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  

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, 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.