Let’s move forward together in unity – every community – every country:

A medical crisis or pandemic is a time for collaborative working, clear leadership by medical professionals with appropriate training and clinical experience in bio-psycho-social risk assessment and risk management, good communication and consistency – following only good clinical evidence.

Medical doctors and colleagues find the leadership, podcast, narratives & information provided by Dr David Nabarro, Chair of Global Health and Co-Director at IGHI ImperialCollege London WHO COVID -19 Special Envoy http://www.4sd.info/covid-19-narratives most positive, reassuring, helpful and valuable.

It is essential that we work together to protect the most vulnerable and the general public, children and adults, in every community and in every country. It is essential that a global health plan is agreed upon and followed to protect every person equally.

Initiatives have to reduce risk, protect the general public and therefore be based on good clinical evidence considering systemic bio-psycho-social risk and protective factors. Many medical doctors agree that many initiatives increase risk and harm, and evidence supports this concern. Please consider supporting evidence and statistics with markedly increased figures relating to general medical, mental health and social concerns including child abuse and risks to children, as documented in 2020 by organisations such as the WHO, UN, UNICEF, NSPCC, Oxfam, England’s Children’s Commissioner, RCPCH, the Trussell Trust, Young Minds, MIND, Samaritans, NCMEC, Alcohol Change UK and the National Domestic Abuse Helpline.  

First do no harm is a prevailing principle to protect during all medical or mental health crises. We have to ask ourselves whether there is good clinical evidence to support decisions and initiatives in every context? Delays increase risk during medical crises.

We have to learn from previous decisions and audit findings (audits have to be completed). We have to ask the right questions. We have to understand the ABC’s of every decision and initiative during this pandemic (the motivation, predisposing and precipitating context, what the initiative looked like, felt like for individuals – qualitative and quantitive details, and then the biological, psychological and social consequences for every initiative put in place. This will facilitate prevention and protection for tomorrow.

The World Health Organisation is a wonderful global organisation with clinically excellent professionals with varied global, medical and mental health training, experience and expertise. The WHO’s recommendations are relevant to every person in every country. The WHO has gone to great lengths to facilitate education and protection – let’s spread the word – let’s be curious – let’s read their recommendations and the information they provide (we have shared some on previous posts), and let’s work together, in unity, to move forward without delay. https://www.who.int

#ImperialCollege #WHO #positive #forward #health #consistency #leadership #communication #PreventHarm #education #children #protection #elderly #vulnerable

#elephants in the #KleinKaroo #SouthAfrica

Colleagues, families and children often ask us what they can do to ‘change the narrative’ of their lives – to ‘think positive’ – to ‘have positive stories or experiences or information to dwell on, rather than to live with a focus on fear or loss’.

This question made us reflect on the story of the 3 orphaned elephants adopted in Buffelsdrift (above). Experiences or adventures often lead to being exposed to new stories, new information and to learning – this occupies the mind and it expands the mind – encouraging growth and life.

We have been asked to provide examples of #positive and enjoyable #adventures in #CapeTown #SouthAfrica where good clinical evidence is followed such as facilitating social distancing at all times and general hygiene, which is relevant in this context.

1. #Buffelsdrift in Oudtshoorn (photo) where Mr Andries Van Schalkwyk is committed to the safety, enjoyment and relaxation of his guests. Social distancing is facilitated at all times, even during #game drives, where solo game drives are offered. This is not offered by all #safari or game farms in South Africa (we have checked). We were inspired by the story about the adoption of the 3 baby #elephants and their journey, and relationships with the staff. We recommend a visit.

2. #Villiera game drives, close to #Stellenbosch – very educational and lovely environment.

3. #MonkeyTown in Somerset and #WorldOfBirds in Houtbay are committed to rescue #animals and education. Children love the #monkeys – they are free roaming.

4. #EagleOutreach in #Spier wine farm, close to Stellenbosch, and #Cheetah Outreach in Somerset share their commitment.

5. #Boulders famous for hosting #penguins shares their commitment.

6. #Crocodile tours offered by Andrew at #LeBonheur close to #Paarl is most educational. We have never seen cleaner areas for animals. The farm also offers excellent food and accommodation.

7. #4×4 #GearUp with Sam and Jarred – very educational to prepare for challenging terrain.

8. #BikeSavvy with Brent – very educational and teaches safe #motorcycle techniques. Many villages in islands can only be reached by 4×4, motorcycles or boats.

