An Achievable, Sustainable, New Normal

An Achievable, Sustainable, New Normal:

In efforts to prepare volunteers for outreach work, and to prepare for service development projects, we remain up to date with local bio-psycho-social risk and protective factors as well as local procedures and policies relating to emergency and general medicine, including infectious diseases and tropical diseases, with relevant management or preventative options, such as vaccines, in various countries.

Questions are asked about a ‘new normal’ on a daily basis in many countries. Many are concerned that they will have to wear face masks for the next 1-5 years, when there is no good clinical evidence to support the wearing of face masks for healthy individuals in the community, as the World Health Organisation and the ECDC agree. Many have raised concerns regarding increased risk and harm due to indiscriminate mandatory face mask initiatives. Many are concerned that regular #travel (without face masks or quarantine) will not resume within the next 2 or more years; many elderly patients report “we need our cruises” and “we want to get back to travelling, but not with face masks”.

We have been asked for our thoughts regarding a ‘new normal’.

In our opinion it is important that we focus on longstanding, well-established, evidence-based strategies (only good clinical evidence) to reduce #risk of #infection or #disease (morbidity and mortality) and to protect (evidence-based protective factors – based only on good clinical evidence). This is likely the first step in #creating #positive and #lasting #change for children and adults – high and low risk individuals.

1. TOOLS – Give all individuals #tools to practice good #hygiene – this relates to alcohol gel on tables, wash rooms with running water and soap, and allow #homeless people access to tools too (more than 50% returning #veterans who risked their lives for the nation’s #freedom , needing and wanting access to #water and #soap , in some states and nations – please know that currently more or less 40,056 veterans are homeless on any given night (see link) – many are informed that they are not allowed to use outside showers, even at night or early in the morning when no one is around). http://nchv.org/index.php/news/media/background_and_statistics/

#Food and drinking water, as well as appropriate shelter, might be relevant here too.

Water quality, which affects children, adults and communities, is relevant. Please see previous comments relating to Bangkok, Thailand and the river – this is relevant in many nations. #Sewerage drains leaking eg into beaches or rivers need to be addressed as a matter of urgency in every country – these concerns precipitate and maintain many different infectious diseases. Numerous infectious diseases including coronavirus can be found in urine/faeces.

Let’s start with the basics, with simple measures, let’s get it right, before we make it more complicated and introduce measures not based on good clinical evidence. What affects one of us, affects all of us – this is relevant in most contexts, but especially with infectious diseases and general health, if a global health perspective is employed.

2. BE AT HOME IF YOU ARE SICK – Be at home and stay at home, if you feel sick, have symptoms or have been in recent contact with a confirmed case – and contact health services for advice. Too many individuals attend #work or #flights or #travel when they are not well. Employers should support employees in this systemic approach. We often offer emergency services during flights and most often the person felt unwell whilst still at home. Individuals report on a daily basis that they travel or leave their homes when they know they have a cold or flu, even during this pandemic, eg “I knew I was getting sick, I felt awful, but I took the flight and thought I will get better on the beach” and “I went for a quick breakfast with my wife although I was sick with the flu, but I thought it would make me feel better”. We observe individuals on a near daily basis who have a cold or flu (raised temperature, clearly sweating but experiencing cold, coughing etc), mostly at restaurants or airports.

3. COVER YOUR NOSE AND MOUTH IF YOU COUGH OR SNEEZE – Cover your nose and mouth if you cough or sneeze whether you wear a mask or not, and no spitting. These behaviours reduce risk. Some nations now offer fines for non compliance.

4. SHARING – Do not share food, drinks, cigarettes or #hookah / #shisha or anything relevant in this same context if you are not confident the person is healthy – think mouths, noses, eyes and hands.

5. FOOD – Food hygiene – cover food at buffets, do not touch items unless you are taking those items with you and supervise children at all times.

6. VENTILATION – Ventilation – open windows and doors to facilitate ventilation or improve ventilation in any way appropriate – this is especially relevant for #restaurants or cafes, #schools , #hospital waiting rooms and #GP practices, and any area where large groups of individuals gather eg during #transit or travel.

7. SPACE – Positive Space – create and maintain space inside and outside, in shade, with seating where individuals can rest and relax in an enjoyable quiet atmosphere. Theme parks such as #DisneyWorld can be wonderful places for #children to #enjoy, #develop and #learn, (we have liaised with numerous children in need or at risk who report their lives have changed with messages from Disney, such as “anything is possible” or “let your conscience be your guide”), however, when there are limited seating options, groups gather in small areas to rest in the same shade to keep an eye on the same seats hoping they would be available. This is also relevant for cruise liners – particularly when doing emergency drills, preparing passengers, when passengers stand in close proximity, often in hot weather.

#Airports and #airplanes are relevant here. Boarding and disembarking are often associated with chaos and several lines, up to 5 lines to board one flight, streamlining with planning and preparation is possible. Airplanes where seats are very small, passengers sit close together and passengers recline onto other passengers’ laps with no healthy or positive space is of particular concern, and avoidable. Many airlines now stop individuals from reclining, which offers more personal and positive space. We have observed, firsthand, that these positive changes are possible in airports and flight in Asia – social distancing and ventilation were facilitated, passengers were asked not to wear face masks unless they presented with clinical indications, with good clinical outcomes.

Small changes can have significant effects on health, mental health and social risk.

8. NUMBERS – Limit numbers to avoid #chaos and #crowding. It is the #culture to encourage and be proud of long #lines and #crowds – it provides messages of popularity, demand and ‘not to be missed’, however, these same factors lead to increased risk in terms of health, mental health and safety. We usually aim to avoid these contexts, by choosing quiet times or alternative options. This is especially relevant for contexts such as cruise liners and theme parks. Individuals sometimes report that they wait in 3-4 lines before entering a theme park, and then wait for approximately 5-7 hours in lines for coffee, food, entertainment or rides – this increases risk, not only during a pandemic. Most individuals report that they “cannot wait for #Disney to reopen” or “I can’t wait to get on a cruise again”, reporting benefits relating to mental health and general health, however, small changes can inspire great health benefits.

9. EDUCATION – Education regarding evidence-based protective factors for the immune system, general health, mental health and social risk. More or less 3/10 individuals could provide us with more than 3 evidence-based protective factors for health, mental health or social risk. Evidence-based protective factors significantly improve prognosis, morbidity and mortality, in terms of mental health, general health and social risk. Please see previous comments on evidence-based protective factors, children’s development, normative activities and the immune system. 

Education regarding evidence-based risk reducing initiatives should also be prioritised eg relating to #respiratory diseases and also #mosquito born diseases – many #infections can be avoided with a little #education and planning. We often ask individuals about the country they have travelled to or are travelling to and less than 3/10 of adults were aware of local health risks or relevant vaccines. These topics reduce risk and harm.

10. EVIDENCE – A commitment to follow only good clinical evidence during clinical or medical emergencies, urgent medical matters and routine medical matters – to weigh evidence-based risk and protective factors, and to first do no harm, ensuring that health and mental health related statistics (morbidity and mortality), as well as child protection statistics, improve, not worsen. A commitment to transparency and collaborative work within nations and amongst nations during clinical or medical emergencies – a global health plan for global health emergencies. These are the #strategies #doctors employ every day during #health #crises to ensure #good #clinical #outcomes (or the best chance of good clinical outcomes) – it only makes sense that these strategies be employed on a larger scale, a #global scale, as part of a global health plan, to protect nations.

Medical doctors engaging in clinical work (who work with patients) usually do not use strategies based on inconsistent or weak evidence – they focus on strategies (recommendations or management plans or treatment) based on good clinical evidence only – before they return to the drawing board (if good outcomes are not achieved) and reconsider their risk assessment, clinical impression and management plan, asking themselves if they have missed anything, liaising with colleagues, and then if the answer is ‘no’, they possibly consider more creative options.

We have been asked whether face masks should be part of a new normal. We would strongly advised that face masks not be #normalised in any way. Face masks have a specific clinical indication where they are likely to be of benefit for certain individuals. We have liaised with the relevant Health Commissions and Health Ministries regarding these concerns, including relating to children in the context of child development and schools.

Based on our experience travelling through different countries, meeting with individuals from various cultural backgrounds, ranging from the most vulnerable to the most fortunate, it is our opinion that these 10 items would improve morbidity and mortality statistics for every child and every adult markedly, in the context of the pandemic, future pandemics and general health risks.

Many countries in Asia reported that they were prepared for the pandemic, based on previous experiences, and that they believe it is likely that repeat occurrences will be relevant. Statistics support their approaches. It is unfortunate that many now report pressure from countries with less experience in infectious diseases to comply with initiatives not based on good clinical evidence.

Let’s learn from our neighbours and follow good evidence to reduce risk and to protect.

#NewNormal #education #children #space #medical #doctors #psychiatrists #travel #health #mentalhealth #volunteer #socialrisk #flight #cruiseline #cruise #themepark #entertainment #symptoms #achievable #sustainable

Evidence-Based Recommendations to Remain Healthy During Travel and Outreach Work

Our evidence-based recommendations to staff, schools, health or mental health services include:

A – Alcohol gel (wash or disinfect hands before eating or touching your face).  

At least 7/10 individuals confirm that they neglect this behaviour, due to “everything to remember, it is too much” and “I wear the face mask, I follow the rules and stay home”.

It is also important to wash or disinfect your hands before handling your mask, WHO guidelines, to prevent increased risk.

Most individuals report that they do not engage in the above behaviour when handling a mask.

B – Be at home and stay at home, if you feel sick, have symptoms or have been in recent contact with a confirmed case – and contact health services immediately for advice.  

At least 7/10 individuals confirm that they do not follow rule B – many report that the mask will protect others and that they “carry on as usual”. Many report “face masks are enough”.

C – Cover your nose and mouth if you cough or sneeze whether you wear a mask or not (and no spitting). 

We observe 9/10 individuals with face masks coughing and sneezing without covering their mouths or noses. Many report “face masks are enough”. Some countries now give fines for spitting.

