Covid-19: control measures must be equitable and inclusiveBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1141 (Published 20 March 2020) Cite this as: BMJ 2020;368:m1141
All rapid responses
On the 31st December 2019, a cluster of pneumonia cases of unknown origin was reported to WHO (1). COVID-19, a new disease caused by the virus SARS-CoV-2, has since reached pandemic status causing swift and deep disruption across all areas of life. Many people may carry the infection asymptomatically and this is thought to be linked to its spread (2–4).
One common response by governments has been to institute ‘lockdowns’: the restriction of movement outside the home and the closure of non-essential businesses and services, in efforts to slow the spread of the disease (5,6). Social distancing has also been strongly encouraged, with large gatherings banned, and advice to remain two metres from contacts in public. These aim to prevent mixing of people susceptible to COVID-19 and people already infected by it.
In the light of these measures, sexual health advice has been issued from various bodies asking men who have sex with men (MSM) to practice safer sex (7–9). These safer sex recommendations include mediating sexual encounters through virtual means, such as webcams, phone-sex, and restricting sexual partners to those in one’s household. There are also recommendations to abstain completely from sex (8).
However, there is little data regarding the acceptability of these measures to MSM. If these measures are unacceptable, then it is plausible that physical sexual encounters will continue to take place, undermining social distancing measures. There are already reports of novel sexual encounters continuing under lockdown (10).
During the Aids crisis, insights from MSM were crucial to developing safer sexual practices (11). As yet there are no studies investigating what novel safe sex practices, if any, are being instituted by MSM over the course of this pandemic. Research is therefore urgently needed to identify how these lockdown measures interact with sexual behaviours.
1. World Health Organisation. Pneumonia of unknown cause – China [Internet]. 2020 [cited 2020 Mar 27]. Available from: https://www.who.int/csr/don/05-january-2020-pneumonia-of-unkown-cause-ch...
2. Ling Z, Xu X, Gan Q, Zhang L, Luo L, Tang X, et al. Asymptomatic SARS-CoV-2 infected patients with persistent negative CT findings. Vol. 126, European journal of radiology. Ireland; 2020. p. 108956.
3. Bai Y, Yao L, Wei T, Tian F, Jin D-Y, Chen L, et al. Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA [Internet]. 2020 Feb 21; Available from: https://doi.org/10.1001/jama.2020.2565
4. Lai C-C, Liu YH, Wang C-Y, Wang Y-H, Hsueh S-C, Yen M-Y, et al. Asymptomatic carrier state, acute respiratory disease, and pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): Facts and myths. J Microbiol Immunol Infect. 2020 Mar;
5. Iacobucci G. Covid-19: UK lockdown is “crucial” to saving lives, say doctors and scientists. BMJ. 2020 Mar;368:m1204.
6. Lau H, Khosrawipour V, Kocbach P, Mikolajczyk A, Schubert J, Bania J, et al. The positive impact of lockdown in Wuhan on containing the COVID-19 outbreak in China. J Travel Med. 2020 Mar;
7. Prepster. COVID-19 tips & tricks [Internet]. prepster.info. 2020 [cited 2020 Mar 27]. Available from: https://prepster.info/covid/
8. Brady M. Don’t hook up during the COVID-19 lockdown [Internet]. tht.org.uk. 2020 [cited 2020 Mar 27]. Available from: https://www.tht.org.uk/news/dont-hook-during-covid-19-lockdown
9. NYC Health. Sex and Coronavirus Disease 2019 (COVID-19) [Internet]. 2020. Available from: https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-sex-guidance.pdf
10. Milton J. Eight men arrested after hosting cocaine-fuelled orgy during coronavirus lockdown. Pink News [Internet]. 2020 Mar 24; Available from: https://www.pinknews.co.uk/2020/03/24/coronavirus-lockdown-orgy-group-se...
11. Leonard W. Safe sex and the aesthetics of gay men’s HIV/AIDS prevention in Australia: From Rubba me in 1984 to F**k me in 2009. Sexualities [Internet]. 2012 Oct 1;15(7):834–49. Available from: https://doi.org/10.1177/1363460712454079
Competing interests: No competing interests
Strategic and unprecedented measures - for the first time in the European Union - have been taken by Italy to face the COVID-19 outbreak. On March 11 2020, the Italian Government passed the Prime Minister’s Decree, known as “Stay at home - Resto a casa”, which established a lockdown in the entire national territory, including penitentiaries and custodial settings. Hence, family and lawyer visits to prisoners have been suspended, as well as the possibility for detainees to get probation and special permits to leave facilities .
