Covid-19: how a virus is turning the world upside down
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1336 (Published 03 April 2020) Cite this as: BMJ 2020;369:m1336Read our latest coverage of the coronavirus outbreak
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Dear Editor;
“We are at a critical point in the global response to COVID-19 – we need everyone to get involved in this massive effort to keep the world safe.” This statement by the WHO Director General also applies to science and research. The “M8 Alliance” of 28 premier Academic Health Centers and Universities from around the globe, and the 140 Academies of Medicine and Sciences in the InterAcademy Partnership (IAP), together with their platform the World Health Summit (WHS) believe firmly that science needs to work together without any borders and political considerations.
Researchers around the world – including from our own institutions - are working at high speed to understand the SARS-CoV-2 virus that causes COVID-19, develop treatments and vaccines to curb the pandemic, understand the social, psychological and economic impact on people and society, and prevent future outbreaks. New forms of collaboration have allowed us and other scientists around the world to share results much faster than during any previous outbreak. We call on researchers, journals and funders to ensure that research findings and data relevant to this outbreak are shared rapidly and openly to inform the public health response and help save lives.
The current COVID-19 pandemic is very different from other outbreaks in terms of scale, connectivity, and political implications. The whole globe is literally moving towards standstill situation. We reinforce our commitment to the sharing of knowledge as a global public good that belongs to humanity. We cannot accept that developing a treatment or vaccine becomes a global competition rather than fostering global cooperation. We know that the greatest burden of disease will fall upon low and middle-income nations. Even in high-income countries, the burden will fall, disproportionately, upon the socially disadvantaged. This amplifies our responsibilities to cooperate more actively to protect our most vulnerable citizens.
The COVID-19 pandemic also is an opportunity to strengthen the Global Pandemic Preparedness Agenda. Effective, equitable partnerships between academia, governments, civil society and the private sector should be leveraged to fill gaps identified through the Joint External Evaluations and to build capacity in low-income countries as requested.
Although each of our institutions and countries has much to contribute, we can do so much more working together and through global solidarity . The M8 Alliance encourages institutions anywhere in the world to come together and take on a collective and non-discriminative responsibility to directly contribute to global response efforts to defeat the COVID-19 pandemic. As we confront this new challenge, science must take even more responsibility in all aspects: research, communication, explaining complexity, advising politicians and the public. The World Health Summit was established for this purpose. We will continue expanding this platform to improve global health in a world defined by a “new normal”, an improved and more equitable world that we would like to see created in the aftermath of the 2020 COVID-19 pandemic.
The fewer people in the dark, the better off everyone will be. We are all in this together.
Authors:
Amirhossein Takian, Detlev Ganten*, Charles Ibingira*, Ali Jafarian*, Julian Kickbusch
On behalf of M8 Alliance of Academic Health Centers and Universities
*Corresponding authors, equally contributed, alphabetically ordered
References:
1. https://www.worldhealthsummit.org/m8-alliance.html
2. https://wellcome.ac.uk/press-release/sharing-research-data-and-findings-...
3. https://doi.org/10.1016/ S0140-6736(20)30668-1
4. https://www.nytimes.com/2020/03/19/us/politics/coronavirus-vaccine-compe...
5. http://www.interacademies.org/59487/IAP-Communiqu-on-COVID19
Competing interests: No competing interests
Dear Editor
The need for international solidarity recommended by the authors has never been greater. Political, econonomic, social, technologcal, legal and environmental (PESTLE) factors are key determinants of society of which healthcare is an integral part.
PESTLE effects of COVID19 have been elaborated widely in some way or the other in the wider media and the consensus is that for a time we face many challenges in being able to recover from these effects. We are as a common denominator, mankind potentially facing an existential threat as individuals, societies and nations from COVID19 and its PESTLE effects.
Political gain, financial return and material acquisition have been key barriers to progress in moving towards more sustainable living and protecting our planet effectively
.This pandemic is the real wake up call and a time to reflect about how we plan the "new" future in the same way that planners of the welfare state did so during World War 2. Crisis is a time of learning from which we learn and grow. The welfare state emerged out of war and was planned during it. .
The Covid-19 wake-up call should compel leaders of governments all around the world to put aside trade wars, military conflict, nationalism, sectarianism and self-interest that has plagued the 21st century. For decades environmental campaigners have called for sustainable living.
The under resourcing of healthcare and the reluctance to suffer economic loss meant that quarantine measures may have been delayed resulting in economic meltdown on a scale not experienced before.
There has been longheld wisdom that if an organisation looks after the interests of people, empowers them and achieves sustainable financial success through social capital.
There has to be a move away factory models of healthcare with workers run through command and control systems emanating from bureaucractic models. Grassroot innovation pushing new ways of staying healthy to prevent illness that mounts up the cost of healthcare and target driven care will have to be harnessed. Fundamentally the healthcare will have to encouraged along models of preventative care rather than the treatment of illness. There is likely to be double tsunami ahead hitting healthcare anyway post pandemic to cater for patients looking for solutions to neglected chronic problems requiring attention.
Now is the time that organisations including those in healthcare will need to ensure a balance of social value, well-being sustainability and employee engagement as much as profit and efficiency are the paradigm to measure success for people, organisations and nations that governments need to legislate into action.
An urgent international consensus similar to that of Bretton Woods Agreement in 1944 that established the financial paradigm after the second world war is necessary. Globalisation of sustainability, health and social value should be the core mission. World leaders must show responsible leadership that serves the interest of all legitimate stakeholders, the environment and the future.
Competing interests: No competing interests
Dear Editor
I have been thinking about the Covid 19 situation from a “what next” perspective.
The current lockdown will certainly have an effect and the effort put in by colleagues is commendable.
The current strategy of flattening the curve so that the NHS can cope, thereby giving patients a chance to be treated, caters to the immediate situation.
However, the lockdown cannot go on forever and cases will continue to occur, hopefully controlled by outbreak management and contact tracing.
In the absence of easy treatment and vaccine, and high fatality rates, I would like to suggest an idea:
This will ideally involve global participation and need international political consensus and leadership:
After a suitable pause in lockdowns, people Around the world should be given an opportunity to equip themselves with enough food and basic necessities in preparation for a planned global or at least multinational simultaneous lockdown for a period that will stop transmission (perhaps 4 to 6 weeks).
