Janet Omondi (Msc Public Health, 2017) is a Trustee for Riana Development Network (RDN) which is a UK based charity that works directly with BAME young people in the UK and overseas. In this blog piece, she discusses how COVID-19 has affected her work and how Kenya’s response to the outbreak has come with challenges.
How has the COVID-19 outbreak affected your work?
Riana Development’s project work in the UK has changed because of the virus. Staff have been based at home and communicating through telephone, e-mail, text and social media for remote working and meetings. There have been challenges in ensuring our team is safe from infection whilst on duty, and morale has been hit as people are uncertain of the future ICT challenges. Also, cash flow issues have arisen as we have low reserves for contingencies in the absence of mainstream funding.
How have you been responding to the outbreak?
We have had to make some changes to the way we work on our UK projects, including the suspension of all our community-based activities, and the launch of new activities via new media e.g. online tuition to continue young people’s programmes. We have launched a relief effort where our staff and volunteers support, befriend and shop for vulnerable people such as the elderly, disabled people and families.
How has your countries response to the outbreak affected your work?
In Kenya, there was a national call for curfew initiated, for 21 days from 7:00pm to 6:00am, in both urban and rural areas. This sent people into panic as movement was restricted, with offices and businesses forced to close indefinitely. Kenya’s informal sector makes up to 81% of the total working population (UN; Dec 2016), with the majority of these employees living on temporary contracts and/or contested daily job opportunities for daily/weekly pay. The closure of businesses prompted drastic movement to rural areas, mostly among slum dwellers. There was more demand for our services within the rural area where we operate from.
How has LSHTM’s training helped you during this outbreak?
The training has helped us to initiate training and sensitisation to communities through health promotion, and to provide public health prevention measures to mitigate and control the spread of COVID-19 pandemic.
Dr Christopher Charles Gawler Draper was born in Malaysia in 1921 and educated at Sherbourne and New College Oxford, graduating in 1945. As a medical student in Oxford he was involved with the trials of penicillin at the Radcliffe Infirmary as part of the war effort and then spent a year as a resident junior doctor before being posted to Japan with the ANZACs for 18 months as a medical officer.
Draper undertook a six month posting in the Middle East with the International Red Cross in 1949, during which he worked as the first medical officer at a Palestinian refugee camp in Jordan. Following his return to the UK, he took the Diploma in Public Health at the London School of Hygiene and Tropical Medicine and became a member of staff at the School and worked at LSHTM as a junior lecturer under Professor George MacDonald for 3 years. During this period he travelled to West Africa for research trips; was recruited by the East African Medical Research Service to take charge of the Pare-Taveta scheme to control malaria and worked on methods of measuring the impact of the disease on the broader health status of the people living in the region. In particular, he carried out a famous study concerning the growth of children, 1954-1960, funded by the British government. The study was written up for Draper’s doctoral thesis which he completed in 1963.
Draper returned to LSHTM in 1959 and spent a year learning the techniques needed to study viruses and was appointed deputy director of the West African Council Unit in Lagos, 1960, where he stayed for 3 years. Draper worked for the Wellcome Foundation as a medical virologist in Kent, 1964-1968 and returned to LSHTM as a senior lecturer in the Department of Tropical Hygiene, 1969. Throughout the 1970s and 1980s he carried out research projects in Brazil, Salvador, the United States, Mauritius, Sudan, Ethiopia, Uganda, Tanzania, Egypt, the Caribbean, Panama, India, the Philippines, Burma, Thailand, Greece, Zambia, Cameroon, Nepal and China. His work mainly concerned malaria as well as rabies, bilharzias (schistosomiasis), Burkitt’s lymphoma and leprosy.
Draper was a member of the WHO advisory committee on malaria and the tropical medicine research board. He travelled to make inspection visits to various countries and was a pioneer of the ELISA tests and research in sero-epidemiology. After retirement he peer reviewed books and wrote several journal articles and still travelled on behalf of the WHO.
Draper died in 2006 and his papers were kindly donated to the School in June 2007 by his daughter Alison. His contemporaries and scientists today consider Draper’s work to have been ahead of its time and his impact on current anti-malaria strategy still continues to be felt.
(28/05)Peter explains on Channel 4 Newsthat focusing on the human experience is imperative during COVID-19. Peter said: “Communication has been too much about figures and concepts … COVID-19 is about people.”
(28/05) In Boston Globe, Peter highlights the need for a coordinated global response in the fight against COVID-19. Peter said:“We must engage now to respond to the humanitarian need, to limit the spread and genetic drift of the coronavirus, and to protect the incredible gains — and lives saved — that the world has achieved through broader global health investments.”
(03/06) Heidi discusses the importance of rebuilding public confidence in vaccines, in WIRED. Heidi said:“We need to recognise that there is a general public who have very valid questions and concerns, and we need to engage them because we’re losing.”
(03/06) Heidi explains the reasons behind vaccine hesitancy on Euronews. Heidi said:“Usually it’s related to a history of issues or breakdowns in trust with government, and it doesn’t have to necessarily be about a vaccine if there’s been another health issue that hasn’t been handled well, or that the public thinks they haven’t been fully informed.”
