Mitigating the wider health effects of covid-19 pandemic response
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1557 (Published 27 April 2020) Cite this as: BMJ 2020;369:m1557Read our latest coverage of the coronavirus pandemic

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Dear Editor,
COVID-19: The interruption of supportive accommodation would place the temporarily housed homeless at higher risk
As the UK continues to face the COVID-19 pandemic, the country faces a crisis with infection in the hospital and care home1, but other people in a vulnerable position such as the homeless are also at great danger. Most homeless have been housed in hotels, but now that the UK is over the first wave peak, the homeless might be sent back to the street.
The situation is a matter of public health. The number of people experiencing homelessness in the UK has significantly increased since 2010. In 2018, 4677 people in England were estimated to be sleeping rough, a worrying increase from 1768 in 20102. Homelessness can be understood as a moment of extreme crisis for individuals and families. It is also associated with deep social exclusion and profound health inequalities3.
Diabetes has been reported to be an epidemiological and clinical risk factor for mortality4. It has been reported that a quarter of Covid-19 deaths in English hospitals were of diabetics5. Reports from intensive care doctors that many of the coronavirus patients they have been treating during the pandemic had underlying diabetes. The importance of protecting the homeless is evident. Health-related quality of life and prevalence of six chronic diseases (Chronic diseases were self-reported asthma, chronic obstructive pulmonary disease (COPD), epilepsy, heart problems, stroke and diabetes) in homeless and housed people was measured to compare health-related quality of life and prevalence of chronic diseases in-housed and homeless populations6. While differences in health between housed and homeless people are better understood as a ‘cliff’.
The prevalence of diabetes in homeless people may be slightly higher (6.2% compared with 4.2% in the general population7). Namely, glucose levels may be higher in homeless people8. Epidemiologically and clinically, Homeless people are in a vulnerable position. The average age of death for homeless people is just 47 years old, while the average life expectancy for the general population is 77 years old9-10. Homeless people are eight times more likely to suffer from mental health problems and 35 times more likely to commit suicide10. In 2018-19, rough sleeping in London reached an all-time high of 8,855. Namely, it represents an annual increase of 18 per cent and the 8.855, 5,529 were new rough sleepers with more than a third of whom had lost private rented accommodation11.
From a public health perspective regarding the homelessness population, a UK change in policy response to the COVID-19 pandemic of keeping the homeless in accommodation would be a risk. Modelling by University College London found that placing vulnerable groups in hotels was also significantly more cost-effective than treating individuals in hospital12. In a 'do nothing' scenario, it is estimated that 34% of the homeless population could get COVID-19 in a six months period, with 364 deaths, 4,074 hospital admissions and 572 critical care admissions13. The interruption of supportive accommodation would negatively impact the homeless population during the COVID-19 pandemic by placing the temporarily housed homeless at higher risk.
1 Thorlby, R. Tinson, Joshua Kraindler, (2020) J. COVID-19: Five dimensions of impact https://www.health.org.uk/news-and-comment/blogs/covid-19-five-dimension... Date: Apr 29, 2020 Date accessed: May 15, 2020
2 UK Ministry of Housing Communities & Local Government Rough sleeping statistics: autumn 2018, England (revised). https://assets.publishing.service.gov.uk/government/uploads/system/uploa... Date: Feb 25, 2019 Date accessed: May 15, 2020
3 De Oliveira, B. (2018) On the news today: challenging homelessness through participatory action research, HOUSING, CARE AND SUPPORT, Vol. 21(1) pp. 13-25.
4 Zhou, F., Yu, T., Du, R., Fan, G., Liu, Y., Liu, Z., ... & Guan, L. (2020). Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The lancet.
5 Campbell, D. (2020) Quarter of Covid-19 deaths in English hospitals were of diabetics https://www.theguardian.com/world/2020/may/14/one-in-four-people-who-die... Date: Apr 29, 2020 Date accessed: May 14, 2020
6 Lewer, D., Aldridge, R. W., Menezes, D., Sawyer, C., Zaninotto, P., Dedicoat, M., ... & Story, A. (2019). Health-related quality of life and prevalence of six chronic diseases in homeless and housed people: a cross-sectional study in London and Birmingham, England. BMJ open, 9(4), e025192.
