>, and dramatically reduce the burden on a health-care budget stretched by the vast capital needed to care for <a href="https://www.theguardian.com/society/2016/feb/01/ageing-britain-two-fifths-nhs-budget-spent-over-65s">older people</a>.</p>
<p>Rock star Marilyn Manson got it right with the lyrics for Leave A Scar. What doesn’t kill you, in many ways, <a href="https://www.psychologytoday.com/blog/insight-therapy/201008/what-doesnt-kill-you-makes-you-weaker">makes you weaker</a>. Those who thrive amid deprivation do so in spite of, rather than because of, the difficulties they experience. Many less fortunate people will struggle to stay fit and well despite making healthy choices. We could do with providing them with a little more support, and a little less judgement.</p><img src="https://counter.theconversation.com/content/92061/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Noortje Uphoff does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Childhood adversity doesn’t just affect our choices – according to new research, it also weakens the body’s fundamental ability to stay healthy in old age.Noortje Uphoff, Researcher in Social Epidemiology, University of YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/873252017-11-15T23:18:46Z2017-11-15T23:18:46ZWhy Canada should declare a national opioid emergency too<p>In the United States, President Donald Trump has <a href="http://www.cnn.com/2017/10/26/politics/donald-trump-opioid-epidemic/index.html">formally declared the opioid overdose crisis to be a national public health emergency</a>. The numbers he cited speak for themselves: More than 64,000 Americans died from opioid overdose last year, which translates to more than 175 per day, or almost seven every hour.</p>
<p>The situation in Canada is just as devastating, with opioid overdoses estimated to cause at least <a href="http://www.cbc.ca/news/politics/opioid-hospitalization-cihi-1.4285968">16 hospitalizations</a> and <a href="https://beta.theglobeandmail.com/news/national/opioid-related-overdose-figures-show-grim-reality-of-canadian-epidemic/article36257932/?ref=http://www.theglobeandmail.com&">eight</a> deaths each day. </p>
<p>This did not happen overnight. The number of opioid overdose deaths has risen at an alarming rate since the early 2000s. Now, more than a decade later, communities, health professionals and some politicians <a href="https://www.theglobeandmail.com/news/politics/jagmeet-singh-addresses-opioid-crisis-in-speech-to-bc-ndp-at-party-convention/article36837626/">such as NDP Leader Jagmeet Singh</a>, are still pushing for a national health emergency to be declared here in Canada as well.</p>
<p>By declaring a national <a href="http://laws-lois.justice.gc.ca/eng/acts/E-4.5/page-1.html">public welfare emergency</a>, the federal government could both acknowledge the scale of the opioid overdose crisis and unlock funds critical to a successful response. </p>
<p>Such a move would not be without precedent.</p>
<h2>From SARS and H1N1 to opioid deaths</h2>
<p>We should have learned by now, from past health crises that have affected our entire nation. </p>
<p>When 44 deaths were caused by SARS in Canada in 2003, the National Advisory Committee on SARS and Public Health <a href="https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/publicat/sars-sras/pdf/sars-e.pdf">urged the Government of Canada</a> to “consider incorporating in legislation a mechanism for dealing with health emergencies” — one that “would be activated in lockstep with provincial emergency acts in the event of a pan-Canadian health emergency.”</p>
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<p><em><strong>Read more: <a href="https://theconversation.com/ca/topics/canadas-opioid-crisis-46272">Solutions to Canada’s opioid crisis</a></strong></em></p>
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<p>In 2009, when <a href="http://www.statcan.gc.ca/pub/82-003-x/2010004/article/11348-eng.htm">428 deaths were caused by the H1N1 flu virus</a> in Canada, an Emergency Operations Centre was mobilized 24 hours a day, seven days a week for several weeks. This provided <a href="https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/about_apropos/evaluation/reports-rapports/2010-2011/h1n1/pdf/h1n1-eng.pdf">more than 6,000 person-days of manpower</a> to help coordinate emergency responses across the country.</p>
<p>In comparison, <a href="https://www.canada.ca/en/health-canada/services/substance-abuse/prescription-drug-abuse/opioids/federal-actions.html">only 113 person-days of assistance for the opioid crisis</a> have been reported by the Public Health Agency of Canada — to help write reports in two jurisdictions last year — <a href="https://beta.theglobeandmail.com/news/national/opioid-related-overdose-figures-show-grim-reality-of-canadian-epidemic/article36257932/?ref=http://www.theglobeandmail.com&">despite more than 2,800 deaths from opioid overdoses in 2016 alone</a>. </p>
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<img alt="" src="https://images.theconversation.com/files/194845/original/file-20171115-19768-1p2zqpn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/194845/original/file-20171115-19768-1p2zqpn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=324&fit=crop&dpr=1 600w, https://images.theconversation.com/files/194845/original/file-20171115-19768-1p2zqpn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=324&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/194845/original/file-20171115-19768-1p2zqpn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=324&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/194845/original/file-20171115-19768-1p2zqpn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=407&fit=crop&dpr=1 754w, https://images.theconversation.com/files/194845/original/file-20171115-19768-1p2zqpn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=407&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/194845/original/file-20171115-19768-1p2zqpn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=407&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Public Health Agency of Canada’s response to the opioid crisis versus the H1N1 flu.</span>
<span class="attribution"><span class="license">Author provided</span></span>
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<p>The federal government has already implemented important measures, such as <a href="https://www.canada.ca/en/health-canada/services/substance-abuse/prescription-drug-abuse/opioids/federal-actions.html">improving access to life-saving treatments</a> and <a href="https://beta.theglobeandmail.com/news/national/federal-government-approves-three-supervised-injection-sites-in-toronto/article35189403/">approving supervised injection sites</a> across the country. </p>
<p>However, there is still much more that can be done. </p>
<h2>Funding pain management research</h2>
<p>For instance, Statistics Canada is mandated to produce statistics on the health of Canadians. Unfortunately, the latest available data on painkiller misuse was released in 2012 (via the <a href="http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=5015&lang=en&db=imdb&adm=8&dis=2">Canadian Community Health Survey – Mental Health</a>) and no updated version has been collected since. Scientists across the country are eager to help, but may not have the resources to do so. </p>
<p>Providing national public data repositories would allow researchers across the country to help determine overdose trends, high-risk sub-populations and other important information that could inform national policy decisions and target health responses where they are most urgently needed.</p>
<p>The federal government also has the power to determine which areas of research should be given priority in funding. New initiatives such as the <a href="http://www.cihr-irsc.gc.ca/e/44597.html">Canadian Research Initiative in Substance Misuse</a> are an important step forward for guiding evidence-based treatments for substance-use disorders. </p>