9. #Snorkel with Craig Foster in Cape Town’s waters – there is no better place for peace, silence and beauty (and interesting relationships). Please see ‘My #Octopus Teacher’ on Netflix.

10. #Sailing in most areas and #boat trips to #CapePoint – most spectacular. Lessons are available locally with accredited teachers. Dolphins, seals, penguins and Southern right #Whales are often seen when sailing.

Based on our or our colleagues’ experiences at the time, these were some of the most enjoyable experiences in recent times.

We always recommend to avoid close contact with wild animals (and never feed them). If they approach you, we usually recommend to slowly and calmly move away. If they jump on you (monkeys for instance), calmly move towards the guide and ask him or her to assist you – always remain calm, so that the animal will remain calm. If there is no guide, the animal will often become bored and move away. Don’t have food or drinks on you when visiting places with animals (they will be reluctant to move away then and risk can increase). Wild animals are wild, and this is often in their best interest and in yours or your child’s best interest. Guides will offer help and give advice, however, remember to also follow your own gut and mind with these decisions if you feel or think that guides are too confident or taking unnecessary chances, which seldom happens, although it can happen (eg if a guide tells you that you can go closer or touch the animal). It is important to follow the guide’s advice when he or she tells you to stop or move away or not touch or feed animals or return to your vehicle. Most guides prioritise safety and have years of experience in maintaining safety for animals and humans.

#Animals can #teach us a lot and can be especially helpful in #social and #emotional #development for #children – such as forming a healthy #attachment and #learning about #interaction #communication and #responsibility – we recommend introducing animals to children at a young age (safely and in age appropriate ways).

Travel and the traveller: 

Clinically appropriate measures based on good clinical evidence are required to reduce risk during this pandemic.  The emphasis needs to be on the traveller, whether the traveller is high or low risk in the context of severe COVID-19; this is indicated by the clinical picture presented to us since January 2020 (please see paragraph below).  Where the traveller is going within the country, where the traveller will be staying, mode of transit, purpose for visit – these are all essential matters to consider in any risk assessment, as it has been previously. 

The important matter is that the responsibility should be on the traveller (autonomy); education, discussion with informed and appropriate health professionals (trained and supported GPs), weighing decisions and making informed decisions considering recommended, necessary or indicated vaccines or protective equipment required. 

“80% of the time COVID-19 is a mild disease that feels like a minor cold or cough”, as reported by Prof Peter Piot, Director for The London School of Hygiene and Tropical Medicine, and 95.5% of the general population will likely not require hospitalisation, only 4.5% of the global population will likely require hospitalisation if infected with SARS-CoV-2, as reported by The London School of Hygiene and Tropical Medicine. 

There are individuals at high risk for severe COVID-19 (eg the elderly, immune compromised and some with underlying medical conditions) and there are individuals not at high risk for severe COVID-19 – two clinical risk groups – one high risk group and one low risk group in the context of COVID-19. Ask your GP if you are not sure in which group you are.

Educating the public in terms of general health, infectious diseases and this pandemic is essential to achieve good clinical outcomes.

Global Health Plan: 

A global health plan is clinically appropriate and required to address a global health crisis.  We have given examples of why a global health plan is essential for a good clinical outcome during this pandemic in previous correspondence.  Our reasons have included for instance the consistent approach that high risk individuals for severe COVID-19, such as the elderly, be vaccinated first, without the delay in the second vaccine, where appropriate, and that staff offering high risk work such as medical doctors and other healthcare workers engaging in clinical work, teachers, Police, Social Care be given an opportunity to be vaccinated as the second priority. 

This clinical recommendations is informed directly by the clinical presentation of this virus. 

Consistency in terms of travel, quarantine or PCR tests would also protect the global public.

Let’s move forward together with eyes wide open – let’s ask questions and consider good clinical evidence.

Helpful websites:

TRAVEL AND WORK

http://www.travelhealthpro.org.uk

http://www.nhs.uk/conditions/travel-vaccinations

BORDERS AND TRAVEL

https://www.iatatravelcentre.com/world.php

https://canitravel.net

https://apply.joinsherpa.com/travel-restrictions?affiliateId=americanairlines

https://www.worldnomads.com/travel-safety/worldwide/worldwide-travel-alerts

https://www.wanderlust.co.uk/content/coronavirus-travel-updates/

#travel #traveller #education #responsibility #SouthAfrica #nature #antelope #Blesbok #Blesbuck #Wanderlust #WorldNomads

Immune system:  Vaccines, travel and various factors

Most intelligent organisms adapt.  We adapt by learning and growing.  We learn by observations and collecting data. 