7 Arnaud A, Fagot-Campagna A, Reach G et al (2009) Prevalence and characteristics of diabetes among homeless people attending shelters in Paris, France, 2006. Eur J Public Health 20: 601–3
8 McCary J (2005) Health, housing and the heart cardiovascular disparities in homeless people. Circulation 111: 2629–35
9 Breese, J. & Feltey, K. (1996) The Exit from home to homelessness. Free Inquiry in Creative Sociology, 24. 67-76.
10 Burki, T. (2010), “Tackling tuberculosis in London’s homeless population”, The Lancet, Vol. 376 No. 9758, pp. 2055-56.
11 CHAIN, (2019) CHAIN ANNUAL REPORT GREATER LONDON APRIL 2018 - MARCH 2019 https://airdrive-secure.s3-eu-west-1.amazonaws.com/london/dataset/chain-... Date accessed: May 14, 2020
12 UCL COVID-19 Public Engagement and Advice https://www.ucl.ac.uk/global-health/covid-19
13 Lewer, D., Braithwaite, I., Bullock, M., Eyre, M. T., & Aldridge, R. W. (2020). COVID-19 and homelessness in England: a modelling study of the COVID-19 pandemic among people experiencing homelessness, and the impact of a residential intervention to isolate vulnerable people and care for people with symptoms. medRxiv.
Competing interests: No competing interests
Dear Editor
Douglas M. et al correctly suggest that refugees, asylum seekers and migrants are more vulnerable to epidemics.(1) Social distancing in overcrowded places where they commonly reside is in most cases impossible, while early detection of infected individuals is difficult due to the exclusion of these population groups from national health coverage schemes and healthcare services. Local outbreaks among displaced population groups living under these conditions are expected during epidemics, outbreaks that in many cases might go unchecked or even concealed.(2)
During the Covid-19 pandemic WHO, UNHCR and IOM have repeatedly recommended that national healthcare plans and disease surveillance systems should integrate all refugees/migrants. Concrete decongestion plans of camps or reception centers need to be prioritized, while most vulnerable displaced individuals need to be immediately released from places of detention and moved to safe accommodation.(2),(3)
In Greece more than 60,000 refugees and migrants reside in 36 reception centers and camps, most of which run beyond their capacity, overcrowded, lacking basic infrastructure and offering poor hygiene living conditions, ideal environments for the spreading of SARS-CoV2.4 Early calls from Civil Society Organisations for the immediate decongestion of these camps have remained unresponded to by the Greek authorities.(4)
From February 23rd (3 days before the onset of the Covid-19 epidemic in Greece) the operating epidemiological surveillance system in these 36 points of care for refugees/migrants has been interrupted and weekly disease reports are no longer publicized in the National Public Health Organisation’s website.(5)
From April 2nd to April 21st (6th to 9th week of the Covid-19 epidemic in Greece) three cases of local outbreaks in refugee camps and reception centers in Greek mainland have occured,(6) in all cases detection of Covid-19 clusters was accidental and late.
Planning and management of covid-19 cases in refugee/asylum seekers/migrant camps remains under the jurisdiction of the Greek Ministry of Migration and Asylum instead of the Ministry of Health. Early on, and lacking any evidence, refugees/migrants were stigmatized by government authorities as possible carriers of SARS-CoV2, increasing public hostility and paving the way for the ongoing operational plan, that foresees the preventive lockdown of all refugee/migrant camps in Greece and the onsite quarantine and self-isolation of any confirmed or suspected cases, offering limited only access to clinical services.
The early introduction of non-pharmaceutical interventions has successfully delayed and controlled the first wave of the Covid-19 epidemic for the time being in Greece.(6) Immediate decongestion of refugee camps, full integration of refugee care in the national healthcare plan, and effective epidemiological surveillance and contact tracing systems for the entire population (including displaced population groups) are public-health prerequisites for sustaining this success.
Declaration of conflicts of interest: all authors (EK, KP, AV, CP, AB) declare that have no conflicts of interest
References:
(1). Douglas M, Katikireddi SV, Taulbut M, McKee M, McCartney G. Mitigating the wider health effects of covid-19 pandemic response. BMJ. 2020;m1557.