(02/06) David comments on President Trump’s decision to terminate the U.S. relationship with WHO, in Bloomberg. David said:“I’m very disappointed that the U.S. would even be thinking of leaving such a vital multinational organization without anything to replace it. It would cause a hole in the polio eradication that would have to be filled and affect many other programs.”
(30/05) David explains that a “phased-in unlocking” is crucial to avoiding a second wave of COVID-19 infections in Singapore, in The Straits Times. David said:“Each country has to do its own risk assessment of different sectors and see where transmission has occurred in the past and where it might be safe to open up first.”
(30/05) David cautions that there is no guarantee a COVID-19 vaccine can be developed in The Straits Times. David said: “We don’t exactly understand the immune response for this coronavirus at present. Hopefully, we will learn that as vaccine research goes on. But we shouldn’t put all our eggs in one basket.”
(29/05) David praises South East Asian countries’ efforts in curbing COVID-19 transmission, in The Straits Times. David said:“The best examples are what is going on in Singapore, in Hong Kong, in Taiwan and South Korea, and in Vietnam. You have been able to keep the reproductive number low, you have been using these unique ‘circuit breakers’ instead of just locking down everything at once.“
(02/06) Adam highlights the importance of timing when it comes to the new test and trace strategy, in the Daily Mail. Adam said:“By the time someone shows symptoms, they have probably been infectious for a day or two already. So that means by the time someone has symptoms, reports as a case, their contacts have potentially already been infected … So I think that what that shows is that for these test and trace, these targeted measures to work, speed is really of the essence.”
(02/06) In BBC News, Adam comments on the current UK rate of daily COVID-19 infections, following estimates of around 8,000. Adam said:“It’s somewhere in the range of 10-fold fewer, but that’s still considerable.”
(01/06) Adam explains what the K number is in The Guardian. Adam said:“Some people might generate a lot of secondary cases because of the event they attend, for example, and other people may not generate many secondary cases at all. K is the statistical value that tells us how much variation there is in that distribution.”
(01/06) Adam discusses the UK’s current reproduction number on BBC Radio 4’s The World Tonight (from 25:24). Adam said:“We’ve got an increasingly good sense of what R is throughout the stages of the outbreak. When a lot of countries had it early on we were looking at something probably in the range of 2 to 3, and now a lot of countries have it under control so it’s going to be below one.”
(02/06) Sally outlines whether gloves are an effective defense against COVID-19 in Huffington Post. Sally said:“Whilst you’re walking around the supermarket, you could easily touch your nose, mouth and eyes with gloved hands. The only reason it might help is if you remember you have gloves on and think: ‘Oh no, I shouldn’t touch my face.’”
(31/05) Sally comments on the UK’s easing of lockdown measures in The Guardian. Sally said:“Our desire to socialise means that the critical nature of our situation is being forgotten. Why introduce all of these measures at the same time – which means that if the situation deteriorates it will be impossible to know which measures need to be reimposed.”
(30/05) Sally discusses the UK government’s guidance around mass gatherings on BBC News. Sally said:“My fear is that ‘gathering’ is going to be taken as we can have a party in the garden now.”
(30/05) Sally talks about the variation in the UK’s lockdown easing guidance on BBC Radio 5 Live (from 1:10:00). Sally said:“The basic principles are the same, it’s just the size of the gatherings. Things have not changed that much in that we are still saying it is safe enough for people to meet outdoors providing they keep that social distance.”
(01/06) Stephen discusses the efficacy of remdesivir in CNN, following further results that suggest the antiviral may speed up COVID-19 recovery. Stephen said: “These improvements are not dramatic – they are not a ‘game changer’ in the terrible jargon, but at least there is some genuine evidence of improvement … Remdesivir is one of the only drugs to show some promise, but … we need to have more transparent data before we can form a good judgment.”
(30/06) In The Independent, Stephen comments on the results of Moderna’s early human trials of a potential COVID-19 vaccine. Stephen said:“It is very difficult to be sure of the results from a press release. It must be noted that this is a Phase 1 study which has an object of showing the vaccine is able to induce an antibody response and that the dose range is appropriate.”
(01/06) In the Daily Mail, John cautions against “relaxing our guard”, amidst the UK easing some of its lockdown measures. John said:“The basic reproduction number for this virus is perhaps three, maybe even more, so we cannot relax our guard by very much at all.”
(30/05) John discusses the UK government’s decision to ease lockdown measures on Sky News. John said: “What the government have to do is they have to take scientific advice alongside other advice … They have to balance that with other things like the economy. The lockdown also has a big impact on people’s mental health and wellbeing.”
Other LSHTM experts
(02/06) Martin Hibberd comments on assertions that COVID-19 is losing potency, in Reuters. Martin said:“With data from more than 35,000 whole virus genomes, there is currently no evidence that there is any significant difference relating to severity.”
(31/05) Martin McKee warns that events and large gatherings could fuel COVID-19 transmission on LBC. Martin said:“The risk of transmission when people are outdoors – providing they do keep their distance – is probably very low. The real concern that is emerging is what we’re calling ‘super spreading’ events, where people are indoors and particularly when they’re speaking loudly or singing, which seems to be associated with an increasing number of clusters.”