As per previous comments regarding respiratory viruses and the immune system, most viruses adapt.  The immune system of most individuals are equipped and designed to respond to infections and manage biological risk appropriately, however, the human’s immune system is complex and sometimes fragile.  The immune system also has to learn, grow and adapt, depending on different stimuli, agents or risks, however recommending and enforcing a context of a non-changeable, semi-permanent, semi-sterile environment, such as ‘stay at home’ initiatives, will likely not assist in these matters for many.  Closing borders and preventing travel will likely not assist in these matters either.  The opposite is likely true and required for most healthy individuals’ immune systems to learn, adapt, grow and function appropriately in risk associated contexts, such as these.  

Staying at home for instance during ‘stay at home’ messages or lockdown can prevent the immune system from exposure to agents that stimulate learning, growing and adapting of the immune system for many individuals (we are not referring to infections when we use the word exposure and we do not recommend in any way that you purposefully expose yourself to anyone with an active infection or who tested positive – this will likely increase risk markedly). Healthcare workers or carers who are exposed to individuals with active infections or individuals who test positive take appropriate clinical precautions to protect themselves.

Many doctors report that when they start working in another country, they often present with minor respiratory infections or irritations for the first few months and sometimes up to two years, which then ends. This is likely due to general exposure in a new community or country.  Many doctors believe that their “body and immune system is getting used to the bugs of the area and then the body and immune system adapt and you don’t get sick or feel any irritations any more, I even see it when relatives come to visit, they are so often a bit sick, but very minor, because they are not used to the bugs”, as reported by a medical doctor.  Exposure can lead to infections, especially with sudden, going from zero to ten, significant exposure, such as moving to another country, far from your home country, in winter time and starting to work in hospitals full time with on calls, without delay or a gradual induction, whereas gradual, minor and regular exposure often prevents significant or serious infections, as many medical doctors agree.

Timing is essential in some circumstances when making decisions regarding various initiatives, and as mentioned before, individuals at high risk for severe COVID-19 require different protocols to facilitate equal protection (such as urgent vaccines with a clinical urgency to be fully vaccinated), however, autonomy, liberty and normalcy are important protective factors for all. 

The immune system can also be harmed significantly by factors such as chronic anxiety, low mood, nihilism (‘no hope’), ‘feeling trapped or stuck’, deprivation of liberty, deprivation of autonomy and deprivation of normalcy.  This is why lifestyle, such as spending time outdoors in nature, camping, hiking, boating and adventure or enjoyment, is very important. Mental state is important; calm, positive thoughts with feelings of ‘freedom’, ’empowerment’ and hope, along with good insight based on good education to prevent illness and infections, and what to do if concerned. These items are important because they contribute to, promote and sustain, a healthy immune system, which markedly affects general health outcomes. Most professionals who work with deprivation of liberty have extensive clinical knowledge and expertise to share, supporting these concerns. Please see previous two posts on deprivation of liberty and the immune system.

It is important to consider that immunity secondary to vaccines or active infections often does not last.  In some infective diseases immunity may be life-long further to various vaccines or further to infections, however, it is the current understanding that immunity for this virus, secondary to a vaccine, will likely not last more than a year, likely 9 months more or less. Most agree that vaccines provide a degree of protection (although not 100%, sometimes may vary between 75-95%) in the context of preventing hospitalisation and reduced mortality rates, and that vaccines are one of the tools in the tool box to prevent infections.  Continued diligence is required to prevent infections such as washing hands, covering nose and mouth when sneezing or coughing, avoiding sharing eg utensils or drinks, remaining at home if sick, symptoms or positive tests, along with eating healthy, remaining calm and regular enjoyment. Interpersonal variation is also sometimes relevant, where some individuals will respond differently in terms of vaccines.

“80% of the time COVID-19 is a mild disease that feels like a minor cold or cough”, as reported by Prof Peter Piot, Director for The London School of Hygiene and Tropical Medicine, and 95.5% of the general population will likely not require hospitalisation, only 4.5% of the global population will likely require hospitalisation if infected with SARS-CoV-2, as reported by The London School of Hygiene and Tropical Medicine.  “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

It is important to consider that these statistics were relevant in a clinical context without vaccines.