D – Do not share food, drinks, cigarettes or #hookah / #shisha or anything relevant in this same context – think mouths, noses, eyes and hands.

We observe these behaviours on a daily basis in more than one country.

E -#Environment – the 3 important factors:  Avoid #restaurants, #shops, #musicperformances, #artperformances, #sportsevents or any other context or situation, if possible, where good ventilation and social distancing are not facilitated and maintained, and where recent contact with a confirmed case, temperature and symptom screens are not in daily use, before entry is allowed. Many schools in countries in Asia ask for these screens to be completed by staff and pupils at home, before leaving home, with good results.  

If you absolutely have to be in these contexts, for work for example, follow WHO and ECDC guidance and wear a mask safely.    

Restaurants, shops and #schools must be encouraged to open #windows and #doors to facilitate #ventilation or improve ventilation in any way appropriate. We have observed, firsthand, that good ventilation and social distancing are possible in most context including #airports and #airplanes during the pandemic through our #travels.

We personally usually aim to avoid indiscriminate mandatory face mask settings where possible and allowed by government rules or policies, we opt for environments and contexts where social distancing and good ventilation are maintained.

As mentioned before, we have never presented with #symptoms, a raised #temperature or a positive test for SARS-CoV -2 after the pandemic was reported in January 2020, despite our #travel through more or less 20 countries. Simple evidence-based (based on good clinical #evidence – longstanding well established good clinical #research) risk reducing and protective factors are effective. If good clinical evidence is not followed risk often increases; #risk from a #medical point of view, as well as #developmental, mental health and #social point of view.

Unfortunately we have observed indiscriminate mandatory mask wearing initiatives indoors and outdoors, whilst hundreds of people sit at restaurants or coffee shops, close together, for hours at a time, often more than once per day. This makes no clinical sense, is not based on clinical indications or good clinical evidence, and will significantly increase risk and harm. Restaurants, shops, #hairdressers, #liveperformances etc should be open – but with the advice worded in a different manner. In our opinion – it is important to word it in this way – good ventilation and social distancing is a MUST – the first priority – and where it is absolutely impossible to facilitate, and individuals MUST be in this context, such as doctors responding to emergencies, a mask must be worn safely.

Many individuals report “we don’t have to do social distancing, because we wear masks”, even in restaurants – evidence does not support this theory.

Clinical indications and good clinical research are essential to reduce risk and harm, and protect the public, high and low risk individuals equally.

F – Focus on evidence-based protective factors to #protect mental health and general #health – such as remaining #calm, #positive and #hopeful, spending positive time with loved ones, outside and in #nature, #eating healthy and #exercising, #enjoyment and #normalcy.  Evidence-based protective factors significantly improve #prognosis, #morbidity and #mortality #statistics, in terms of mental health, general health and social risk. Please see previous comments on evidence-based protective factors, children’s development, normative activities and the immune system. 

G – Good Food Hygiene: We prefer that food for sale in public is covered, especially when you are not going to wash or cook it, such as #pastries or #breads at #buffets or #bakeries or #farmstalls (people often cough and sneeze whilst walking around planning their meals). We prefer contexts where children are supervised (children sometimes touch food, put food back, of course adults also do the same sometimes). We will provide thoughts on general tips to remain healthy when travelling or visiting high risk areas or countries, which includes items re food.

Sharp mind – soft hands, as the #Jamaican #Bobsledders in #CoolRunnings suggested. 

As mentioned before, we have followed these recommendations in at least 20 countries during the pandemic and have never presented with symptoms, a raised temperature or tested positive for SARS-CoV-2. We usually prefer environments where face masks are not indiscriminately mandatory, and where social distancing and ventilation are facilitated and maintained.

HOWEVER, WE ALWAYS ADVISE EVERYONE TO FIRST FOLLOW THE LOCAL GOVERNMENT’S LAWS, RULES AND POLICIES, WHICH MAY SOMETIMES DIFFER SLIGHTLY. 

We will provide further details in future blogs, including of our go-bag and medical kits, along with practical recommendations and information.

CURRENT EVIDENCE REGARDING FACE MASKS December 2020 and January 2021

Let’s follow only good clinical evidence to protect children and communities.

Indiscriminate Mandatory Face Mask Initiatives:  Evidence and Recommendations

“”At present there is only limited and inconsistent scientific evidence to support the effectiveness of masking healthy people in the community to prevent infection with respiratory viruses, including SARS-CoV-2”  WHO

The WHO says when it MAY be helpful to wear a face mask – December 2020:

https://apps.who.int/iris/rest/bitstreams/1319378/retrieve.  

“Wear a mask if you cannot maintain a physical distance from others”. 

“In areas where the virus is circulating, masks should be worn when you are in crowded settings, where you can’t be at least one metre from others, and in rooms with poor or unknown ventilation.” 

“Individuals/people with higher risk of severe complications from COVID-19 (individuals > 60 years old and those with underlying conditions such as cardio-vascular disease or diabetes mellitus, chronic lung disease, cancer, cerebrovascular disease or immunosuppression) should wear a mask when physical distancing of at least one metre CANNOT be maintained.” 

“Caregivers or those sharing living space with people with suspected or confirmed COVID-19, regardless of symptoms, should wear a medical mask when in the SAME room”.

https://apps.who.int/iris/rest/bitstreams/1319378/retrieve

https://www.who.int/news-room/q-a-detail/coronavirus-disease-covid-19-masks

https://www.ecdc.europa.eu/en/covid-19/questions-answers/questions-answers-prevention

https://www.ecdc.europa.eu/en/covid-19/prevention-and-control/protect-yourself

The ECDC (European Centre for Disease Prevention and Control) says when it may be helpful to wear a mask – January 2021: 

“If you are infected, the use of medical face masks (generally pale blue in colour and available from pharmacies) MAY reduce the risk of you infecting others.”  

“Consider using a face mask when visiting busy, enclosed spaced, such as grocery stores and shopping centres, or when using public transport, where it is NOT possible to maintain a social distance from others.” 

“We strongly recommend the use of medical face masks for individuals with risk factors for severe COVID-19, for all people in airports, and for all passengers during flights.”

“Wear a face mask indoors and outdoor whenever physical distancing with other people CANNOT be guaranteed.”  

The ECDC have updated their advice. No good or strong clinical evidence or research supports the wearing of face masks for healthy individuals in the community.

https://www.ecdc.europa.eu/en/publications-data/using-face-masks-community-reducing-covid-19-transmission

Recommendations as published in newspapers in Singapore, February 2020, a country with experience and relative success in managing previous and current outbreaks of coronavirus:

“Do Not Wear a Mask” unless at higher risk: “Do Not Wear A Mask If You Are Well.” 

“Who Needs To Wear A Mask?  IF you have a Fever, Cough or Runny nose and IF you are Recovering from an Illness.”

Conclusion

The WHO and the ECDC therefore do not recommend indiscriminate mandatory face mask wearing as an initiative for the general public indoors or outdoors; it is clear that the WHO and ECDC specify specific contexts where this initiative will likely reduce risk on balance (balancing evidence-based risk and protective factors), which cannot be ignored, generalised or misinterpreted.  

These recommendations also make sense from a clinical point of view based on clinical training and clinical experience, along with research and statistics that risk is increased and harm is caused by these initiatives if not applied as clinically indicated.  

WE ALWAYS ADVISE EVERYONE TO FIRST FOLLOW THE LOCAL GOVERNMENT’S LAWS, RULES AND POLICIES. 

#evidence #recommendations #healthy #travel #children #schools #smoking #drinks #Cambridge #UK #ChildPsychiatrist #Mentalhealth #Health #International #ServiceDevelopment #OutreachWork

Liberty linked to Peace

Liberty is a longstanding, well established, evidence-based protective factor for children’s development, well-being, general health, mental health, social risk, safety and security.  

The same is true for adults with different cultural and psycho-social backgrounds.

Nations protect liberty, advocate for liberty and prioritise liberty for these reasons.  Many prioritise liberty over safety or health, because liberty has significant effects on, is an evidence-based predisposing, precipitating and maintaining factor for, safety, mental health, general health and well-being.  Liberty also facilitates and maintains peace in communities, in nations and between nations.

Nations define their identity with liberty and many have sacrificed their lives for liberty.  “Remove a person’s liberty, you remove a person’s voice, rights, hope and life, you take control of him or her”, as reported by a medical colleague. 

Many children’s emotional, language, cognitive, social and physical development, as well as mental health, general health (morbidity and mortality), well-being and safety are significantly affected by ongoing measures depriving liberty intended to protect, not based in good clinical evidence.  Please see statistics regarding risk and harm previously mentioned.

There can be no further delay in weighing evidence-based risk and protective factors for children by medical specialists with training and experience in this regard, and acting accordingly.  

Medical emergencies require a systemic approach with clear clinical leadership; assessment of clinical presentations and relevant bio-psycho-social risk and protective factors by doctors with clinical experience.

First do no harm is a prevailing principle that leads clinicians in high risk and complex contexts, and this is a principle that must be employed with no further delay. 

#liberty #children #development #safety #wellbeing #evidence #ProtectiveFactor #peace #identity #doctor #medicine #medical #psychiatrist #free #freedom

#Cambridge #UK #ChildPsychiatrist #Mentalhealth #Health #International #ServiceDevelopment #OutreachWork

Paint the walls of your mind with many beautiful pictures – William Phelps

#LatinAmerica – more beauty – thank you for your lessons.

We can change our day or our year or the outcome when we change our thoughts.

Many therapies are based on this principle, as most medical doctors would agree.

The body and the brain listen to thought and usually complies.

We have spoken to many children, families and communities, along with medical colleagues, who have serious concerns (“dark thoughts” as reported by a medical doctor) about ongoing indiscriminate mandatory mask wearing, lockdown, stay at home, quarantine and curfews.

Many professionals are working hard to liaise with appropriate health and governmental organisations to raise concerns regarding risk and harm in the context of ongoing indiscriminate mandatory initiatives, and many leaders share these concerns. Your thoughts are heard and will be taken seriously.