<p>Priority funding pools could also be set aside to encourage research, education and clinical care targeted toward finding <a href="https://theconversation.com/how-to-fix-canadas-opioid-crisis-it-starts-with-pain-and-the-prescription-pad-78512">safer pain management approaches</a> — a serious problem that exists for much of the opioid-using population. Currently, there is a concerning lack of evidence-based alternative treatments for chronic pain patients whose opioid prescriptions are being cut off.</p>
<h2>All hands on deck</h2>
<p>Finally, empowering the health-care workforce to help address the opioid epidemic is essential. </p>
<p>In the United States, nurse practitioners (NPs) and physician assistants (PAs) play an important role. The Comprehensive Addiction and Recovery Act signed by President Obama on July 22, 2016, <a href="https://elearning.asam.org/buprenorphine-waiver-course">authorizes qualified NPs and PAs to prescribe medications for patients with Opioid Use Disorder</a>. This provides <a href="https://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.html">more than 86,000 extra people</a> who could be eligible to help prescribe life-saving addiction treatments, in addition to physicians. </p>
<p>In Canada, there is not enough recognition of the <a href="https://theconversation.com/better-medical-education-one-solution-to-the-opioid-crisis-81019">potential role for nurses and other allied health professionals to help</a>. Allocating funding for more training and staffing for these skilled professionals would promote an “all hands on deck” approach to assessing and treating pain and addiction, administering overdose-reversing interventions, assisting with urgent clinical research and educating and supporting affected communities. </p>
<p>If Canada were to declare a public welfare emergency, more health centres with skilled staff performing these essential roles could be immediately mobilized to help curb the opioid epidemic.</p>
<p>It’s time to recognize the opioid overdose crisis as the national public health emergency that it is.</p><img src="https://counter.theconversation.com/content/87325/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Pauline Voon is a Research Associate with the BC Centre on Substance Use. She receives funding from the Canadian Institutes of Health Research through a Vanier Canada Graduate Scholarship and a doctoral scholarship from the Pierre Elliott Trudeau Foundation - an independent, non-partisan charity foundation.</span></em></p>Opioids kill an average of eight people every day in Canada. The federal government must officially declare this a ‘public welfare emergency’ and invest the funds critical to a humane response.Pauline Voon, Research Associate at the BC Centre on Substance Use and Doctoral Candidate in Population and Public Health, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/864732017-10-31T13:16:24Z2017-10-31T13:16:24ZNurses strike shows poor management of health care in Kenya<figure><img src="https://images.theconversation.com/files/192443/original/file-20171030-18686-elq2gl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Striking Kenyan nurses take part in a protest in Nairobi.</span> <span class="attribution"><span class="source">Reuters/Baz Ratner</span></span></figcaption></figure><p><a href="http://www.nation.co.ke/news/Uhuru-governors-nurses-strike/1056-4070042-lkbsnz/index.html">Nurses in Kenya’s public hospitals</a> have been on strike <a href="http://www.nation.co.ke/news/Nurses--strike-continues-as-leaders-fault-governors/1056-4108744-vuae08z/index.html">since June</a>, paralysing health care services countrywide.</p>
<p>At the centre of their dispute is a collective bargaining agreement that had been struck with county governments through the <a href="http://www.nation.co.ke/news/Governors-signal-move-to-end-nurses--3-month-strike-/1056-4072516-bowl6bz/index.html">council of governors</a>. The agreement addresses pay, working conditions and promotions. But it’s not been honoured by the governors because they say it’s <a href="http://universalhealth2030.org/2017/06/14/kenya-governors-approving-nurses-cba-will-burden-tax-payer/">too costly</a> and hasn’t been cleared by the <a href="http://www.src.go.ke/">salaries and remunerations commission</a>. The commission’s mandate is to set and regularly review salary and benefits of all state officers and to advise the government on remuneration and benefits of other public servants.</p>
<p>The government has responded to the impasse by threatening to <a href="http://www.nation.co.ke/news/Defiant-nurses-to-be-sacked--governors-insist-/1056-4110518-8s31wuz/index.html">sack the nurses</a> and freezing their salaries.</p>
<p>Some nurses have gone back to <a href="http://www.nation.co.ke/counties/tharaka-nithi/Tharaka-Nithi-nurses-back-at-work/3370192-4135302-10adjm8/index.html">work</a>, though most remain on strike.</p>
<p>The nurses strike began less than three months after a <a href="https://www.standardmedia.co.ke/article/2001232717/apology-to-kenyans-as-doctors-strike-ends-with-return-to-work-formula">doctors’ strike</a> that lasted for 105 days. It had a <a href="https://www.theguardian.com/world/2017/feb/13/kenyas-health-system-verge-of-collapse-doctors-strike-pay-staffing-union-leaders-jail">devastating effect on the health sector</a> as essential health services such as antenatal clinics, care of mothers during delivery, immunising babies and attending to patients with chronic diseases were not offered.</p>
<p>The strike has overwhelmed the two national referral hospitals; <a href="http://knh.or.ke/">Kenyatta National Hospital</a> in Nairobi and the <a href="http://www.ampathkenya.org/our-partners/mtrh/">Moi Teaching and Referral</a> hospital in Western Kenya because they are treating patients who should have been served at the peripheral health facilities.</p>
<p>Many expectant mothers are <a href="http://www.nation.co.ke/news/Hospitals-turn-to-private-birth-attendants-as-strike-bites-/1056-4068542-ikb1stz/index.html">giving birth at home</a> while some patients have had to travel to <a href="http://www.theeastafrican.co.ke/news/Kenya-patients-troop-to-Tanzania/2558-4091972-v3oyjl/index.html">neighbouring countries like Tanzania for treatment</a>.</p>
<p>There is also a danger that the significant gains Kenya has made in the <a href="http://www.who.int/features/2015/kenya-closing-pneumonia-gap/en/">fight against childhood illnesses such as pneumonia</a>, diarrhoea and measles <a href="http://www.nation.co.ke/health/Vaccination-Nurses-strike-and-the-coming-disease-crisis/3476990-4121352-15blt8dz/index.html">could be reversed</a>.</p>
<h2>Calling for better pay</h2>
<p>The <a href="http://www.knun.org/">Kenya National Union of Nurses</a>, the trade union representing the nurses, has made major concessions in the salary negotiations by bringing down their pay demands.</p>
<p>The <a href="https://www.google.com/url?url=http://www.nation.co.ke/news/KNH-nurses-down-tools/1056-4039258-51tvih/index.html&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwjhjLzUhZDXAhVGOBoKHfrKBf4QFggTMAA&usg=AOvVaw0UFt_szLHnDWy7AYmkP7zN">26,000 nurses</a> also want a uniform allowance, a risk allowance and changes to entry level for new employees.</p>
<p>Kenyan nurses work under difficult conditions. Understaffing is <a href="https://www.ncbi.nlm.nih.gov/pubmed/18796157/">acute, particularly</a> in remote dispensaries and health centres where they performs duties normally done by clinicians or pharmaceutical technologists. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ZskkoTOAn6o?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Nurses in public hospitals in Kenya are on strike negotiating for better terms. KTN Kenya.</span></figcaption>
</figure>
<p>The situation has deteriorated over the past four years since the government <a href="https://www.healthpolicyproject.com/pubs/479_KenyaPETSCountyReadinessFINAL.pdf">devolved health services</a> from national to county level.</p>
<p>While counties are now responsible for labour relations, they rely on the national government for funds to pay salaries. This binds the council of governors from giving increments without a guarantee of approval from the national government. </p>
<p>Strikes in the health sector have been driven by factors such as the fact that: </p>
<ul>