(31/05) Beate Kampmann is quoted in Bloomberg about the rise of vaccine hesitancy during COVID-19. Beate said:“These are of course very personal decisions, but everybody needs to ask themselves: Would I want the vaccine for my child later on, when other people have contributed to making it safe?”
(30/05) Rein Houben explains how asymptomatic carriers of COVID-19 could be accelerating the spread of the virus, in The Guardian. Rein said:“For any virus or bacteria, making people infectious but not ill is an excellent way to spread and persist in populations.”
(30/05) On Nine News Melbourne, James Logan explains dogs’ acute sense of smell, following new LSHTM research that is looking into whether dogs can detect COVID-19. James said:“Dogs have an incredibly good sense of smell in comparison to ours and even some of the machinery that we have in our labs.”
(29/05) Mishal Khan warns of the dangers of neocolonialism during COVID-19, in NPR. Mishal said:“The lessons and expertise of the East and of African countries, coupled with the resources and power of the West, could have allowed us all to fare better. And as COVID-19 spreads globally, we will be called upon to collaborate. We need to make sure we answer that call.”
(28/05) Pauline Paterson highlights the importance of public trust in the COVID-19 vaccine development process, on The World. Pauline said: “It’s important to be transparent because there’s a lot of hopes on this vaccine.”
(28/05) On BBC News, Jimmy Whitworth outlines the steps that are needed to ensure the success of the new track and trace system. Jimmy said:“I think for this to really work, we need to get the tests back very quickly – twenty-four hours is what we should be aiming for. And also, we need to make sure that the public has confidence in the system, and does actually follow the guidelines.”
Further LSHTM coverage
(03/06) Vikram Patel explains why we need to take emotional pain as seriously as physical pain on CBC. Vikram said:“It turns out that psychological pain, just like a physical pain, is a fundamental and universal human experience, and I think this is a very powerful piece of science because it suggests to us that knowledge around how you can help people with mental health problems recover that has been generated in one context, can have a great application in other contexts.”
(01/06) In the Financial Times, Peter Piot emphasises the need for a primary prevention strategy against Ebola, following the latest outbreak in Democratic Republic of Congo. Peter said:“Outbreaks of Ebola in central Africa are unavoidable and may be increasing in frequency as the population is growing and more in contact with nature. This is a strong case to deploy Ebola vaccines in the entire region.”
(29/05) Dixon Chibanda explains how the Friendship Bench initiative is helping to bridge the mental healthcare gap in Zimbabwe, on BBC World Service. Dixon said:“It’s a psychological talk therapy that is delivered by trained community grandmothers who spend a month of intensive training on the basics of cognitive behavioural therapy, with an emphasis on problem-solving therapy.”
(28/05) A report led by LSHTM, which found that more preparation is needed to reduce the risk of adverse health effects during periods in the summer when temperatures are below the current heat-health alert thresholds, is featured in the Daily Mail.
On social media
This week’s social media highlight comes from Twitter, where we launched a video with creative media agency, Brickwall, to highlight young people’s social distancing stories across the UK.
For the second in our Decolonising the Archive series – we are re-examining Roads to Africa, a film documenting a 1936 field trip to East Africa, by the entomologist Major H.S. Leeson and his then assistant David Gillett. The men were in East Africa to conduct research into malaria, and Leeson would go on to make a significant contribution to malaria prevention throughout the world. The film is a rare historical item, showing the men collecting samples for research, as well as interactions with people local to the places they visited. The footage is accompanied by a narration from Gillett, added in 1995. This blog will look closely at Roads to Africa, analysing the material from a decolonising perspective in order to challenge some of the long held perceptions and assumptions associated with the colonial era that continue to inform contemporary social discourse.
To some extent the film could be interpreted in a positive light. From the beginning of the footage there is a sense that the researchers are attempting to actively engage with the people they meet and there is an effort to represent them in the film – rather than simply document the colonial experience. For example, at the start of the film, Leeson employs two local Ugandan assistants. Kaddu who acts as ‘mosquito collector’ and interpreter, and a cook named Ezra or ‘Ezira’ as Gillett insists on calling him in reference to the way his name is pronounced locally. The very fact that these two men are referred to by name, goes some way to acknowledge them as individuals and could be viewed as progress when compared to the anonymous crowds briefly referred to in the Carpenter Diary. However, Gillet’s deliberate mispronunciation (as he sees it) of Ezra’s name as ‘Ezira’ demonstrates the superior attitude of the white men in relation to their Ugandan assistants – a little ‘in-joke’ about the cook’s inability to ‘put two consonants together’ that even 60 years later Gillett is clearly still amused by.
This superior attitude is evident throughout the film. An early scene shows the two Ugandan men packing the car, while Leeson, wearing those hallmarks of the colonial era – safari suit and pith helmet – supervises. The travel arrangements, as described in Gillett’s voiceover, highlight the inequality implicit within the relationship between the men. Gillett and Leeson sitting in relative comfort in the front of the car, while Kaddu and Ezra are crammed in alongside the luggage in the back. Gillett goes someway to acknowledge the unfairness of this, wondering in the commentary ‘how they survived, cramped in this position, crowded like this, I don’t know’, before going on to seemingly satisfy his own conscious by declaring that ‘they didn’t seem to mind’. Whether or not Gillett ever asked either of the men if they did mind their uncomfortable mode of travel is unclear. The fact that neither Kaddu or Ezra appeared to voice their discomfort could be interpreted as a manifestation of the imbalance of power between the British and Ugandan men, rather than a quiet acceptance of the situation.