Inmates reacted to the directive staging violent protests at 49 different sites across the Country, leading to 12 deaths among prisoners, 19 offenders escaped and 40 injured guards. Authorities estimate the correctional facilities damage at around €35 million .
According to the Ministry of Justice, a total of 191 penitentiaries are housing 61.230 inmates, with the prison system operating, on average, at 129% of its capacity. Despite legal dispositions, one person cells may de facto host up to three prisoners, giving less than four square-metres of personal space each one .
The overcrowding of Italian detention centres as well as their limited access to medical care may represent an immediate risk to the spread of the COVID-19 pandemic. Yet, 4 COVID-19 cases have been registered amongst prisoners.
On March 17 2020, the Cabinet issued the “Cura Italia - Care Italy” Decree, to offset the economic impact of the COVID-19 on the general welfare of the Country, including, among others, the justice sector. The latest directive allows for early supervised release of detainees with less than 18 months left to serve on their sentence, in order to protect the health of inmates and guards as well as alleviate overcrowding in its penitentiary system . The measure should affect approximately 4.000 prisoners which will spend their unspent conviction under house arrest until 30 June 2020. Detainees are required to carry a personal identification device, a house arrest monitoring system that automatically verifies the presence or absence of prisoners at the prescribed location .
There are critical lessons learned from the current COVID-19 pandemic: i) the systematic problem of overcrowding of Italian prisons proves to be a limit to principles of humanity and human rights safeguard (including health); ii) Nearly 16.000 people incarcerated in Italian correctional facilities were 50 or older in 2019. Almost 70% of the penitentiary population suffer from at least one disease, posing them at higher COVID-19 vulnerability ; iii) adequate penitentiary financing is required to address the needs of detainees excluded from the temporary release ordinance; this includes appropriate technology equipment to re-establish contacts with their families; iv) interventions to strengthening prisons and custodial settings emergency preparedness must be in place to prevent the outbreak; among others, the distribution of protective masks for the prisoners and the guards is essential.
Consistent policies to screen, monitor, and treat people suspected of having COVID-19 are needed to ensure marginalized group of patients the same level of care of the general population.
1. Ministry of Health of Italy. Covid-19, in Gazzetta ufficiale Serie Generale, n. 64 del 11 marzo 2020). Available at: http://www.trovanorme.salute.gov.it/norme/dettaglioAtto?id=73643
2. Coronavirus, s'infiamma la protesta nelle carceri: morti tre detenuti a Modena, sequestrati due agenti a Pavia – Repubblica. Available at: https://www.repubblica.it/cronaca/2020/03/08/news/paura_per_il_coronavir...
3. Statistiche, Ministero della Giustizia. Available at: https://www.giustizia.it/giustizia/it/mg_1_14.page [last accessed on 28 March 2020]
4. DECRETO-LEGGE 17 marzo 2020, n. 18. Misure di potenziamento del Servizio sanitario nazionale e di sostegno economico per famiglie, lavoratori e imprese connesse all'emergenza epidemiologica da COVID-19. In Gazzatta Ufficiale serie generale n.70 del 17 marzo 2020.
5. Tremila braccialetti elettronici saranno installati entro tre mesi. Agenzia Italia. Available at: Available at: https://www.agi.it/cronaca/news/2020-03-18/carceri-braccialetti-elettron...
6. Voller, F., Silvestri, C., Martino, G. et al. Health conditions of inmates in Italy. BMC Public Health 16, 1162 (2016).
Competing interests: No competing interests
Berger et al. 2020 make salient points about the importance to respect the needs of vulnerable groups, and in response Lloyd-Sherlock et al., 2020 call for the World Health Organization to prioritise the needs of older people as one of the most vulnerable groups in the Covid-19 pandemic.
We endorse the importance of attending to the needs of older people, recognising that they people may be more vulnerable to greater morbidity and mortality from Covid-19 infection. We further recognise that older people are also part of the societal response to the crisis regularly providing care to other older people and making many valuable contributions to families and society. While people at higher risk because of their age may need to be protected, they also need to be respected as human beings with unalienable rights, and valued for their many contributions.