<li><p>Counties have weak human resource management structures marred by claims of poor working conditions, <a href="https://www.google.com/url?url=https://www.standardmedia.co.ke/article/2000212376/bribery-nepotism-most-prevalent-form-of-corruption-in-counties-survey&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwiij4SqmpDXAhVIXBQKHeeXANEQFggTMAA&usg=AOvVaw3t_fLdA3csClNe_3kp4LBC">corruption, nepotism and tribalism</a>. The lack of proper structures has eroded the confidence of workers leading to an <a href="http://www.businessdailyafrica.com/corporate/Devolved-healthcare-turns-sour-as-doctors-quit-service/539550-2929750-31c6hq/index.html">exodus</a> to the private sector and to other countries. Nurses in Kenya have emigrated to work in southern African countries such as <a href="http://www.nation.co.ke/news/diaspora/Namibia-nurses-Kenya/2107720-2344560-vo1mqn/index.html">Namibia</a>, Botswana and <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-6-89">developed countries like the United Kingdom</a> , Canada,<a href="http://www.nbcnews.com/id/13618952/ns/health-health_care/t/african-nurses-head-us-better-pay/">USA</a> and Australia in search of better pay.</p></li>
<li><p>Devolution of health care services was done haphazardly without passing the requisite <a href="https://www.standardmedia.co.ke/health/article/2001243022/proposed-law-to-take-away-health-sector-from-governors">health bill</a> into law. The nascent county structures were ill prepared to deal with the colossal burden of health care workers.</p></li>
<li><p>The rising cost of living and inflation for all workers countrywide has also fuelled the unrest. If this is not controlled, then workers across all sectors will continue to clamour for pay increases to meet the rising cost of living.</p></li>
</ul>
<h2>Averting health workers’ strikes</h2>
<p>To end health worker strikes, a number of crucial steps need to be taken.</p>
<p>Firstly, the government needs to appreciate that it shares mutual interests with employees and should work with unions to reduce conflict and promote productivity.</p>
<p>Secondly, the government should encourage trust among all parties. Industrial relations should be anchored on good faith, mutual trust and respect. The parties must engage with honesty, transparency and integrity.</p>
<p>Thirdly, a much deeper relationship needs to be established between the government and the workers’ unions so that there’s constant engagement between the two sides before tensions deteriorate into strikes. Trade unions should also be engaged in major policy decisions that affect the sector.</p>
<p>And lastly, the government should create a conducive working environment, including ongoing improvements in the conditions and terms of work to address both workers’ and patients’ needs. As the employer, it should ensure that workers are treated fairly, and that issues such as training, deployment and disciplinary measures are properly managed. This would attract health care workers, improve retention and reduce industrial unrest</p>
<p>In the long run, Kenya urgently needs three key entities to come to the party to fix the country’s health care system. </p>
<p>The county health departments must fight for enough resources from the central government to be able to provide quality services. They also need to step up and prove that they can manage health workers effectively or surrender the role back to the central government.</p>
<p>Health workers need to be more vocal and proactive against flaws in the way health care is run, and to correct the current state of things. </p>
<p>And finally the public needs to agitate for improved health care services by calling on governors and other leaders to account for poor services. Kenyans are <a href="http://www.klrc.go.ke/index.php/constitution-of-kenya/110-chapter-four-the-bill-of-rights">guaranteed quality health service by the country’s constitution</a>. They shouldn’t settle for anything less.</p><img src="https://counter.theconversation.com/content/86473/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Moses Masika is a member and former Deputy National Treasurer of the Kenya Medical Practitioners, Pharmacists and Dentists' Union. </span></em></p>A strike by Kenyan nurses points to the country’s failure to manage the devolution of responsibility for health care from national to county governments.Moses Masika, Tutorial Fellow, School of Medicine, University of Nairobi, University of NairobiLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/811372017-08-17T16:31:37Z2017-08-17T16:31:37ZThe seven tactics unhealthy industries use to undermine public health policies<figure><img src="https://images.theconversation.com/files/182196/original/file-20170816-11027-84ex13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">African governments efforts to improve health are being undermined by corporations luring clientele. </span> <span class="attribution"><span class="source">Reuters/Baz Ratner</span></span></figcaption></figure><p>Across Africa there are examples of governments trying to introduce policies that improve health, and protect the environment only to find their efforts undermined by unhealthy corporations, and their industry associations. A case in point is South Africa’s <a href="https://theconversation.com/south-africans-have-a-sweet-tooth-so-shouldnt-say-no-to-a-sugar-tax-64390">efforts</a> to introduce a tax on sugary drinks to reduce the growing burden of obesity. In the process they are facing a barrage of resistance. This is one small example of unhealthy industries undermining the public’s health and the global environment. </p>
<p>If you are working to improve public health and the environment in Africa, you need to know what your opponents are up to. </p>
<p>Below is a quick guide to their tactics, which I have assembled as a summary from three sources: Naomi Oreskes and Eric M Conway, <a href="https://www.bloomsbury.com/us/merchants-of-doubt-9781608193943/">Merchants of Doubt</a>, William Wiist’s <a href="https://www.google.rw/search?q=Wiist+W.+The+corporate+playbook%2C+health%2C+and+democracy%3A+the+snack+food+and+beverage+industry%E2%80%99s+tactics+in+context.+In%3A+Stuckler+D%2C+Siegel+K%2C+eds.+Sick+Societies.+Oxford%2C+UK%3A+Oxford+University+Press%3B+2011&rlz=1C1GGRV_enZA749ZA749&oq=Wiist+W.+The+corporate+playbook%2C+health%2C+and+democracy%3A+the+snack+food+and+beverage+industry%E2%80%99s+tactics+in+context.+In%3A+Stuckler+D%2C+Siegel+K%2C+eds.+Sick+Societies.+Oxford%2C+UK%3A+Oxford+University+Press%3B+2011&aqs=chrome..69i57.2675j0j4&sourceid=chrome&ie=UTF-8">The Corporate Playbook, Health, and Democracy: The Snack Food and Beverage Industry’s Tactics in Context</a>, and Nicholas Freudenberg’s <a href="https://www.amazon.com/Lethal-But-Legal-Corporations-Consumption/dp/0190495375">Lethal but Legal</a>.</p>
<h2>1. Attack legitimate science</h2>
<ul>
<li><p>Accuse science of deception, calling it “junk science” or “bad science,” claiming science is manipulated to fulfil a political agenda.</p></li>
<li><p>Attack the scientific institutions and government agencies perceived to be acting against corporate interests.</p></li>
<li><p>Insist that the science is uncertain by claiming scientists don’t know what’s causing it, and that more research is needed.</p></li>
<li><p>Withholding any data unfavourable to the corporate product.</p></li>
<li><p>Using information in a misleading way; cherry-picking by using facts that are true but irrelevant.</p></li>
<li><p>Insist that there are many causes to a health or environmental problem, and that addressing just one of them will have minimal impact.</p></li>
<li><p>Exaggerate the uncertainty inherent in any scientific endeavour to undermine the status of established scientific knowledge.</p></li>
<li><p>Use corporate-funded studies.</p></li>
<li><p>Fund researchers sympathetic to corporate causes or products.</p></li>
</ul>
<h2>2. Attack and intimidate scientists</h2>
<ul>
<li><p>Create doubt by attacking the authenticity and integrity of the author.</p></li>
<li><p>Attack the credibility of the messenger and allege ulterior motives.</p></li>
<li><p>Have “attack dogs” intimidate opponents.</p></li>
