39
views
0
recommends
+1 Recommend
2 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found

      COVID‐19: Vulnerability and the power of privilege in a pandemic

      editorial
      1 , , 2
      Health Promotion Journal of Australia
      John Wiley and Sons Inc.

      Read this article at

      ScienceOpenPublisherPMC
      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          On 11 March 2020, the World Health Organization announced that COVID‐19 was characterised as a pandemic—a global first for coronavirus. 1 Coronaviruses are a large family of viruses that cause illness such as the common cold to more severe diseases such as Severe Acute Respiratory Syndrome. 2 A novel coronavirus is typically a new strain of the infectious disease that has not been previously identified in humans. 2 COVID‐19 is the most recent version of a novel coronavirus. 2 COVID‐19 has received significant public and government attention over the past weeks after it was first detected in the Wuhan province of China in December 2019, with subsequent epidemics in China, Italy, Republic of Korea and Iran. 1 As of 12 March 2020, 125 000 cases were reported from 118 countries and territories globally, with predictions this will continue to rise rapidly. 3 This has led to an array of public health measures being advocated by the WHO, including four critical areas for action—(a) prepare and be ready; (b) detect, protect and treat; (c) reduce transmission; and (d) innovate and learn. 3 This has been complemented, to varying degrees, through concurrent action by local, state and national governments worldwide. There can be a tendency in the health promotion profession to think of infectious diseases from a biomedical viewpoint. As such, the prevention and treatment of infectious diseases is sometimes perceived to be the responsibility of the clinical realm. Yet, the reality is that both nonclinical and clinical public health responses are required—and sometimes we need to relax professional boundaries to work collaboratively for the health and wellbeing of our communities. We need to work in partnership with health surveillance teams, epidemiologists, environmental health scientists, public health physicians, infectious disease physicians, general practitioners, nurses, allied health professions, health policy‐makers, health planners, health geographers and many others, to reduce the risks associated with pandemics. We also need to work across sectors to achieve the best possible outcomes. The health promotion profession plays a vital role in pandemics, and this has been abundantly evident in the responses to COVID‐19. Messaging about health and hygiene, particularly hand‐washing, is one example of the role that health promotion has played—ultimately drawing on our expertise in delivering health education, and implementing health‐related mass media and social marketing campaigns. Over the last two decades, information technology and social media have transformed the way we can reach people during pandemics. Indeed, social media has catapulted the ability to reach large populations, while also simultaneously targeting vulnerable and at‐risk populations, to deliver health messages, such as those associated with hand‐washing. Over the past few weeks, there has been a steady flow of memes urging people to wash their hands, often with thoughtful use of graphics alongside a successful use of humour. JS's personal favourite, was an online post from Round Rock Texas that read: ‘Texas Coronavirus Protection—wash your hands like you just got done slicing jalapenos for a batch of nachos and you need to take your contacts out (that's like 20 seconds scrubbing, y'all)’. It delivers an essential public health message in a factual, yet contextually relevant and humorous way. However, social media can also have its pitfalls. Misinformation and fake news are rampant. This has the potential to stifle health promotion efforts in times of need, such as during the current COVID‐19 pandemic. Therefore, it is important to know who is saying what, why, and with what level of authority. As mentioned above, we also need to be mindful of cross‐sectoral communication efforts during pandemics. As an example, JS received 12 emails from his children's schools and 14 from his current workplaces about COVID‐19—a total of 26 emails from educational institutions in both Australia and the United States. Email topics ranged from: hygiene issues such as hand washing and sanitiser use; social distancing, self‐isolation and self‐quarantining strategies such as cancellation of school activities and fundraisers; proposed adoption of online learning options, and flexibility about attendance at school/work, including possible closures; travel restrictions imposed by schools and universities associated with concerts, plays, public events/seminars and conferences; guidance to limit travel on public transport; and advice about when to seek help and access local health services if myself or my family members experience symptoms associated with COVID‐19. This bombardment of communication, albeit extremely useful, emphasises the importance of coordination in key messaging between health, education and various other sectors, when planning and implementing effective pandemic responses. In health promotion, we need new strategies to communicate important health messages in a concise and meaningful way that makes it easy and accessible for citizens to understand, navigate and take action. We also need to be careful how we convey content through electronic communication channels and consider an appropriate level of frequency of such communication to achieve optimal impact. Without doing so, there is potential to reinforce community ambivalence at one end of the spectrum and create panic at the other. The recent toilet paper saga in Australia, whereby stocks of toilet paper were rapidly depleted from grocery stores in response to the perceived likelihood of home quarantining measures, is one such example (albeit somewhat humorous and embarrassing). Panic buying like this reinforces the powerful ramifications of communication gone wrong. Health literacy research that embraces new and emerging technologies will be particularly important to guide online health promotion efforts of this nature in the future. To emphasise the importance of getting health communication right, the Australian Medical Association were particularly critical of the mixed‐messaging of public health directives between the Australian, State and Territory Governments concerning COVID‐19. 