Immune system:  Vaccines, travel and various factors

Immune system:  Vaccines, travel and various factors

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

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

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

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

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

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

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

“80% of the time COVID-19 is a mild disease that feels like a minor cold or cough”, as reported by Prof Peter Piot, Director for The London School of Hygiene and Tropical Medicine, and 95.5% of the general population will likely not require hospitalisation, only 4.5% of the global population will likely require hospitalisation if infected with SARS-CoV-2, as reported by The London School of Hygiene and Tropical Medicine.  “Earlier estimates that 80% of infections are asymptomatic were too high and have since been revised down to between 17% and 20% of people with infections.”

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

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

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

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

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

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

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

Statements or quotations in South Africa: 

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

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

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

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

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

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

Prevention:  Following only good clinical evidence

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

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

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

WHO – “At present there is only limited and inconsistent scientific evidence to support the effectiveness of masking healthy people in the community to prevent infection with respiratory viruses, including SARS-CoV-2” World Health Organisation.  More details available at  

European CDC – “There is limited evidence on the effectiveness of medical face masks for the prevention of COVID-19 in the community.” ECDC, European Centre for Disease Prevention and Control

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

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

Education is essential to prevent illness or infective diseases.

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

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

Travel and Traffic Light Systems

Travel and traffic light systems: 

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

We say this for the reasons including the following: 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

#Travel #Borders #Risk #Health

Travel and Red List Countries

Travel and Red List Countries:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

#Travel #Borders #SouthAfrica #CapeTown #space #normalcy #normal #liberty #autonomy #sailing #GameDrives #animals #BirdWatching #camping #education #health #MentalHealth #statistics #barbecue

Simple strategies

Many children continue to live and work on the streets.

Estimates, several years ago, were that more or less 250 000 children lived on the streets in South Africa.

Homeless children need to be protected as a priority in every nation.

Homeless children need to be supported from a systemic point of view.

How to eradicate poverty? How to end homelessness for children?

It is important to understand the ABC’s of outcomes or events or behaviour. What happened before the event or occurrence to predispose or precipitate the event, what happened during the event, who suffered, who gained, details are important, how were systems affected, what maintained the event or occurrence or behaviour, what happened after the event, the consequences, how was the system affected afterwards, who gained.

For example, most individuals understand that if you provide money to individuals or parties in debt, they are often in worse debt within a very short period of time. Systemic thinking, clinical thinking, based on bio-psycho-social risk and protective factors, are required when understanding behaviour, thoughts, emotions or events, and when making decisions.

Simple and systemic solutions are often the most effective.

Homeless children can have different lives if bio-psycho-social systemic thinking is applied, beyond housing or finance, to maintain the positive outcome.

Sustainability should be an important goal.

A safe and stimulating environment is key.

Education is key.

A place to ‘belong’ is key. This can be a team or a place of work, if need be.

Responsible carers are key.

Responsible peers and seniors are key.

Close, healthy, positive relationships with warmth and caring are key. Animals can be sufficient, if no other alternatives are available. Many adults report that their lives changed or were saved due to an animal.

Engagement in regular, positive, normative activities, where a child is interested and enthusiastic, such as playing a sport or musical instrument, is key.

Accessible, user-friendly, effective, evidence-based (good clinical evidence) healthcare services are key.

Simple strategies can precipitate and maintain positive outcomes.

Some organisations estimate 100-150 million homeless children living in the streets around the world with at least 250,000 children dying every week from diseases and malnutrition.

Please see UN comments relating to homeless children on relevant web pages.

We have joined a Hot Cross Bun Run this year, for Easter – drop a few sealed hot cross buns off with someone in need. Join us.

#belong #enthusiastic #simplesolutions #education #fun #enjoyment #UN #poverty #homeless #children #animals #change #sustainable #debt #developing #hotcrossbun

Priorities for Children and Families

One of the largest informal settlements in the country with approximately 40 000 children under the age of five.

We asked children what their greatest wish was today, and they said “to go to the #beach , but without the masks”.

Children are children in every corner of the world.

We asked 17 year olds what their greatest wish was, they reported “to have our soccer field back, they are taking it away, and it keeps us on the straight and narrow, we have a team we belong to, it is home, it is nice, it is good”.

Simple strategies change children’s lives.