<li><p>Smear the enemy – for example, by calling environmentalists “watermelons” (green on the outside and red on the inside), use hatred and fear of communism to transfer animosity to the environmental movement.</p></li>
<li><p>Threaten to sue -— or actually sue -— scientists and advocates but avoid or delay
hearings of the facts.</p></li>
<li><p>Make accusations using the rhetoric of political suppression.</p></li>
<li><p>Infiltrate scientific groups and monitor prominent scientists.</p></li>
<li><p>Create enough doubt to forestall litigation and regulation.</p></li>
<li><p>Constantly repeat the doubt, using surrogates or “message force multipliers”.</p></li>
<li><p>Use pejorative terms repeatedly such as “excessive” regulation, “over” regulation, “unnecessary” regulation, “nanny state,” and “health Nazis” to promote fear and disdain.</p></li>
<li><p>Always demand more proof.</p></li>
<li><p>Alternatively, aim for self-regulation instead of regulation; introduce corporate voluntary codes to forestall government regulation.</p></li>
</ul>
<h2>3. Create arms length front organisations</h2>
<ul>
<li><p>Create front groups.</p></li>
<li><p>Run projects through front groups (“information laundering”) – especially law firms, because they can avoid scrutiny due to attorney – client privilege.</p></li>
<li><p>Create research institutes that can create their own scientific studies.</p></li>
<li><p>Sponsor conferences and workshops. </p></li>
<li><p>Create “independent” newsletters, magazines, and journals (not subject to peer review).</p></li>
<li><p>Publish findings selectively.</p></li>
<li><p>Manipulate research funding, design, and authorship.</p></li>
<li><p>Distribute materials— targeted pamphlets and booklets, social media.</p></li>
<li><p>Use public opinion polling.</p></li>
</ul>
<h2>4. Manufacture false debate and insist on balance</h2>
<ul>
<li><p>Create the impression of a controversy.</p></li>
<li><p>Maintain the controversy, keep the debate alive.</p></li>
<li><p>Create false dichotomies.</p></li>
<li><p>Insist that responsible journalists cover both sides of the argument equally.</p></li>
<li><p>Demand balance, relying on the <a href="http://content.time.com/time/nation/article/0,8599,1880786,00.html">Fairness Doctrine</a>.</p></li>
<li><p>Divert attention from harmful products.</p></li>
<li><p>Focus on corporate social responsibility.</p></li>
<li><p>Set up corporate social responsibility foundations; find small-scale, apparently well-meaning community activities.</p></li>
<li><p>Focus on other issues as the problem, like physical activity instead of diet, for example.</p></li>
</ul>
<h2>5. Frame issues in highly creative ways</h2>
<ul>
<li><p>Insist that the problem is very complex, thus implying it can’t have a simple solution, if any.</p></li>
<li><p>Insist it is premature to suggest remedies.</p></li>
<li><p>Constantly repeat that technological advances will obviate the need for regulations and that the problem can be solved only through the marketplace.</p></li>
<li><p>Insist on personal or parental responsibility and insist that government should have no role in influencing individual health behaviour.</p></li>
<li><p>Use colourful imagery such as “a billion dollar solution to a million dollar problem”); use words like “speculative,” “oversimplified,” “premature,” and “unbalanced”.</p></li>
<li><p>Use the creation of fear as a tool for change of policy.</p></li>
<li><p>Diminish the severity of the problem while giving some ground.</p></li>
<li><p>Admit that it is a serious problem, but not a life-threatening one.</p></li>
<li><p>Admit that there may be a problem, but it is less severe than everyone says.</p></li>
<li><p>Argue that the problem is less severe than other problems -— those should be
the priority.</p></li>
<li><p>Argue that the cost to fix the problem is too high.</p></li>
<li><p>Argue that the benefits of the problem haven’t been considered.</p></li>
<li><p>Argue that other options haven’t been considered.</p></li>
<li><p>Understand and use the power of language – the other side’s language is filled with uncertainties, so make sure yours is certain.</p></li>
</ul>
<h2>6. Fund industry disinformation campaigns</h2>
<ul>
<li><p>Run industry disinformation campaigns using new and creative forms.</p></li>
<li><p>Pay and co-opt celebrities and sympathetic expert witnesses.</p></li>
<li><p>Sponsor conferences to challenge scientific consensus.</p></li>
<li><p>Align with other issues – employment discrimination, antitax groups.</p></li>
</ul>
<h2>7. Influence the political agenda</h2>
<ul>
<li><p>Donate to political parties across the political spectrum.</p></li>
<li><p>Get representatives from unhealthy industries around the policy table, for guideline development or standard setting.</p></li>
<li><p>Invest heavily in paid lobbyists.</p></li>
<li><p>Get “friends” in important and influential government roles —- for example, by targeted hiring of politicians, their advisers, or senior administration officials once they leave office.</p></li>
<li><p>Aim to reduce government budgets for regulatory or scientific, or policy activities against corporate interests.</p></li>
</ul>
<p><em>This is an edited version of <a href="http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2017.303861">an article</a> that appeared in a publication of the American Journal of Public Health.</em></p><img src="https://counter.theconversation.com/content/81137/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rob Moodie has received funding from the Australian Department of Health, and chaired the National Preventative Health Taskforce from 2008-2011. He chairs the GAVI Alliance Evaluation Advisory Committee and he receives sitting fees. He has worked with WHO as an adviser over many years. He is currently on the WHO expert panel on Health Promotion</span></em></p>Unhealthy food corporations use various tactics to undermine public health policies aimed at tackling the scourge of non-communicable diseases like diabetes and obesity.Rob Moodie, Professor of Public Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/802902017-07-23T11:43:58Z2017-07-23T11:43:58ZHypertension: the silent killer spreading across Africa<figure><img src="https://images.theconversation.com/files/177893/original/file-20170712-19681-1f6wh2x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If not treated properly, hypertension can lead to strokes, heart attacks or kidney failure.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Hypertension is a rising global health problem. An estimated <a href="http://edition.cnn.com/2016/11/15/health/high-blood-pressure-global-statistics/index.html">one billion</a> people live with what is more commonly known as high blood pressure. Of these, more than <a href="http://ish-world.com/downloads/pdf/global_brief_hypertension.pdf">nine million</a> die from the condition each year. </p>
<p>When hypertension is not treated properly, sufferers develop cardiovascular diseases such as strokes, heart attacks or kidney failure. </p>
<p>Cardiovascular diseases – and particularly hypertension – have traditionally been diseases associated with an ageing population. It mainly affects people over the <a href="https://patient.info/health/preventing-cardiovascular-diseases">age of 40</a>. </p>
<p>In Africa these diseases have tracked the wave of “western” lifestyle practices sweeping across the continent: rapid urbanisation and people indulging in bad diets with fast foods and little to no exercise. </p>
<p>On top of this, Africa faces a unique challenge. As anti-retroviral treatment is rolled out to everyone living with HIV, and general improvements in health care take place, life expectancy is increasing. The incidence of hypertension is therefore likely to rise. It’s projected that <a href="https://doi.org/10.1161/HYPERTENSIONAHA.116.08290">75% of older people</a> will be hypertensive in low and middle income countries by 2025.</p>
<p>But few large studies have explored hypertension in Africa. Anecdotal evidence collected by researchers suggest the actual burden of the disease is poorly understood: people don’t know that they suffer from the condition and therefore don’t seek treatment. </p>