We have to ask ourselves, whether we will ask the public to engage in annual vaccines for a viral infection where more or less 80% of the global population will likely experience a mild cold or minor flu and no serious symptoms if actively infected. We have to ask ourselves how long will we ask travellers (with and without vaccines) to engage in 7 PCR tests (risk associated invasive nasopharyngeal tests) within 10 days for travel related purposes (no clinical indications) at more or less £100 per PCR test. We have to first do no harm, at all times.

Immunity due to everyday exposure (not infection or vaccine) is relevant and important, which is one of the reasons many medical doctors have advised that liberty is not deprived by lockdown or stay at home or quarantine, and travel not be discontinued in any way; immunity in this context will likely continue, as individuals will continue with exposure by regular travel and daily life. As mentioned earlier, we have travelled through more or less 20 countries during the pandemic, usually for work and within high risk areas, and have never presented with any symptoms, an elevated temperature or a positive test since the onset of the pandemic in January 2020 (our trip started mid January in Asia) – it is relevant to know that all flights during the first 5 months, except for one, did not require face masks – more than one specifically asked that face masks not be worn. We travelled through at least 10 countries, most in Asia, during this time.

Risk usually has to be balanced carefully; often when one extreme approach is taken to reduce risk, risk increases markedly in other contexts eg social contexts or psychological context or other biological or medical contexts, and when risk is ignored completely with a laissez-faire approach, risk often continues to increase unnecessarily.  A careful balance is required and can be achieved by asking individuals with appropriate, clinical training and experience in bio-psycho-social risk assessment and risk management to contribute to the discussion. 

Our work with children with poor immune systems due to a range of difficulties including eg infective diseases such as HIV, nutritional problems or an environment of threat and anxiety, has inspired us to take a systemic approach at all times.  It is essential to understand that biological factors such as infections, psychological factors such as anxiety or ‘feeling trapped’ or ‘feeling forced’ and social factors such as being asked to remain in the same space for a few days, can increase risk to present with infective diseases significantly for most individuals via the negative effect on the immune system.   

As mentioned earlier, mental state is an essential predisposing, precipitating and maintaining factor for general health (and mental health).  Mental state markedly affects the immune system.  A mental state of calm, confidence, positive thoughts, feelings of freedom, autonomy (“being in control of one’s life, the comings and goings, it keeps people healthy”, as reported by a medical doctor), normalcy (that “things are normal”, as reported by medical doctor) and empowerment (“we know how to stay healthy”, as reported by an individual living in an informal settlement), as well as calm, positive behaviours along with insight based on good education regarding the risks associated with the infection and the options to manage risk appropriately (based on good clinical evidence) is of significant benefit to general health. 

We were interested in the different mental states in the different countries.  It is important to consider that mental state, like risk, is dynamic, and varies from moment to moment, based on context and bio-psycho-social factors. 

Statements or quotations in South Africa: 

1. “We are fine here, we are healthy, …, we are happy, it is what we do, it is what we always do.  We know HIV, we know TB, we know how to stay healthy and if HIV did not get us, this will not get us.”  Community elder in a location

2. “We are doing very well actually, the problems we have are not related to the pandemic, it is the problems we’ve always had, but now they are taking a backseat …, but from a pandemic point of view we are all very lucky here, I wouldn’t be anywhere else if you paid me.”  Medical specialist working in an informal settlement

3. “Things are not bad in South Africa, our winters are not really winters, they are mild, like European summer, actually I see most people are very healthy, most people here are happier and healthier than before, I think it is because they look after themselves better now, they eat better, they rest more, I don’t want to be in a place where there is so much fear …, I am happy here.”  Medical doctor

4. “I worry now that we have had good results in …, people are becoming ‘hans’ (over confident), they are not greeting with elbows any more, they are back to hugging and kissing, we see party busses, parties in restaurants acting as clubs, people say they better get their social on, because lockdown is coming again – this is a problem, because some people base behaviour on lockdown rules, rather than infection risks, so before or after lockdown they go crazy, rather than think ‘infection risk’ – the story was not pitched as ‘protect yourself’ to all, it was more ‘avoid lockdown’ … for some which won’t help”. Medical doctor

5. “Things were very bad when you weren’t allowed to leave your homes, the military soldiers were outside our houses and said we couldn’t stand on our own lawn, .., the kids were so frightened they didn’t eat or sleep, but now we can live again.  Although my son hasn’t spoken in months, his therapist says it is the masks.”  Mother, baker 

It is important that good clinical evidence is followed in every context to reduce risk and to prevent harm, to protect yourself and the general public. We need to ask questions and educate ourselves based on good clinical evidence.