This could be followed by rigorous testing and surveillance.
The advantage of simultaneous global participation as early as possible is that it may result in elimination or certainly reduce incidence to more manageable levels. The advantage of doing it early is that it will also give the chance of preserving this year’s agricultural cycle with a view to avoiding food shortages next year both in the U.K. and other countries.
If global participation is not possible then even if a consortium of countries adopt this, then borders between these countries could be opened.
If internationally, the medical profession champions this idea, then there is just a chance we may have a good result. Simultaneous global lockdown has never been tried before but it would give the human race a fighting chance in the absence of other means.
Competing interests: No competing interests
Dear Editor
The BMJ invariably has a striking cover page. The 11th April edition was no exception.
The headline, “Covid 19 turning the world upside down”, shows a health professional wearing a face mask with an image of the world map upside down.
Or should I say, part of the world. In this case, New Zealand, is absent. I was bothered by this omission.
New Zealand has kept an enviably low rate of infectivity (1094 ) and deaths ( 11 ) at the time of writing.
It has also leapt to world news due to the recent heroics of Nurse Jennie who hailed from Invercargill in New Zealand. Our Jennie was lauded by Boris Johnson during his stay in Intensive Care. To the adoring throngs she simply said “I was just doing my job.”
Being a New Zealander, I am accustomed to seeing maps that neglect to show NZ.
We frequently feel excluded and often ridiculed, unless the conversation turns to rugby.
However distance and obscurity is maybe an advantage. Because of this, it’s heavy handed approach to completely eradicate Covid 19 appears successful so far. I fear though exclusion of a disease that the rest of the world are battling with, may not in time be practical once the borders re open.
I am sure the artist’s omission was an oversight, but maybe “being cut off from the beaten track” may have to apply for some time to keep New Zealand Covid free.
Dr Rina Mehrotra
Consultant Anaesthetist
Guys and St Thomas NHS Foundation Trust.
Competing interests: No competing interests
Dear Editor,
We appreciate and second the points discussed recently by Kickbusch I et al quoting, ‘If economies and social order collapse in South Asia, Africa, or Latin America, no border, wall, or boundary will be enough to contain the consequences’ and that ‘the global health must also be guided by Africa and Asia’ [1]. To further expand the concerns raised [1], we discuss and highlight the emerging scenario of Covid-19 in Pakistan.
The rising situation of Covid-19 in Pakistan, a South Asian country, is a matter of serious public health concern not only for the inhabitants of the country, but for the entire region and the world. Since the first imported case of Covid-19 in Karachi, Pakistan, contracted from Iran [2], the number of infections soared to over 7000 with 135 deaths in the five provinces and the capital territory of Islamabad (As of April 17, 2020) [3].
Inappropriate response of the authorities, coupled with non-serious and irresponsible behavior from the general public, resulted in the contraction and establishment of infection in Pakistan. Social settings, joint family systems and religious gatherings like congregational prayers particularly on every Friday further escalated the infection in Pakistan. Circulation of the SARS-CoV-2 virus in Pakistan is the biggest threat of international importance, due to many factors, directly and indirectly associated with the disease it causes; summary below.
First, with over 207 million inhabitants [4], distributed in five provinces (154 districts), and only 25 diagnostic laboratories [5] with limited capacity (84704 tests in total; 1700 tests per day on average) [3], the masses in Pakistan are becoming potential carriers, particularly owing to the asymptomatic transmission of infection [6]. As a result, the virus is spreading among the general public in Pakistan because of a lack of proper diagnosis and surveillance systems as directed by WHO [7]. Further, as it is a densely populated country with over 24% of people living below the poverty line [8], an allocation of low budget (only 2.5% of GDP on average) [9] and owing to the higher prevalence of other diseases along with injuries and road accidents, the health system in Pakistan is heavily laden already and will not be able to bear the brunt of Covid-19. Consequently, a large population of the country remains undiagnosed and untreated, paving the way for circulation and transmission of the virus en masse. This implies that the number of infected/carriers will be much higher than the current official version in Pakistan.
Second, a higher mortality rate due to Covid-19 has been observed in people with pre-existing medical conditions--as is the situation in Pakistan. Being the 5th highest in the world in tuberculosis with new cases emerging at a rate of 4.3%, 154 per million measles cases, endemic status of malaria, with 6% of the population carrying hepatitis C virus [10] along with ischemic heart diseases, cancers and lower respiratory infections (8% prevalence each) as the leading causes of deaths [11], Covid-19 may bring devastation beyond imagination in Pakistan.
Last but not least, Covid-19 should be controlled to keep the tally of deaths low before the onset of the time period of dengue outbreaks (52000 cases with 100 deaths in 2019 alone) [12]. This is usually the end of April to November each year.
In view of the factors mentioned above, it is highly probable that, on the one hand, Covid-19 can causes irreversible human losses and, on the other, the infection can evolve as endemic disease in Pakistan in the near future, without proper intervention. As a consequence, the world may plunge into a non-ending crisis that humanity has never faced before. Hence, a unified and consolidated approach from local and international authorities is the need of the hour in order to curtail the viral infection in Pakistan and prevent it from becoming an emerging epicenter for Covid-19 so as to safeguard humanity in the long run.
References
1. Kickbusch I, Leung GM, Bhutta ZA, et al. Covid-19: how a virus is turning the world upside down. BMJ 2020; doi: 10.1136/bmj.m1336
2. Pakistan reports first coronavirus case in Karachi, raising infected toll to two. https://www.thenews.com.pk/latest/620148-pakistan-confirms-first-case-of...
3. Government of Pakistan. Coronavirus in Pakistan. http://covid.gov.pk/ (Accessed April 17, 2020).
4. Pakistan bureau of statistics. Population Census. http://www.pbs.gov.pk/content/population-census (Accessed April 17, 2020).
5. List of laboratories performing Covid-19 tests. https://www.nih.org.pk/wp-content/uploads/2020/04/List-of-Laboratories.p... (Accessed April 17, 2020).