<p>We set out to establish whether people knew they had the condition and if they did, whether they controlled their blood pressure. We did a survey in four countries: Burkino Faso, Ghana, Kenya and South Africa, looking at both rural areas and the peri-urban settings in the cities of Nairobi and Johannesburg.</p>
<p>Our study shows hypertension is a critical health problem in Africa. The picture it paints is that there are stark differences in the prevalence, awareness and control of high blood pressure on the continent. Ultimately there is a need for regionally tailored intervention. </p>
<p>Although hypertension can easily be detected by routinely measuring blood pressure, the reality is that across the regions studied, up to half of the population are unaware of their condition. And of those who are aware, up to half of them show poor control through treatment.</p>
<h2>Vast differences</h2>
<p>We <a href="http://dx.doi.org/10.1016/j.gheart.2017.01.007">found</a> that some parts of the continent are worse than others. In South Africa, for example, up to 50% of the people between the ages of 40 and 60 suffered from high blood pressure. In rural Burkino Faso though, there was only a 15% prevalence. </p>
<p>In addition, there were also stark difference in different settings in the same countries. And in some areas despite treatment being high, people’s blood pressure was not under control, raising questions about the effectiveness of their treatment and how well they stuck to drug regimens.</p>
<p>It shows that health promotion needs to be improved to increase awareness but more importantly that better access to care, and infrastructural changes to existing primary health care facilities are required for treatment to improve, and for it to be adhered to. </p>
<p>As part of our survey we measured the blood pressure of people between the ages of 40 and 60 from rural areas in east, west and South Africa as well as two peri-urban areas in the cities of Nairobi and Johannesburg. </p>
<p>Hypertension rates were low in West Africa, higher in East Africa. Prevalence ranged from 15% in West Africa to 25% in East Africa, and between 42% and 54% in South Africa. </p>
<p>There are many reasons for these different rates.</p>
<p>East Africa, which has lower levels of hypertension, could be at this point because it is in the early phases of the epidemiological and health transition. But the risk here is that as people gain more access to fast foods, and live more sedentary lifestyles, hypertension rates could spurt. </p>
<p>South Africa on the other hand has the highest prevalence of hypertension on the continent. Diets are rich in refined and fast foods, lifestyles are sedentary, and obesity is a norm. It also has the largest number of people whose blood pressure is still not controlled despite them being on treatment.</p>
<p>In addition to the differences in hypertension rates across the continent, there were other differences too. Gender is one example. </p>
<p>Only 40% of the men who suffered from hypertension were aware of their condition. And of those who were aware and on treatment, only 39% had controlled blood pressure. </p>
<p>Women, however, were more aware of their condition (54%) than men and just over half of those undergoing treatment had controlled blood pressure. This is a common observation that’s common in many studies of hypertension across the continent.</p>
<p>Why there is this difference between men and women is unclear. One answer could be related to the higher levels of employment of men, who will subsequently have limited access to health care outside of their working hours.</p>
<h2>Improving the data sets</h2>
<p>Assessing the burden on the continent is challenging because of the paucity of data on hypertension from different African countries. But our study provides actual baseline data for older adults. The next step is to engage with these participants in five years again in a follow up study. </p>
<p>This will help us assess the main drivers and consequences of hypertension in the different regions. At that point we will examine how many new cases of hypertension have arisen and interrogate the health status and genetic background of participants with long standing hypertension. We will be able to evaluate how these changes may be related to the environment.</p>
<p>Most importantly though non-communicable diseases, including hypertension, must be prioritised and managed to reduce the public health burden and to avert a new epidemic on the African continent.</p><img src="https://counter.theconversation.com/content/80290/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This research has been funded by the National Institutes of Health (Grant No. 1U54HG006938) awarded to the AWI-Gen Collaborative Centre as a member of the H3Africa Consortium.</span></em></p><p class="fine-print"><em><span>Francesco Xavier Gomez-Olive Casas does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Although hypertension can easily be detected in Africa, up to half of the population are unaware of their condition.Stuart Ali, Researcher at the Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, and AWI-Gen Project Manager, University of the WitwatersrandFrancesco Xavier Gomez-Olive Casas, Research Manager at MRC/Wits Agincourt Research Unit, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/808642017-07-18T23:09:15Z2017-07-18T23:09:15ZCanada could lead the fight for life in a post-antibiotic world<figure><img src="https://images.theconversation.com/files/178530/original/file-20170717-6084-14ldnjt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Drug-resistant strains of gonorrhoea, once easily dispatched with penicillin, are spreading across the globe resulting in chronic pain and sterility</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Infectious diseases that once were tamed are roaring back, past the last line of our antibiotic defences. They threaten the lives of millions, but where is the public outcry? </p>
<p>Drug-resistant strains of gonorrhoea, once easily dispatched with penicillin, are spreading across the globe. The result: chronic pain, sterility and a <a href="http://www.who.int/mediacentre/news/releases/2017/Antibiotic-resistant-gonorrhoea/en/">call for new drugs by the World Health Organization</a>. In North America, <a href="https://www.cdc.gov/mmwr/volumes/66/wr/mm6601a7.htm?s_cid=mm6601a7_w&utm_source=Global+Health+NOW+Main+List&utm_campaign=813e656ea4-EMAIL_CAMPAIGN_2017_01_12&utm_medium=email&utm_term=0_8d0d062dbd-813e656ea4-890763">people are dying</a> from infections caused by bacteria that are resistant to all available drugs. And sepsis, a deadly syndrome triggered by untreatable bacterial infections, is causing <a href="http://www.contagionlive.com/news/sepsis-remains-significant-challenge-for-hospitals-public-health-watch-weekly-report">millions of deaths</a> and <a href="https://www.bloomberg.com/news/articles/2017-07-14/america-has-a-27-billion-sepsis-crisis">massive health-care costs</a> among the elderly and very young.</p>
<p>Where is the Canadian co-ordination, leadership and resolve to develop new antimicrobial substances? To move innovations into the marketplace?</p>
<p>This spring, we represented Canada at the Drug-Resistant Infections Conference in Brisbane, Australia — an event that featured academic, public health and pharmaceutical industry researchers from around the world. The goal of the conference was to showcase the best research and development available to battle the antibiotics crisis. We are proud to report that Canadian research is among the most innovative in the world. </p>
<p>The time is right to launch a Canadian Anti-Infectives Innovation Network. It is time to coalesce and co-ordinate Canadian academic, private sector, not-for-profit and government research to solve the antibiotics crisis. Such a network would galvanize Canadian antibiotic research and development. It could ensure that we play a role on the international stage commensurate with our ability and promise.</p>
<h2>The microbes are winning</h2>