Much of the footage from the film shows the researchers visiting villages and interacting with the local population. Once again, this attempt by Leeson and Gillett to capture these interactions on film can, to a degree, be interpreted positively. It could be argued that such footage makes the lives of colonised people visible within history. However, despite these efforts the limitations of the film are all too apparent. For example, in one scene the camera focuses on an East African man, in non-western dress. Gillett’s commentary informs us that ‘whenever we saw something interesting we would stop and film it’. There a is a sense – highlighted here, but replicated within the many interactions caught on camera by Gillett – that the man has not given his consent to be filmed. Denied the right to exercise his own agency, in this instance, the anonymous man on camera has been reduced to an object by the researchers. Gillett’s use of the word ‘something’ emphasising the idea that, from the colonial perspective, this man is simply an interesting part of the scenery, rather than a person in his own right.
It can be argued that Roads to Africa renders visible the presence, and in some instances the individual identities, of people colonised by the British in early twentieth century Africa. However, on closer inspection, the nature of these interactions between colonised and coloniser only serves to further highlight the power imbalance between the two groups. Throughout the film Gillett and Leeson never move beyond treating the people they encounter with a kind of detached curiosity, and there is little or no attempt to understand or communicate with them on an equal footing. Even the claim, made by Gillett, that the local people were ‘as interested in us as we were in them’ – which could be viewed as an attempt to redress the balance between the local people and the colonial researchers – is somewhat undermined when Gillett uses the same phrase to describe the mutual curiosity between them and a giraffe they come across. This once again, highlights the fact that to the researchers, the people, animals and environments they encountered as they travelled through Africa were all similarly part of a romantic notion of what Gillett calls ‘life in the raw’.
Beyond the assumptions made by Gillett within the narration regarding the reactions of people they met, we have no real sense of the true feelings of the Ugandan people to the colonial presence. For example, aside from being ‘interpreter’ and ‘cook’ respectively, who were Kaddu and Ezra? How did they feel about their British employers? Were the local people Gillett and Leeson encountered really ‘always cheerful’ as Gillett asserts or did they resent the intrusion of the British men, violating their privacy by insisting on filming them? Almost a century later, these questions are difficult to answer. However, even by posing such questions we begin to disrupt the colonial narrative and reject the assumptions made about the lives and experiences of colonised people. In this context, the ‘cheerful’, ‘interested’ people broadly defined by Gillett within the film can instead be re-framed as individuals with thoughts, feelings and identities of their own.
During the COVID-19 pandemic, individuals all around the world have found themselves in ‘lockdown’. In many cases this has meant only leaving your home for essential reasons, following social distancing rules and only socialising with members of your household.
2020 has brought many changes to our lives, with virtual means of communicating being more important than ever. Some individuals have found themselves with more free time and others have had to shift their focus to deal with issues that have arisen from the outbreak. We have a global alumni community and want you to feel supported by LSHTM, and each other.
We are asking you, as our alumni, to share one or two images that represents your lockdown experience. This could involve hobbies you have been doing, virtual activities, your working routine, or anything that you feel represents your time in lockdown.
Your images could be used on our social media platforms, on our alumni blog or in our annual alumni magazine. Please send your image(s) to firstname.lastname@example.org with your full name, a caption for each image and the subject line ‘life in lockdown’.
If identifiable individuals appear in your photo, please ensure that you have their permission before submission.
Please provide a caption for your photos, this will be included in the Alumni magazine and may appear in other print and digital publications, and on social media. The caption may be edited.
Entries may be selected to appear on the School’s website, Flickr page and social media platforms, which are open to the public.
Entries may be used for promotional purposes e.g. School website, social media, annual report, Chariot, prospectus, exhibitions, postcards and others.
Copyright – by entering the competition, competitors warrant that they own the copyright in their photograph and they give consent to the London School of Hygiene & Tropical Medicine to store the image and reproduce it in any School-related publication or medium.
Mahoko Kamatsuchi (Doctorate in Public Health, 2016) works as a Senior Health Specialist and Task Team Leader for the World Bank. Here, she talks about how her role has been involved in COVID-19 preparations since early February and the challenges that the Central African Republic (CAR) are facing.
How has the COVID-19 outbreak affected your work?
I am based in Washington DC, and have been working from home during the COVID-19 restrictions which has been a blessing in disguise. I am able to spend more time with my family despite the emergency, and long nights with much coffee and WhatsApp calls with Bangui and colleagues from around the globe.
How have you been responding to the outbreak?