6. Rothe C, Schunk M, Sothmann P, et al. Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany. N. Engl. J. Med 2020; 382: 970-97
7. WHO coronavirus briefing. https://www.weforum.org/agenda/2020/03/testing-tracing-backbone-who-coro...
8. Asian Development Bank. Poverty Data: Pakistan. https://www.adb.org/countries/pakistan/poverty
9. Health spending as percent of GDP. https://www.theglobaleconomy.com/Pakistan/Health_spending_as_percent_of_...
10. WHO. Pakistan. Health Situation. https://apps.who.int/iris/bitstream/handle/10665/136607/ccsbrief_pak_en....
11. CDC. CDC in Pakistan, Factsheet. https://www.cdc.gov/globalhealth/countries/pakistan/pdf/pakistan.pdf
12. Pakistan continued to face double burden of diseases in 2019. https://www.thenews.com.pk/print/600903-pakistan-continued-to-face-doubl...
Competing interests: No competing interests
The ‘COVID-19 Pandemic’ is unquestionably a ‘COVID Phenomenon’ of the 21st Century: ‘Unprecedented Roaring Devastation’ on ‘Mankind’/ ‘Plethora of Potentially Sustainable Benefits’ for ‘Our Improved Common Humanity’ [1-10]. With the ‘Rapidly-Dynamically-Transmuting Scourge Variables’, the ‘COVID-19 Pandemic Literature’ MUST become even more ‘Rapidly-Dynamically Replete’ with ‘Evolving-Metamorphosing Informed Conversation’! The ‘COVID-19 Pandemic’, a ‘COVID Phenomenon’, is ‘BAD’ with ‘AVOIDABLE DOOM’ [1-7] but is equally ‘GOOD’ with ‘SUSTAINABLE BOOM’ [4,7-10]!! The ‘Pandemic’ is an ‘Infection’, albeit an ‘Infection with a Novel Coronavirus: ‘SARS-CoV-2’’ and ought to be ‘Approached’-‘Handled’ with the ‘Best Known Scientific Principles-Ethos’!!! The World is embarrassingly and disgustingly enmeshed in ‘AVOIDABLE POLITICS’ which is ‘SUBMERGING and ERODING’ the ‘KNOWN and TIME-TESTED PRINCIPLES-PILLARS’ of the ‘SCIENCE-FACTS-RESEARCH EVIDENCE’ deployed to unravel/ address such ‘Epidemics-Pandemics’; The World has a ‘Rich Armoury of Experience-Learnt Lessons’ [11,12]! Some argue that the World should have embraced ‘EVIDENCE-BASED MEDICINE’ in its ‘APPROACH’ to the ‘COVID-19 Pandemic’!!
‘Evidence-based Medicine’ sought, at the outset, the ‘Best Available Research Evidence (BARE)’ for the ‘Optimal Clinical Decision-making Process’ for the ‘Best Patient Care Outcomes’ virtually to the ‘Complete Exclusion’ of other ‘Equally Determinant Parameters’: ‘Expert Opinion-Clinical Expertise’, ‘Patient Values-Preferences’ etc [13]! Unfortunately, ‘Evidence-based Medicine Movement’ remains ‘Work in Progress’ with ‘Transmuting Concepts and Difficult Realities’ with ‘Robust Critical Conversations’ [14-17]!! The ‘COVID-19 Pandemic’ ignites a ‘Foundational Threat’ to ‘Evidence-based Medicine’ with the ‘Rapidly Ravaging Politics’ which ‘Launch Destructive Missiles’ at the ‘Science-Facts-Research Evidence’ of the ‘Raging Pandemic’!!
A ‘Tantalizing Teaser’ exposes some of the ‘Political Threats’ to the ‘Science-Facts-Research Evidence’ of ‘COVID-19 Pandemic’:
1. Source of the Novel Coronavirus: The ‘Novel Coronavirus’ was originally thought to be from Wuhan, China. Some suggest it was from outside China! Science is about ‘Facts’ and ‘Facts are ‘Sacred’! Not for ‘Politics’!!
2. Name of the Novel Coronavirus: ‘Politics-driven Work in Progress’ and still in a flux; ‘Wuhan Virus’, ‘Wuhan Coronavirus’, ‘China Coronavirus’, ‘China Virus’, ‘Chinese Virus’, ‘American Coronavirus’, ‘Virus of the COVID-19’, ‘COVID-19 Virus’, ‘2019-nCoV’, ‘nCoV-2019’, ‘SARS-CoV-2’, ‘Human Coronavirus 2019 (HCoV-19)’ etc [11, 18-21]!
3. Name of the Novel Coronavirus Disease: Equally still in a flux undermining ‘Best Practices’; ‘Kung-Flu’, ‘Coronavirus Disease 2019 (COVID-19)’ and variously documented as COVID-19, Covid-19, covid-19, Coronavirus (Covid-19), Corona Virus etc!
4. Disease Transmissibility-Modes of Transmission: With the documented ‘Genomic Diversity’-‘Viral Recombination Capacity’, the ‘Protean Transmission Modes’ should have been incontrovertibly addressed to avoid ‘Missed Opportunities’ in ‘Policing the Virus’!
5. Aerosolization/ Mask Use: The ‘Possible Aerosolization’ of ‘SARS-CoV-2’ implied ‘Probable Airborne Transmission’ for which the ‘Potential Role of Mask Use’ needed ‘Consideration-Exploration’ as a ‘Scientific Option’ but this was marred by ‘Politics’ of ‘Mask Production-Supplies-Distribution’ and ‘Critical Shortages’ where most ‘Critically Needed for Frontline Healthcare Staff’! The ‘Science of the Disease’ should hold sway rationally!!
6. Ventilator Production-Distribution: The ‘Politics’ encapsulating ‘Ventilator Production-Stockpiling’ is legion with resistance of the ‘Science-Facts-Logic-Evidence’!
7. Age Susceptibility-Critical Care Prioritization: The ‘Facts-Evidence’ for ‘Age-Susceptibility’ exist but the ‘Politics’ is begetting ‘Ethical Dilemmas’!
8. Mitigation Measures: There are ‘Time-tested Impactful Mitigation Interventions’ re: ‘Non-Pharmaceutical Measures’ including Social Distancing, Social Solidarity, Self-Isolation, Mass-Gatherings Restrictions, Country Lockdowns-Shutdowns, Shelter-in-Place etc! For ‘Political Considerations’, these ‘Impactful Measures Implementation’ defied known ‘Scientific Principles-Approaches’ in terms of Acceptance-Declaration, Extent, Duration, Precocious Relaxation-Reopening etc with implications for the ‘Epidemic Curve-Peak’!!