We would also make the following points:
• Most older people are not in long term care facilities. The needs of the majority of older people in the community must be considered, including access to food and other essentials and access to medical care, social and personal care, and other services.
• Age is only one factor that increases vulnerability to Covid-19 risk. Other medical conditions increase risk and can affect people at ages less than 60. Moreover, all people, even young healthy people are vulnerable to severe effects.
• Health care rationing should not be made on the basis of age alone, but on a consideration of other factors which may affect treatment response and prognosis. A healthy person in their 60s may have more potential years of healthy life than a younger person with multiple comorbidities.
• Older people can be at risk of social isolation, increasing risks of depression, malnutrition, neglect and abuse.
• The public health message for protection against the spread of COVID-19 should emphasise “physical distancing” to protect against the virus, and “social closeness” using alternative means as required, to protect against risks of social isolation. People of all ages are at risk of social isolation in times of “lock down”.
In our genuine concern for age-associated increases in risk from COVID-19, we must guard against being overly paternalistic and stereotyping older people as vulnerable and dependent.
Julie Byles BMed. PhD. FAAHMS
Faculty of Health, The University of Newcastle
HMRI Building, The University of Newcastle Callaghan NSW 2308
Briony Dow BSW MA PhD
Honorary Professor, School of Nursing and Midwifery, Deakin University
Honorary Professor, School of Population and Global Health, University of Melbourne
Victoria Cornell BSc Honours PhD
Housing Research Manager, ECH
174 Greenhill Road, Parkside, SA, 5063
Dr Judy Lowthian PhD MPH BAppSc(SpPath)
Principal Research Fellow and Head of Research
Bolton Clarke Research Institute
Suite 1.01, 973 Nepean Highway Bentleigh, VIC 3204
Meredith Tavener B Appl Sc. M Med Sc. PhD
Faculty of Health, The University of Newcastle
HMRI Building, The University of Newcastle Callaghan NSW 2308
On behalf of the International Longevity Centre Australia
Berger Zackary D, Evans Nicholas G, PhelanAlexandra L, Silverman Ross D. Covid-19: control measures must be equitable and inclusive BMJ 2020; 368 :m1141
Lloyd-Sherlock PG, Kalache A, McKee M, Derbyshire J, Greffen L, Gomez-Olive. Re: Covid-19: control measures must be equitable and inclusive - Open letter to World Health Organisation (and to Member States). Response to BMJ 2020;368:m1141 https://www.bmj.com/content/368/bmj.m1141/rr-5 and letter https://www.bmj.com/content/368/bmj.m1164
Competing interests: No competing interests
The Australian Association of Gerontology (AAG) strongly supports the Editorial premise that policies aimed at ending the pandemic must respect and be sensitive to members of vulnerable communities.
AAG’s purpose is to improve the experience of ageing through connecting research, policy and practice. Its principles are to be evidence informed, multi-disciplinary and holistic, independent, collaborative and fair. As Australia is in the relatively early stages of dealing with the pandemic, we are in a position to learn from other countries in later stages.
“OLDER PEOPLE” ARE NOT A HOMOGENOUS GROUP
Age itself is not a risk factor for vulnerability to Covid-19. Rather, age is correlated with other underlying risk factors. Researchers are still learning about the full range of risk factors for Covid-19. A simplistic use of age to determine Covid-19 vulnerability and underpin policy and rationing choices is therefore inappropriate. Policy making and public statements must not inadvertently, or explicitly, draw from or reinforce ageist stereotypes concerning the risk factors experienced by, the needs of, or the potential of “older people”.
AAG is concerned that some of the messaging around vulnerabilities, both in Australia and internationally, suggest that all “older people” above arbitrary cut-off ages would most-likely not survive a Covid-19 infection. Public health messaging must make it clear that current evidence shows the majority of people of all ages are likely to survive a Covid-19 infection. Resources must be allocated to prioritise the research required into protective factors and strategies aimed at prevention and that promote recovery from Covid-19 for people of all ages.
AN ETHICAL FRAMEWORK IS NEEDED FOR RATIONING OF RESOURCES
An ethical framework is required in order to address the rationing of resources for the pandemic (1). This framework must explicitly state under which situations rationing would be enacted, and when it would cease. This would ensure that it is not used as a tool to motivate ongoing discriminatory health resource allocation. Like all policies in response to Covid-19, this ethical framework must respect members of vulnerable communities and not reinforce negative stereotypes and generalisations. This includes not basing any ethical framework on simplistic correlated general groupings of vulnerable people (such as by age) and instead focussing on clear ethical values (such as maximising benefits through being responsive to evidence).