Most children and families, in various countries including the UK, countries in Europe, India, Sri Lanka, Thailand, Cambodia, Malaysia, Vietnam, New Zealand, South Africa and countries in Europe report that the most important items for their family are:

1. physical safety

2. freedom (many explain that this means “education for children”), then

3. health

4. mental health

5. peace

6. joy, then

7. victory with goals (such as “learning to swim”)

Many include beauty, animals, loved ones and friends.

We have been asked to provide a text, book, manual or summary of principles to precipitate and maintain these items for children and for adults, based on our clinical training and experience assisting children and families, from all walks of life, with these goals for the last 20 plus years.

Simple items are often the most effective.

Please email us at if you would like a copy. This is likely to take us a while though, but if there is a sufficient need, we will oblige.

#joy #peace #safety #health #mentalhealth #victory #success #simple #soccer #book #principles #maintain

Relax – enjoy – experience normalcy – learn

Children and families report that they need ideas of places, or a place, to safely relax – enjoy – experience normalcy – learn – evidence-based protective factors to improve health and mental health for themselves and their children.

They want places where evidence-based (good clinical evidence) strategies are followed such as

– alcohol gel, along with wash rooms with soap and water available

– social distancing facilitated and maintained on for example safari or a game drive with animals

– food hygiene where food is covered and children are supervised

– practical education is prioritised for example cover your mouth and nose if you cough or sneeze

– staff and customers are calm and positive

We will provide thoughts on local options. We have liaised with travel agencies and organisations offering these services to families and children.

1. Houtbay has a bird park, a small zoo, where children walk amongst monkeys, which most families enjoy. This is an excellent environment to teach children about animals and social behaviour. All safety regulations are followed, from reports and firsthand experience during our brief visit.

2. Sailing in the Waterfront on the Victoria is advised. This is an excellent environment to teach children about the sea, seals and dolphins. All safety regulations are followed, from reports and firsthand experience during our brief visit.

3. Imhoff farm offers lessons on horse riding (very limited instructions for beginners, please ask for more information if you need to – a slow walk through vineyards, valleys and on the beach is available, this remains a high risk sport), 4×4 skills and preparing for challenging terrain and breakdowns, animal farms for children, goats, fish markets and restaurants. Wonderful opportunities for families to relax together and for children to learn about animals. All safety regulations are followed, from reports and firsthand experience during our brief visit.

4. De Meye – a wine farm close to Stellenbosch – offers a wonderful meal next to vines under trees with dogs at your feet. We can absolutely recommend their food and the environment for safe relaxation and enjoyment. Very informal. Lovely people. All safety regulations are followed, from reports and firsthand experience during our visit.

5. Klein Joostenberg – a wine farm close to Stellenbosch – offers a beautiful meal within a ‘kraal’, outside, on the grass or a ‘stoep’ or porch, with dogs at your feet. Lovely staff and friendly people. Very informal. All safety regulations are followed, from reports and firsthand experience during our visit.

We have been asked about ideas or a place that offers safe, normative activities for children and families, to relax, enjoy and learn together, to recover, restore health or mental health and to maintain or promote health or mental health, for several months.

Many want to “blow off steam”, “fill my tank”, “get my bounce back”, “feel like a person again, “get some perspective”, “tick some bucket list boxes”, “make up for lost time” or “enjoy life again”.

We are now working on developing a service in Europe for children and families to recover – relax – laugh – learn (practical skills like survival in the woods or fishing or swimming or snorkelling or boating or cooking food outdoors or working with animals) – we plan for at least half of the service to be pro bono services.

This service will aim to meet the needs of very fortunate children, every day children and also children who have experienced serious trauma.

#safari #game #animals #SouthAfrica #Africa #learn #relax #enjoy #families #children #normalcy #calm #positive #developing #services #Europe #recover #laugh #fishing #snorkelling #boating #cooking #Houtbay #birdpark #zoo #waterfront #sailboat #Imhoff #horseriding #beach #winefarm #vineyard #vines #DeMeye #KleinJoostenberg #Stellenbosch

Normalcy and Good Clinical Evidence in Cape Town, South Africa

A small team arrived in #CapeTown #SouthAfrica.

We have been asked to provide information on #experiences of #normalcy and the following of #goodevidence.

Normalcy is an evidence-based protective factor for children and adults. Protective factors reduce morbidity and mortality from a general health, mental health and social risk point of view. These factors are important in healthy child development (language, cognitive, physical, social and emotional development), children’s well-being, children’s general safety, mental health and general health.