I am the Team Leader of the Health portfolio for the World Bank for the Central African Republic (CAR), and I am responsible for the COVID-19 project where the World Bank was among the first responders. We have already initiated the first preparedness initiatives from early February with the onset of COVID-19 transmission. The entire World Bank team has been working through sleepless nights to prepare COVID-19 projects. We are funding and working with the Ministry of Health and UN partners (especially through UNICEF and WHO for supply delivery) on the ground to supply the CAR with technical assistance, personal protective equipment (PPE), medicine, water and sanitation supplies, risk communication and community sensitization resources, and surveillance and diagnostic materials. This is still a challenge to bring into the country given the very difficult circumstances. As the diagnostic coverage capacity is steadily increasing, the number of apparent confirmed cases are soaring, a trend we also see in other countries.
How has your countries response to the outbreak affected your work?
Central African Republic is a landlocked country where the airports are now blocked. It has been a huge challenge to bring in the supplies and technical expertise needed to ensure the appropriate response is given to the extremely fragile, conflictive and impoverished country that CAR is. The challenges to bring in, deliver and distribute essential supplies and services to the people are enormous, unlike any other countries I have worked in around the globe.
How has LSHTM’s training helped you during this outbreak?
Courses on systematic reviews, and refresher courses on epidemiology and analysing health systems in sub-Saharan Africa really help to gauge and understand how best to respond as the COVID-19 transmission spreads.
By Hasbullah Thabrany (Chief of Party, the USAID-Health Financing Activity in Indonesia – personal view) and Virginia Wiseman (London School of Hygiene & Tropical Medicine, The Kirby Institute at University of New South Wales)
In this blog series we are giving a voice to practitioners, implementers and policy-makers involved in national COVID-19 responses in low- and middle-income countries. These posts seek to facilitate timely cross- learning by sharing opinions, insights and lessons on the challenges and actions taken by those on the COVID-19 front line.
As of the end of May 2020, the Indonesian government reported 1,613 deaths out of a total of 26,473 confirmed cases, a fatality rate of 6.1%. While Indonesia’s mortality rate is slightly higher than the current world average (5.9%), it is still relatively low given the country’s population size (approximately 267 million). There are many reasons for this, including the low rate of testing. To date, Indonesia has one of the lowest rates of COVID-19 testing in the world with only 1,183 per million people tested. The presence of underlying conditions in COVID-19 patients also make it difficult to determine the cause of death. The prevalence of smoking amongst adult males in Indonesia is 82.7%, placing these individuals at higher risk of acute respiratory tract infections and more likely to have complications from COVID-19. Despite issues of under-reporting, the number of confirmed cases is on the rise in Indonesia with a significant spike occurring between the 1st April and the 31st May 2020 when the number of cases rose from 1,677 to 26.473. This is in contrast to other countries such as China, South Korea, Australia and some European countries where the number of reported cases has plateaued or is on a downward trend.
After widespread criticism of government inaction, on the 31st of March 2020 the President of Indonesia issued a government regulation (No. 21/2020) on large-scale social distancing (LSSD). The LSSD policy delegates responsibility for the implementation and enforcement of this regulation to local governments and authorizes provincial governments to close schools, offices, recreation/tourist areas, limit public transportation, supplement the national social assistance programs, and undertake appropriate actions to enforce the law. By the third week of April, a ban on traditional mass home comings (known as mudik) during the fasting month of Ramadhan was also introduced. LSSD has triggered a major debate across the country about the rationale for banning mudik. In this blog we discuss some of the implications and challenges of implementing these policies across a country of around a quarter of a billion people, the vast majority of whom live on Java, which is the most densely population island in the world.
Even outside a pandemic situation, public policy implementation in Indonesia presents a major challenge politically, socially, and economically. This is not least because it is held together through a decentralized government system consisting of 74,000 villages, 514 cities/districts and 34 provinces each with an elected head. Policies are not always consistent across these various levels of government. Strong directive from the national government can also be is interpreted as a potential threat to democracy which has been embraced by so many since its establishment in 1998. On April 15, the President expressed his disappointment on television pointing out that only one third of cities/municipalities had followed his LLSD policy response and reallocated existing budgets to focus on controlling the COVID-19 outbreak. Three weeks after the introduction of the LSSD policy in Jakarta, the COVID-19 curve remains on an upward trend. Debates about delayed decision making, the need for urgent lock downs, and protecting the economy, continue.
Social distancing measures
As is the case for many other countries, the Indonesian government is confronted with the difficult task of weighing up the likely deaths from COVID-19 against deaths from economic deprivation and preventable diseases. The LSSD policy is resulting in substantial economic losses, especially for those who work in Indonesia’s informal sector. These workers are typically involved in construction, food markets, and many other small businesses where they earn a daily cash wage, have little or no savings, and no access to social safety nets. There are currently 74 million workers in the informal sector compared to 55 million people in the formal sector. The LSSD policy requires employers to pay part or full salaries to their employees while they are based at home. But for labourers in the informal sector, working from home means no income. In addition to increasing cash transfers to the existing 10 million households of the Conditional Cash Transfer (CCT) programme by 25%, the government is now also offering cash transfers to those that have fallen below the poverty line due to the pandemic (i.e. the ‘newly poor’) and subsidising food, electricity and other essentials.