The ethical framework must be transparent and communicated to all members of the community in a sensitive, respectful and appropriate format. People’s value, contribution to society, and right to be heard must be acknowledged; no matter what their age.
USUAL CARE MUST BE BOOSTED IN THE FACE OF COVID-19
Simultaneously boosting primary health care, disability, aged care and social services in the face of Covid-19 will ensure that peoples’ usual health care needs are addressed. This will prevent additional harm from Covid-19 and relieve pressure on the secondary- and tertiary health care systems. For example, the primary care system can be strengthened by:
• Fast-tracking models of care such as telehealth for an expanded group of primary care providers.
• Clarifying that “usual” care is an essential service and must continue to the highest extent possible, even during periods of lock-down.
Supporting health care, disability, aged care and social service workers to be able to safely provide services during the pandemic is vitally important. They need clear advice on the use of, and access to, personal protective equipment. An ethical framework should guide the allocation of these resources to different services during shortages. Health care, disability, aged care and social service workers must be assisted to address their own needs during the pandemic (such as the recent moves to allow free city parking) and be reassured through any ethical framework that their own health is a high priority.
LANGUAGE MATTERS: PHYSICAL ISOLATION, NOT SOCIAL ISOLATION
Messaging needs to focus on the physical, not social, isolation of vulnerable people. AAG supports community and Government initiatives to reduce social isolation during periods of physical isolation, including intergenerational efforts. However, there is a risk of increased abuse and fraudulent activity so any such efforts must maintain rigorous screening, recruitment and monitoring processes.
In summary, AAG calls on the World Health Organisation, Governments, service providers, research institutions and other entities to consider how they discuss age sensitively and respectfully when developing policy responses to Covid-19; which would be supported by adopting an ethical framework to guide resource rationing.
Professor Christine Stirling
President, Australian Association of Gerontology
1. Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A., . . . Phillips, J. P. (2020). Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine. doi:10.1056/NEJMsb200511
Competing interests: No competing interests
1. Yes, control measures should be equitable and inclusive. They also should depend upon where the infection came from, how it spread. Did commerce have a hand in its spread? Was it merely tourism?
Have the health checks at the relevant airports been as good as they should be? Have the passenger baggages been inspected closely for contraband meat?
If the staff concerned were offered amnesty, they might disclose where and when they made errors.
2. Here in England, WHY has the government failed to supply adequate masks for the NHS staff? Is it shortage of money? Was it failure of the computers? Was it failure of someone go press the correct button on the computer - all innocently, accidentally. ( Barely a fortnight ago, somewhere in England, many people including myself, received computer letters apologising that they had NOT received their appointments for a certain speciality. A case of wrong computer, perhaps. I informed them that I had had my eye operation more than two years earlier. ).
If you do not protect the staff, you the NHS will be guilty of spreading the infection.
3. Assuming you have identified a case. Why do you not do contact tracing? This was always the first step in control of communicable disease.
Or, have you given up the struggle and decided to let the disease spread, cause illness in many, cause sub-clinical infection in others, and ultimately produce herd immunity in the survivors .
If this is the strategy, the Chief Medical Officer should tell us. ( It is the Chief Medical Officer whose advice matters. The Chief Scientific Officer has no locus as adviser to the public).
4. Or, should we assume that you do not have enough money to order the kits for all the hundreds of thousands who might be excreting the virus? Either patients or family contacts or staff?
5. Have you enough money and laboratory facilities to test sewage for the virus, and then work proximally, to identify premises where the virus is being excreted.
6. I am surprised that up to now, the press have not woken up to these little matters.
Competing interests: A citizen
With considerable interest I have read this editorial by authors from the John Hopkins School of Medicine and various other leading institutes of our world . May I submit that just for once there is a definite need to see beyond the absolute numbers of all those getting infected by COVID-19 to really understand the main point. This virus is a novel corona virus, which is highly contagious, but isn't it correct that 90 % and more of all those infected by this virus have mild symptoms and will recover well.