Activities on offer in Cape Town, South Africa, offering normalcy in the context of the pandemic, that do not increase risk, if engaged in safely, with evidence-based risk reducing initiatives.


1. Sailing – there are whales, dolphins, seals and penguins in the bays

2. Horse riding – in vineyards, valleys, mountains or on the beach

3. Hiking

4. Exploring mountains by 4×4 or mountain biking

5. Volunteering with animals or visiting animal parks – many safari experiences in the area now offer private drives to facilitate social distancing.

6. Surfing or kite surfing

7. Tours in vineyards – private tours to facilitate social distancing

8. Live music performances outdoors (or art performances)

9. Restaurants, cafes, pubs, shops – most facilitating social distancing and ventilation

10. Swimming or snorkelling

Cape Town offers lessons on developing or increasing skills in all activities above in safe ways that do not increase risk.

Many refer to the CCHH rules of evidence-based risk reducing initiatives (good clinical evidence):

1. Close – keep a safe distance at restaurants, cafes, pubs or during sport or exercise.

2. Cover – cover your mouth when cough or sneeze – avoid those who don’t, and cover food.

3. Hands – keep hands clean before touching food or face.

4. Home – stay home if you have symptoms or are sick or have been in recent confirmed contact with a positive case.

Good Clinical Evidence:

1. Temperature and symptom screens are available at nearly every shop, restaurant, cafe or pub. Screens were offered at airports and hotels.

2. Alcohol gel is available on nearly every restaurant table.

3. Many restaurants eg #Wimpy have facilitated screens to ensure social distancing.

4. Outdoor events such as music shows are on offer to facilitate social distancing.

5. People engage in protective and normative initiatives and activities – eg many children and adults are spending time with loved ones in nature – in safe ways – ensuring their hands are clean before eating and keeping a safe distance. Most individuals appear very calm and positive – “we do the basics, we look after ourselves, do what relaxes us and makes us happy, and we believe we will be fine, then we are fine”, as reported by a father of five children.

Unfortunately masks are mandatory for every individual in every context. Except for this item, South Africa is following good clinical evidence.

“At present there is only limited and inconsistent scientific evidence to support the effectiveness of masking healthy people in the community to prevent infection with respiratory viruses, including SARS-CoV-2” World Health Organisation, Dec 2020.  More details available at  

“There is limited evidence on the effectiveness of medical face masks for the prevention of COVID-19 in the community.” ECDC, European Centre for Disease Prevention and Control

We will provide more details in the next days or weeks.

#safari #4×4 #mountainbiking #hiking #horseriding #surfing #kitesurfing #sailing #mountains #livemusic #artperformances #whales #dolphins #seals #penguins

Evidence-based risk reducing initiatives for children in schools

Evidence-based risk reducing initiatives for children in schools:

Schools and education play an important protective role for all children, including the most vulnerable, in terms of cognitive, language, social, emotional and physical development, mental health, physical health, social risk and well-being.  Please see statements relating to evidence-based protective factors and normative activities.

Systemic risk and protective factors in the context of #covid19 must however be assessed, identified, considered, weighed and managed by professionals with experience in this context (experience in respiratory infections, children’s health, children’s social, emotional, language, cognitive and physical development, including children’s neurodevelopment, children’s mental health and social risk).

Doctors with training and experience in neurodevelopment, especially in the context of respiratory infections, will likely have concerns regarding schools opening without additional and effective (based ONLY on GOOD clinical evidence) risk reducing initiatives, that do not increase risk for children in other ways.  

Most adults who work with children present with frequently increased incidence of upper respiratory infections (colds or flu).  Children also visit grandparents and elderly relatives, and engage within the general community unsupervised or supervised.  This impacts on risk for communities.  

Normal neurodevelopmental stages of children indicate that children (without learning, neurodevelopmental and mental health problems) are often significantly more physically playful, fidgety, impulsive, inattentive and forgetful than adults.  Consider research where authority figures inform children that they cannot touch an object; that it would very likely result in imminent death.  Children proceed to touching and playing with the object within minutes.  This is normal behaviour for most children without mental health, neurodevelopmental or learning problems.  Research indicates that adults (mostly with fully developed frontal lobes and neurological systems) touch their faces more or less 16-23 times per hour, often without registering this behaviour.  In Europe and the UK, we observe most adults #touching their #faces underneath their #masks with #unwashed #hands on a daily basis, masks hanging on #ears or #chins, or adults dropping masks on wet floors and wearing it again – this increases risk and harm relating to general health significantly.  We can provide many photographs from many countries. Children’s behaviour in this context will likely not be safer or more #responsible, the contrary will be likely. 