Loss of income
The loss of income due to the pandemic also threatens contributions made by the 224 million current members of the National Health Insurance Scheme (NHIS). Since starting in 2014, the NHIS is suffering from six years of consecutive deficits. In January 2020, the President issued a decree raising premiums for the NHIS. Although the cost of health care for COVID-19 cases will be financed by the national budget, the indebted NHIS is now facing the impossible situation of rapidly increasing claims and falling contributions due to loss of income especially amongst Indonesia’s vulnerable informal sector workers. There is also huge variation in access to health care facilities across Indonesia. The country has an estimated 321,544 hospital beds which equates to about 12 beds per 10,000 people, a quarter of which are critical care beds. The ratio of doctors to population is also low at around 4 per 10,000 people. Even though the comparative ratios for large cities like Jakarta are higher (i.e. 13 doctors and 30 hospital beds per 10,000 people), health services in these cities are under considerable pressure and struggling to cope with the ever-increasing number of COVID-19 patients.
There are additional ‘cultural’ challenges to implementing the LLSD policy in Indonesia, one of the biggest and most immediate has been mudik. Each year around 20-30 million Muslims return to their home villages to celebrate Ramadhan Festival with their extended family. Most travellers typically make the exodus on crowded buses, trains and ferries, increasing the risk of spreading the virus. These travellers are also expected to place further pressure on resource-constrained health facilities outside the major cities, many of which were already understaffed before the pandemic. Under growing pressure, the President introduced a ban on all inter-provincial public transport, except for logistics and essential services. However, regardless of the ban, many people insisted on taking part in mudik or had already left before the ban was implemented.
The logistics are inevitably complex and the economic fallout huge but like so many countries Indonesia has now taken considerable strides towards implementing social distancing policies. These actions will continue to take their toll on the poor. Continuing to extend Indonesia’s social protection system to those who are currently not beneficiaries but likely to face impoverishment due to the pandemic is of paramount importance. This needs to be backed up by strong, united and consistent messaging around social distancing that is executed . Finally, much can be learnt from the thousands of trusted community networks across the country that are ramping up efforts to protect households that are falling through the cracks of social distancing and relief packages.
Image credit: Wikipedia Commons [A beach in Padang appear to be quiet as the Indonesian government calls on the public to implement social distancing]
Dr Blair Bigham (Diploma of Tropical Medicine & Hygiene, 2018) works a Resident Emergency Doctor. Here, he discusses what it has been like to work within a hospital during this pandemic and how important providing accurate information has been for Canada.
How has the COVID-19 outbreak affected your work?
The Emergency Room (ER) has been really quiet, with volumes down about 60%. But the acuity is higher – people seem to be waiting longer to come to the ER for help and we’re seeing diseases in later stages. I’ve had a few cases with poor outcomes that I consider to be collateral damage of this pandemic, even though the patients didn’t have COVID-19. Of course the COVID-19 patients are there too, but we avoided the tidal wave experienced in other cities and we are grateful for the warnings that came early and fiercely from China, Italy, New York and elsewhere that encouraged us to take things seriously and prepare aggressively.
How have you been responding to the outbreak?
In addition to my ER duties, I’ve been asked to staff Intensive Care Unit (ICU) shifts at a community hospital across town that was hit particularly hard. At one point the ICU was mostly COVID-19, and we had to surge into the post-operation care area. I’ve also been battling the fake news, what the World Health Organization (WHO) calls “the COVID infodemic”, by providing commentary in national newspapers and on the airwaves. My training as a journalist has helped me synthesize the massive amount of information flooding social media, the literature, and the hospital hallways. I think that right now, it is so important that doctors are the public face of the pandemic and are out there providing accurate information and analysis for the public.
How has your countries response to the outbreak affected your work?
I think we (Ontario, Canada) locked down just in time. We have not seen the surge we were fearing. The projections were terrifying, but fortunately, have not materialised. We are now starting to focus on catching up on cancelled services while maintaining PPE stock, capacity for outbreaks, and social distancing measures. We have had some exemplary public health leaders, and some that serve as an example of what not to do – so I think there will be a chance to learn from this pandemic and be better prepared to communicate honest, accurate information to the public that strengthens, not undermines, the social contract we have as members of Canadian society. Canadian journalists have also stepped up – I think they may have saved more lives than doctors during this pandemic by accurately conveying important information to Canadians, and building a sense of community from coast to coast.
How has LSHTM’s training helped you during this outbreak?
Having training in public health has certainly allowed me to sift through some of the literature with a better aptitude than my emergency medicine training provided me. I was also able to connect with LSHTM colleagues around the world – I have alumni friends on every continent except Antarctica – to get a grasp of what other countries were experiencing and doing to address the pandemic. And the COVID-19 course offered by LSHTM in March gave me a great sense of how COVID-19 came to be, and how it might eventually be resolved.
Supporting global eye health during the COVID-19 pandemic
An update from the International Centre for Eye Health, with news about a Community Eye Health Journal issue on COVID-19
Nearly three months after the World Health Organization declared COVID-19 a public health emergency of international concern, we are continuing to feel the effects of the global pandemic. Our partners and colleagues, and those working in the eye health community in general, are very much in our thoughts at this time.