9. Vaccines Production-Trials: There are ‘Established Scientific Principles-Processes-Procedures’ for ‘Vaccines Production-Trials’ in ‘Phases’ lasting 12-18 months at the fastest! With ‘Politics’, there is intense ‘Performance Pressure’ to ‘Rapidly Conclude’ this ‘Vaccines Production Intervention’ with obvious implications!!
10. Drugs Production-Trials: Several drugs are touted for ‘Treatment Effectiveness’ against ‘COVID-19’ but the ‘Drugs Production-Trials’ are receiving the ‘Baptism of Politics’ with ‘Performance Pressure’ to possibly ‘Deliver without Best Scientific Principles-Practices’!
11. Screening-Test Kits: There has been monumental ‘Performance Pressure’ to flood the ‘Health Systems’ with these ‘Rapidly Developed-Produced-Supplied Screening Kits’ but huge problems of ‘Sensitivity’-‘Specificity’ remain a ‘Difficult Reality’!
12. ‘COVID-19 Pandemic Research’: Like never before, the ‘Scientific Research Process’ risks kowtowing to the ‘Politics Pressure-Manipulation’; The ‘Conceptualization-Conduct-Data Production-Publication-Dissemination’ are expected to ‘Receive Approval’ from ‘Political Authorities’! The ‘Best Available Research Evidence (BARE)’ can obviously not be ‘Sourced and Harvested’ in this ‘Politics-tinted Research Regime’!!
13. Information Communication-Infodemic: The ‘Science-Facts-Evidence’ are known but ‘Politics’ adds to ‘Dangerous Pandemic-Infodemic’!
One obvious ‘Potentially Sustainable Benefit’ of the ‘COVID-19 Pandemic’, ‘Beyond the 17 Integrated SDGs’8,9, is the imperative to have a ‘Critical Rethinking’ on the ‘Evidence-based Medicine Concept’ since what is expectedly considered as the ‘Best Available Research Evidence (BARE)’ can be a ‘Subject of Manipulation’: ‘Political Pressure’-‘Commercial Influence’-‘Conflicts of Interest’ etc! Other ‘Determinants’ that have been critically reported to ‘Alter or Modulate’ the ‘Best Available Research Evidence (BARE)’, most likely from ‘Systematic Reviews-Meta-Analyses (SRMA)’, include in addition to others: ‘Research Question’-‘Research Hypothesis’-‘Selection-Inclusion Criteria for Studies’-‘Forest Plot’ Issues: What are the ‘Evaluated Specifics’ regarding ‘Sensitivity-Heterogeneity-Publication Bias Analyses’ [17,22-24]? This is the imperative to ‘Rekindle’ the ‘Multiparameter-based Medicine (MBM)’ which facilitates the ‘Best Decision-making Process’ to be crystallized through the ‘Composite Consideration’ of ‘ALL Relevant Parameters’ (Previously ‘Circles of Influence’) taking cognizance of the ‘Best Available Research Evidence (BARE)’ but ALSO being aware that there may be ‘Other Compelling and Confounding Influence’ that may ‘Purposely Colour the Research Evidence’ [17]!
The ‘Relevant Parameters’ include: Initially the ‘Research Evidence’-‘Clinical Expertise’-‘Patient’s Preferences and Actions’-‘Clinical State and Circumstances’ and the ‘New Parameters’ of ‘Family Parameter’-‘Societal Parameter’-‘Cultural-Traditional Parameter’-‘Resources Availability Parameter’! With the ‘COVID-19 Pandemic’, an additional ‘Politics Parameter’ may be included in the ‘Multiparameter-based Medicine (MBM) Model’!! The various possible ‘Parameters’ represent ‘Forms of Evidence’!!! The ‘Best Available Research Evidence (BARE)’ can no longer be the ‘SOLE DETERMINANT’ of ‘Critical Decision-making Process’ as it is not ‘Immunized’ against ‘Commercial Influence’-‘Political Considerations-Manipulations’-‘Conflicts of Interest’ etc [25,26]!
With the ‘Evidence-based Medicine (EBM) Movement’ as continued ‘Work in Progress’, the World is in a flux regarding ‘Best Decision-making Process’ but the ‘COVID-19 Pandemic’ brings to the fore, once again, the imperative to embrace the ‘Multiparameter-based Medicine (MBM) [17]!
REFERENCES
1. Godlee F. COVID-19: Weathering the storm. BMJ 2020; 368:m1199 of 26th March 2020
2. Eregie C.O. COVID-19 Pandemic: The difficult unresolved increasing challenges in weathering the storm. https://www.bmj.com/content/368/bmj.m1199/rr-10 of 31st March 2020
3. Eregie C.O. COVID-19 Pandemic: Still on the difficult unresolved increasing challenges in weathering the storm. https://www.bmj.com/content/368/bmj.m1199/rr-13 of 2nd April 2020
4. Kickbusch I, Leung GM, Bhutta ZA, Matsoso MP, Ihekweazu C, Abbasi K. Covid-19: how a virus is turning the world upside down. BMJ 2020; 369:m1336 of 3rd April 2020
5. Eregie C.O. COVID-19 Pandemic: Further perspectives on the difficult unresolved increasing challenges in weathering the storm. https://www.bmj.com/content/368/bmj.m1199/rr-16 of 5th April 2020
6. Eregie C.O. COVID-19 Pandemic: The daunting challenges of assuring sustainable benefits from weathering the storm. https://www.bmj.com/content/368/bmj.m1199/rr-14 of 8th April 2020
7. Eregie C. O. COVID Phenomenon: An innovative conceptual coinage in human development and sustainable development in the 21st Century. https://www.bmj.com/content/368/bmj.m1199/rr-17 of 9th April 2020
8. Eregie C.O. Breastfeeding and ‘COVID Phenomenon’: Demystifying the innovative conceptual coinage in human development and sustainable development. https://www.bmj.com/content/369/bmj.m1336/rr-14 of 12th April 2020