Mental health problems, learning problems or neurodevelopmental disorders such as #ASD or #ADHD, often increase these features, relating to physical playfulness, fidgeting, impulsivity, inattentiveness and forgetfulness, markedly for children or adults.  

In the UK more or less 2.5% of children present with #learning disabilities, as reported by MENCAP.  Learning problems are more prevalent, 14.9% of school aged children have special educational needs, as reported by GOV. UK.  Many children with learning problems have not been identified.  More or less 30% of children with developmental delay, present with associated mental health problems or concerns. 

Prevalence of neurodevelopmental disorders, such as ADHD, in children is more or less 3-4% in England and Wales.  It must be noted that children in this category are often most vulnerable for co-morbid mental health morbidity, often presenting with more than one co-morbid mental health diagnosis or concern, which are not always easy to identify; this is one of the reasons we recommend that children are assessed, diagnosed and treated or managed by Child Psychiatrists with training, CCTs, in Child Psychiatry, and that children with #ADHD or #ASD remain within generic #CAMHS teams, rather than be referred to separate neurodevelopmental, ADHD or ASD teams.  Children also often wait months or years on ADHD waiting lists, whilst presenting with serious co-morbid concerns such as #depression and #suicidal ideation, which lead to markedly increased risk.  Co-morbidities of ADHD include depression (15%), anxiety disorders (25%), learning disabilities (15-40%), language impairment (15-75%), Oppositional Defiant Disorder (35-50%) and Conduct Disorder (25%).  More than 50% of children with ADHD meet criteria for 2 co-morbid conditions.  

The WHO reports that more or less 20% of adolescents may experience a mental health problem in any given year.  GOV.UK reports that more or less 12.5% of 5-19 year olds had at least one mental health disorder and that more or less 5% met criteria for 2 or more mental health disorders (survey 2017, published 2019).  The Children’s Society reports that more or less 10% of children and young people aged 5-16 years have a clinically diagnosable mental health problem, yet 70% of children and adolescents with mental health problems have not had appropriate interventions at a sufficiently early age. This is one of the reasons we recommend that children referred to CAHMS are seen by a medical doctor / Child Psychiatrists within 2 weeks of referral.

It might be relevant to add in this context, considering recent research published by the Lancet, that longstanding research indicates that all or most physical health problems or disorders can increase mental health morbidity by up to 50%, neurological injury can increase prevalence by up to 500%, and neurological injury associated with epilepsy can increase prevalence by up to 1000%.

Biological risks in schools will affect risk in communities.  Risk reducing initiatives, based ONLY on GOOD clinical evidence, have been employed to reduce risk and harm from a bio-psycho-social point of view for children attending schools in many nations – we will provide examples.  

Evidence-based risk reducing initiatives for children in schools:

1. Children now rotate through schools in some countries to keep the numbers down per classroom (if a large number of children in a small classroom) and at the school in general, for instance in corridors, to facilitate social distancing and reduce risk.  

2. We have observed that social distancing is possible in almost all contexts in the public.

3. Good ventilation is facilitated, even if it has to be through open windows and doors.

4. Some classes are taught in gym class or outside if weather permits.

5. Clear instructions are given to staff and pupils to remain at home if a raised temperature, symptoms or recent confirmed contact (some include a recent traveller at their homes).

6. Temperature screens and symptom or health questionnaires are in place for every student, staff member and teacher to complete every morning at home before attending schools on interactive apps or on paper format. Many countries still identify individuals with symptoms by paper questionnaires and old fashioned temperature screens, this is equally effective.

7. It is our clinical opinion as Consultant Child Psychiatrists with more or less 15 years training and more than 20 years clinical experience that indiscriminate mandatory mask wearing will likely increase risk markedly from a general health, mental health, child development and social risk point of view for children (and adults).

There is no good clinical evidence that supports the wearing of face masks in the community for healthy individuals, there is however significant evidence indicating increased risk.

The WHO and ECDC agree that there is no good clinical evidence to support face masks for healthy individuals in the community:

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

“There is limited evidence on the effectiveness of medical face masks for the prevention of COVID-19 in the community.” ECDC, European Centre for Disease Prevention and Control

In our opinion it is not clinically indicated and it is not based on good clinical evidence to ask all children to wear face masks in schools.