<p>The incredible scientific advances of the last century have allowed us to live longer and better lives by preventing or treating many diseases that were once fatal. Pneumonia, blood infections and tuberculosis were once common killers. Now they are generally cured with antibiotics. Cheap and abundant antibiotics have allowed us to <a href="http://dx.doi.org/10.1016/S1473-3099(13)70318-9">cure illnesses, keep fragile pre-term babies alive, carry out safe surgeries and treat cancer</a>.</p>
<p>Those very benefits have lulled us into ignoring a frightening problem that has been looming for decades, undermining that progress and threatening to undo those advances. </p>
<p>While we were enjoying the benefits of antibiotics, the microbes were fighting back. They were finding ways around the obstacles science and medicine had placed in their way. Now the microbes are starting to <a href="http://www.who.int/mediacentre/news/releases/2017/bacteria-antibiotics-needed/en/">win</a>. And although we have good reason to believe <a href="http://www.pewtrusts.org/en/research-and-analysis/analysis/2017/01/18/why-the-antibiotic-pipeline-is-broken-and-how-to-fix-it">new weapons</a> could beat them back again, for some reason the world is not making enough effort to preserve our fragile safety.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/178534/original/file-20170717-6075-x8zy1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/178534/original/file-20170717-6075-x8zy1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/178534/original/file-20170717-6075-x8zy1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/178534/original/file-20170717-6075-x8zy1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/178534/original/file-20170717-6075-x8zy1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/178534/original/file-20170717-6075-x8zy1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/178534/original/file-20170717-6075-x8zy1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sepsis dates back to ancient Greece and is now a global public health challenge, resulting in millions of death every year.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>We are in this situation because of the ever-increasing number of <a href="https://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf">bacteria</a> that are no longer sensitive to the antibiotics we discovered decades ago. And because most pharmaceutical companies no longer see profitability in new antibiotic drugs. The <a href="http://petrieflom.law.harvard.edu/assets/publications/Outterson_Health_Law_Workshop_paper.pdf">business case </a>is not strong for inventing drugs that patients will only need for a short time, compared to lifelong prescriptions to treat heart and blood-pressure conditions, for example. </p>
<p>But this is not a business case. This is a public health crisis.</p>
<h2>Ordinary illnesses could kill millions</h2>
<p>We are perilously close to plunging back into a time when illnesses we consider ordinary could kill tens of millions. For some deadly strains of bacteria, we are already in a post-antibiotic world. Clinicians are out of options. Once curable diseases are incurable. <a href="http://www.contagionlive.com/news/sepsis-remains-significant-challenge-for-hospitals-public-health-watch-weekly-report">Six million people already die of sepsis</a> every year for want of effective antibiotics, and the cost to the U.S. alone is <a href="https://www.bloomberg.com/news/articles/2017-07-14/america-has-a-27-billion-sepsis-crisis">$27 billion annually</a>. Highly resistant <a href="http://www.cbsnews.com/news/superbug-gene-spotted-on-us-pig-farm/">superbugs are being found on our farms</a>.</p>
<p>In September 2016, 193 members of the United Nations came together to announce that <a href="http://www.un.org/pga/71/2016/09/21/press-release-hl-meeting-on-antimicrobial-resistance/">anti-microbial resistance (AMR) is the largest threat to medicine</a>. This was reaffirmed this month in the final statement from the <a href="https://www.g20.org/gipfeldokumente/G20-leaders-declaration.pdf">G20 meeting in Hamburg</a>. Without urgent action to overcome AMR, the <a href="https://amr-review.org/">UK’s Review On Antimicrobial Resistance</a> estimates the world could witness 10 million extra deaths every year by 2050. That is an increase of total deaths by one sixth.</p>
<p>Even those who survive drug-resistant infections will need twice as much time in hospital. And that is just one expense flowing from a problem that is expected to cost the global economy <a href="https://amr-review.org/">$100 trillion by 2050</a>.</p>
<h2>Canada could lead</h2>
<p>In a context of neglect and inaction, and the misconception that antibiotic discovery is the job of the private sector, no country is ideally positioned to solve this problem alone. Canada, however, is in a position to lead if it wants to.</p>
<p>Canadian researchers have pioneered creative solutions: alternatives to antibiotics that block and inhibit resistance, innovative drug combinations that boost antibiotic activity and enhance host immunity to prevent infection.</p>
<p>Canada’s natural resources, including the Arctic and three oceans, have the potential to deliver new antimicrobial and anti-infective substances. Vaccine development for animals and humans can reduce our need for new drugs. Our innovative thinking can deliver alternatives to reduce dependency on antibiotics. </p>
<h2>Canadian Anti-Infectives Innovation Network</h2>
<p>Innovations alone won’t help. We must do more to get Canadian know-how into action immediately. Canada is a global leader in many areas of basic and applied research that can contribute to solving the problem. But we lack co-ordination, common objectives and resolve.</p>
<p>We need to develop our innovations so we can lead the world in alternatives and adjuncts to antibiotics. We need to become an essential partner in international initiatives such as CARB-X, a public-private accelerator funded by the U.K. and U.S., to move creative antibiotic discoveries into the marketplace. Ironically, two discoveries made at McMaster University are being considered by CARB-X for funding, following licensing to U.S.-based companies. Two others developed at the University of British Columbia, and originally the basis of Canadian spinoffs, are in advanced clinical trials with U.S. companies.</p>
<p>The opportunity to grow these discoveries here in Canada has been lost. So has the associated commercial, employment and skills benefits.</p>
<p>Canada is competing and leading in anti-infective innovation, but we are rapidly falling behind in our ability to capitalize on these discoveries, foster and support new research and commercialization in Canada. </p>
<p>We must act now to ensure that we not only do our share on the international stage to solve the antibiotic crisis, but also provide a made-in-Canada innovative approach. We can do so, with support and leadership, in the form of a Canadian Anti-Infectives Innovation Network that assembles leading researchers in universities, hospitals, government and the private sector.</p><img src="https://counter.theconversation.com/content/80864/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gerry Wright is a Professor and Director of the Michael G. DeGroote Institute for Infectious Disease Research at McMaster University. He is a co-founder and owns shares in the company Symbal Therapeutics that seeks to identify new anti-infective agents and strategies to address the antibiotic crisis. He consults widely for private sector and not-for profit agencies in the antibiotics field. His laboratory receives funding from federal and provincial funding agencies and not-for-profit groups such as the Bill and Melinda Gates Foundation. His lab has received funding over the years from both large and small pharmaceutical companies working in the area of antibiotic research and discovery.</span></em></p><p class="fine-print"><em><span>Bob Hancock has been awarded 56 patents for his UBC discoveries, largely in the area of alternatives to antibiotics, and these have been assigned to his university and licensed to several companies. If these products are successful in the long run there is the possibility that he and his co-inventors could receive milestone payments or royalties.