4 There was concern about how this mixed‐messaging was being interpreted by the Australian public, but also how it was likely to impact health professionals and the use of Australia's hospitals and health care system more broadly. The Australian Government has since committed a $2.4 billion health package to protect all Australians from COVID‐19, including vulnerable groups such as the elderly, those with chronic conditions and Indigenous communities. 5 The US Government pledged $50 billion on the same day. Importantly, the Australian health package includes $30 million for implementing an information campaign to provide people with practical advice on how they can play their part in containing the virus and staying healthy. 5 We trust health promotion professionals with expertise in health literacy, health communication, and social marketing will be consulted throughout its development. We also trust that health promoters will be involved in the multi‐million dollar primary care and research responses outlined by the Australian Prime Minister. At this juncture, it is worth reflecting on who is most vulnerable in pandemics. While COVID‐19 has the potential to impact everyone in society, these impacts will be felt differentially. That is, the way we prepare, protect, treat, reduce transmission and innovate, needs to be viewed from a health equity lens. It is essential to recognise that pandemics—and the respective Government and corporate decisions that emanate—both influence and are influenced by social, economic and political determinants of health. As the WHO Director‐General has recently stated—‘all countries must strike a fine balance between protecting health, preventing economic and social disruption, and respecting human rights’. 3 However, knowing what this ‘fine balance’ constitutes can be difficult. As such, it helps to reflect on what we know. While we do not know much about COVID‐19, we do now how pandemics can impact vulnerable populations. We know that many developing countries do not have the surveillance systems, health resources and health infrastructure to respond in a manner that can slow the harms of COVID‐19 in the way we would like. 6 , 7 , 8 We know that there are vulnerable populations, such as: the elderly, those with disabilities, people in prison, Aboriginal and Torres Strait Islander communities, people with chronic conditions, and people from Culturally and Linguistically Diverse (CALD) backgrounds, that will be impacted disproportinately by COVID‐19, particularly if assertive health promotion action is absent. 9 , 10 , 11 , 12 , 13 We know that people from low socio‐economic backgrounds, those who work in casual employment, and many racial and ethnic minorities, are unlikely to have the necessary financial resources to make self‐distancing and self‐isolation a viable option within the context of their daily livelihoods. 12 , 13 , 14 We know that access to health services in some countries, including basic primary health care, is contingent upon insurance and user‐pays systems that already make them inaccessible to the people most at‐risk. 15 , 16 We know that the elderly and people with disabilities rely on public transport to access essential services, including food shopping and health services that are required during pandemics. 17 , 18 We know that vulnerable populations may not have the necessary language and literacy skills to understand and appropriately respond to pandemic messaging. 19 We know that mental health concerns among the most vulnerable within our communities will be exacerbated by expectations to self‐isolate if not approached sensitively. 20 , 21 We know that governments have trouble implementing strategies focused on reducing health inequities through action on social determinants of health. 22 We know all these things, but what do we do about them? Most of the evidence‐based discussion presented above demonstrates the power of privilege in a pandemic. It indicates that those most vulnerable will be the hardest hit. The health promotion community must ensure that considerations of health equity and social justice principles remain at the forefront of pandemic responses. 12 , 14 This will not be easy at a time when neoliberal forces pitch population health against national economic stability. While hand‐washing is a significant health promotion intervention, it can also act as a useful façade for advancing actions that enhance equitable social and economic outcomes for those most vulnerable during pandemics. The WHO has encouraged us to think innovatively. 1 , 3 The health promotion profession can lead this charge and advocate for a national public health social media campaign and other pragmatic measures that reach people most in need. This will help support them to get accurate and timely information to prepare and reduce the risk to themselves, their families, friends and their community.

