Latin America’s Treasures

#LatinAmerica has many treasures and many lessons to teach.

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

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

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

1. Good music

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

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

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

5. Learning new things and trying new things

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

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

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

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

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

Thank you for all the #kindness and #laughter.

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

It Takes a Village

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

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

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

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

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

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

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

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

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

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

#LatinAmerica

Safe Face Mask Wearing

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Statistics and Research to Protect Children and Families

Statistics and Research to Protect Children and Families:  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Important statistics to consider regarding children in schools are

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Quotations:

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

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

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

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

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

International Outreach Services

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We thank you for your support.

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

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

Global health perspective and plan:

 We have followed international statistics and patterns since January 2020.  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Please see earlier comments on deprivation of liberty.

Firsthand Observation in Various Countries

Please know that initiatives often change in countries over time or are often different in different areas of the same country; the above comments are based on our firsthand observations and experiences during our travels.

We have however noticed this consistent trend and pattern since January 2020.  

We observed no indiscriminate mandatory mask wearing, stay at home, lockdown, curfew or quarantine (self-isolation) initiatives for the general public during our travels in Asia.  

We observed no instruction to the general public to avoid or close any beaches, public spaces or businesses such as shops or restaurants; some individuals decided to close businesses and some decided to continue working with advised safety guidelines.  

It is our understanding that SARS-CoV2 tests are prescribed only for individuals with symptoms, which is based on clinical evidence and possible benefits outweigh risks in these contexts (clear clinical indications for testing especially if symptoms are severe or there are high risk individuals at home).  

Mask wearing, stay at home and quarantine were recommended only for individuals with symptoms, as is supported by clinical evidence, and the public mostly adhered to these evidence-based guidelines, as one individual commented “if it makes sense, most people comply”.

Evidence-based information was shared with the general public, as part of an initiative to educate the public regarding risk, and the public was asked to make responsible decisions in their work and personal life.  

The public, including business owners, appeared to understand, based on our direct observation, that transmission of respiratory infections such as SARS-CoV2 usually occurs through behaviours relating to hands (touching objects), mouths (coughing) and noses (sneezing); the importance of enabling social distancing, that communal items such as salt and pepper shakers should be avoided or cleaned between every usage, that unnecessarily touching items in public should be avoided, that food and drinks should not be shared amongst friends (eating from the same fork or drinking from the same glass), that hands should be washed before touching food or the face and that individuals with symptoms or an elevated temperature should stay at home until they have recovered.  

These initiatives and decisions are evidence-based (based on good clinical evidence).  

It was also evident, based on news reports to the public and observing the public’s response, that protective factors were emphasised and understood; calm, positive mental states and environments were prioritised and maintained, normalcy was advised and the general public along with governmental and health officials appeared to focus on immediate, short term as well as long term risk from a bio-psycho-social point of view. 

Public messages were positive, focussed on protecting the public and inspired hope, calm and camaraderie.

Simple measures often have the most significant positive effect on outcome.

Clinical Indications based on Clinical Evidence

We have been asked what our recommendations are within our organisation.

Firstly, we always recommend that every individual affiliated or associated with our organisation follows the local laws, rules, policies and recommendations. It is important to be aware of the National Health Plan, local laws, cultures and customs, and to consistently comply with regulations. It is also important to be curious and ask questions, respectfully, to gain a better understanding about risks and benefits, strengths and weaknesses, and to consider the clinical evidence, and it is appropriate to share concerns.

Secondly, when national and local laws allow, these are our recommendations, based on clinical evidence, good medical practice (General Medical Council) and appropriate legislation to safeguard adults and children such as the Mental Health Act, the Childrens Act and the Human Rights Act.

Clinical Indications based on Clinical Evidence:

Many doctors agree that good medical or clinical practice and medico-legal consideration dictate that – 

A. For individuals without symptoms or a raised temperature – 

1. the WHO and ECDC guidelines have to be followed regarding masks (no indiscriminate mandatory mask wearing indoors or outdoors)

2. curfews, lockdown and travel related quarantine (or mandatory self-isolation) must be discontinued

3. travel, businesses, art and music performances must resume and public spaces such as beaches must be opened 

B. For individuals with vaccines – the above applies.  

C. Individuals with symptoms, an elevated temperature or recent exposure to a confirmed case should be asked to engage in PCR tests and protocols such as quarantine or stay at home become relevant, clinically indicated and evidence-based in these contexts.  PCR tests cannot be mandatory for healthy individuals. 

D. For individuals at high risk for severe COVID-19 different recommendations are required for instance self-isolation or ‘stay at home’ where possible is relevant, however, protective factors must be included in recommendations.  Capacity and competency must be considered, as per good medical practice and medico-legal guidelines.  