Prevention:  Following only good clinical evidence

The most important and essential strategy in Medicine or Health is prevention.  We are sharing this information for this purpose.  Much of the morbidity and mortality outcomes can be prevented if a systemic, evidence-based (only based on good clinical evidence) bio-psycho-social approach is followed, including relevant risk and protective factors. 

We have to ask whether there is good clinical evidence to support initiatives in the general public. We have to ask these questions whilst still following local laws and rules.

The World Health Organisation and the European CDC have clear guidelines in terms of when a mask may be helpful, as posted earlier.

WHO – “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” World Health Organisation.  More details available at https://apps.who.int/iris/rest/bitstreams/1319378/retrieve.  

European CDC – “There is limited evidence on the effectiveness of medical face masks for the prevention of COVID-19 in the community.” ECDC, European Centre for Disease Prevention and Control https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-face-masks-community-first-update.pdf

It is our understanding that the CDC has now advised that face masks not be worn outside when social distancing is possible, which is congruent with current UK guidelines. We understand that Disney recently changed their mask wearing policy allowing guests to not wear masks outdoors in contexts that are clinically appropriate. We understand that the UK plans (hopes) to end all mask wearing, indoors and outdoors, in June 2021.

Asking questions, finding evidence-based answers (based on good clinical evidence) moves us forward.

Education is essential to prevent illness or infective diseases.

For Educational Purposes – we have observed than many report various different symptoms as the ‘most common’ symptoms. Please see helpful links (details of where links were founded on photographs).

#travel #borders #adapt #learn #grow #ImmuneSystem #lifestyle #outdoors #nature #bird #sugarbird #freedom #MentalState #calm #positive #camping #adventure #sailing #hiking #education #SouthAfrica #Africa #statistics #symptoms #children #health #education

Travel and traffic light systems: 

As professionals who have more than 20 years experience in bio-psycho-social risk assessment and risk management, and regularly complete bio-psycho-social risk assessments in various countries and specific areas in various countries, we have concerns regarding whether applying a traffic light system to countries, in the context of the pandemic and travel, is clinically appropriate or helpful.

We say this for the reasons including the following: 

1. Countries often vary markedly in terms of risk in different areas.  The north of the country, or centre, or west, east or south, or the city areas, or some city areas, often present with a very different risk profile compared to the rest of the country.  This is relevant for biological risk, psychological risk and social risk.  This is also often relevant from an economic, financial and emergency services perspective, which is appropriate to consider in risk assessments. 

2. Protective factors in nations are not considered, such as culture, mental state, public education, cohesion within emergency services, emphasis on evidence-based strategies, normalcy, autonomy and liberty, along with communication style of officials.

3. Activities or purpose of visit is not considered eg will individuals be hiking the isolated mountains, spending their time sailing the ocean or attending a festival (which many agree is clinically inappropriate during a pandemic).  This influences risk markedly. 

4. Means of transport and accommodation:  Individuals who rent their own car and spend a week or a month on a driving trip, staying in isolated rentals without much or any human contact, camping, picnicking and hiking pose a very different risk to individuals taking the bus and train, staying at busy resorts.  

5. Personal background is relevant.  A medical doctor or nurse with training, skills and experience to prevent infections poses a different risk compared to an elderly individual with serious medical problems or a child with a compromised immune system.  

6. Risk is dynamic and fluctuates from day to day depending on context and varying bio-psycho-social factors.  This is relevant for every corner of every country, and for every individual in every country. 

7. Exposure and immunity is relevant in this context. We will comment more later.

8. The clinical profile and clinical presentations relating to this virus is relevant in these decisions. We have commented on this before, and will comment again later.

9. Good clinical evidence relating to increased risk and harm in relation to deprivation of liberty, autonomy and normalcy is relevant here. 

10. Many medical doctors report that a traffic light system is clinically inappropriate, because it is “not clinically doable due to the nature of risk in the context of whole countries”, “this will only cause more anxiety and …” and “now people will have to hop scotch through different countries to make their way to their destination, (which can increase risk for many, visiting many airports and taking many flights) causing anxiety, frustration, anger, low mood and general increased risk for many reasons, this is not normal, … and makes no medical sense”.  We certainly agree that this initiative will complicate matters significantly for travellers, likely increasing risk, considering a longterm perspective, and possibly a short term perspective, rather than decreasing risk. 