          Related collections

          Most cited references16

          • Record: found
          • Abstract: found
          • Article: not found

          Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?

          The most distinctive comorbidities of 32 non-survivors from a group of 52 intensive care unit patients with novel coronavirus disease 2019 (COVID-19) in the study by Xiaobo Yang and colleagues 1 were cerebrovascular diseases (22%) and diabetes (22%). Another study 2 included 1099 patients with confirmed COVID-19, of whom 173 had severe disease with comorbidities of hypertension (23·7%), diabetes mellitus (16·2%), coronary heart diseases (5·8%), and cerebrovascular disease (2·3%). In a third study, 3 of 140 patients who were admitted to hospital with COVID-19, 30% had hypertension and 12% had diabetes. Notably, the most frequent comorbidities reported in these three studies of patients with COVID-19 are often treated with angiotensin-converting enzyme (ACE) inhibitors; however, treatment was not assessed in either study. Human pathogenic coronaviruses (severe acute respiratory syndrome coronavirus [SARS-CoV] and SARS-CoV-2) bind to their target cells through angiotensin-converting enzyme 2 (ACE2), which is expressed by epithelial cells of the lung, intestine, kidney, and blood vessels. 4 The expression of ACE2 is substantially increased in patients with type 1 or type 2 diabetes, who are treated with ACE inhibitors and angiotensin II type-I receptor blockers (ARBs). 4 Hypertension is also treated with ACE inhibitors and ARBs, which results in an upregulation of ACE2. 5 ACE2 can also be increased by thiazolidinediones and ibuprofen. These data suggest that ACE2 expression is increased in diabetes and treatment with ACE inhibitors and ARBs increases ACE2 expression. Consequently, the increased expression of ACE2 would facilitate infection with COVID-19. We therefore hypothesise that diabetes and hypertension treatment with ACE2-stimulating drugs increases the risk of developing severe and fatal COVID-19. If this hypothesis were to be confirmed, it could lead to a conflict regarding treatment because ACE2 reduces inflammation and has been suggested as a potential new therapy for inflammatory lung diseases, cancer, diabetes, and hypertension. A further aspect that should be investigated is the genetic predisposition for an increased risk of SARS-CoV-2 infection, which might be due to ACE2 polymorphisms that have been linked to diabetes mellitus, cerebral stroke, and hypertension, specifically in Asian populations. Summarising this information, the sensitivity of an individual might result from a combination of both therapy and ACE2 polymorphism. We suggest that patients with cardiac diseases, hypertension, or diabetes, who are treated with ACE2-increasing drugs, are at higher risk for severe COVID-19 infection and, therefore, should be monitored for ACE2-modulating medications, such as ACE inhibitors or ARBs. Based on a PubMed search on Feb 28, 2020, we did not find any evidence to suggest that antihypertensive calcium channel blockers increased ACE2 expression or activity, therefore these could be a suitable alternative treatment in these patients. © 2020 Juan Gaertner/Science Photo Library 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: not found

            COVID-19: what is next for public health?