Children at high risk for severe COVID-19 and children who have symptoms need to follow different protocols.

8. It is our clinical opinion that face masks should never be ‘normalised’ for children or adults, considering the lack of good clinical evidence to support face masks in the community for healthy individuals, and the evidence that risk is increased for many. We have written extensively on this topic, normalcy (and evidence-based protective factors), liaising with appropriate parties.

9. It is our clinical opinion that absolutely no #clinical #tests (side-room or special #investigations) should be completed on children unless there are clinical #indications based on good clinical #research.

Children are very sensitive to various mental health problems including different anxiety disorders at different ages, which can cause long term, sometimes life long, debilitating symptoms, distress and impairment. Medical #tests provide a very strong #message to a #child, often of ‘sick’ or ‘patient’, which often causes emotions such as fear, panic, frustration, anger or low mood, and negative beliefs regarding germs, sickness, health, death and safety – this affects behaviours, general health, mental health and social risk.

Most professionals who work with children with mental health problems have seen children referred with little or no #skin on their hands due to excessive, repetitive and longstanding #handwashing eg due to #OCD or #germ #phobias , or children with serious #wounds due to #selfharm (we have often had to refer children to plastic surgery). Children may also present with wounds inside of their mouths due to regular biting, secondary to high levels of anxiety or stress – adults, parents or carers, are sometimes not aware that children engage in these behaviours. These are often complex matters with complex predisposing, precipitating and maintaining factors, and it is essential that clinical experts in this domain be consulted.

It is our clinical opinion that indiscriminate mandatory mask wearing initiatives, along with other initiatives associated with deprivation of liberty, not based on clinical indications and good clinical evidence, such as ongoing and repetitive quarantine, curfews, stay at home and lockdown, will likely markedly affect children’s social, language, cognitive, emotional and physical development, along with mental health, general health and social risk in negative ways.

Children’s development often (not always) experiences ‘catch up’ when they are removed from abusive or neglectful environments, however, we have to ask whether it is ethical to expose children to initiatives associated with risk, when there is no good clinical evidence to support these initiatives. We have to first do no harm, as per the oath most medical doctors took after their initial 6 years of training.

Increased risk in terms of mental health, general health and social concerns, such as violence, however, can be associated with significant long term consequences. It is also important to note that mental health affects general health and social risk; any one of these factors, including child development, affects the other factors. Immediate, short term, long term risk is therefore increased.

Ethical and medico-legal questions have to be asked and answered in these contexts, considering that this is a health (or medical) crisis and medical (or clinical) decisions are (or should be) made based on medical (clinical) evidence and patient specific clinical indications to protect children and adults in the community, preventing increased risk and harm.

10. Education is key – regarding good hand or food #hygiene and #healthy #food and life style – but this has to be executed in a #fun and ‘ #normalising ‘ manner – children should not experience increased anxiety, anger, frustration or sadness by these ‘ #lessons ‘, the opposite should be relevant – children should be #distracted, #relax, #enjoy themselves and feel #empowered by these #narratives and #activities, by #learning new #skills and developing exciting dreams for tomorrow. This is essential.

It is very important to focus on age appropriate topics for children, considering their developmental age, not chronological age – and to execute the lessons or education in an age appropriate manner.

We receive too many statements from children age 3 to 13, that are not appropriate for children relating to the pandemic. Many children do not have the tools, due to their normal developmental age, to manage these concerns. Let children be children and let them deal with children’s issues, until it is their time to gradually start taking different roles, and eventually lead. We often refer to children taking adult roles as ‘young carers’ – this is not in the best interest of a child’s development, mental health and general health.

#Creative evidence-based options to reduce risk are always available in every domain and context, however, it is essential that risk factors and protective factors are assessed, identified, acknowledged, understood and managed appropriately, by professionals with experience in this domain, with regular review.  

The importance of #eduction for the general public is relevant in this and every context.  It is our opinion, based on observation in more or less 20 countries since the pandemic was reported, that this has not been achieve in many nations regarding the basic evidence-based (good clinical evidence) risk reducing and protective factors in the context of respiratory infections.

We have shared observations and concerns with relevant authorities since March 2020. Many authorities, health ministries, public health departments as well as international and national organisations safeguarding children are working together to ensure that good clinical evidence is followed to prevent increased risk and harm for children and adults. We thank everyone for their responses and efforts to work in collaboration to achieve clinical goals.