We, like many medical doctors, triage using a traffic light system, as mentioned in previous correspondence.  We are often asked to clinically lead a team and for one doctor to take over more or less 300 children who are on medication, but have not been seen by a doctor in a year or sometimes many years.  One specialist usually sees no more than 100 children per year, although this number is often 50 or 30 or even less depending on complexity and other commitments.  We usually use a traffic light system to triage in these cases.  We liaise with staff who know the children and we consider documentation to triage.  We usually ask staff to contact children and families to confirm our conclusions in terms of low risk (green), medium risk (orange) and high risk (red).  A traffic light system is appropriate as part of a risk assessment strategy in this context, because it refers to a specific patient with a specific presentation in a specific context at a specific time. 

We also use a traffic light system to plan our trips, which sometimes extend for several months and in high risk and low risk areas and countries.  We spent nearly two years to gather data and identify bio-psycho-social risk and protective factors in various areas of the countries, liaise with relevant local parties, liaise with authorities (on social security and health) on the matter in the UK to give us an opinion on our provisional risk assessment and confirm our findings and comment on our plan.  We ensure that after spending a few months in high risk areas, that we would spend time in low risk areas, and we usually have a low risk base in close proximity during high risk commitments.  

It is important to note that our risk assessment and management plan is based on: 

1. Biological, psychological and social factors – risks and strengths,

2. in very specific areas in specific countries, with a very specific route to travel,

3. with a specific travel plan, which included transport, accommodation etc,

4. based on specific individuals (doctors, volunteers) with a specific bio-psycho-social profile, 

5. with specific equipment and medical kits to manage risk appropriately,

6. engaging in a specific task or tasks in a specific environment, 

7. at a specific time of year (to consider weather patterns with associated infection risk patterns). 

The key is – specific.  Risk assessments must be specific to a specific clinical context, setting, patient and time.  Generalisation is often not helpful within risk assessments and can increase risk markedly rather than decrease risk.  Much like the question of capacity, which is relevant only in terms of a specific question, such as does this person have capacity to decide to get this flu vaccine, risk also needs to be assessed, considered and applied as specific. 

Our journey was planned very specifically in advance.  If we had planned to visit different areas in the same country, our risk assessment would have been different, and a ‘red’ country, might have been a ‘green’ country.  We spend a significant amount of time researching entire countries to determine the patterns and outlay of the various risk profiles to educate volunteers, but also to plan our route and decide whether or not to accept different service requests, based on our understanding of the relevant risk and protective factors.  We know from experience, like most medical doctors, that the “north and the south of the same country is often very different planets in terms of medical risk”, as reported by a colleague.

We then usually employ a “sharp mind, soft hands” approach, as per the Jamaican Bobsledders.  In an emergency or a crisis most medical doctors agree that to control everything brings relief of anxiety or uncertainty, however, in most medical emergencies or medical crises, the opposite is often clinically necessary.  Collaboration, working with the human body, immune system and risk factors, is often required, however, collaboration has to be based on good clinical evidence, extensive training and experience alone. 

We are very concerned by a ‘box’ approach, “where India is high risk, South Africa is high risk, Italy is this, Switzerland is that”, as reported by a medical colleague, for several reasons: 

1. The risk will vary markedly within the same country depending on location. 

2. The risk will vary markedly within the same country within the same location depending on cultural and other bio-psycho-social and protective factors, which can also vary markedly, and are not being considered. 

3. The risk will vary markedly within the same country depending on activities planned by the traveller. 

4. The risk will vary markedly within the same country depending on methods of transport and accommodation of the traveller. 

5. The risk will vary markedly within the same country depending on personal background and relevant medical and mental health history of the traveller. 

6. “The risk will increase for us all if some countries are cut out, we won’t get exposed as we should, and our immune systems will stay compromised and in the dark, not adapting as it should.”  Medical doctor

7. Risk is dynamic and will vary from day to day.  “Risk does not change from week to week or three week to three week, it changes all the time”.  Medial doctor

8. Risk is not reported accurately in many contexts in many countries. 

9. “If we don’t get some normalcy, travel, freedom and autonomy back into our bones very soon, the negative consequences like child abuse, assault and illness will only increase exponentially, and a traffic light system is far from normal or freeing, I don’t understand how an infection that only seriously affects 20% of the population can warrant this ..”  Medical doctor

10. “It seems like it is political, …I worry about agendas, …now we want to box the world up into safe and not safe, …, it is time to let go and remember this is a medical problem, it is not that complex, no boxes are required, normal life is now required urgently to prevent further illness”, as reported by a colleague. 