9. Eregie C.O. Still on COVID-19 Pandemic as a ‘COVID Phenomenon’: beyond the impact on the goals of sustainable development. https://www.bmj.com/content/369/bmj.m1336/rr-16 of 14th April 2020
10. Eregie C.O. COVID-19 Pandemic, ‘COVID Phenomenon’ and appropriate assessment of nations: rekindling the imperative of the ‘Eregie Performance Gap Index (e-PGI)’ as a Development Ranking Tool (DRT). https://www.bmj.com/content/369/bmj.m1336/rr-19 of 15th April 2020
11. WHO. Disease Outbreaks. https://www.who.int/emergencies/disease/en of 12th February 2020
12. COVID-19: Lessons and Recommendations. www.isglobal.org/coronavirus of 12th March 2020
13. Evidence-based Medicine Working Group. Evidence-based Medicine: A new approach to teaching practice of medicine. JAMA 1992; 268 (17):2420-2425
14. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence-based Medicine: What it is and what it isn’t. BMJ 1996; 312:71-72
15. Haynes BR, Devereaux PJ, Guyatt GH. Clinical expertise in the era of evidence-based medicine and patient choice. BMJ 2002; 7:36-38
16. Forsyth S. What is opinion and what is evidence? BMJ 2019; 366:l5395 of 13th September 2019
17. Eregie CO. Beyond Evidence-based Medicine (EBM) as ‘Work In Progress’: An Innovative Proposal for ‘Multiparameter-based Medicine (MBM)’. https://www.bmj.com/content/366/bmj.l5395/rr of 4th October 2019
18. Zhu N, Zhang D, Wang W et al. A novel coronavirus from patients with pneumonia in China, 2019. N Eng J Med DOI:10.1056/NEJMMoa2001017 of 24th January 2020
19. Gorbalenya AE, Baker SC, Bric RS et al. Severe ARS-related Coronavirus: the species and its viruses- a statement of the Coronavirus Study Group. BioRxxiv 2020 DOI:2020.02.07.937862 of 11th February 2020
20. Jang S, Shi Z, Shu Y et al. A distinct name is needed for the new coronavirus. Lancet 2020; 395:949
21. Wu Y, Ho W, Huang Y et la. SARS-CoV-2 is an appropriate name for the new coronavirus. Lancet 2020; 395:949-950
22. Higgins JPT, Green S editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.2 (Updated September 2009). The Cochrane Collaboration; 2009. Available from www.cochrane-handbook.org
23. Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group Preferred Reporting Items for Systematic Reviews and Meta-analyses: The PRISMA Statement. J Clin Epidemiol 2009; 62:1006-1012
24. Haidich AB. Meta-analysis in medical research. Hippokratia 2010; 14 (Suppl 1):29-37
25. Eregie CO. Research Evidence as the Sine Qua Non for Evidence-based Medicine (EBM) as ‘Work In Progress’: How Justified? https://www.bmj.com/content/366/bmj.l5395/rr-0 of 6th October 2019
26. Eregie C.O. ‘Commercial influence and conflicts of interest on research evidence, medical education and patient care: Rekindling the imperative for transparency independence with medical socioeconosophy (MSE) and multiparameter-based medicine (MBM). https://www.bmj.com/content/368/bmj.m471/rr of 12th February 2020
Professor Charles Osayande Eregie,
MBBS, FWACP, FMCPaed, FRCPCH (UK), Cert. ORT (Oxford), MSc (Religious Education),
Professor of Child Health and Neonatology, University of Benin, Benin City, Nigeria and
Consultant Paediatrician and Neonatologist, University of Benin Teaching Hospital, Benin City, Nigeria.
UNICEF-Trained BFHI Master Trainer and ICDC-Trained in Code Implementation.
*Technical Expert/ Consultant on the FMOH-UNICEF-NAFDAC Code Implementation Project in Nigeria.
*No Competing Interests.
Competing interests: No competing interests
Beyond the ‘Unprecedented Devastating Havoc’ wreaked on its trail, the ‘COVID-19 Pandemic’ has also brought ‘Illumination’ to the ‘Development Trajectory’ for ‘Our Common Humanity’ [1-4]! The ‘Pandemic’ is disposed as a ‘COVID Phenomenon’: Impacting ‘Virtually ALL Aspects of Human Existence-Development’ denominated verifiably in ‘ALL 17 Integrated SDGs’ [3,4]! The ‘COVID Phenomenon’ of the ‘COVID-19 Pandemic’ has also been indelibly denominated in some ‘Other Aspects of Human Existence-Development ‘Beyond the 17 SDGs’’ [5]!!
One of the ‘Positives’-‘Benefits’ of ‘COVID-19 Pandemic’ is that ‘Governments’-‘Country Leaderships’ are being held ‘Accountable’ re: Their ‘Pandemic Response’ using the ‘Comparative Asian-African Performance Signposts’ [1]. This is another ‘Aspect of Human Existence-Development ‘Beyond the SDGs’’ [5]. This, indeed, is a ‘Positive’-‘Benefit’ of the ‘COVID-19 Pandemic’; An ‘Imperative for Sustainable Development’: ‘Government-Governance-Accountability-Assessment’! There are several ‘World Development Ranking Metrics’ and these have been variously reviewed and criticized in previous Presentations-Publications [6-16]! With the ‘COVID-19 Pandemic’ disposing ‘Benefits for Our Common Humanity’ [1-5], the World is, once again, reminded of the ‘Followership Imperative’ to hold ‘World Governments-Leaderships’ to ‘Accountability’ [1]! As a ‘COVID Phenomenon’, the ‘Pandemic’ brings to the fore the ‘Compelling Issues’ of ‘Good Governance’!! Not all ‘Development Ranking Metrics’ are ‘Good Governance Assessment-compliant’ [16]! This is the imperative to ‘Rekindle’ an ‘Innovative Development Ranking Tool (DRT)’: ‘Eregie Performance Gap Index (e-PGI)’!!
A ‘Tantalizing Teaser’ on some ‘Extant DRTs’ disposes ‘Single-Domain Tools’ and ‘Multi-Domain Tools’!