E. Evidence-based initiatives such as washing hands before touching the face or eating, not sharing food or drinks, social distancing, covering mouth and nose when coughing or sneezing, and remaining at home if symptoms, contacting medical professionals without delay, remain relevant for all individuals in all contexts. 

It is important that the general public is educated regarding evidence-based protective factors and risk factors in the context of respiratory infections. Please see previous comments relating to protective factors, normalcy, liberty, autonomy, the immune system, general health and mental health.

Comments such as “you can make people sick if you have no symptoms” and “but we don’t know who are high risk”, which many “doctors reported from the start make little clinical sense, because it is relevant for many infectious diseases and usually a small part of the population” cannot lead to 80-95% of the population being exposed to high risk (up to 400-500%) and harm without clinical evidence that benefits outweigh risks.  This is especially relevant for children.  

If individuals are concerned that they might be high risk, they should seek immediate medical advice or remain at home as much as they can, self-imposed self-isolation is associated with a very different risk profile compared to mandatory indiscriminate self-isolation.  

The determining factor in every clinical decision is – is this decision right for this patient weighing specific potential risks and potential benefits for this patient in this context at this time. 

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

Travel

Travel: 

Most leaders share a priority to reduce risk and harm to the general population, in any context, and certainly during a crisis, including a health crisis.  

A. Many doctors report that they do not believe that it is clinically indicated to limit or discontinue #travel, not to or from any country, not due to morbidity or mortality statistics, and not due to variants, mutations, related medical practices or vaccines.  

It is however clinically indicated to prevent travel for those with an increased temperature, symptoms, a confirmed diagnoses or recent confirmed contact, which makes sense from a clinical point of view and is based on clinical evidence. 

Many medical doctors agree that it is negligent to not facilitate social distancing on #flights and #airports (which many countries have consistently illustrated is possible), consistently ask about recent confirmed contact, #symptoms and check #temperature before and after flights.

B. Most medical doctors recommend that those at high risk for severe COVID-19 only travel when necessary (20% of the global population and 4% of those under age 20). 

C. Many doctors agree that flight cancellations increase risk, especially direct flights, as individuals are now asked to take numerous flights to reach one destination, which increases risk for the general public. 

It is also relevant to add that most countries in #Asia, as well as #France and the #USA (#Hawaii and #California) ensured that travellers had sufficient and good quality #food, drinks and facilities available such as ablutions, hotels, taxis and rental cars, this reduces risk for individuals who travel.  

Some leaders have stated their intention to cause “discomfort” for travellers and it must be noted that many individuals now travel for work, including to provide medical and mental health care, to provide relief and to reach hospitals for medical procedures.  Many agree that it is not #ethical or #legal, certainly not clinically indicated, quite the contrary, to intentionally cause discomfort, and increase risk of harm, to any individual, especially to individuals who are vulnerable, unwell or assisting those who are not well or vulnerable. 

It is of note that we were offered a warm welcome, friendly service and the usual range of food and drinks within #Asia and the #USA in airplanes during the pandemic, however in #Europe we were often offered no or little choice regarding food or drink (sometimes only water available), and no food or no good quality food; we were informed that this was due to the pandemic, which made little clinical sense. 

D. Social distancing was successfully facilitated in most airports and #airplanes in Asia, as well as in Hawaii, Los Angeles and Cape Town, however this was not observed in most European cities, and most European airlines did not prioritise or facilitate social distancing; eg 1 individual was placed next to 3 open seats, whilst 2 strangers were asked to sit immediately next to each other in rows of 2 for a 12h flight.  Social distancing could have been facilitated, but was not facilitated.

E.  Some individuals or doctors with no symptoms and no raised temperature are now asked to engage in 5 PCR tests (some 2 days apart) and 17d quarantine (despite negative tests) within a 20 day period during travel and transit due to different countries’ policies and protocols making no allowance for clinical context, clinical indications or evidence.  

These concerns now exist for individuals who have had the #vaccine, which makes no clinical sense if risks and benefits are weighed for individual patients, especially individuals at low risk for severe COVID-19 (80% of the general population). 

A global health plan is essential to facilitate #communication and clinical #coordination to protect the general public; reduce risk, rather than increase risk from a bio-psycho-social point of view.

F. Many #medical colleagues agree that #variants, new variants or #mutations should not be a determining factor in the context of travel or quarantine.

Based on current #evidence and trends relating to new cases, #morbidity and #mortality statistics, as well as variants (such as the #SouthAfrican variant, with the same #mutation now having occurred independently in UK #variants, ie not being in the UK due to travel from South Africa), many doctors agree that it is not clinically indicated to quarantine individuals from ‘variant of concern’ or ‘high incidence’ countries.  