It has been our consistent experience that everyone in every country that we have visited have tried their utmost to reduce risk and to prevent harm. We want to thank every party and every organisation for their efforts and commitment to moving forward. We realise that every person, organisation and country has a different perspective and considers matters and risks from various view points; these perspectives are most valuable and important, as this is how we learn and we can all learn from each other.

We want to thank the UK for their diligence and commitment in regards to the vaccine rollout, which has been inspiring and which most appreciate sincerely.

It is important that we focus on the strengths and positive progress within every country, that we work together collaboratively and that we spend a significant amount of time to audit and learn from current, recent and previous events, decisions, strategies, initiatives and outcomes, we do not move forward without this last step.

#Travel #Borders #Risk #Health

Travel and Red List Countries:

It is important to ask ourselves whether it is useful or helpful to use a traffic light system in terms of risk during the pandemic.

South Africa now has a worldwide reputation for being on the ‘red list’.

We have recently spent time in South Africa. Most days we travelled in townships, informal settlements or locations. We liaised with the public from various cultural and bio-psycho-social backgrounds regarding their observations, thoughts, concerns and opinions. We liaised with medical consultants in government hospitals, Deans of Universities and DOH delegates. We assisted individuals requiring hospital appointments and were informed that the waiting list is often no longer than a few weeks for non-urgent matters.

From a clinical or medical point of view we can confirm, from firsthand experience, that we have not spent time in a country that is significantly lower risk in the context of COVID-19 than South Africa since June 2020. We say this for many reasons, which include:

1. Space – South Africa has space. Individuals or families now spend weeks or months in chosen isolation when on safari, camping or hiking. This is part of the culture for many and these activities maintain a healthy mental state, immune system and general health. Most people who have visited South Africa are aware of the vast spaces available in nearly every corner of the country, where one can spend days, weeks or months without seeing another human being, and many do, as they have done for decades. Camping, cycling, walking and safari by car are usually extremely common in South Africa, and it has increased markedly. Individuals engage in animal or bird watching, adventure activities such as swimming or snorkelling in the sea or 4×4 driving in mountains. Significant time is spent in nature and with animals. We understand that equipment to engage in above is often now sold out. We have visited some of the areas mentioned above and have discovered families from various cultural and social backgrounds camping in very isolated areas in mountains, game reserves or by the ocean, dams or lakes. Good social distancing, hygiene and other evidence-based protective behaviours are maintained at all times, based on our direct observation; more than 90% of the time. We have also been asked to enquire with various game farms or activities whether social distancing is maintained during eg game drives or sailing excursions, which we have done, usually with positive outcomes. Facilities are clean with soap and water available. We have met numerous foreigners travelling in South Africa in these contexts, stating that they had to “escape to find normal and freedom to stay healthy”. We have spent time in most countries in Europe and the space in South Africa cannot compare, it is truly vast.

2. Mental State – As mentioned previously, we were asked why individuals in high risk settings are not “sick and dying” by many. We have not been able to confirm that there is a pattern where most active cases and mortalities are not from high risk settings such as informal settlements, however, we have spoken to residents in many informal settlements as well as medical doctors offering services who confirm that “most people or actually all people are well, healthy and going on with life as normal” and “we thought we were all going to die, because we live on top of each other, but no, everyone is fine, I think it is because we are not afraid, we know about infections, we do the common and simple things that work, like we have always done”. People commonly refer to strategies relating to TB and HIV, which are also effective in this context, and that most people are “very experienced” with preventing respiratory infections. Most mental states observed are calm, confident, with positive thoughts regarding health, outcome and risk, along with positive feelings and mood, with good insight regarding current risk, maintaining health and steps to take if concerned. These are significant protective factors. These protective factors are based on good education, good communication and communities working together.

3. Education – South Africa is a country, like many other countries, where education is emphasised and opportunities to educate are never missed, often to an extreme degree. We observe more or less 20 educational leaflets per day in various contexts in the public, clear information and messages instilling calm, confidence (“empowers people”) and positive thoughts. All information is evidence-based, except face mask wearing, which we are told by some is associated with cultural reasons. Please know that some countries in Europe have the same rules regarding face masks in place, that face masks are compulsory indoors and outdoors, and considering an international context, despite no good clinical evidence supporting this strategy. We have also observed individuals behaviour in the context of hygiene in the public; 90% of individuals carry and use their own alcohol or sanitising gel (we have not observed this in the UK or Europe to the same degree), hands are washed appropriately (eg between fingers), but not unnecessarily excessively (this is very important, as germ phobias and OCD is a concern for many, none of us are immune to these mental health concerns) and individuals mostly engage in social distancing and other evidence-based strategies such as covering nose and mouth when coughing or sneezing. Our direct observation indicates that South Africans are significantly more confident, educated and diligent regarding reducing risk in the context of respiratory infections, which might relate to their longstanding experience in managing TB and HIV.