Some ‘Single-Domain Single-Indicator Tools’ include:
1. Income Domain: Gross Domestic Product (GDP), Gross National Income Per Capita (GNI/pc), Gini Index, Population below International Poverty Line (IPL)
2. Health Domain: Infant Mortality Rate, Under-Fives Mortality Rate, Maternal Mortality Ratio, Life Expectancy, Population using Improved Drinking Water Sources
3. Education Domain: Adult Literacy Ratio, Population with at least Secondary Education, Gross Primary Enrolment Ratio
4. Environment Domain: Primary Energy Supply (Renewables), Emission Per Capita (CO2)
5. Innovation and Technology Domain: Research and Development Expenditure, Patents granted to Residents and Non-Residents
The ‘Multi-Domain Tools’ include:
1. Human Development Index (HDI): Life Expectancy, Education Index, Income Index
2. Inequality-adjusted HDI (IHDI): Life Expectancy, Education Index, Income Index with Adjustments for Dimensional Inequalities
3. Gender Inequality Index (GII): Reproductive Health, Empowerment, Labour Market; Women and Men Differences
4. Multi-dimensional Poverty Index (MPI): Deprivations in Health, Education and Income (Living Standards)
5. Corruption Perception Index (CPI): Bribery of Public Officials, Kickbacks in Public Procurements, Embezzlement of Public Funds, Effectiveness of Public Sector Anti-Corruption Efforts
6. World Governance Index (WGI): Voice and Accountability, Political Stability and Absence of Violence/ Terrorism, Government Effectiveness, Regulatory Control, Rule of Law and Control of Corruption
7. Open Budget Index (OBI): Openness, Transparency and Budget Implementation
8. Global Competitiveness Index (GCI): Institutions, Infrastructure, Macroeconomic Environment/ Framework, Health and Primary Education, Higher Education and Training, Efficient Goods Market, Efficient Labour Markets, Developed Financial Markets, Harnessing Benefits of Existing Technologies, Domestic and International Market Size, Sophisticated Production Processes, Innovation
9. Mo Ibrahim Index (MII): Safety and Rule of Law, Participation and Human Rights, Sustainable Economic Opportunity and Human Development
10. Eregie Performance Gap Index (e-PGI): Resource Endowment and Generation, Leadership, Followership, Corruption Level, Electoral Credibility, Mortality of Women and Children, Inequalities and Sustainable Development.
Of the various ‘DRTs’, the ‘Eregie Performance Gap Index (e-PGI)’ has several ‘Governance-related Domains’ and relatively more manageable ‘Included Indicators’ possibly making it comparatively superior to other ‘Development Metrics’ [16]! The ‘Government-Governance Concept’ reflects the process of using the ‘Entrusted People Power-Authority’ to ‘Manage Transparently Public Resources’ for the ‘Common Good’ of the ‘Majority of the People’ [17-19]. Additionally, ‘Good Governance’ includes ‘Origin and Mechanism of Change of Government’ [16,18,19]! The ‘Performance Concept’ concerns utilizing ‘Available Resources’ to ‘Efficiently and Effectively Achieve’ the ‘Set Governance Goals’ [17-19]! The ‘Performance Gap Concept’ was popularized by UNICEF20 and extrapolated to develop the ‘e-PGI’ [16]!! To optimize the ‘Government-Governance Benefit’ of the ‘COVID-19 Pandemic’ towards galvanizing ‘Our Improved Common Humanity’ and ‘Sustainable Development’ through ‘Good Governance’, the ‘e-PGI’ should be ‘Rekindled’ for a better ‘Understanding and Universal Application’ so that the ‘Pandemic’ will leave an ‘Indelibly Amplified Human Development Positive’ in its trail [1,16-19]!!
A ‘Tantalizing Teaser’ on the ‘e-PGI’ disposes its ‘Included Indicators’ for the ‘8 Computed Domains’*:
1. Resource Endowment and Generation (REG): GDP, GDP Per Capita
2. Leadership (Bad Insensitive Leadership with Budgetary Indiscipline (BILBI)): Government Policies Sensitive to Security and Welfare of all Citizens, Government upholds Rule of Law and Constitutionality, Budget Appropriation Becomes Law, Preceding Year or Mid-Year Budget Openness, Transparency and Implementation; % GDP Expenditure on Research and Development, Patents Granted to Residents and Non-Residents, FDI (Net Inflows) % GDP
3. Followership (Followership with Responsible Constitutional Expectation (FRCE)): Government held Accountable by Citizens/ Legislature, Confidence Vote on Government by Citizens/ Legislature, Voice and Accountability
4. Corruption Level (C): Corruption Perception Index by Transparency International
5. Electoral Credibility (K): Electoral Credibility and Government Change/ Stability
6. Mortality of Women and Children (M): U5MR and MMR
7. Inequalities (Q): Gini Index, Gender Inequality Index
8. Sustainable Development (S): Renewable Energy (% Energy Supply), Total Dependency Ratio on Ages 15-64 years, CO2 Emissions
*The ‘Included Indicators’ are bifid: Those ‘Developed’ by this ‘Author’ and those ‘Adopted**, Adapted, Classified-Scored and Infused’ into the ‘Computational Equation’!
The ‘Computational Equation’ for the ‘e-PGI’ is 2-Staged: Computation of the ‘Performance Gap Score (PGS)’ and the ‘Transformation of the PGS to an ‘Index’ (e-PGI)’ vide infra:
PGS = - (BILBI/ FRCE) REG + (C + K +M + Q + S);
e-PGI = |(PGS –WPS/ BPS – WPS)|; range is ‘0 to 1’;
WPS = Worst Possible Score, BPS = Best Possible Score Note: positive and negative signs are not considered in the ‘Absolute’ Mathematical Operation.
This ‘Communication’ disposes a ‘Positive-Benefit’ of the ‘Ravaging and Devastating COVID-19 Pandemic’ in the ‘Aspect of Human Existence-Development’: ‘Government-Governance Sphere’! The ‘Citizenry’ should now hold ‘Governments-Leaderships’ to be ‘Accountable’ in their ‘COVID-19 Pandemic Response’ situate with ‘Good Governance Principles’!! The ‘Eregie Performance Gap Index (e-PGI)’ is disposed as a ‘DRT’ for ‘Comparative Performance Assessment’ of ‘Governments-Leaderships’ in this era of the ‘Pandemic’ which is a ‘COVID Phenomenon’!!!