What can you do now?

Focus on today – focus on now – what can you do – to lighten the load – to have a good day today or a good moment or few hours today?

We will share thoughts on this matter in the next few posts.

For today – think about your thoughts.

Thoughts drive our mental health and our health (blood pressure, heart rate, breathing rate, immune system), and thoughts also drive our safety and security, our well-being, our development and success with our goals.

It is important to accept and acknowledge thoughts relating to anxiety, depression, anger or risk – and to share them with someone you trust (with an adult if you are under 18). Think about whether there is something that needs to be done right now – such as getting help in an emergency to keep someone safe or healthy.

If there is no urgency or emergency – think about future plans and strategies to improve things. Thoughts give us information – the body and the brain often give us messages – we need to listen and act accordingly (after we have made a plan with a calm mind).

After you have considered the message your thoughts have given you – and have discussed it with someone – and have a provisional plan or strategy – now is the time to manage your thoughts – until you go back to the drawing board – and think about ‘life’ again and strategise further (perhaps once a week – make a dedicated time and keep boundaries to stick to the plan).

Needless to say – in an emergency or urgent situation – act now – get help and advice without delay. Our thoughts often save our lives or the lives of others. Your GP or the Emergency Department can give you contact details.

If there is no urgency or emergency – now to manage your thoughts – to manage the moment, to manage your morning or your day and to manage your life – to have a good life.

If we take care of the moments, the years will take care of themselves. Edgeworth

Real generosity towards the future consists in giving all to what is present. #Camus

Nothing is worth more than this day. #Goethe

The importance of thought and public messaging inspiring thoughts have been known for a very long time:

Do not think that what your thoughts dwell upon is of no matter, your thoughts are making you. B Steere

A man is but a product of his thoughts, what he thinks, he becomes. M #Gandhi

For as he thinks within himself, so is he. King Solomon

All a man achieves, all that he fails to achieve is the direct result of his own thoughts. James Allen

The belief in a thing makes it happen. Frank L Wright

Whether you believe you can do a thing or not, you are right. #HenryFord

The height of your accomplishments equals the depth of your conviction. #Scolavino

What a man thinks of himself determines and indicates his fate. H #Thoreau

The secret of living a life of excellence is a matter of thinking thoughts of excellence; a matter of programming our minds with information that will set us free. C Swindoll

Master your thoughts to master your life. A #Lincoln

Happiness does not depend on outward things, but on the way we see them. #Tolstoy

How do I start to do this?

1. Start by thinking about your happiest or calmest moments or times in your life – were you at the beach or planting a garden or walking in the woods or working with animals?

Dwell on those thoughts – take mental pictures – dwell on the feelings. Spend time in those moments – like visiting a friend.

2. Put pictures that remind you of these moments on your phone, in your home – little tokens to remember wherever you can. Look at the pictures and take time to enjoy the moment and the thoughts.

Many report that their blood pressure and heart rate go down as they think of enjoyable and relaxing memories or thoughts. This makes sense from a medical point of view – this benefits health – immediate and long term effects. Simple measures can affect health outcomes significantly.

3. Many children and adults find it helpful having a mantra – such as “I can do this” or “It’s in the bag” – children often have an action hero who has a certain saying – and repeating this mantra – reminds them of this person and their attitude and inspires thoughts of “can do” and feelings of excitement and enthusiasm. Quotations or narratives or images (pictures or thinking of this action hero can help).

4. Many children or young people find it helpful to have a bucket list of exciting plans (this must not be to-do or work items – it must bring you a smile when you think about it), this may include getting a dog, learning a language, taking a trip or going for a hike. Think about your exciting plans for this evening, for Friday or Saturday, or for long term – make a list – put some visual reminders to it. It is often a good idea to have something to look forward to at the end of the day, at the end of the week, month or a few months, one day. Carrots move us forward with positive thoughts.

Many people have bucket lists full of travel itineraries – pick a #destination and plan a day or weekend to celebrate it – find the right #books or blogs and read about it, find the right #music – find the right #food or learn the #dance of the destination eg #Cuban #salsa – there are lots of wonderful websites to learn the dance or to make the local dishes. These simple efforts built around thoughts – will likely transport you to another place – and provide you with a #positive #mentalstate.

5. Many find it helpful to have a gratitude list – a physical or mental list – every morning or evening, first thing or last thing, or both – think about what you are grateful for – it can be that nice cup of tea, your favourite tea mug, your garden, the blue sky and sun, your cat, your favourite blanket or music or song – don’t just list it – think about it and feel every single happy or relaxed feeling you can.

What you think about multiplies. If you constantly or often think ‘my knees are sore’ – your knees will likely feel worse. Go see a doctor and get advice and think about something else for a while. If you think about how kind your neighbour is – your neighbour often gets kinder. The mind is much more powerful than we think, but we will not go into this now.

Changing thoughts takes a bit of time – like any habit – but every day it gets easier if you stick to it.

If you find yourself thinking something negative such as “what is the point” – say “stop” to yourself and REPLACE it with – “there is a point – everything happens for a reason and I can do this and will do this until it is done” – an example of a medical colleague.

“It always seems impossible until it is done.” Mandela

It is important that you are KIND to yourself at all times when you learn or understand something new – hostile or negative environments do not facilitate learning, growth, development and well-being.

“Constant kindness can accomplish much. As the sun makes ice melt, kindness causes misunderstanding, mistrust, and hostility to evaporate.” Albert Schweitzer

Habits are often not ‘stopped’, but rather replaced by others – so choose your own replacement.

It is also important to remember that there are two steps forward, one step back – in every new venture – so expect difficult days where things don’t work out – but tomorrow – start anew. Animals often make excellent progress with learning in life because they live in today – their lives start anew every day – they don’t ponder yesterday’s failure. We can learn from them.

Have fun with this new #venture, it is a true #adventure, because you decide who you are and where your life takes you – and most often, it starts with thoughts …. start small and simple – your mind will take it from there and will ‘run with it’ – it will get easier and easier…. start with a beautiful picture you have had in your life and allow yourself a voyage to another frontier during this storm.

One example of a child who changed her life by changing her thoughts is of a 14 year old girl in Cambridge who left prostitution and stopped heroin, she was on methadone and was seen weekly in clinic. She had one #dream that consumed her life, she wanted a child and a family with her boyfriend “to feel a family’s love”. We spent some time thinking about what she wanted, what she hoped to gain from it, what her other wishes were (if she believed anything was #possible, which she didn’t initially). She eventually changed her thoughts from “I need a baby and a family to feel good and worth something” and “good things are not meant for me, I am not worthy” to “I can and will make myself happy”, “good things are meant for me if I show up to work for it and don’t give up” and “I am worthy, because I was born – there is a plan for each of us – our past only teaches us lessons, it doesn’t define us”. She decided a few months later, that she would rather wait with starting a family with her boyfriend (“my child deserves a happy mum with a job”), that she would rather get a dog and start College, which she did. She stopped methadone a few months later and she completed her degree with her dog by her side, as a single, confident and determined young person.

If children see you see something #positive in them, that you see that anything is possible for them, despite context, they start to #believe, and that is often the first step towards positive #lasting #change for children often referred to us with “no (or little) hope” as part of the referral.

#thoughts #crises #positive #calm #beauty #health #children #habit #health #mentalhealth #beauty #success #wellbeing #development #goals #happiness #safety #bloodpressure #heartrate #Mandela #quotations #habits #grateful #bucketlist #venture #travel

Latin America’s Treasures

#LatinAmerica has many treasures and many lessons to teach.

We were reminded of the importance of #community, #nature, #freshfood, #relaxation, #enjoyment and #normalcy.

We had the best #RedSnapper ever – picture. The fish was caught by the same person who prepared the fish.

We asked the locals what their advice was to relax and be healthy:

1. Good music

2. Good food – “but it has to be fresh” – “nothing beats fresh fish”

3. Food that you “catch yourself, clean yourself, make yourself” – and ideally a lot of “coconut, chillies and lime”

4. Good people around you – the kind who “don’t take themselves too seriously”, who laugh, who listens, who thinks positive

5. Learning new things and trying new things

6. Looking at the sunrise “if you are a fisherman” or at the sunset “if you are the chef” – but taking time to sit still and be quiet “within yourself”

7. Nature gives gifts every day to be happy and to be calm

8. Playing games with children or dancing – “the whole family”

9. Beauty – “seeing it everywhere, because it is everywhere”

10. Being grateful and hopeful – “having the right attitude”

Thank you for all the #kindness and #laughter.

#music #nature #dancing #family #beauty #grateful #hopeful #calm #fish

It Takes a Village

Poverty is a problem in every nation. Implications are vast.

Many children cannot reach #health or #mentalhealth #clinics due to various reasons, often it is not allowed to cross #borders, often #transport is expensive, often travelling is associated with #risk; #outreach work is therefore essential.

#Ofcom estimated in 2020 that between 1.14m and 1.78m #children in total in the #UK have no home access to a #laptop, #desktop or #tablet (or #computer or similar), and “an estimated 60 000 11-18 year olds in the UK have no home #access to #internet at all”. This is true for many or most nations.

“Even in the world’s richest countries 1 in 7 #children still live in poverty. Today 1 in 4 children in the #EU are at risk of falling into poverty.” UNICEF

1 in 6 children lives in extreme #poverty, World Bank-UNICEF analysis, Oct 2020

More or less 50% of children “1 billion of the 2.2 billion children worldwide are multi-dimensionally poor – without access to #education, #health, #housing, #nutrition, #sanitation or #water”. More or less 40% of the world’s population will require adequate and affordable housing by 2030. UNICEF

Many challenges can be overcome and risk can be reduced markedly with simple measures. Please contact us at admin@cinaps.co.uk for more information or to attend our annual #presentation, Complex Problems, Simple Solutions.

“More or less 25% of the world’s urban population live in informal settlements.” United Nations

“Children make up less than one third of the global population, but were 50% of the world’s #refugees in 2018.” UNICEF

#Positive #change is more than #possible, but we need to work #together – it takes a village.