            The WHO Scientific and Technical Advisory Group for Infectious Hazards (STAG-IH), working with the WHO secretariat, reviewed available information about the outbreaks of 2019 novel coronavirus disease (COVID-19) on Feb 7, 2020, in Geneva, Switzerland, and concluded that the continuing strategy of containment for elimination should continue, and that the coming 2–3 weeks through to the end of February, 2020, will be crucial to monitor the situation of community transmission to update WHO public health recommendations if required. Genetic analysis early in the outbreak of COVID-19 in China revealed that the virus was similar to, but distinct from, severe acute respiratory syndrome coronavirus (SARS-CoV), but the closest genetic similarity was found in a coronavirus that had been isolated from bats. 1 As there was in early January, 2020, scarce information available about the outbreak, knowledge from outbreaks caused by the SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV) formed the basis for WHO public health recommendations in mid-January. 2 However, the availability of more evidence in the past month has shown major differences between the outbreaks and characteristics of COVID-19 compared with those of SARS-CoV. Recognising the Wuhan-focused and nationwide outbreak responses in China, WHO has encouraged countries with heavy air travel exchange with Wuhan to take precautionary public health measures 2 and, if there is imported infection, to undertake activities that could lead to the elimination of the virus in human populations as occurred during the 2003 SARS outbreak. 3 After the SARS outbreak, a few follow-on outbreaks occurred, including accidents in laboratories researching SARS-CoV. 4 SARS-CoV is thought to have been eliminated from human populations during 2003, and there have been no reports in the medical literature about SARS-CoV circulation in human populations since then. The 2003 SARS outbreaks are thought to have originated from the spillover of a mutated coronavirus from animals sold in a live animal market in Guangdong province in China to a few humans, and it then surfaced as a large cluster of pneumonia in health-care settings in Guangdong province. 5 Although the causative agent was then unknown, an infected medical doctor who had been treating patients in Guangdong province travelled to Hong Kong when he became ill and became an index case for hospital-associated and community outbreaks in Hong Kong and in three countries outside of China. The causative agent was later identified as a coronavirus and named SARS-CoV. The SARS outbreaks were at times characterised by several superspreading events—eg, hotel-based transmission from one infected hotel guest to others who travelled to Canada, Singapore, and Vietnam. 6 One large apartment complex-based outbreak of SARS was later found to be caused by aerosolisation of virus contaminated sewage. 6 COVID-19 is thought to have been introduced to human populations from the animal kingdom in November or December, 2019, as suggested by the phylogeny of genomic sequences obtained from early cases. 7 The genetic epidemiology suggests that from the beginning of December, 2019, when the first cases were retrospectively traced in Wuhan, the spread of infection has been almost entirely driven by human-to-human transmission, not the result of continued spillover. There was massive transmission in a matter of weeks in Wuhan, and people in the resulting chains of transmission spread infection by national and international travel during the Chinese New Year holidays. COVID-19 seems to have different epidemiological characteristics from SARS-CoV. COVID-19 replicates efficiently in the upper respiratory tract and appears to cause less abrupt onset of symptoms, similar to conventional human coronaviruses that are a major cause of common colds in the winter season. 8 Infected individuals produce a large quantity of virus in the upper respiratory tract during a prodrome period, are mobile, and carry on usual activities, contributing to the spread of infection. By contrast, transmission of SARS-CoV did not readily occur during the prodromal period when those infected were mildly ill, and most transmission is thought to have occurred when infected individuals presented with severe illness, thus possibly making it easier to contain the outbreaks SARS-CoV caused, unlike the current outbreaks with COVID-19. 6 © 2020 Kyodo News/Contributor/Getty Images 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. COVID-19 also has affinity for cells in the lower respiratory tract and can replicate there, causing radiological evidence of lower respiratory tract lesions in patients who do not present with clinical pneumonia. 8 There seem to be three major patterns of the clinical course of infection: mild illness with upper respiratory tract presenting symptoms; non-life-threatening pneumonia; and severe pneumonia with acute respiratory distress syndrome (ARDS) that begins with mild symptoms for 7–8 days and then progresses to rapid deterioration and ARDS requiring advanced life support (WHO EDCARN clinical telephone conference on COVID-19, personal communication with Myoung-don Oh [Seoul National University Hospital] and Yinzhong Shen [Shanghai Public Health Clinical Center]) The case fatality ratio with COVID-19 has been difficult to estimate. The initial case definition in China included pneumonia but was recently adjusted to include people with milder clinical presentation and the current estimate is thought to be about 1–2%, which is lower than that for SARS (10%). 9 The actual case fatality ratio of infection with COVID-19 will eventually be based on all clinical illness and at the time of writing information on subclinical infection is not available and awaits the development of serological tests and serosurveys. Presently COVID-19 seems to spread from person to person by the same mechanism as other common cold or influenza viruses—ie, face to face contact with a sneeze or cough, or from contact with secretions of people who are infected. The role of faecal–oral transmission is yet to be determined in COVID-19 but was found to occur during the SARS outbreak. 10 The lock-down of Wuhan City seems to have slowed international spread of COVID-19; however, the effect is expected to be short-lived (WHO modelling group). Efforts are currently underway in China, in the 24 countries to which infected persons have travelled, and in public conveyances, such as cruise ships, to interrupt transmission of all existing and potential chains of transmission, with elimination of COVID-19 in human populations as the final goal. This WHO-recommended strategy is regularly assessed each week by STAG-IH on the basis of daily risk assessments by WHO as information becomes available from outbreak sites. A plausible scenario based on the available evidence now is that the newly identified COVID-19 is causing, like seasonal influenza, mild and self-limiting disease in most people who are infected, with severe disease more likely among older people or those with comorbidities, such as diabetes, pulmonary disease, and other chronic conditions. Health workers and carers are at high risk of infection, and health-care-associated amplification of transmission is of concern as is always the case for emerging infections. People in long-term care facilities are also at risk of severe health consequences if they become infected. Non-pharmaceutical interventions remain central for management of COVID-19 because there are no licensed vaccines or coronavirus antivirals. If the situation changes towards much wider community transmission with multiple international foci, the WHO strategy of containment for elimination could need to be adjusted to include mitigation strategies combined with the following activities currently recommended by STAG-IH on the WHO website. First, close monitoring is needed of changes in epidemiology and of the effectiveness of public health strategies and their social acceptance. Second, continued evolution is needed of enhanced communication strategies that provide general populations and vulnerable populations most at risk with actionable information for self-protection, including identification of symptoms, and clear guidance for treatment seeking. Third, continued intensive source control is needed in the epicentre in China—ie, isolation of patients and persons testing positive for COVID-19, contact tracing and health monitoring, strict health facility infection prevention and control, and use of other active public health control interventions with continued active surveillance and containment activities at all other sites where outbreaks are occurring in China. Fourth, continued containment activities are needed around sites outside China where there are infected people and transmission among contacts, with intensive study to provide information on transmissibility, means of transmission, and natural history of infection, with regular reporting to WHO and sharing of data. Fifth, intensified active surveillance is needed for possible infections in all countries using the WHO-recommended surveillance case definition. 11 Sixth, preparation for resilience of health systems in all countries is needed, as is done at the time of seasonal influenza, anticipating severe infections and course of disease in older people and other populations identified to be at risk of severe disease. Seventh, if widespread community transmission is established, there should then be consideration of a transition to include mitigation activities, especially if contact tracing becomes ineffective or overwhelming and an inefficient use of resources. Examples of mitigation activities include cancelling public gatherings, school closure, remote working, home isolation, observation of the health of symptomatic individuals supported by telephone or online health consultation, and provision of essential life support such as oxygen supplies, mechanical ventilators and extracorporeal membrane oxygenation (ECMO) equipment. Eighth, serological tests need to be developed that can estimate current and previous infections in general populations. Finally, continued research is important to understand the source of the outbreak by study of animals and animal handlers in markets to provide evidence necessary for prevention of future coronavirus outbreaks.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: found
              Is Open Access