His laboratory has been highly funded in the past by Canadian funding agencies, and his current research is funded by CIHR, NSERC, CFI, Cystic Fibrosis Canada, and Genome Canada, as well as funding from NIH and the Australian granting agency NHMRC. He believes that he has a responsibility to ensure that his inventions are developed for the good of the Canadian public, and as such he recently founded, and is a majority shareholder in, two virtual companies - ABT Innovations and Sepset Inc - that are developing new anti-infective therapeutics and sepsis diagnostics, respectively. He consults extensively with both large Pharma and small to medium-sized biotech companies.</span></em></p>Without leading edge innovations and coordination, Canadians will die from the epidemic of antibiotic resistant infections.Gerry Wright, Professor of Biochemistry and Biomedical Sciences, McMaster UniversityBob Hancock, Professor of Microbiology and Immunology, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/759312017-04-23T10:21:10Z2017-04-23T10:21:10ZEbola virus response: experiences and lessons from Sierra Leone<figure><img src="https://images.theconversation.com/files/164575/original/image-20170409-27621-1gyz9gm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The public in Sierra Leone was proactive in reporting suspected Ebola cases.</span> <span class="attribution"><span class="source"> Reuters/Luc Gnago </span></span></figcaption></figure><p>It’s 18 months since Sierra Leone was declared Ebola free after a <a href="http://www.who.int/mediacentre/factsheets/fs103/en/">two-year outbreak</a> that left 4,000 people dead.</p>
<p>While the outbreak might be over, its effects will persist for many years. In the small nation with a population of just <a href="http://www.fao.org/sierra-leone/fao-in-sierra-leone/sierra-leone-glance/es/">7 million</a> many lost relatives and friends to the disease. And its economy which was <a href="https://news.vice.com/article/the-economies-of-guinea-liberia-and-sierra-leone-have-been-wrecked-by-ebola">growing rapidly</a> before the outbreak was <a href="https://www.afdb.org/en/countries/west-africa/sierra-leone/sierra-leone-economic-outlook/">devastated</a>.</p>
<p>It will take time for Sierra Leone to rebuild. But there are valuable lessons learnt from the outbreak. The importance of engaging communities in outbreak response is one of the most important. The country’s commitment to public health awareness about the disease was critical in disease prevention and control. This was seen in the active participation of ordinary citizens in reporting the suspected cases.</p>
<p>The public health response to the outbreak was structured in three phases. In the first the government increased the treatment beds and encouraged behaviour changes like handwashing to prevent the spread of the disease.</p>
<p>In the second phase health workers engaged and worked in communities to identify infected people and those in close contact with them. Communicating with the community groups built trust and confidence in the response efforts.</p>
<p>In the third phase, the focus was on accurately defining and rapidly eliminating all new chains of Ebola transmission while restoring health services to normal.</p>
<p>I was a member of the response team as a consultant epidemiologist with the World Health Organisation during the third phase using my training on surveillance for diseases and management of outbreaks. We needed to address complex challenges such as the coordination of many actors in health and the way the disease was spreading through the community. </p>
<h2>The field work</h2>
<p>We had an immense task. Together with the local health teams, we established a monitoring system to detect infected people early and provide them with an effective response. Our daily routine included reviewing the number of cases reported, assessing the investigations and conducting field visits. </p>
<p>We also needed to ensure that hospitals’ health systems functioned normally. While Ebola was the most serious disease around, there were also cases of other common diseases such as malaria and pneumonia that also needed attention.</p>
<p>And we needed to implement a stronger surveillance system which would provide information on priority public health events like outbreaks as soon as they were detected. The Ebola outbreak had “surprised”, devastated and collapsed the health system. We wanted to avoid a repeat.</p>
<p>The outbreak was unanticipated and its magnitude overwhelming. In the initial phases, infection spread, killing many health workers which led to the closure of health facilities.</p>
<h2>The power of public health education</h2>
<p>With health facilities closed, communities were pushed to the forefront of the Ebola outbreak response. They became first responders. The Ebola treatment centres were few and community members had to initially attend to infected people.</p>
<p>The key messages from health authorities was that Ebola was incurable and sick people therefore needed to be taken to treatment centres. The message was factual but the citizens interpreted it as a death sentence.</p>
<p>Most stayed with their infected loved ones at home, fuelling the spread further and more aggressively. The community’s participation and response to the disease needed to be refocused urgently. And a massive public health awareness was rolled out. </p>
<p>The message development and deployment closely engaged local leaders and stakeholders to learn and address what influenced people’s decisions and their resistance to following advice on Ebola prevention.</p>
<p>Through the campaign, the residents realised their power in ending Ebola. Simple infection prevention and control lessons such as washing hands with soap regularly and avoiding contact with people likely to be infected with Ebola were key. </p>
<p>They learnt Ebola related symptoms and this triggered proactive reporting of suspected cases through a toll free line.</p>
<h2>The road to recovery</h2>
<p>When the outbreak was <a href="http://www.afro.who.int/en/sierra-leone/press-materials/item/8140-statement-on-the-end-of-the-ebola-outbreak-in-sierra-leone.html">officially declared over</a>, the country moved to maintaining a no-outbreak status (zero Ebola cases). The health facilities and the affected communities were recovering from the effects of the outbreak. </p>
<p>During this time, there were fears that Ebola would re-emerge but the strong reporting collaborations between the health workers and the community members was commendable.</p>
<p>For example, one Sunday afternoon, we received a call of a sick person. This description required a rapid response. A team was activated and dispatched within an hour. By the time we arrived the person had died after bleeding from the mouth and nose. But there were crowds, anxious to know whether Ebola had comeback.</p>
<p>They had isolated the body and closed contact. We urgently delivered samples for testing and when the results returned negative the following morning, there was a sigh of relief.</p>
<p>This was a powerful demonstration of health promotion from communities.</p>
<h2>The way forward</h2>
<p>The Ebola outbreak in Sierra Leone reflects the challenges facing health systems at local, national and international levels. When the national health system is inaccessible and unresponsive to community needs, alternative solutions outside the health system are sought. This makes it more difficult to identify acute health problems. </p>