Of interest is an article from JAMA that has reflected upon the characteristics of patients dying in relation to COVID -19 in Italy . So far, with all the worldwide data and research available, we all are sure of the fact that it is the elderly frail population, who have some underlying co-morbities, would be facing the brunt and taking the maximum damage. No one is immune to this virus, not even the VIPs of the world or their family members, or any of the staff assigned at their service. Therefore they too would need a redoubled effort at isolation and quarantine unless this pandemic comes to a halt. Doctors and healthcare staff, as well as all those individuals with weak and lowered immunity status due to any cause, are at greater risk of mortality. Hence they too would require redoubled protection.
Simply stated, shouldn't the efforts at isolation, quarantine and provision of adequate healthcare be redoubled for these groups that have been identified and who are at unusual risk of dying due to COVID-19. In healthy individuals, sickness due to this virus seems to be quite contained, and as is usual in most viral catarrh, it is over in a week or so in most otherwise healthy patients. Secondary infection needs to be prevented. This percentage of patients with mild illness is roughly 90 to 95 % of all those infected by this virus. All that these majority of healthy people will require is perhaps adequate rest, take fresh air, and an occasional Paracetamol / Acetaminophen (Tynelol) over a few days, besides avoidance of social contact till afebrile and asymptomatic for a continuous period of three days and falling back on their own doctor or emergency whenever needed, Ideally they should not pass on their infection to anyone else, but owing to its very high infectivity rate and difficulty in detecting with the present wherewithal, is that practically possible even with a total lockdown?
According the Director General of the World Health Organization, this pandemic is accelerating giving out the numbers as well . But would locking up a complete town or district, stopping travel, business, work, etc, be really helpful, when our intention remains to prevent mortality in a group that is so easily identifiable? We don't have a cure as yet, or a vaccine for this viral disease. In this situation, wouldn't a rapid increase of 'herd immunity' be of considerable help in the long run, and specially so when we know that at most this disease is a mild flu like illness that clears off on its own in a week or so in nearly all healthy individuals.
Complete lockdowns for extended period of time of nearly of the whole world really doesn't stand to reason. Shouldn't our limited and finite resources and energies be more fruitfully channelized for basically the elderly, and the population with lowered immunity and who are weak and frail? Why generate unnecessary panic and anxiety, and why create conditions which can craft long term problems related to economy and growth, as also problems related to law and order which could throw up challenges of peculiar nature.
Locking up all the youth and healthy individuals just for preventing this COVID-19 reaching the weak and frail elderly population who have other underlying health issues is not what the pioneers of modern medicine would have contemplated. This, especially when the number of infections we might be anticipating are colossal and can't be easily managed without grievously hurting the economy and earning Therefore, we really need to take a fresh look at equitable and inclusive containment strategy, so that we might get out of a logjam situation when practically the whole world has been brought to a standstill due to this COVID-19
So now we know who all are at risk of dying due to COVID -19. Even the best economies and countries with best healthcare resources may not find complete lockdown for extended periods of time truly viable and in the best interests of their country. As a solution, with life going on as usual, why can't the frail elderly with co-morbidities and other individuals at risk of contracting severe illness be identified, and given a redoubled healthcare facilities, along with appropriate isolation and quarantine so that they all may escape COVID-19. This way the resources can be channelized for those who require them the most and not frittered away in vain. These people on high risk of dying must not be allowed travel by public transport of whatever form, and must not be allowed to mix up with anyone, besides their own care givers and healthcare professionals, who would have to redouble their personal protection so that they may not pass on this infection to anyone thus identified at risk of having a severe disease or of resultant death. Why lock up towns and cities for everyone for an illness that is highly contagious and already so many people have already been affected, and many more will be affected by the time I finish writing this letter to the editor and dispatching it online.
Dr (Lieutenant Colonel) Rajesh Chauhan
MBBS (AFMC), Master in Medicine (CMC Vellore), PGDGM (Geriatric Medicine), PGDDM (Disaster Management), AFIH (Industrial Health), DFM (Family Medicine), FISCD, ADHA (Hospital Administration) & LLB
1. Berger Zackary D, Evans Nicholas G, Phelan Alexandra L, Silverman Ross D. Covid-19: control measures must be equitable and inclusive BMJ 2020; 368 :m1141
2. Onder G, Rezza G, Brusaferro S. Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy. JAMA. Published online March 23, 2020. doi:10.1001/jama.2020.4683
3. WHO Director-General's opening remarks at the media briefing on COVID-19 - 23 March 2020. Available at https://www.who.int/dg/speeches/detail/who-director-general-s-opening-re... Accessed on 24 March 2020
Competing interests: No competing interests
1. Ong and Lester (19 March) in their responses make valuable suggestions.
Is OUR GOVERNMENT listening?