REFERENCES
1. Kickbusch I, Leung GM, Bhutta ZA, Matsoso MP, Ihekweazu C, Abbasi K. Covid-19: how a virus is turning the world upside down. BMJ 2020; 369:m1336 of 3rd April 2020
2. Eregie C.O. COVID-19 Pandemic: The daunting challenges of assuring sustainable benefits from weathering the storm. https://www.bmj.com/content/368/bmj.m1199/rr-14 of 8th April 2020
3. Eregie C. O. COVID Phenomenon: An innovative conceptual coinage in human development and sustainable development in the 21st Century. https://www.bmj.com/content/368/bmj.m1199/rr-17 of 9th April 2020
4. Eregie C.O. Breastfeeding and ‘COVID Phenomenon’: Demystifying the innovative conceptual coinage in human development and sustainable development. https://www.bmj.com/content/369/bmj.m1336/rr-14 of 12th April 2020
5. Eregie C.O. Still on COVID Pandemic as a ‘COVID Phenomenon’: beyond the impact on the goals of sustainable development. https://www.bmj.com/content/369/bmj.m1336/rr-16 of 14th April 2020
6. McGillivray, Mark. The human development index: yet another redundant composite development indicator?. World Development 19 (10) (1991): 1461–1468..
7. Sala-i-Martin, Xavier and Artadi, Elsa V., The Global Competitiveness Index, Global Competitiveness Report, Global Economic Forum 2004
8. McGillivray, Mark; White, Howard Measuring development? The UNDP's human development index. Journal of International Development 5 (2) (2006): 183–192.
9. International Budget Partnerships. Annual Report . Centre on Budget and Policy Priorities. Centre,cbpp.org. 2010
10. Eregie, Charles O. TEA TRIAD-compliant Technology in Health and Development. Paper presented at the World Forum, American Biographical Institute and International Biographical Centre, San Francisco, California, United States of America, 30th June 2011.
11. Wikipedia. Human Development Index. Wikipedia.com, Wikipedia, the free encyclopedia .htm. 2011
12. Eregie, Charles O. Eregie Performance Gap Index (e-PGI): An Innovative Computed Multi-domain Comparative Tool for Development Ranking and Resource Utilization. Paper presented at the Institute Monthly Seminar, Institute of Child Health, University of Benin, 30th May 2013.
13. HDR 2013 United Nations Development Programme. Human Development Report 2013. The Rise of the South: Human Progress in a Diverse World. UNDP. New York, USA. 2013
14. Schwab, Klaus. The Global Competitiveness Report 2012-2013. 1-527, Geneva, Switzerland, World Economic Forum.2013
15. Wikipedia. Mo Ibrahim Index of African Governance. Wikipedia.com, Wikipedia, the free encyclopedia.htm. 2013
16. Eregie C.O. Eregie Performance Gap Index (e-PGI): An Innovative Computed Multi-domain Tool For Development Ranking Of Nations Based On Resource Utilization For Sustainable Development. Forum on Public Policy 2014; http//forumonpublicpolicy.com/Vol2014no1Health/Eregie.pdf
17. Eregie, Charles O. The Impact of Good Leadership/ Policy on Child Health in Africa. Paper presented at Vision Africa Merit Award. Johannesburg, South Africa. November 2007
18. Odion-Akhaine, Sylvester. The Political Economy of Good Governance and Transparency. Lagos: Spectrum Book Ltd. 2008.
19. Ozekhome, Mike A. Good Governance in Sub-Saharan Africa: A recipe for poverty reduction and development. Paper presented at the World Forum, Cambridge, USA. 28th June -3rd July 2013.
20. UNICEF. Progress of Nations. New York. 1996.
**’Rule of Law’ and ‘Voice and Accountability’ from World Governance Indicators (Kaufmann, D., Kraay, A., and Mastruzzi, M. The Worldwide Governance Indicators Project: Answering the Critics. World Bank Policy Research Working Paper [Kaufmann, Kraay, Mastruzzi 2003]. 2007.
Open Budget Index from International Budget Partnership 2010
Professor Charles Osayande Eregie,
MBBS, FWACP, FMCPaed, FRCPCH (UK), Cert. ORT (Oxford), MSc (Religious Education),
Professor of Child Health and Neonatology, University of Benin, Benin City, Nigeria and
Consultant Paediatrician and Neonatologist, University of Benin Teaching Hospital, Benin City, Nigeria.
UNICEF-Trained BFHI Master Trainer and ICDC-Trained in Code Implementation.
*Technical Expert/ Consultant on the FMOH-UNICEF-NAFDAC Code Implementation Project in Nigeria.
*No Competing Interests.
Competing interests: No competing interests
Dear Editor
Mawson, Craft and Gonzales construct a very plausible hypothesis.
Could it be put to practical use?
I see nothing remotely risky.
I seem to recall from my memory of the Physiology books of the dim distant past that hunters in the frozen tundras who were ignorant of the dangers of eating the liver of the bear, reportedly suffered from hypervitaminosis A.
It was also believed in those days, that Vitamin D (I forget which variety) taken by mouth countered Vitamin A. However, Vitamin D produced in the skin was not antagonistic to Vitamin A.
I would appreciate if someone could correct my beliefs - if they are false?
Thank you.
Competing interests: Elderly. Perhaps “false memories”?
A cartoon picture circulating in the Greek social media depicts the following scene: in the centre there is a scientist looking through his microscope, while religious leaders are standing next to him in profound anxiety. One of them cries out: ‘please son, please hurry, we need to tell the flock that our prayers have been heard.’
In the past few weeks we have come across unprecedented uncertainty and fear. Our sense of being safe and healthy has been lost, given that the endpoint of the COVID-19 pandemic is unknown, and treatment is not in sight. We need comfort and solace; and religious faith is what a lot of people rely on in circumstances like this (1).
So, why does God ‘allow’ this pain? A lot of people are sick and die. A lot of people have already died (2). Why does it seem that God is not intervening to outwardly stop the pandemic? These are the silent (and sometimes not so silent) thoughts of many people during these past few weeks in Greece, a country where religion still plays a significant role in public discourse, with Greeks being the most devout believers in Western Europe (3).
What is the Greek church’s position in all this? Its stance so far has caused a lot of controversy. Initially, the ruling body of the Greek church (alongside some scientists) declared that the virus is not transmitted through Holy Communion, during which worshippers sip from the same spoon(4). The religious temples did not close down despite increasing fears of the virus being transmitted in confined spaces, until the government forced the Greek church leadership to do so.
Instead, people are tuning on their TVs at 6pm every day to hear Professor Tsiodras, the infectious disease specialist and head of the National COVID-19 Scientific Committee. His calm voice, his resilient demeanour and his insistence on an evidence-based approach has gained the trust of the vast majority of the population (5). Greece, compared to most countries, even the most developed ones, has been doing relatively well in this crisis (6), which has increased public trust in the scientific approach .