#LatinAmerica

Safe Face Mask Wearing

Firsthand observations and information reported for more than 6 months in more than one country in the context of face masks, lockdown, curfews, stay at home, self-isolation and quarantine: 

Please see WHO recommendations regarding mask wearing and safe mask wearing.  

A. Many (or most in some European countries) individuals wear masks in ways that increase risk for COVID-19, rather than decrease risk, such as wearing masks under noses, on chins, on arms or hands. We sometimes or often observe that most individuals, at least 75%, in our surroundings engage in this behaviour, and that not many individuals, more or less 10%, wear masks to cover noses.

B. Many or most individuals regularly touch mouths with unwashed on unclean hands, often underneath masks, which increases risk for COVID-19 markedly.  

Research indicates that most adults touch their faces more or less 16-23 times per hour, often without registering this behaviour.  In the context of youth, elevated emotion eg anxiety, mental health problems, learning problems and/or neurodevelopmental problems, these behaviours usually increase markedly. Please see earlier references to children and schools.

C. Most individuals, not living in poverty, report that they never replace masks even though they fall on wet floors, which increases risk markedly.  

Most individuals report that they have worn the same mask for at least 3-6 months.  Many report that they have extra masks, but will rather “save them for emergencies”.  

D. Not one person has admitted to cleaning his or her hands before and after using a mask, as per WHO guidelines, December 2020, which increases risk markedly.  

It is also important to consider where the mask is ‘kept’ if not worn; wearing or keeping masks on arms or wrists are not good practice.

Most doctors will agree that if a recommendation or behaviour cannot be engaged in safety, it could increase risk significantly, rather than decrease risk.  

E. Many individuals report that they drink alcohol, take over the counter or prescription medication (for other purposes) or illicit drugs to “cope” with lockdown, curfews, quarantine and mask wearing; many report these behaviours on a daily basis.  Many individuals in this context never used alcohol or illicit drugs before the pandemic.

Many individuals do not know that a medical certificate can be requested to avoid mask wearing.

It is important to seek advice and assistance without delay in these contexts – GPs will have helpful information, and in an emergency, contact emergency numbers. Many organisations will keep concerns confidential. Please see Helpful Links at http://www.cinaps.co.uk for more information.

F. Many individuals report, during quarantine at home, that they could not access necessary healthcare, medication or food to maintain health.

G. Many report markedly increased social risk in their homes or immediate environment due to indiscriminate mandatory initiatives such as relating to mask wearing, curfew, lockdown and quarantine.  Concerns include general violence, domestic violence, child abuse, alcohol abuse and illicit substance abuse.  

It is important to seek advice and assistance without delay in these contexts – GPs will have helpful information, and in an emergency, contact emergency numbers. Many organisations will keep concerns confidential. Please see Helpful Links at http://www.cinaps.co.uk for more information.

H. Many report “breaking rules” regarding safety and health to comply with curfew rules, such as driving too fast.

I. Many individuals, with and without a relevant mental health history, report significant mental health symptoms or morbidity due to indiscriminate mandatory mask wearing initiatives, stay at home, curfew, lockdown and quarantine. 

It is relevant to note that many individuals report that their concerns are not related to COVID-19, but due to initiatives depriving liberty and autonomy.  

It is important to seek advice and assistance without delay in these contexts – GPs will have helpful information, and in an emergency, contact emergency numbers. If you are not sure if it is an emergency, get immediate advice. Many organisations will keep concerns confidential. Please see Helpful Links at http://www.cinaps.co.uk for more information.

J. Many individuals report significant general health symptoms due to indiscriminate mandatory initiatives such as relating to mask wearing, curfews, lockdown, stay at home and quarantine.  We have referred to these concerns in Deprivation of Liberty. Medical doctors often report that they fall into this group.  

It is important to seek advice and assistance without delay in these contexts – GPs will have helpful information, and in an emergency, contact emergency numbers.

K. Many individuals report that they are not engaging in protective behaviours such as washing hands before eating, covering faces when sneezing or coughing, or remaining home if sick or if symptoms and contacting health professionals, and comment on indiscriminate restrictive initiatives maintaining lethargy and nihilism (no hope for the future or that things will change).  

L. Many individuals report that they are not engaging in medical or mental health appointments to avoid face masks and due to stay at home messages, lockdown or quarantine.  

M. Many individuals report that they will not seek medical assistance or buy medication needed for themselves, their children or family due to mandatory mask wearing initiatives, or due to curfew, during lockdown, quarantine or stay at home messages.  Some report that messages such as ‘pretend you have the virus’ and ‘anyone can make you sick’ cause confusion and “fear”, “it is safest to stay at home”, as reported by a family. 

It is important to prioritise general health and mental health, along with a safe and calm environment in this time.

Most individuals report that their concerns, as above, are not secondary to the risk of the virus, but due to restrictive initiatives; indiscriminate mandatory face masks, travel related quarantine, curfews, lockdown and stay at home messages for individuals without symptoms and not at high risk for severe COVID-19.

Most families report that the “most helpful thing” is to know that they are not alone in presenting with these thoughts, feelings, behaviours or mental health or general health presentations, that many experience the same concerns. This is our reason for sharing these thoughts today.

We have shared observations and concerns with relevant organisations, updating observations since our initial correspondence in March 2020. Many organisations share these concerns.

Finally, it is always important to prioritise general health and mental health, along with a safe, calm and positive environment, but it is especially important in this time. Please see previous comments on evidence-based protective factors and the immune system.

Simple measures often affect outcome in very significant ways. We provide an example – take a daily or weekly walk – one parent or carer with one child – where the rule is to only talk about positive and fun topics – if this is difficult in the beginning – focus on what you see around you that you like. This one to one time with every combination of child and parent or carer provides opportunities to share enjoyment, relax, bond, learn and develop. The walk does not have to be long, 10 minutes might be sufficient, but take the time to experience life and the precious moments if you can. We often recommend this simple strategy to families, often with good outcomes.

Statistics and Research to Protect Children and Families

Statistics and Research to Protect Children and Families:  

A. More or less 80-83% of individuals with infections will present with symptoms of COVID-19.   “Earlier estimates that 80% of infections are asymptomatic were too high and have since been revised down to between 17% and 20% of people with infections.”  https://www.bmj.com/content/371/bmj.m4851  

Many medical doctors agree that consistent temperature and symptom screens in ports, airports, schools and the general public are essential to effectively reduce risk and prevent harm for the general public. 

B.  “80% of the time COVID-19 is a mild disease that feels like a minor cold or cough”, Prof Peter Piot, Director for The London School of Hygiene and Tropical Medicine.

C. “4.5% of the global population is likely to require hospitalisation if infected with SARS-CoV-2 and 95.5% of the general population will likely not require hospitalisation”, The London School of Hygiene and Tropical Medicine.   

D. A COVID-19 related infection mortality rate of more or less 0.14% has been reported, and a case mortality rate of 2.63% has been reported in the UK, 2.37% in France, 1.66% in the USA, 0.94% in Denmark, 0.88% in Norway and 0.05% in Singapore (January 2021).

E. “4% of those younger than 20 years could be at increased risk for severe COVID-19”, The London School of Hygiene and Tropical Medicine.  

“About 1 in 5 individuals worldwide could be at increased risk of severe COVID-19, should they become infected, due to underlying health conditions, but this risk varies considerably by age, for instance, the risk is 4% for those younger than 20 years and >66% for those 70 years and older”.  https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30264-3/fulltext  

It is important to consider these figures relating to risk of general hospital admissions (4.5%) for the global population and relating to children (4%) at risk for severe COVID-19 when considering figures relating to increased risk and harm to the general population and children (up to 400- 500% increase) due to indiscriminate mandatory initiatives.  

Risks and benefits must be weighed in all bio-psycho-social contexts to comply with ethics and medico-legal guidelines. 

F. The purpose of most vaccines is to reduce serious morbidity and mortality, not to reduce or avoid mild symptoms.  

Available SARS-CoV-2 vaccines present with a likely efficacy rate of more or less 70-90% (after two vaccine doses given 21-28 days apart for vaccines available in the UK), which loses efficacy over time and will likely require annual boosters.  

Doctors agree that immunity, after active infection, likely lasts more or less 4-5 months, and immunity from vaccines will likely last more or less 8 months.  

Doctors are concerned that instead of providing vaccines as per manufacturer’s guidelines, 21-28 days apart, it has been decided to extend this interval to 3 months in the UK, the British Medical Association has raised concerns regarding consequences.  We have been informed that some pharmaceutical companies now state that 3 month intervals are acceptable, however, doctors continue to be concerned and many agree that maximum protection, without the extra 2 months delay, for high risk individuals (for severe COVID-19) should be the clinical priority. 

It is our understanding that the first vaccine dose provides a likely efficacy of more or less 50% and the second vaccine dose provides a likely efficacy of more or less 70-90%.

Many agree individuals should be vaccinated first who are (and many countries follow these guidelines):

• high risk for severe covid-19 due to age or illness (category 1)

• health professionals and category 2/3 individuals with the above concerns fall into category 1

• individuals offering public services such as healthcare, education, social care or Police (category 2)

• and individuals not able to socially distance (category 3)

• with the rest of the general public (category 4)

Most doctors are happy to take or to have taken the #Oxford (#AstraZeneca) #vaccine, due to the pharmaceutical company’s longstanding reputation regarding safety and also because the organisation offered to make no profit during the pandemic (despite news of research likely soon to be published, which many medical doctors are not very concerned about).  Most doctors realise a vaccine is “one of the tools in the tool box to manage infections”.  

G. More or less 30-40% of the world’s population presents with chronic disease.  Some studies report that more or less 4.3% of the world’s population had no health problems in a 1 year period and that 30% of the world’s population experiences more than 5 ailments in a 1 year period. “Mortality, morbidity and disability attributed to the major chronic diseases currently account for almost 60% of all deaths and 43% of the global burden of disease.  By 2020 their contribution is expected to rise to 73% of global burden of disease.”  WHO.  