              A systematic review of factors that affect uptake of community-based health insurance in low-income and middle-income countries

              Background Low-income and middle-income countries (LMICs) have difficulties achieving universal financial protection, which is primordial for universal health coverage. A promising avenue to provide universal financial protection for the informal sector and the rural populace is community-based health insurance (CBHI). We systematically assessed and synthesised factors associated with CBHI enrolment in LMICs. Methods We searched PubMed, Scopus, ERIC, PsychInfo, Africa-Wide Information, Academic Search Premier, Business Source Premier, WHOLIS, CINAHL, Cochrane Library, conference proceedings, and reference lists for eligible studies available by 31 October 2013; regardless of publication status. We included both quantitative and qualitative studies in the review. Results Both quantitative and qualitative studies demonstrated low levels of income and lack of financial resources as major factors affecting enrolment. Also, poor healthcare quality (including stock-outs of drugs and medical supplies, poor healthcare worker attitudes, and long waiting times) was found to be associated with low CBHI coverage. Trust in both the CBHI scheme and healthcare providers were also found to affect enrolment. Educational attainment (less educated are willing to pay less than highly educated), sex (men are willing to pay more than women), age (younger are willing to pay more than older individuals), and household size (larger households are willing to pay more than households with fewer members) also influenced CBHI enrolment. Conclusion In LMICs, while CBHI schemes may be helpful in the short term to address the issue of improving the rural population and informal workers’ access to health services, they still face challenges. Lack of funds, poor quality of care, and lack of trust are major reasons for low CBHI coverage in LMICs. If CBHI schemes are to serve as a means to providing access to health services, at least in the short term, then attention should be paid to the issues that militate against their success. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1179-3) contains supplementary material, which is available to authorized users.
                Bookmark

                Author and article information

                Contributors
                james.smith@menzies.edu.au
                Journal
                Health Promot J Austr
                Health Promot J Austr
                10.1002/(ISSN)2201-1617
                HPJA
                Health Promotion Journal of Australia
                John Wiley and Sons Inc. (Hoboken )
                1036-1073
                2201-1617
                20 March 2020
                April 2020
                : 31
                : 2 ( doiID: 10.1002/hpja.v31.2 )
                : 158-160
                Affiliations
                [ 1 ] Wellbeing and Preventable Chronic Diseases Division Menzies School of Health Research Casuarina Australia
                [ 2 ] School of Health Medical and Applied Sciences Central Queensland University Bundaberg Australia
                Author notes
                [*] [* ] Correspondence

                James A. Smith, Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Casuarina, Australia.

                Email: james.smith@ 123456menzies.edu.au

                Article
                HPJA333
                10.1002/hpja.333
                7165578
                32197274
                6f02b3de-1942-429d-a5bf-47d74c0f0c07
                © 2020 Australian Health Promotion Association

                This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

                History
                Page count
                Figures: 0, Tables: 0, Pages: 3, Words: 2247
                Categories
                Editorial
                Editorials
                Custom metadata
                2.0
                April 2020
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.8.0 mode:remove_FC converted:16.04.2020

                Comments

                Comment on this article