The COVID-19 pandemic has caused severe disruption in eye care delivery in many countries worldwide. In many areas, routine eye services have been suspended and only patients with emergency eye conditions are receiving direct care. Eye health workers are faced with numerous challenges, such as deciding who should still be seen, making choices about personal protective equipment, and reducing the risk of viral spread within eye clinics and hospitals – all while continuing to provide high quality eye care.
To address this challenge, ICEH is publishing a special issue of the Community Eye Health Journal with up-to-date guidance on COVID-19 specifically for the eye health community.
Due to the urgency of the situation articles are being published online as soon as they are available, with several already live:
Similarly, whilst health care services around the world seek to prioritise emergency care and hospital space, it is important that vital healthcare in other areas is not neglected. We are carrying out and coordinating research to assess the impact of this on eye health.
The unprecedented disruption to travel and social contact has provided a unique challenge for the continuation of our training and education programmes. We are making more of our resources available online, whilst also organising more virtual meetings between our partners, to ensure the momentum of learning and access to knowledge, now and in the future. Please check our website and social channels regularly for further information on upcoming activities. We hope that we can continue to support all those involved in eye health throughout this situation.
Looking beyond the time of the pandemic, we are currently working on a global collaboration, the Lancet Commission on Global Eye Health, to strengthen the evidence base that eye health needs to be an international priority and that people receive the care and treatment they need.
The full impact of the pandemic on eye health will only be fully understood some time into the future. Despite current difficulties, we are continuing with our research and will keep you updated as and when we have information. Please also don’t hesitate to get in contact with us through the email below or on our social media.
(26/05) Peter recounts his first-hand experience of contracting and recovering from COVID-19 in the New York Times. Peter said:“I had three stages — first fever, then needing oxygen, and now the storm. People think that, with COVID-19, 1 percent die and the rest just have flu. It’s not that simple — there’s this whole thing in the middle.”
(23/05) Peter tells Der Spiegel that we should be more open to unconventional ideas in our COVID-19 response. Peter said:“I do think it is possible that we will have a treatment for COVID-19 before we have a vaccine. Thus far, the goal has exclusively been that of combatting the virus. But maybe we also need to think about controlling the immune response. We should test whether antiviral agents might be suitable as preventive agents as well.”
(21/05) Peter warns against “vaccine nationalism” in the fight against COVID-19, on CNN’s Amanpour programme. Peter said:“We need to make sure that everybody who needs it, gets it. And that it’s not just limited to a few countries that produce these vaccines.”
(27/05) Heidi is quoted in Nature about public confidence in vaccines. Heidi said:“If the public opt to forgo vaccination the way they did during the 2009 swine-flu pandemic, we’re in deep trouble.”
(26/05) Heidi recalls watching her husband, Peter Piot, being taken into the COVID-19 ward in the New York Times. Heidi said:“When I saw Peter go through the double doors on that cart — I had the same feeling as the Ebola families we knew in Sierra Leone.”
(24/05) Heidi explains how timing can affect a vaccine’s uptake in The Atlantic. Heidi said:“In mid-March, 7% said they would refuse a COVID-19 vaccine, which dropped to 5% when deaths spiked, then rose to 9% during talk of loosening lockdowns.”
(27/05) Stephen tells talkRADIO (from 01:44) that very few drugs alone have dramatic benefits in the treatment of infectious diseases. Stephen said:“When we look back at HIV, we found that even though individual drugs worked quite well, the way to make a big difference was by using a combinations of drugs.”
(26/05) In the Financial Times, Stephen comments on the provisional approval of remdesivir as a treatment for COVID-19 patients in the UK. Stephen said: “It is important to realise that this allows for legal access to an unlicensed medicine. The amount of evidence on remdesivir’s efficacy and safety is still limited and it’s possible it will not become licensed.”
(26/05) Stephen discusses the suspension of trials of hydroxychloroquine in the Evening Standard. Stephen said:“A definitive answer still awaits the results of the randomised trials, but it is clear that the drugs should not be given for treatment of Covid-19 other than in the context of a randomised trial.”
(26/05) On BBC Horizon (from 43:16), Roz explains why contact tracing and quarantine measures are needed on top of mass testing efforts to curb COVID-19 transmission. Roz said: “We think people are infectious for a fairly short time, and so they’ll only test positive for a short amount of time.”
(22/05) Roz is quoted in The Guardian about role of children in COVID-19 transmission. Roz said:“The available evidence suggests that they may play a smaller role in the epidemic as a whole. This new evidence will help us better understand the possible effect of school reopening on transmission in schools and in the community.“
(26/05) Adam is quoted in the Daily Mail about why a combination of social distancing measures, contact tracing and mass testing is needed to tackle COVID-19. Adam said:“An important finding of our study was that moderate social distancing, combined with contact tracing and testing, could help control the spread of COVID-19 while reducing the number of people who need to be in quarantine.”
(25/05) Adam describes the unpredictable nature of disease outbreaks, and how pandemics can differ greatly, in the Irish Independent (£). Adam said:“If you’ve seen one pandemic… you’ve seen one pandemic.”
(21/05) Adam speaks to BBC Radio 4 (from 25:54) about the dangers of countries lifting lockdown restrictions without tracing systems in place. Adam said: “We have to be very careful about lifting restrictions without having something in place that can ensure reduction in transmission. The hope over time is that we can have something more targeted like track and trace, so that we don’t need these blanket measures. But the UK and many countries are still seeing cases appear, so we have to be cautious about how lift those measures.”