Some individuals in this group are at high risk for severe COVID-19 (group A) and some individuals are not at high risk for severe COVID-19 (group B).  Group B constitutes at least 50% of this group (chronic disease), but likely more, and can constitute up to 36% of the general population, which is significant (some doctors report this figure may be much higher).  Some individuals in group B have made an appeal and have advocated for normalcy, liberty and autonomy (many have concerns regarding reduced life expectancy).  Many of our medical colleagues in group A, due to age with associated underlying medical problems, agree with group B. 

Many children or families living in poverty, in informal settlements or in detention camps, where face masks are clinically indicated (due to social distancing not being possible or due to medical symptoms or problems), do not have access to face masks.  Individuals not living in poverty, not with symptoms or medical problems, where social distancing is possible, 1km from informal settlements, are however “threatened with fines and prison sentences if they do not wear masks”, without clinical indication or evidence to support this initiative. 

H. “Even in the world’s richest countries 1 in 7 children still live in poverty.  Today 1 in 4 children in the EU are at risk of falling into poverty.”  UNICEF.  1 in 6 children lives in extreme poverty, World Bank-UNICEF analysis, Oct 2020, and more or less 50% of children “1 billion of the 2.2 billion children worldwide are multi-dimensionally poor – without access to education, health, housing, nutrition, sanitation or water”.  More or less 40% of the world’s population will require adequate and affordable housing by 2030.  UNICEF.  These statistics were concerning before the pandemic and as many organisations report, the figures have increased significantly in the last year due to measures restricting liberty. 

I. More or less 25% of the world’s urban population live in informal settlements.  United Nations

J. Children make up less than one third of the global population, but were 50% of the world’s refugees in 2018.  UNICEF 

K. Children, 0-15 years, make up more or less 20% of the population in the UK.  Most doctors refer to children under age 18, when referring to children.  

Children have to be protected during the pandemic from a bio-psycho-social point of view.  

Schools play a protective role for most children, however risk reducing measures within schools such as temperature screens and symptom questionnaires (before school attendance) are essential to safeguard the general public, and are not in place in many countries.  

Important statistics to consider regarding children in schools are

Please see relevance https://mentalhealthbus.wordpress.com/2020/11/16/children-neurodevelopment-learning-mental-health-and-schools/

L. More or less 2.5% of children present with learning difficulties, more or less 15% of school aged children have special educational needs.  

M. More or less 3-4% of children present with ADHD and more than 50% of children with ADHD present with at least 2 co-morbidities.  

N. More or less 20% of adolescents are at risk of experiencing mental health problems in any given year, more or less 12.5% of 5-19 year olds had at least one mental health disorder and 10% of children 5-16 years have a clinically diagnosable mental health problem, yet 70% of children with mental health problems have not had appropriate interventions (diagnoses and treatment) at a sufficiently early age, as reported by The Children’s Society.  These figures were reported before the pandemic.

Mental health concerns have increased markedly over the past year, 55-80%, as reported by most mental health organisations.  Many individuals report that their main concern does not relate to the biological risk of the virus, but relates to restrictive initiatives depriving liberty, not based on good clinical evidence, weighing risks and benefits, such as indiscriminate mandatory mask wearing, stay at home, curfews, quarantine and lockdown initiatives.  

O. Prevalence of mental disorders in the WHO European region was more or less 15% before the pandemic and 50% if neurological disorders such as epilepsy, dementia and headaches are included, as reported by the WHO.  

“Mental disorders are one of the most significant public health challenges in the WHO European Region, being the leading cause of disability and the third leading cause of overall disease burden, following cardiovascular disease and cancers.”  WHO

“People with mental health disorders die 20 years younger than the general population.  The great majority of these deaths are not cause specific (in particular suicide) but rather from other co-morbidities associated with their mental conditions, notably noncommunicable diseases that have not been appropriately identified and managed.”  WHO  

We always recommend that children referred to child and adolescent mental health teams be seen by a Child Psychiatrist, with CCT’s (specialist qualifications) in Child Psychiatry, within the first 2 weeks for this reason, to screen for medical problems, and for the concerns raised by The Children’s Society, that 70% of children with mental health problems have not had appropriate interventions (diagnoses and treatment) at a sufficiently early age. Please contact us for more details.

P. It was reported by the WHO that 18.6% of children in England alone (2.2 million) lived with domestic abuse, parental drug or alcohol dependency and/or severe parental mental illness before the pandemic.  WHO.  

Risk to children has increased 80-400% during lockdown in this context, as reported by England’s Children’s Commissioner, and 581%, as reported by Respect, a national domestic violence charity. 

Q. More or less 50% of children aged 2-17 suffered violence and 75% of children aged 2-4 years regularly suffered physical or psychological violence before the pandemic.  Globally it is estimated that nearly 50%, 1 billion children out of 2.2 billion children worldwide, aged 2-17 years, experienced child abuse in the past year (before the pandemic).  WHO  

The NSPCC has reported that risk to children has increased 30-65% in this context, further to lockdown and many organisations including UNICEF have raised concerns regarding stay at home, curfew and/or quarantine initiatives for children in this context.  NCMEC has commented on a 90% increase in concerns relating to child sexual exploitation. 

Please know that statistics relating to child abuse, mental health and neurodevelopmental problems are likely much higher than reported. 

Indiscriminate Mandatory Stay at Home, Shelter in Place, Curfew, Quarantine, Mandatory Self-Isolation and Lockdown Initiatives:

Statistics indicating increased risks due to above indiscriminate mandatory initiatives (most research relates to the UK):

A. 30-65% increase in child abuse, NSPCC, with 60% increase in concerns regarding online sexual abuse, NSPCC, and 90% increase in concerns regarding child sexual exploitation, NCMEC.  

B. 300% increase in violence.  “In the UK 14 women and 2 children were murdered in the first 3 weeks of COVID-19 lockdown, the highest figures in 11 years.”  WHO

C. 400% increase in alcohol abuse, Alcohol Change UK, 2020.  The Royal College of Psychiatrists reported in September 2020 that “new analysis find nearly 8.5 million adults drinking at high risk (up from just 4.8 million in February 2020), while number of people addicted to opiates seeking help in April at highest level since 2015”.  Many individuals report that they  “drink to cope with masks”, lockdown, curfews, quarantine or stay at home initiatives.  It is important to note than when alcohol sales are banned, individuals usually find other, often more harmful, ways to “cope”.

D. 80% increase in domestic violence, National Domestic Abuse Helpline, 2020.  “In the UK, calls, emails and website visits to Respect, the national domestic violence charity, have increased 97%, 185% and 581% respectively.”  WHO

These figures are likely much higher than reported.  It is important to note that most children do not report abuse, and that most women and men do not report domestic violence, alcohol or drug abuse. 

E. 75-80% increase in mental health morbidity in individuals with a relevant mental health history during lockdown and 55% increase in mental health morbidity in individuals without a relevant mental health history have been reported during lockdown. Concerns also increase in terms of self-harm and suicidal ideation or attempts.  These concerns relate to children and adults of all ages and cultural, educational, professional and bio-psycho-social backgrounds.  Please see MIND, Young Minds and Samaritans for more details. 

Significant numbers of individuals with mental health and general health concerns have not been identified and many do not seek help for various reasons. 

F. 93% increase in non-engagement in required hospital appointments, RCPCH.  50% of individuals with a worsening condition did not seek assistance, UK GOV.  40% of individuals with mental health problems did not seek assistance.  Young Minds.  Many report “protect the NHS” messages, mandatory mask wearing initiatives, quarantine, stay at home directives, lockdown and curfews prevented them from “seeking help”.   

G. Cabinet Office polling, UK, indicates that only 17% of individuals with symptoms of COVID-19 informed health staff or requested tests in the UK.  Many report “we live without freedom if we are healthy, why make it worse”, this increases risk. 

H. The increase in statistics relating to poverty and extreme poverty has been extensively documented by many organisations.  The Trussel Trust, UK, reported an 89% increase in need for emergency food parcels in the UK, April 2020.  Oxfam identified that border closures, curfews and travel restrictions caused breaks in food supply that threatened to cause 12 000 deaths a day worldwide, exceeding the 10 000 deaths a day recorded from COVID-19 in April 2020.

WE RECOMMEND THAT YOU ALWAYS FOLLOW GOVERNMENTAL LAWS, RULES AND POLICIES.

Quotations:

“Lockdowns have just one consequence that you must never ever belittle, and that is making poor people an awful lot poorer.”  Dr David Nabarro, Special Envoy on COVID-19, World Health Organisation 

The UN reports “we are just beginning to fully understand the damage done to children because of their increased exposure to violence during pandemic lockdowns, said Henrietta Fore, UNICEF Executive Director.”

UNICEF, October 2020, reports “Lockdowns and shelter in place measures come with a heightened risk of children witnessing or suffering violence and abuse and can also expose children to new protection risks. When it comes to violence, a number of factors related to confinement measures are likely to result in increased risk for children including heightened tensions in the household, added stressors placed on caregivers, economic uncertainty, job loss or disruption to livelihoods, and social isolation. Children may also increasingly witness intimate partner violence.”

“Children have fewer health risks from COVID-19 and yet they have suffered disproportionally from the nation’s efforts to contain this virus.”  Anne Longfield OBE Children’s Commissioner for England, Summer 2020 

“This war, and I think it is reasonable to call it a war, against this virus, which is going to go on for the foreseeable future, is not going to be won by creating tougher and tougher rules that attempt to control people’s behaviour. The only way we will come out ahead of this virus is if we are able to do the right thing in the right place at the right time, because we choose to do it.” Dr David Nabarro, Special Envoy on COVID-19, World Health Organisation

International Outreach Services

We are medical doctors and specialists in Child and Adolescent Psychiatry.  We have been based in Cambridge, England, since 2005.  We offer NHS, private and pro bono services.  

Our offices are in Cambridge and London, however, we offer services throughout the UK and Ireland, as well as internationally where requested.  