4. Evidence-based initiatives: Nearly every shop, restaurant, hotel and transport agency or vehicle check temperature, and ask regarding symptoms, also taking personal contact details (on paper, to be destroyed later). Disinfectant hand gel is offered and compulsory before entering most establishments. Social distancing is facilitated in most areas, at least 80-90% of the time in public establishments (like in any country some individuals engage in clubbing or pub events where there is no social distancing, but this is observed rather infrequently, perhaps less than 10% of the time, which is less than observed in other countries). Salt and pepper, as well as cutlery and menus are usually cleaned and sealed where appropriate before and after usage (these behaviours are completed in view of the public). Restaurants where chairs and tables are fixed to the floor have installed perspex dividers to reduce risk. Ventilation is prioritised and seating is almost always available outdoors (some wine farm restaurants have even placed restaurant tables amongst vines, which many appreciate). Individuals are asked to remain at home when sick or symptomatic or when recent positive confirmed contact is relevant, and most seem to comply.

5. Culture – The culture of camaraderie has never been stronger. A sense of helping each other, looking out for each other, laughing and being positive, “it will be fine”, are very relevant. South Africans have not presented more positive towards each other in decades, as per our observation, which is something we treasure. Most South Africans respond to emergencies or urgent matters by becoming calm, the word ‘extreme’ is relevant and appropriate in this context; we have observed this cultural phenomenon in different ethnic, age and educational groups for several decades. Considering longstanding everyday psycho-social risks in South Africa, perhaps along with biological risks, this cultural approach in emergencies makes sense. Please also see item 1 relating to culture.

6. Normalcy – South Africa has ample opportunities to engage in normalcy every day in the context of significant space and beauty. Many agree that this maintains their health and mental health (since early February 2021).

7. Autonomy – South Africa facilitates autonomy. We were interested to hear and observe how many individuals in the public understand and comply with protective initiatives to reduce risk; this is inspiring and it is important to give individuals with capacity to make good decisions regarding specific health related decisions the option of choice. Many agree that this maintains their health and mental health (since early February 2021).

8. Liberty – South Africa facilitates liberty. Many agree that this maintains their health and mental health (since early February 2021).

These significant protective factors lead to reduced risk, mental health and general health.

Many are concerned that if ‘prophylactic lockdown’ is enforced in South Africa, which is now considered, general and mental health will deteriorate markedly.

It is important to understand bio-psycho-social risk and protective factors relating to general health and mental health in any context, however, it is essential to understand these unique factors for every country in the context of the pandemic.

Clinicians with experience in bio-psycho-social risk assessment and risk management will agree that it is not possible to compare the UK to many developing countries such as South Africa or India due to vastly different bio-psycho-social and cultural predisposing, precipitating and maintaining risk factors, as well as unique protective factors and strengths.

We receive many questions comparing South Africa or India and the UK with fears such as “will the UK go the same way as…”. As mentioned earlier, many countries worldwide, despite practising more clinical diligence and prioritising more evidence-based clinical initiatives, compared to more developed countries, which need to be applauded, will have a more challenging longterm outcome, which is affected by the relevant predisposing and precipitating risk factors. Most people who have travelled in countries such as South Africa or India know their significant and unique strengths, but also, like most other countries, the bio-psycho-social risk factors which will make a national good outcome more challenging, please see photographs on our social media pages such as twitter and instagram. As before, countries such as India must however be recognised for their evidence-based strategies, commitment and diligence to protect the public and visitors without delay after the pandemic was announced; mere days after the announcement in January temperature and symptom screens were in place. We will certainly remember India’s significant kindness and commitment to the public and to travellers during this difficult time.

We have also been inspired by South Africa, as we have been in the past, by their diligence, the consistent following of good clinical evidence by most parties, the collaborative approach and the significant camaraderie; South Africa currently presents with an abundance of protective factors in the context of the pandemic, much more so than many other countries at this stage.

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