(22/05) In Huffington Post, Jimmy Whitworth emphasises the importance of mass testing and contact tracing to curb COVID-19 transmission. Jimmy said:“Testing and tracing is most feasible as an effective strategy at the start of an outbreak when there are just a few chains of transmission of the disease.”
(21/05) Jimmy explains the importance of “human capital” in mass contact tracing and testing efforts, in The Guardian. Jimmy said:“The human element is central. If you have a web-based system or an app, those are things that add value but they don’t replace the human capital. They are good when tracing becomes difficult like if a confirmed case has got on a bus. That’s where an app can identify potential contacts.”
(22/05) Sally explains how to minimise packaging contamination when eating, in BBC News. Sally said:“Empty the contents into a clean dish, dispose of the packaging into a refuse bag and wash your hands thoroughly before you eat.”
(22/05) On BBC Radio 5 Live (from 2:50:52), Sally outlines the precautions that are needed when ordering a takeaway during COVID-19. Sally said:“Make sure it’s from a reputable supplier and that they have highest hygiene standards. COVID-19 is not a food poisoning organism – if it’s ever in our food it’s because of the people who have prepared the takeaway.”
Other LSHTM experts
(27/05) Dixon Chibanda is quoted in BBC Future about the Friendship Bench, an intervention developed in Zimbabwe to bridge the mental health treatment gap. Dixon said:“It’s rooted in evidence-based therapy, but it’s also equally rooted in indigenous concepts. I think that’s largely one of the reasons it’s been successful, because it’s really managed to bring together these different pieces using local knowledge and wisdom.”
(27/05) Richard Coker writes in The Guardian, highlighting the importance of maintaining public trust during COVID-19. Richard said:“Public health is about trust, a largely unwritten contract between all of us and the state. We need to trust that we each have our own and others’ interests at heart, that we share a sense of solidarity and will all do our best to protect the most vulnerable among us.”
(27/05) Martin McKee comments on remdesivir as a potential treatment for COVID-19 on LBC. Martin said:“This is a really complex multi-system disease so ultimately, any treatment that we have is likely to involve a combination of drugs that do different things to prevent the virus from infecting the body. This certainly is encouraging, although I think it’s a bit early to be absolutely clear on what it will do.”
(26/05) Alex Bowmer writes in The Conversation about why banning bushmeat could make it harder to stop future pandemics. Alex said: “Because of bushmeat’s cultural value, taking away the choice to consume it permanently would probably be resisted. It would also likely encourage unregulated underground markets.”
(26/05) Val Curtis explains how social factors can affect adherence to COVID-19 precautionary measures, in New Scientist. Val said: “To encourage a particular behaviour, it’s important that people perceive that everybody around them is doing that behaviour.”
(24/05) David Heymann explains why some people experience long-lasting symptoms following initial COVID-19 infection, in The Guardian. David said:“In some persons they begin to feel well again and signs and symptoms including fever decrease, but some then go on to develop respiratory distress and must be provided oxygen in hospital. It appears to be a delayed immune response that is more serious in some persons and that reacts to remaining virus in various organs.”
(22/05) Brendan Wren comments on the changing nature of current estimates of reproduction number in the UK, on Sky News. Brendan said:“I think the key issue is that it really needs to be backed up with real-time diagnostic tests and at the moment, we’re still getting 3,200 new cases each day.”
(22/05) LSHTM modelling that suggests that there are more than 100 vaccine-preventable deaths for every COVID-19 death prevented by cancelling routine immunisations, is featured in The Telegraph (£).
(22/05) Mishal Khan cautions in The Telegraph (£) that a lack of reliable death data will add to uncertainty about the result of lockdown relaxations in Pakistan and India. Mishal said:“Among public health people there is a strong feeling that accurate death info is going to be really useful to see the impact of increasing population mingling, although there doesn’t seem to be a good source of this information.”
(22/05) Martin Hibberd explains why false negative COVID-19 test results can be particularly dangerous, in The Guardian. Martin said: “This could be devastating if a patient was returned to a care home and passed the disease on.”
(22/05) Chris Bonnell discusses the need for contact tracing to support the reopening of schools on LBC. Chris said:“If there’s an infection in a bubble, then the bubble needs to be sent home until we can establish whether they have got an infection.”
(22/05) Annelies Wilder-Smith explains why timing is crucial in curbing COVID-19 spread, on BBC News. Annelies said: “The effectiveness of quarantine measures really depends on timing, and that’s why countries that have low cases will need to focus on extremely stringent entry measures. But it always has to be combined with containment at source.”
(21/05) Chris Retsch outlines research findings that show black and Hispanic Americans are being disproportionately affected by COVID-19 on BBC World Service’s Science in Action (from 17:30). Chris said:“Our findings highlight the need for improved strategies to prevent and contain further outbreaks in ethnic minority communities.”
This week’s social media highlight comes from Twitter, where we released our latest Viral podcast episode with James Logan, Clare Guest and Steve Lindsay, who discussed the current research underway into whether dogs can detect COVID-19.