Our interest relates to service development and service provision for hard to reach children; vulnerable children in need or at risk from a bio-psycho-social context in developing or developed countries. 

We consider a systemic approach in our assessment and management, considering general health and mental health, along with culture and social risk for families and communities.  

In preparation of service development work in developing countries we regularly review National Health Plans and relevant strategies to safeguard and promote children’s and families’ general health and mental health in different cultural and risk contexts.  We remain up to date with local and general knowledge regarding emergency medicine and general medicine, including infectious diseases and vaccines, to prepare volunteers and to meet patients’ needs who refuse to see another medical doctor.  

Our background includes working with children and adults with medical problems, including infectious diseases with secondary complications, in emergency, hospital based, community based and outreach settings in developing and developed countries.  

We left for Asia on 11 January 2020 and travelled through more or less 15 countries during the pandemic.  We returned 5 months later, further to cancelling our trip due to lockdown initiatives and closed borders.  One of the reasons for our trip was to meet with Health Ministries who had requested service development for children.  We plan to resume our trip when borders open.   

We have continued to travel for work between June 2020 and today, often travelling to and from different countries on a weekly basis. We have travelled through at least 20 countries during the pandemic to date. It is relevant to add that we have never presented with symptoms, a temperature or a positive test. We go to great lengths to protect our health and those around us (some details provided – see evidence-based risk reducing and protective factors, normalcy, the immune system) and we prefer contexts, even in airports and airplanes, where good ventilation and social distancing is facilitated, rather than where face masks are indiscriminately mandatory.

We observed various medical and/or governmental protocols with different public responses and statistical outcomes during our travels.  We were particularly interested in these observations, because we offer services to individuals in diverse settings and high risk in social (eg homeless), biological (eg infective diseases such as HIV, TB, HEP B) and psychological (eg high levels of threat) contexts; our consultation includes, but is not limited to, assessment and management of environment, social context, physical safety, mental health, neurodevelopment, general health, immunisations or vaccines, nutrition and access to clean water. 

Our South African background, working in various informal settlements, inspired our interest and commitment to contribute to positive change in diverse settings. 

We have shared observations with relevant Health Ministries, Public Health Departments and colleagues, along with organisations such as the WHO, UNICEF and the UN, and organisations safeguarding children such as the NSPCC and England’s Children’s Commissioner, since March 2020. We are grateful for many positive responses from the UK and various counties in Europe and abroad, and for sharing thoughts, concerns and questions. Common clinical goals, to protect, to reduce risk and to prevent harm, are essential during a global health crisis.

We are happy to share our observations and concerns with relevant educational, social care, criminal justice, legal, health, mental health, managerial or governmental parties, please contact us at admin@cinaps.co.uk to request a copy of this 84 page summary; our summary is often updated daily, based on requests and questions.

We continue to make ourselves available to assist in any medical or mental health context during the pandemic in any country. We have offered our services to the UK, countries in Europe such as France and Ireland, the USA, Africa, Latin America and the Pacific during this pandemic.

Please contact us at admin@cinaps.co.uk if you require our services or input. We offer virtual consultation to patients, families, medical colleagues and mental health teams. Most of our crisis related work during this time is pro bono. For more or less 10 years, our pro bono work has been mainly funded by our directors.

We hope to return to previously requested service development and outreach projects in the near future. If you are interested in volunteering please contact us at admin@mentalhealthbus.co.uk – a background in mental health or Medicine is not required. More details at http://www.mentalhealthbus.co.uk and we provide annual seminars on volunteering.

We thank you for your support.

#Cambridge #UK #ChildPsychiatrist #Mentalhealth #Health #Medical #International #ServiceDevelopment #OutreachWork #probono #charity #HardToReachChildren #ChildrenInNeed #ChildrenAtRisk #France #Africa #SouthAfrica #USA #Europe #Pacific #LatinAmerica #Ireland #NHS #private #London #travel #pandemic #VoluntaryWork #volunteering

Children’s Home – Nazareth House – A Global Perspective – A Global Health Plan

Global health perspective and plan:

 We have followed international statistics and patterns since January 2020.  

As per correspondence since March 2020, we have recommended that a global health crisis requires a global health plan; a systemic, evidence-based, consistent approach is required with a focus on risk management in the context of respiratory infections (eg hand washing before touching the face) and protective factors that support and strengthen the immune system and contribute to general and mental health, reducing general health and mental health related morbidity rates and mortality rates (eg #calm, #normalcy, #liberty and #autonomy, giving individuals with #capacity to make good decisions the responsibility and tools to act responsibly).  

We have received positive responses from Health Ministries and colleagues in countries such as France, Italy, Spain, Switzerland, the USA, and international organisations, as well as national organisations in the UK. We appreciate your input, concerns and questions.

We have recommended a global health plan, because, in our opinion, this is the only approach that would safeguard children and families of all bio-psycho-social backgrounds including the most vulnerable, at risk and in need children and families, along with staff working in high risk contexts such as Police, as well as individuals needing to travel for various reasons (consistency, coordination and communication between countries to reduce risk for individuals eg unnecessary or repetitive PCR tests and quarantine or self-isolation for healthy individuals) in developed and developing countries; safeguard from a clinical general health, mental health and social risk, as well as legal and ethical point of view.  

In our opinion a global health plan would promote fairness, equality, collaboration (camaraderie, collaborative working relations) and liberty (protection of human rights and children’s rights).  Risk or need in one community or country affects risk and need in other communities or countries, a “we are in this together” approach has numerous benefits to affect general clinical outcome.  A systemic approach will protect on an individual patient specific level, a national level, and an international level.

A systemic approach or perspective implies that everything is connected, every risk and protective factor must be considered and weighed, and objectivity, evidence and consistency are required, which is often helpful in complex high risk contexts, and has numerous benefits, for example, if Police are protected and supported, and feel protected and supported, they will likely be able to contribute even more to the important role of protection and support within the general public.  The same is relevant for other professionals including medical doctors, medical staff, mental health staff, social workers or teachers.  This pattern is relevant in most cultures and communities in every country.  

Reassurance and effective communication from medical leads are important in this context, we contain with information provided, language used and quality of communication, we teach by doing, we lead by doing, and equality is important; medical doctors in #Essex cannot feel that they would have been offered a vaccine or more liberty and would have been protected if they lived in #India or #Suffolk or vice versa.  

A global health plan, consistency in every nation, would be a systemic approach in a global health crisis. 

Transparency, continued liaison with open communication, sharing of expertise and learning from neighbours are essential to achieve good clinical outcomes.  Liaison with countries in Asia, such as #Singapore, who have managed to contain this virus to a relatively successful degree and who have experience in previous Coronavirus outbreaks is an example of collaborative work (please see Singapore’s mortality statistics).  Communication and collaborative work are evidence-based strategies in health crises or medical emergencies and imperative for good clinical outcomes.  

This approach, working collaboratively with nations focussing on evidence, education and protection, is evidence-based and clinically appropriate during health crises, and preferable to an approach associated with blame, competition, showboating or profit, as most professionals with experience in emergency healthcare would agree.  It has been our longstanding opinion and understanding that most leaders have only the best intentions for the general public, their nations and their neighbours, and that collaborative protective initiatives are consistent priorities for most, and we have been inspired by the collaborative practices of many nations. 

Systemic or ‘big picture’ views or approaches are often required to effectively manage risk in most communities or settings, and certainly in pandemics, in our opinion.  

A review of local statistics, relevant research (to separate good clinical evidence versus no or weak evidence) along with public, professional and systemic liaison are often required to assess cultural factors, bio-psycho-social risks or weaknesses, protective factors or strengths, available resources and needs before risk management plans can be finalised.  

Evidence-based bio-psycho-social risk and protective factors should directly inform risk management plans to achieve good clinical outcomes in high risk and complex contexts, such as relating to this pandemic.  

Relevant evidence-based bio-psycho-social risk and protective factors have to be identified, understood, considered and weighed during risk assessments and risk management plans by clinicians with clinical experience in complex and high risk contexts. 

Social risk, poverty, displaced children or families, informal settlements, statistics relating to biological risk such as #HIV, and psychological factors such as cultural beliefs regarding #illness and traditional #healing are examples of important factors to consider in any local or global health management plan; clinical outcome will be affected by these factors despite best efforts to reduce risk, however, risk can be significantly and effectively reduced in most contexts.  

Statistics and patterns of #statistics must be understood in this context when conclusions are drawn or comparisons made between nations or initiatives.  What works in one country or area will therefore not necessarily work in another country or area, and may indeed increase risk.  

Countries with experience in managing high bio-psycho-social risks (often developing countries) are sometimes able to offer useful leadership or contributions in global health crises, because systemic thinking is encouraged during medical training, most medical students usually have at least 4 years clinical experience, often working 120 hour weeks, in managing and clinically leading in medical emergencies in most medical domains in diverse, high risk and complex settings before they qualify as doctors, and subsequent systemic thinking is required in day to day practice.  It is important to consider that every single country, despite risk profile, has unique strengths and protective factors, that we can learn from. 

A global health plan needs to consider all of the relevant risk and protective factors or strengths for children and adults in every country, socio-economic and risk context, and cannot be based on laboratory conditions (like most medical decisions for patients or the general public), which will not protect any #child or adult in any country.  Longstanding, well established evidence-based clinical evidence (good clinical research, rather than weak, inconsistent or limited evidence) is required to prevent harm, to protect and to reduce risk, along with general morbidity and mortality rates.  We should ask ourselves questions regarding the differences in #morbidity and #mortality rates in different countries.   

Indiscriminate lockdown, quarantine, stay at home, curfew and mandatory mask wearing initiatives for the general public are associated with significant short term and long term negative consequences, increased risk and harm, for many in developed and developing nations in every cultural and socio-economic context, as per recently published statistics, statements, observations and evidence-based research regarding children and adults in the UK and worldwide, however, in the context of informal settlements, #displaced children and families, detention camps, #homelessness and #poverty, risks and harm increase exponentially.  

