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