<p>In 2005, the World Health Assembly foresaw an outbreak whose magnitude was closer to the devastation caused by Ebola and adopted a code of conduct, <a href="http://www.who.int/ihr/9789241596664/en/">International Health Regulations</a>.</p>
<p>This international protocol was signed by about 200 countries and is aimed at preventing, protecting, controlling and providing a public health response to the international spread of disease. These minimum capacities were to be achieved by 2004, but less than 30 countries have fulfilled. None of these are from Africa.</p>
<p>The code is a relevant and critical mechanism to help countries work together to prevent the spread of diseases and other health risks. It’s evident that gaps in early detection and rapid response to a disease outbreak leads to a public health crisis.</p>
<p>An efficient disease surveillance system rapidly detects and reports public health events. Disease outbreak preparedness should be in place before an outbreak, information shared and resources adequately determined. </p>
<p>Finally, winning the trust and confidence of communities plays a central role in the rapid control of an outbreak – it saves lives.</p><img src="https://counter.theconversation.com/content/75931/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eric Osoro does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The power to overcoming Ebola was in public awareness by performing simple yet basic infection prevention and control measures like washing hands, isolation and reporting suspected cases.Eric Osoro, Medical Epidemiologist , Washington State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/751392017-03-30T14:29:06Z2017-03-30T14:29:06ZThe Kenyan doctors’ strike is over, but there’s a lot of unfinished business<figure><img src="https://images.theconversation.com/files/162907/original/image-20170328-30782-189bog1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The end of the doctors' strike in Kenya is a truce in the fight for better health care. </span> <span class="attribution"><span class="source">Noor Khamis/Reuters</span></span></figcaption></figure><p>Kenyan doctors have <a href="http://www.bbc.com/news/world-africa-39271850">returned to work</a> after a gruelling 100-day strike, but a pressing question lingers: what are the long-term implications of their action on Kenya’s creaking health service?</p>
<p>The doctors had gone on strike to push the government to implement a <a href="https://www.standardmedia.co.ke/health/article/2000225884/details-of-the-disputed-salary-deal-signed-by-kenyan-doctors-and-nurses">collective bargaining agreement</a> signed in 2013. They ended the strike after reaching a deal with the government on salary increases of between 40% and 50% for all doctors in the public sector, signing of a collective bargaining agreement within sixty days and that there would be no victimisation of those who had been on strike.</p>
<p>A 40% salary increment is a formidable achievement for a trade union in Kenya: nonetheless other key issues that the union had raised were not fully addressed. </p>
<p>Doctors have <a href="https://www.standardmedia.co.ke/health/article/2001232422/doctors-in-nairobi-resume-work-amidst-kmpdu-threats">resumed work</a>. But the health facilities they work in remain unchanged. The long queues in public hospitals, insufficient supplies, lack of specialists in peripheral facilities and many preventable deaths are still a reality.</p>
<p>Moving forward, the health agenda should take centre stage in Kenya’s political and development debates to push for quality health care and ensure that the colossal health bills don’t continue to cripple Kenyans. </p>
<p>The end of the doctors’ strike should be viewed as a truce in the fight for better health care for all. Kenyans – including those in the health sector, the government, civil society and in communities – should make the best of it and heighten the level of cordial engagement to avoid a similar strike in future.</p>
<h2>Unfinished business</h2>
<p>The agreement to end the strike bears mixed fortunes for the heath sector. If implemented fully, it will form a good foundation for the government and doctors to pull together towards improved healthcare. </p>
<p>But the odds of this happening aren’t looking good. The process of implementing the return-to-work agreement has already hit speed bumps. This shows a lack of a goodwill which is likely to strain the relationship between the union and the employers. </p>
<p>This is a pity because the government has the opportunity to win the confidence and goodwill of the doctors’ union and other trade unions in the country by honouring the agreement. And both parties have a good opportunity to engage amicably during ‘peace-time’ which is preferable to negotiating during a strike. </p>
<p>The government needs to engage the union in major decisions that affect doctors. If this avenue is used properly, thorny issues can be sorted out in good time. This is especially important for key policy decisions on matters concerning human resource management and health facility infrastructure. </p>
<p>Over the coming weeks, both parties have an opportunity to reach a collective bargaining agreement which would be a major boost to the health sector in the country. The agreement is expected to streamline recruitment, equipping, training and retention of doctors in the public sector. </p>
<h2>The question of industrial action</h2>
<p>Another outcome of the strike is an awareness that <a href="http://www.health.go.ke/wp-content/uploads/2015/09/LABOUR_RELATIONS_ACT_2007.pdf">the laws</a> governing Kenya’s labour relations need to be aligned with the constitution.</p>
<p>The act, which predates the country’s current constitution, attempts to limit the freedom of workers to go on strike as defined in the <a href="http://www.klrc.go.ke/index.php/constitution-of-kenya/110-chapter-four-the-bill-of-rights">constitution</a>.</p>
<p>This is why many strikes in Kenya are declared unprotected by the courts which then issue orders to stop them, curtailing the freedom of employees to go on strike.</p>
<p>This issue is a common source of disagreement between trade unions and the courts and was a major point of contention in the doctors’ strike. It needs to be addressed to safeguard human rights and preserve the dignity of the courts.</p>
<h2>The reality of public health facilities</h2>
<p>The public had high expectations that the quality of health services would improve markedly once the strike was over.</p>
<p>But very little has changed at public health facilities which remain crowded, understaffed and poorly equipped.</p>
<p>Doctors need to continue persuading key decision makers to allocate more funds to the health docket to <a href="http://med.stanford.edu/careercenter/highlights/files/Weisburst.pdf">improve health </a> infrastructure, equipment and supplies. </p>
<p>But doctors can’t bring about change on their own. Civil society and the general public needs to push elected leaders and public officials to fix the health care system.</p>
<p>And community members need to be encouraged to demand that local health centres are well staffed and equipped to provide basic health care services.</p><img src="https://counter.theconversation.com/content/75139/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Moses Masika does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Kenya’s doctors embarked on a strike for a 100 days to push the government to implement a collective bargaining agreement signed in June 2013.Moses Masika, Tutorial Fellow, School of Medicine, University of Nairobi, University of NairobiLicensed as Creative Commons – attribution, no derivatives.