Initiatives put in place to protect the public have to protect the public; it is everyone’s duty to ask questions and be curious in this context.  It is important to adhere to governmental and medical recommendations, policies and rules, whilst being curious and asking questions.  Good clinical evidence is essential for the basis of initiatives to protect the general public; to ensure initiatives are ethical, legal and clinically effective to reduce risk and harm and to protect high risk and low risk individuals equally.  First do no harm has to be a prevailing principle in all decisions affecting the general public.  

A global perspective and understanding from a bio-psycho-social context is therefore essential when commenting on clinical outcomes of local risk reducing initiatives such as lockdown and deciding whether recommendations are generalisable to the general public, various communities or other nations.  Low risk and high risk children, young people and adults, from a bio-psycho-social point of view, as well as in the context of COVID-19, have to be protected equally; we cannot allow harm to one group to protect another.  

Many organisations report that lockdown “disproportionately affect disadvantaged groups, including people in poverty, migrants, internally displaced people and refugees, who most often live in overcrowded and under resourced settings, and depend on daily labour for subsistence”, WHO.  We sincerely agree with this statement.

Most people report that children and families in developing countries, especially in informal settlements, are “suffering more” during this pandemic and that indiscriminate mandatory face masks and lockdown initiatives cause “more harm” to children and families in these contexts, and we have been asked for our opinion.  We will attempt to provide qualitative and quantitive information to assist with this question in this section. 

We have asked children, adults and elders in these contexts, what they would answer regarding “suffering” or “more harm”?  We also posed these questions to a psychiatrist currently working in informal settlements and responses were “we are actually doing ok” and “there is much to be thankful for”.  It must be added that no lockdown, stay at home, curfew, self-isolation or quarantine are relevant in this context, and many informal settlements, masks are clinically indicated, due to lack of social distancing possible, however, masks are not available, and lack of clean water and clean ablution facilities are relevant, which is in significant contrast to comments from colleagues in the UK, where conversations often include thoughts of suicide and hopelessness.  

It is essential to ask the right question or questions if helpful answers are to be provided and an improved understanding behind answers is important.  Qualitative information and quantitative information are helpful when considering risk or any medical topic, and a global view is essential in a global health plan.  

United Nations reports that more or less 40% of the world’s population, “an estimated 3 billion people will require adequate and affordable housing by 2030”.  UNICEF estimates that 34.2-35.4% of the world’s children live in monetary poor households (baseline before pandemic 31.9%); East Asia and Pacific (15.5-17.9%), Europe and Central Asia (16.1-18.8%), Latin America and Caribbean (45.3-46.5%), Middle East and North Africa (29.8-30.5%), South Asia (28.3-29.3%) and Sub-Saharan Africa (48.5-49.4%).  Globally, the World Bank has estimated recent increases in extreme poverty of 40-60 million people, while similar estimates by the UN suggest 84-132 million people.  UNICEF reported “in developing countries the number of children living in monetary-poor households could increase by 142 million by the end of 2020”.  

It is estimated that 1.2 billion people in general, or 25% of the world’s urban population, live in informal settlements.  “The absolute number of people living in slums or informal settlements grew to over 1 billion, with 80% attributed to three regions: Eastern and South-Eastern Asia (370 million), sub-Saharan Africa (238 million) and Central and Southern Asia (227 million).”  United Nations, 2018

UNICEF reported, April 2020, “Children make up less than one third of the global population, but they were 50% of the world’s refugees in 2018.  Today, nearly 1 in 3 children living outside their countries of birth are child refugees; for adults, the proportion is less than 5%.”  

It is estimated that more or less 1:97 people are displaced worldwide.  The UN estimated, end 2019, that 79.5 million people are forcibly displaced worldwide; 40% are children.  UNICEF reports, Lost at Home, May 2020, that in 2019 more or less 19 million children were living displaced in their own country due to conflicts and violence and that “this figure is the highest number ever of internally displaced children”.  UNICEF reported that these children are among the most vulnerable to direct and indirect impacts of COVID-19.  “In total, at the end of 2018, over 31 million children were living in forced displacement due to violence and conflict within their own country or abroad.  This includes some 13 million child refugees, around 1 million asylum-seeking children, and an estimated 17 million children displaced within their own countries.  It is estimated that around 3.7 million child refugees live in camps or collective centers.”  UNICEF, September 2020 

United Nations reported that “38 million (31.6 – 44.5 million) people globally were living with HIV in 2019”, “1.8 million (1.3 million – 2.2 million) children (0-14 years)”, that “1.7 million (1.2 million – 2.2 million) people became newly infected with HIV in 2019”, and that “75.7 million (55.9 million – 100 million) people have become infected with HIV since the start of the epidemic (end 2019)”.  It was reported that “690 000 (500 000 – 970 000) people died from AIDS-related illnesses in 2019″ and “32.7 million (24.8 million – 42.2 million) people have died from AIDS-related illnesses since the start of the epidemic (end 2019)” with 26 million people accessing antiretroviral therapy as of the end of June 2020.  Please see the following link for further details https://www.unaids.org/en/resources/fact-sheet.  

Reports increase regarding deaths due to other causes, such as relating to HIV, car accidents or cancer, being recorded as COVID-19 deaths when patients tested positive, despite cause of death not relating to COVID-19.  We have been informed of families complaining with medical staff that they want their parent’s or sibling’s death certificate to state eg ‘cancer’ due to long term debilitating symptoms secondary to cancer, which resulted in death, as per the family’s or GP’s understanding.  Families were informed by medical staff, in these contexts, if a patient dies for any reason and tests positive for this virus, before or after death, the death must be recorded as due to COVID-19, which makes little clinical sense and will be unhelpful in drawing accurate conclusions regarding 2020 and 2021 morbidity and mortality rates for many #diseases on a #global level. 

Reports are available on the organisations’ websites for more information. 

It is difficult to draw direct comparisons between children in different risk contexts for many reasons.  Many children in informal settlements comment on a sense of adventure, enjoyment, excitement, #happiness, #gratitude (appreciation for simple things) and #belonging, “I know where I belong, who my people are”, being part of a “team” or community and that “someone always has your back” (it might not be necessary to add that this is not always the case for many children in these contexts), whilst many children in #Cambridge comment on “constantly being alone”, “having no friends”, “no one is there for me” and “I don’t belong”.  The fear or experience a child describes in a township or informal settlement regarding existing or opposing gangs is no different to the fear or experience a child describes in Cambridge from a ‘bully’ in school.  

Children have different strengths and protective factors within different risk profiles and a child at risk or in need in the #UK is no different to a child at risk or in need in #India despite vastly different bio-psycho-social, cultural, educational and economic contexts.  Children experience risk and need as the same.  

Considering statistics published in 2020 regarding increased risk and harm secondary to indiscriminate mandatory initiatives, such as curfews, stay at home, quarantine (self-isolation) and lockdown, that deprive liberty without good clinical, medical or scientific evidence to support these initiatives, children in most parts of the world are currently at high or very high risk from a social, mental health and general health point of view.  These rules are often not enforced to the same degree in informal settlements and individuals in informal settlements report less anxiety secondary to these initiatives, most report “I don’t notice it, we carry on as usual”.  

Children or families who present with certain social risk factors, for instance, with inadequate or poor shelter and without necessary tools to protect and maintain health eg who are homeless, living in informal settlements, living in detention camps or living with poverty or extreme poverty, are however at significantly increased risk in the context of the pandemic.  Certain biological risk factors, such as HIV, and certain psychological risk factors, such as mental illness, also increase risk markedly.  

Children in high or very high bio-psycho-social risk contexts in developing countries or very deprived areas in developed countries often present with significant protective factors or strengths, which are sometimes lacking in wealthy areas in developed countries.  Many professionals, children and families report that they prefer to live or work in lower socio-economic areas due to the frequent sense of #community and #collaborative working cultures often finding #creative solutions for problems.  

We offer an example.  We have chosen to spend a significant amount of time during our 5 month trip, January to May 2020, during the pandemic, when in developed countries, in lower socio-economic areas, sometimes areas with informal settlements, because the levels of anxiety, fear and panic were much lower, anger was expressed less often, #camaraderie usually existed in these contexts (strangers often started talking to us about how beautiful certain trees were or the ocean was, and how fortunate they were to live in such a beautiful place, made good eye contact, enquired about others’ experiences and well-being, and shared stories about their families), a sense of #normalcy often existed in these contexts, and people were #generous towards each other with food, support and #kindness.  

These are significant #protective factors for general health and mental health, along with social risk.  The Police tended to consistently spend less time in these areas during the day, based on our experiences during our visits.  We were frequently informed that the Police knew the areas well, were often part of the community, and would often arrive over lunch to eat with colleagues or friends, or return for a meal after shifts.  It must be added that almost all individuals we encountered followed local rules and policies (except for one or two people sitting on benches to rest or eat, however they honoured social distancing rules), and reported “trust” between the Police and themselves.  Further to observing the frequency of Police cars driving onto the beach, using megaphones to inform people to “keep moving” when resting was not allowed, or to question individuals for various reasons within tourist and wealthy areas (Police were only following instructions), and observing the secondary ongoing panic and frustration, we decided that we could be of more use in areas of poverty and that these contexts will also protect our health.  We also #learn more in these contexts; #communities spoke to us about the significant amount of #veterans living as homeless or in their cars (not allowed to use public showers to maintain hygiene), and one community informed us of the importance of school meals in their area (#Pacific) and offered continued school meals at closed schools, and neighbours organised affordable meals for sale when most could not afford food.  We usually left being inspired with a sense of meaning and being a part of the world, which is why we always inform new volunteers that volunteers usually gain more and learn more than they can ever give or teach.

It is our opinion that these narratives of positive experiences, creative solutions and strengths would encourage significantly more monetary and physical support for charities, #NGOs and aid organisation, rather than photographs of children in tears.  As one doctor recently commented, “we all want to be a part of something positive”.  Needless to add that significantly high need, risk and trauma often (and sometimes always) exist in these contexts eg deaths of children, adults, in some areas particularly doctors and police officers, due to homicide. 