2. We might learn lessons from Italy and from Wuhan if we study the pattern of spread in these two large areas of Covid 19.
Have the Chinese established by now the genetic similarities between the human cases and the known animal hosts which were also part of diet?
Have the Italians established genetic identity between their cases AND the Wuhan cases?
Have the Italians established whether there were no other visitors from Wuhan, nor returning Italians or Wuhan people resident in Italy who were sources of further virus imports?
We should not publicise untruths. Nor should we hide facts - else the public will lose faith in epidemiologists.
Dr JK Anand
(retired doctor with some memory of previous frightening outbreaks)
Competing interests: Old citizen
Re: Covid-19: control measures must be equitable and inclusive - Open letter to World Health Organisation (and to Member States).
Open letter to World Health Organisation (and to Member States).
WHO must prioritize the needs of older people in its response to the Covid-19 pandemic.
WHO is the most influential global organisation in guiding responses to the Covid-19 pandemic. It is working around the clock to issue helpful guidance for technical experts and the general public. WHO has just issued guidance for long term care facilities.  However, this new guidance is not placed on the main page of technical guidance reports. Instead, it is hidden behind a link to “Guidance for schools, workplaces & institutions.” People responsible for long term care facilities are unlikely to identify with this link. Even more importantly, WHO has not issued any guidance of specific relevance to the more than 98% of older people who do not live in such facilities.
This is an alarming oversight, given that this age group accounts for the large majority of severe cases and of deaths. This oversight must be addressed immediately. WHO must issue different sets of expert guidance on issues such as:
• Guidance for health workers, especially in primary care, about how to work with older people, including those who are frail and cognitively impaired.
• Guidance for older health workers (including those coming out of retirement)
• Guidance for older people and their families to manage infection risks, deal with symptoms and mitigate wider issues such as depression.
Unless WHO acts immediately to address its neglect of older people and Covid-19, we believe it will lose credibility as an organization with a special mandate to provide guidance to Member States.
Member States must urge WHO to act on this now and must ring-fence part of Covid-19 funding provided by WHO for this purpose. They must also ensure they prioritise the needs of older people in their own national responses and in their support for low and middle-income countries.
Peter G Lloyd-Sherlock
Professor of Social Policy and International Development
University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
Former Director, WHO Department of Ageing and Life Course
Centro Internacional de Longevidade - ILC BRASIL , Ladeira da Glória, 26 - Bloco 3 - Centro, Rio de Janeiro - RJ, 22211-120, Brazil
Professor of European Public Health
London School of Hygiene and Tropical Medicine, London, UK
HelpAge International, 6 Tavistock Pl, London WC1H 9NA
Samson Institute For Ageing Research, 234 Upper Buitenkant St, Cape Town, South Africa
MRC/Wits Agincourt Research Unit, New School Of Public Health Building, Education Campus, University of the Witwatersrand, Parktown, South Africa
1 World Health Organization. Coronavirus disease (COVID-19) technical guidance: Guidance for schools, workplaces, and institutions. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technica...
Competing interests: No competing interests
Re: Covid-19: control measures must be equitable and inclusive. Covid-19 should trigger release of detainees from Immigration Removal Centres
Correct and consistent implementation of government advice on Covid-19 presents an impossible challenge for Immigration Removal Centres (IRCs) 1.
As with all places of detention, those incarcerated in IRCs are denied control over many aspects of their lives. Cells and bathrooms are shared, outside space and fresh air limited, and cleanliness is difficult to maintain. Sustained and effective social distancing is an impossibility for all within IRCs. Many detainees are especially vulnerable due to their age, co-existing physical illnesses and, in a high proportion of cases, mental illness. These vulnerabilities predispose to a marked deterioration in health caused by immigration detention. IRCs are high risk for clusters of Covid-19 2, and staff provide a conduit for infection to and from the community. Healthcare staff and healthcare resources within the IRC would be more useful helping the mainstream NHS at this time of crisis.