We offer pro bono training and presentations relating to this topic to staff supporting vulnerable children such as teachers, youth offending teams, Social Care or the Police, twice a year. Please contact us at for details of upcoming training events.

For more comments on protecting children, please see comments on:

An Achievable, Sustainable New Normal

Our General Recommendations to Maintain Good Health

Healthy Enjoyable Food Options

Simple Initiatives to Support the Immune System

The Importance of Normalcy for Children and Adults

Simple Initiatives Can Positively Impact on Mental State

#adhd #asd #neurodevelopment #learning #schools #mentalhealth #disabilities #childrensdevelopment #masks #facemasks #playful #fidget #hyperactive #impulsive #forgetful #inattentive #risk #depression #comorbidities #mentalillness #ventilation #safety #health #neurological #socialdistancing #education #teachers #pupils #college


Fear Can Put Us in Chains

Fear can put us in chains:

This photo was taken in Asia in January 2020. #Tourists paying to #touch this #tiger supports this industry that has taken away #rights of #animals including tigers. The tiger’s eyes say quite a lot.

Fear is one of the emotions that can save our lives and keep us safe, it is therefore important to listen to what the emotion is saying, but it can also lead to losing lives and increasing risk and harm.

We need to listen to fear, question it, be curious, look at the evidence, weigh evidence-based risks and benefits, finalise a risk management plan or strategy, and act accordingly to reduce risk and prevent harm. This often means running towards a building on fire or meeting with the child in prison classed as ‘very dangerous’, when a team advised that the child not be seen, to positively affect morbidity or mortality.

Risk assessment and management should be completed by individuals, eg clinicians or doctors or Police Officers or social workers, with extensive training and experience in systemic risk assessment and management.

Assessment and management in Medicine are associated with risk – risk is divided in immediate, short term or longterm, and low, high and very high.

We have worked in high risk fields from a bio-psycho-social point of view for at least 25 years and we know from experience that when one tries to avoid risk, one usually causes more harm and increased risk. This is very relevant in when working with hard to reach children, child protection work or working with personality difficulties.

In most medical or mental health domains it is impossible to avoid risk – but clinicians or doctors with extensive and appropriate training and experience in risk assessment and management (which includes assessment of protective factors) can balance risks and benefits, and provide a systemic risk management plan where risk is reduced effectively from a biological, psychological and social view.

Decisions should never be based in fear, if a good outcome is the goal.

Decisions should be based on information, good clinical, medical or scientific evidence and strategy; systemic risk assessments and a risk management plan.

Decisions should be made with a calm mind. Liaison with colleagues or seniors, collaborative working and good communication are evidence-based strategies of risk assessment and management, leading to good clinical outcomes.


May your choices reflect your hopes, not your fears. Nelson Mandela

I have learned over the years that when one’s mind is made up, this diminishes fear; knowing what must be done does away with fear. #RosaParks

We owe our children, the most vulnerable citizens in any society, a life free from violence and fear. Nelson Mandela

I learned that courage was not the absence of fear, but the triumph over it. The brave man is not he who does not feel afraid, but he who conquers that fear. #NelsonMandela

Courage is not the absence of fear, it’s #inspiring others to move beyond it. Nelson Mandela

We can easily forgive a child who is afraid of the dark; the real tragedy of life is when men are afraid of the light. Plato

Fear is mastered through love. Hate is rooted in fear, and the only cure for fear-hate is love. #MartinLutherKingJr

Fear is the path to the dark side. Fear leads to anger, anger leads to hate, hate leads to suffering. Yoda, Star Wars

The enemy is fear. We think it is hate; but, it is fear. #Gandhi

In time we hate that which we often fear. #WilliamShakespeare

Nothing in life is to be feared, it is only to be understood. Now is the time to understand more so that we may fear less. #MarieCurie

Fear defeats more people than any other one thing in the world. #RalphWaldoEmerson

No power so effectually robs the mind of all its powers of acting and reasoning as fear. #EdmundBurke

#Ignorance is the parent of fear. #HermanMelville

A man that flies from his fear may find that he has only taken a short cut to meet it. #JRRTolkien

He who has overcome his fears will truly be free. Aristotle

#fear #chains #safe #prison #child #children #harm #risk #medicine #mentalhealth #training #experience #balance #decisions #calm #mind #communication #yoda #starwars #hope #courage #free #love #quotations

An Achievable, Sustainable, New Normal

An Achievable, Sustainable, New Normal:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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