It has been our consistent experience that some ‘shacks’ in informal settlements in developing countries or deprived areas in developed countries are cleaner and more welcoming, offering wonderful tea in clean cups on clean tables, than many houses in developed countries, since we started engaging in home visits in the UK in February 2002.  Children in these contexts often comment (or share through behaviour, play, pictures, internal world assessments) that they feel loved, cared for and guided by the community who acts as ‘elders’ to teach children (parenting duties are often shared by communities).  Children in informal settlements often report that they are “free” to roam and play, that they feel they “belong” and are a “part of the community”.  Music and flowers in gardens have often been shared with us in these contexts.  However, many risks also exist in this context, eg individuals often live 10 per room, clean water and bathrooms are not available and gang activities are often an ongoing and serious threat to children and families, especially if #borders are crossed to reach clinics, which is why home visits and #outreach work are often essential (it is often necessary to gain permission from elders and groups regarded as leaders in the community).  

Colleagues working in townships or informal settlements often report increased #energy and job satisfaction; they report that they have the #authority to make good decisions for the health of the community, that they #educate the community and that the community educates them, and that they work together #collaboratively towards common goals, eg keeping children safe (often creatively eg Police sometimes agree to act as ambulance or taxi to ensure that children or families have access to medication or clinics), to achieve good clinical outcomes.  The clinical leaders in these contexts are also usually the clinicians engaging in #frontline work and taking most of the medical (including #surgical or #anaesthetic), #nursing and porter roles.  Many medical #students were trained to effectively take these roles in developing countries. 

Children and families in #detention camps, however, often live in extreme high risk contexts, and they have no choice to find a better place to live.  Children in these contexts have sometimes experienced significant trauma and often have experiences relating to war in their personal backgrounds (scars relating to torture are sometimes visible on faces, hands and arms).  We started a group for young mothers, aged 15-19, in #Liverpool, unaccompanied minors who were #pregnant further to assault whilst on route to the UK, who knew little about motherhood or #babies, and had concerns regarding HIV contracted during transit.  The backgrounds of asylum seeking and refugee children vary vastly.  

The recent focus on changing how the public perceives unaccompanied minors, asylum seekers and #refugees is interesting, especially in the context where most of our child psychiatry consultant and mental health colleagues started their lives in the UK as refugees or children of refugees.  In Liverpool, in 2004-5, we learnt much from #unaccompaniedminors from areas such as the Sudan, Somalia and Vietnam (aged 8-17), who were more #courageous, generous and sometimes more educated than any child ever encountered of the same age (and often compared to adults).  

Social Care was on strike for 6 months or longer during this time, which left many children vulnerable, however, in this context, these children offered the little food that they had to those around them when the food delivery was delayed, they played music for peers and they spoke of their plans to “change the world and help children”, which some did, despite significant challenges.  “This is the definition of generosity and character; to share everything that you have”, as commented by a drama therapist.  Most children in this context appreciated the opportunity of education and employment, and achieved highly in their respective fields of interest.  Children in these contexts often have advanced personal skills and #determination, significant #strengths and #protective factors, compared to peers in developed countries, that will benefit any developed country to significant degrees. 

HIV is also another relevant place to pause.  We worked on a #Paediatric #Oncology and HIV ward in 1998-9; some children had to have blood tests every few hours due to certain brain tumours.  We learnt much from the #nurses and we decided to change the ward into the ‘happiest’ ward in the hospital.  Most patients were #orphaned due to HIV and never left the hospital.  We decided to turn blood tests and various interventions into games with rewards (eg blood tests will be completed by the count of 3), which children looked forward to.  The children were taught to ride #bicycles and play various #games on the ward.  The ward was a place of tears when we started, however, with the initiatives and support of the nurses, it was a place of laughter when we left.  

It is our opinion that this context contributed to the children’s general health (life expectancy for children with HIV was about 5-6 years at the time) and many children with HIV left for a children’s home at age 5-6 in relative good health (usually #NazarethHouse in #CapeTown).  We visited Nazareth House in 2015 when we were in South Africa to discuss a possible pro bono service development project with the Department of Health, and not much has changed. They are worth a visit – bring toys for all ages, especially age 4-12, and sports equipment. #Simple measures and protective factors can affect clinical #outcome significantly, even in high risk and complex contexts, we have seen this firsthand for more than two decades.  

We share these narratives in an attempt to answer the question posed regarding comparison, and to illustrate that countries, cultures and risk contexts are complex matters, and risks and strengths cannot be summarised in a sentence or paragraph; factors vary significantly and the first step to an effective global health plan, is to realise this important fact.

We were recently asked by a doctor abroad to “draw up a detailed service development plan to fit all child mental health services in different countries” for an international health organisation, unfortunately, this is not possible. Certain items must be consistent in all teams (details on http://www.mentalhealthbus.co.uk), but teams need to adapt to meet the unique strengths, risks and needs of the communities. We usually start service development projects by speaking to the community and local colleagues to learn more about their views regarding risk, needs and strengths.

The second step is to spend time in these contexts, experience the benefits, and experience the risk and need.  We would however advise that you plan visits in collaboration with existing NGOs or existing services who can offer advice regarding safety and practical matters, and who can chaperone during transit and during visits; this will be in your own best interest and in the interest of the community.  

Child abuse and violence is another place to pause and are very relevant in all contexts, and in our opinion, a determining factor when making decisions regarding medical and mental health interventions; most doctors were trained to ‘put safety first’.  In our opinion, based on our training and at least 20 years experience in child protection in different cultures, countries and contexts, child abuse is not specific to culture, education, socio-economic status, employment or professional backgrounds or position.  Narratives are available to illustrate this point, but will not be shared here.  We keep records of all clinical work, as most medical doctors do.  Many factors are relevant, however, anxiety, stress, low mood, frustration, “feeling trapped”, #agitation, anger, alcohol abuse and substance use are some of the significant factors that increase risk markedly for every family and child; it is important to note that all of these risk factors can present without mental health causes (and often do).  

In our opinion it is not always helpful to consistently attribute risks to ‘mental health’, as many other relevant and important factors will be missed in this way.  These risks are equally relevant and significant for every child or vulnerable adult in every home in every country. 

The important point to remember is that every country is different and biological, psychological, cultural and social contexts vary vastly between countries and within many countries.  

We know from professional experience in the UK that child mental health teams need to be developed and need to function very differently in #Cambridge compared to Liverpool or #Wales to be effective in reducing risk and to be helpful to the public; one service development plan is not always generalisable or useful to other communities.  

Culture and social environment must be considered and understood to provide safe and effective services and interventions.  We have been informed, for example, that there are six main reasons for wearing face masks in East Asia and that only one reason relates to infection risks (despite some governments recommending that face masks not be worn as standard practice).  Photographs available on our social media links illustrate various living quarters for children; many individuals live 10 per room, do not have plumbing, clean water and do not eat if they do not leave home.  The latter is true for many families in nearly every country including the UK (please see recent reports by The Trussell Trust) and the USA.  Living arrangements, lifestyles, public transport requirements and requirements for work and income are also different in countries or areas with similar cultures or socio-economic environments such as Hong Kong and Korea or Canada and New Zealand or Wales, Ireland, London and Leicester (in lockdown for extended periods of time in 2020).  

A global health plan therefore has to consider a global view and agree on a global evidence-based approach to protect high risk and low risk individuals equally.  Most doctors will agree that weak evidence (which is often understood as no evidence for the particular research questions or scenario) cannot be considered in evidence-based initiatives, particularly considering the high risk and complexity associated with this medical crisis. 

Protective initiatives and risk management plans for children or families in high risk settings in developing countries are often no different to protective initiatives and risk management plans for children and families in high socio-economic contexts in developed countries, however, bio-psycho-social factors affect outcomes, and additional and creative support and risk management strategies are usually required in complex or high risk presentations to offer equal support (eg homeless children, veterans or families require access to clean and hot water and soap to protect and manage hygiene, and access to clean drinking water and food to maintain health).  

The clinical and social outcomes of initiatives put in place to protect the public have to be considered in every country and context.  

We shared concerns with appropriate parties in March 2020 that restrictive initiatives put in place to protect the general public might increase risk more than the biological risk of the virus for many in developed and developing countries.  

First do no harm is a principle that protects children and families in every context or medical domain. 

General health, mental health and social risk outcomes secondary to this pandemic and secondary to relevant initiatives put in place to protect in one country, will affect all countries; a global and systemic approach is important.  Consider the relevance of infectious diseases (in general or for instance relating to mosquitoes) and childhood immunisations or vaccines in this context.  

Equal, considered and consistent protection in communities and countries should be a treatment goal; a global and consistent approach is essential to protect all nations. 

It is essential that a global health plan prevents harm, protects and is simple, generalisable and evidence-based, not indiscriminate, prescriptive, dictatorial or micro-managing, but rather providing all responsible adults with tools (such as information and education) to make good decisions for themselves, their families and communities in every bio-psycho-social context.  This is the clinically safest approach, considering a systemic and evidence-based view, and is congruent with relevant laws and ethics relating to health, liberty and children. 

The truth is that only the family or community is aware of or understands their unique needs, risks and strengths, until they share this with you.  Give people the tools, including information and education, and let every adult make responsible decisions for self and others.  This approach has good clinical outcomes in many or most medical fields in all socio-economic and cultural contexts. 

Dr David Nabarro, Special Envoy on COVID-19, World Health Organisation, echoed the importance of this approach in the last months of 2020:  “This war, and I think it is reasonable to call it a war, against this virus, which is going to go on for the foreseeable future, is not going to be won by creating tougher and tougher rules that attempt to control people’s behaviour.  The only way that we will come out ahead of this virus is if we are all able to do the right thing in the right place at the right time, because we choose to do it.”   

Empower people, educate people, rather than restrict or remove their liberty regarding daily decisions such as pertaining to health, travel, shopping or engagement within the community; deprivation of liberty has devastating immediate and long term consequences for the immune system, general health and mental health for the general public, as per evidence-based research.   

Please see earlier comments on deprivation of liberty.