The stated rationale for the use of IRCs is to hold migrants in the immediate period before removal from the UK. In practice, many individuals are held for months. Immigration detention is not a punishment for a criminal offence, but rather part of an administrative process. Mechanisms to identify and protect vulnerable detainees are almost entirely ineffective, and inquests into deaths in detention have raised concerns about standards of care and neglect. Access to lawyers and international flights are increasingly restricted, so continued detention may now be unlawful in a large number of cases.
As Covid-19 cases soar, it is inexcusable to continue with using immigration detention. All immigration detainees must urgently be released in order to protect detainees and staff, to dissipate this needless potential hub of infection, and allow redeployment of valuable healthcare staff and resources. Outbreaks of Covid-19 within the IRCs are inevitable and may already be occurring. Following legal action, 300 immigration detainees have been released 3. We call for urgent release of the remainder of detainees in IRCs and also those in prisons who are held under immigration powers. Covid-19 is an added reason for the government to heed previous advice from the BMA and others and close the IRCs.4,5
Mary Kamara clinical advisor, Medical Justice
Teresa Wozniak retired general practitioner
Hilary Pickles retired Director of Public Health firstname.lastname@example.org
1. Berger Z D, Evans N G, Phelan A L, Silverman R D. Covid-19: control measures must be equitable and inclusive. BMJ 2020;368:m1141
2. Coker R 2020 Report on Coronavirus and Immigration detentionhttps://detentionaction.org.uk/wp-content/uploads/2020/03/Report-on-Dete...
4. BMA Medical Ethics Committee. Locked up, locked out 2018. https://www.bma.org.uk/media/files/pdfs/collective%20voice/policy%20rese...
Competing interests: Mary Kamara works for and Teresa Wozniak and Hilary Pickles are trustees for Medical Justice, a charity that supports immigration detainees
Societal and personal benefit from controlled transmission of Covid-19 transmission among consenting volunteers?
Is the approach to Covid-19 containment making it too hard for those who would be prepared to help society by contracting Covid-19 in a controlled manner which would pose no safety or financial risk to others while also benefitting the herd?
Would it not be a good idea to equip a hospital-ship with a staff of medics who have already recovered from Covid-19, and then moor it somewhere suitably remote. In an organised and regulated process, volunteers (only those who wish to do so!) would be allowed visit the ship for the purpose of contracting the disease in controlled conditions. Having contracted it, these volunteers would would move to a quarantine area in the ship. After 20 days the survivors would be given the all clear and let back onto the mainland with a certificate saying they were good to go back to work, etc. Visitors could paid for their own stay if the Government was unwilling to cover the cost. The fee to participate might including either a non-returnable insurance payment together with larger (but returnable) deposit to cover burial/funeral costs (etc) in the event that bad things happen. The insurance fee would cover the possibility that you end up with a long term health problem (other than death) needing on-going care as a result of complications. Volunteers would understand that they are risking their lives and would sign disclaimers, etc, saying that they understood the limited healthcare facilities on the ship, and did not expect to be flown back if their complications were not treatable with the ship’s equipment, so as to avoid burdening the NHS.
Why would volunteers visit such a ship given the significant risks they would face?
For some, the personal benefits of being able to return quickly to society, to get industry, pubs, schools and shops working again, would far outweigh the negatives. Successful individuals would know they had increased herd immunity thereby benefitting society and protecting the weak and vulnerable. The knowledge that it had been accomplished at negligible cost to the taxpayer would add to this. The process could even be coupled with experimental vaccine trials for those who also wished to participate in them.
Yes, risks would be taken by every participant, but life is full of risks. Each of us should be able to determine how we measure our own expected future quality of life. Entering this ship would, in essence, be much like deciding to have a surgical operation (e.g. kidney transplant) which carries non negligible risk of failure, but which (for some individuals) would have potential to vastly increase quality of life through being removed from the need to isolate. I am 44 and would volunteer, but even some people facing much higher risks than me might be happy to participate. For example, an old person fearful that the remaining ~five of year of his or her life might be spent trapped under house arrest for the protection of both themselves and society might take the view that even a 20% chance of death is good if it allows them to spend their remaining days with family and friends in society. The number taking this view could be low, but those who make that calculation should be empowered.
Life is not without risk. We let people paraglide, or parachute jump, or climb sea cliffs and mountains without ropes. The case should be even stronger for allowing people to take risks which benefit society.
Success here depends on doing the process in a controlled environment. This environment does not reduce risks for the participants — it is there to eliminate the risks to the persons choosing to remain in the shore.
Competing interests: No competing interests