It has become clear that COVID-19 does not discriminate; it affects everyone regardless of beliefs, social class, skin colour. Believers and atheists run the same risk. Faith does not protect; religious leaders and religious believers seem to be as helpless as everyone.
Facing a biothreat of this scale has pressured people to evaluate and compare what is helpful and what is not as a coping strategy during this physical and psychologically challenging crisis. People need explanations and seek answers, which divine preaches may not satisfy. The scientific announcements and recommendations help them understand what is happening and how to best deal with it. Faith is working in tandem with science; and, symbolically, the health response against this unprecedented catastrophe is defined by science leading the way. Τrust – and faith - in science is at an all-time high, and this can only be a good thing.
References
1. Grabenstein JD. What the World’s religions teach, applied to vaccines and immune globulins. Vaccine [Internet]. 2013 Apr;31(16):2011–23. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0264410X13001898
2. Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU) [Internet]. 2020 [cited 2020 Apr 11]. Available from: https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd4029942...
3. Fouka G, Plakas S, Taket A, Boudioni M, Dandoulakis M. Health-related religious rituals of the Greek Orthodox Church: their uptake and meanings. J Nurs Manag [Internet]. 2012 Dec;20(8):1058–68. Available from: http://doi.wiley.com/10.1111/jonm.12024
4. Reuters. In era of coronavirus, Greek church says Holy Communion will carry on [Internet]. 2020 [cited 2020 Apr 12]. Available from: https://www.reuters.com/article/us-health-coronavirus-greece-church/in-e...
5. Matina Stevis-Gridneff. The Rising Heroes of the Coronavirus Era? Nations’ Top Scientists [Internet]. The New York Times. 2020 [cited 2020 Apr 13]. Available from: https://www.nytimes.com/2020/04/05/world/europe/scientists-coronavirus-h...
6. Bloomberg Opinion. https://www.bloomberg.com/opinion/articles/2020-04-10/greece-handled-cor... [Internet]. 2020 [cited 2020 Apr 12]. Available from: https://www.bloomberg.com/opinion/articles/2020-04-10/greece-handled-cor...
Competing interests: No competing interests
Lockdowns: Towards a Nuanced View
Dear Editor
Lockdowns across the world have the potential to do more harm than good. Well-meaning policies from Geneva may not be as applicable to lower-resourced countries.
734 million people live on less than $2 per day. (1) The median household income across the world is less than $10,000. (2) There are dozens of countries across the world which have no critical care facilities; many others have limited or poor quality equipment, few trained staff, and no realistic possibility of acquiring such facilities.(3) If someone contracts severe COVID19, they will not be able to afford several weeks in an ICU, even if they belong to one of the fortunate new global “middle classes”. Even in economically developed countries, Level-3 care is not affordable for most; only in those countries with a national health system or good medical insurance schemes have patients hope of acquiring ICU care. Even before the pandemic, most countries were not in a position to rapidly increase hospital capacity in a crisis. The latter is now compounded by worsening economic recessions; rapid price inflation of medical equipment; large scale procurement of medical equipment by richer governments; healthcare staff becoming sick or refusing labour due to safety issues; and no effective, coordinated strategies or funding from IGOs, NGOs or individual national governments. The rationale for lockdown, to buy time to increase healthcare capacity, is not valid for most of the world.
What does lockdown mean across the world? In Cairo, lockdown means not leaving the house on Friday or Saturday, or at night; otherwise it’s ok. In Atlanta, lockdown means that one can still get tattoos completed because it is considered an essential service. Even in enlightened Germany and the UK, to help pick the harvest governments can relax rules on lockdown to transport workers from Eastern Europe in their hundreds on packed busses or aeroplanes. For the majority of the world, in dense urban settings like slums (where 100,000 can easily live in the same square mile) and rural villages (where sanitation is already a premium, open air toilets are the norm) staying home cannot prevent the virus from spreading. Lockdown means little in Khayelitsha.
If British workers who are unable to work have not already been furloughed, then the vast majority can fall back on the benefit system. But for most people in the world, if you do not work, you do not get paid; if you do not get paid, you cannot feed your family. Food insecurity is real for those who do not live in the West’s socio-economic bubble. Because of the lockdown, food supply chains have become more precarious. Whereas in the UK this might mean limited food choices, in poorer countries it can lead to starvation. As people cannot grow or harvest food because of lockdowns, almost a billion people across the world are facing a decrease in calorific intake or outright famine. (4) Malnutrition and starvation due to lockdowns may kill more people than the pandemic.
Furthermore, water scarcity is also worsened by lack of machinery to maintain pumps and to transport water; and lack of clean water for sanitation exacerbates all communicable diseases. In an informal economy, needing to work every day to feed one’s family remains the priority, and impeding economic activity rapidly becomes disastrous. If someone’s family is starving because of denial to work, it is understandable that they are not going to stay at home and listen to official government advice - they are going to get on their bike and go out to find work: the threat of a possible ‘virus from China’ is not going to be at the forefront of the mind. When states have limited budgets and capacity to support their locked-down populations, lockdowns result in widespread starvation and civil unrest. And all the while, the poorer countries' debt burden (with its implications for long-term health outcomes) increases.
As with any national emergency, governments are using fear to roll out executive powers to restrict populations. Minorities, already facing discrimination and oppression, are being scapegoated as the locus of infection. Freedom of expression is being curtailed. Government surveillance and information control has intensified. Rule by diktat is becoming normalised. People are being arbitrarily arrested, fined or imprisoned, even executed, on the pretext of public health. Populations are in effect imprisoned in their own homes.
Lockdowns don’t work if people aren’t locked down. People will not be able to tolerate being shut in their houses for long periods. With economic imperatives, ignorance and misinformation surrounding the virus, people will flout the lockdown.
A more nuanced approach to lockdown and social distancing is required across the world.
1 https://www.worldbank.org/en/topic/poverty/overview
2 https://news.gallup.com/poll/166211/worldwide-median-household-income-00...
3 Winter T. Critical care in low-income countries. Trop Med and Int Health February 2009
4 https://www.wfp.org/news/wfp-chief-warns-hunger-pandemic-covid-19-spread...
Competing interests: No competing interests