It is however clinically indicated to consider #quarantine or self-isolation at home for individuals with a raised #temperature, relevant #symptoms or confirmed diagnoses or recent contacts, which is an evidence-based approach observed in much of Asia. 

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

Families First, Children First

Government Facility Quarantine: 

Government facility or hotel quarantine now costs £1750 per person in the UK, much more than an average all inclusive hotel.  

Private security guards are now in place in the UK at these ‘hotels’ and ’10 year prison sentences’ are threatened, which is more than individuals receive secondary to conviction of violent / sexual crimes.  

Please see statistics relating to general risk of hospital admissions (4.5%) for the general public, and individuals at risk for severe COVID-19 (20% of the general population and 4% of children < age 20), along with statistics relating to symptoms and mortality secondary to COVID-19.  

We have to ask whether clinical evidence, or statistics, supports these indiscriminate initiatives (which increase risk markedly and cause harm for many or most) or penalties in these contexts. 

A. Most individuals report, during quarantine (not at home), that they could not access necessary healthcare, medication or food to maintain health, much more so compared to quarantine at home, and that appropriately trained medical professionals were unavailable to offer advice (in most countries).  These have been consistent and well-documented concerns since March 2020.

B. During a recent Australian Government Panel Review of hotel quarantine it was estimated that more or less 20% of individuals will suffer mental health issues during a period of enforced hotel quarantine.  It is evident that sufficient mental health support is not available in most countries.  

As mental health professionals in the UK it is our serious concern, based on 20 years practice in the UK, that sufficient support will not be available for individuals in quarantine in the UK. 

C. The risk to children and adults would increase markedly, as supported by recent evidence and statistics, during ‘government hotel quarantine’, which is not based on clinical evidence (to quarantine individuals without clinical indications such as symptoms or a raised temperature).  

Many report markedly increased social risk in their immediate environment due to indiscriminate mandatory initiatives such as quarantine; concerns include general violence, domestic violence, child abuse, alcohol abuse and illicit substance abuse.  Concerns have been raised by organisations such as the WHO and UNICEF.  Please see markedly increased statistics (up to 400-500% for children and adults).  

D. Based on current evidence and trends relating to new cases, morbidity and mortality statistics, as well as variants (such as the South African variant, with the same mutation now having occurred independently in UK #variants, ie not being in the UK due to #travel from South Africa) it is not clinically indicated, in our opinion and the opinion of many medical colleagues, to quarantine individuals from ‘variant of concern’ or ‘high incidence’ countries.  

It is however clinically indicated to quarantine individuals with a raised temperature, relevant symptoms, confirmed diagnoses and recent confirmed contact with confirmed diagnoses, which is an evidence-based approach observed in Asia. Statistics support this approach.

We have travelled through at least 20 countries after the outbreak was reported, mostly in areas where masks were not mandatory and social distancing was facilitated, and we have never presented with symptoms, a raised temperature or a positive test.  We go to great lengths to take practical precautions to remain healthy and we aim to avoid indiscriminate mandatory mask wearing areas or contexts. 

E. The general public, including medical doctors, report on receiving phone calls during post-travel quarantine or mandatory self-isolation to answer questions or receive information, however, they report that they cannot understand the person’s accent providing them with advice.  Many medical doctors have reported that the advice was often inconsistent, not congruent with good practice and was not offered by individuals with appropriate medical training.  

F. It is our understanding that most cases of COVID-19 are not identified from individuals without symptoms in travel related quarantine (or self-isolation) or individuals with negative PCR tests; that these figures are negligible or non-existent.  

We have to ask what the benefits are to expose 80% of the population (96% of those under age 20) to risk (as reported 400-500% increase) and harm by initiatives such as indiscriminate mandatory quarantine, where it is evident that these groups will receive no benefit in the risk benefit analysis. 

Many medical doctors agree that quarantine in government facilities or hotels will increase morbidity and mortality relating to general health, mental health and social risk markedly for the general public, including vulnerable children, much more so than quarantine at home, which also increases risk unnecessarily if not clinically indicated. 

Many medical doctors agree that no good clinical evidence supports these ongoing indiscriminate initiatives, “blanket quarantine” at home or in government facilities or hotels for individuals not at risk and not presenting with appropriate clinical presentations, and significant clinical evidence is available to illustrate that risk is increased markedly and harm is caused by these initiatives. 

Many raise concerns that only 17% of individuals with symptoms are accessing tests and subsequent self-isolation or quarantine, however 100% of individuals without symptoms are confined to government quarantine without clinical indication and exposed to 400-500% increased risk.  Research and statistics do not support deprivation of liberty and exposure to high risk or harm in this context, as agreed by medical colleagues. 

We have asked leaders to review these decisions and the risk management plan. We are pleased to report that many share these concerns.

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