(2). World Health Organization. Interim guidance: preparedness, prevention and control of coronavirus disease (Covid-19) for refugees and migrants in non-camp settings. Geneva: World Health Organization; 17th April 2020.
(3). IFRC, IOM, UNHCR, WHO. Interim guidance: scaling-up Covid-19 outbreak readiness and response operations in humanitarian situations, including camps and camp-like settings. Version 1.1. Geneva: Inter-Agency Standing Committee (IASC) secretariat; 17th March 2020.
(4). Hargreaves S, Kumar BN, McKee M, Jones L, Veizis A. Europe’s migrant containment policies threaten the response to covid-19. BMJ. 2020;m1213.
(5). National Public Health Organization. Epidemiological surveillance in points of care for refugees/migrants weekly report: week 8/2020 (17/02 to 23/02). Athens: Ministry of Health; 2020.
(6). Kondilis E, Pantoularis I, Makridou E, Rotulo A, Seretis S, Benos A. Critical assessment of preparedness and policy responses to SARS-CoV2 pandemic: international and Greek experience. CEHP Report 2020.2. Thessaloniki: CEHP - Centre for Research and Education in Public Health, Health Policy and Primary Health Care; 2020. Available at https://www.healthpolicycenter.gr (accessed 10th May 2020)
Competing interests: No competing interests
Dear Editor
Douglas and colleagues (1) offer a welcome and reasoned assessment of how the lockdown that has shut down large sections of the UK economy, and indeed the world’s, is likely to ratchet up health inequalities in the absence of decisions to avoid further austerity and 'build a more sustainable and inclusive economy'.
However, they do not inquire into the political economy of such decisions. Even if the governing party wishes to repudiate the decade of austerity that compromised both social justice (2) and capacity to respond to the pandemic, the relevant policy choices may be dictated by the requirements of financial markets and the International Monetary Fund (IMF); the Fund may well function as a gatekeeper to those markets as it has done for much of the developing world in the past decades. (3)
Consequently, as I have argued, (4) the best model we have for the effects on wider health indicators may be the collapse of the Russian economy after the dissolution of the Soviet Union, whose direct effects were worsened by IMF “shock therapy” prescriptions. (5) A quarter century later, the effects of eventual economic recovery are still only partially reflected in improved Russian life expectancy, (6) perhaps as a result of the capital flight and dramatic increases in inequality that accompanied the recovery. We would do well to be warned.
References
(1) Douglas M, Katikireddi SV, Taulbut M, McKee M, McCartney G. Mitigating the wider health effects of covid-19 pandemic response. BMJ 2020 April 27;369:m1557.
(2) Alston P. Visit to the United Kingdom of Great Britain and Northern Ireland: Report of the Special Rapporteur on extreme poverty and human rights, A/HRC/41/39/Add.1 .New York: United Nations; 2019. https://undocs.org/A/HRC/41/39/Add.1.
(3) Kentikelenis A, Gabor D, Ortiz I, Stubbs T, McKee M, Stuckler D. Softening the blow of the pandemic: will the International Monetary Fund and World Bank make things worse? The Lancet Global Health 2020; doi: 10.1016/S2214-109X(20)30135-2.
(4) Schrecker T. No exit? The United Kingdom's probable Russian Future. Health as if Everybody Counted (second edition) [On-line]. 2020 April 18. https://blogs.ncl.ac.uk/theodoreschrecker/2020/04/18/no-exit-the-united-....
(5) Field MG, Kotz DM, Bukhman G. Neoliberal Economic Policy, "State Desertion," and the Russian Health Crisis. In: Kim JY, Millen JV, Irwin A, Gershman J, editors. Dying for Growth: Global Inequality and the Health of the Poor. Monroe, Maine: Common Courage Press; 2000: pp. 155-73.
(6) Shkolnikov VM, Andreev EM, Tursun-zade R, Leon DA. Patterns in the relationship between life expectancy and gross domestic product in Russia in 2005-15: a cross-sectional analysis. The Lancet Public Health 2019;4:e181-e188.
Competing interests: No competing interests
Dear Editor,
Douglas et al discuss adverse effects of lockdown. Maybe to balance this we need to find out what is acceptable risk for society, to help find a way forward.
There have been about 11 corvid-19 deaths in the under 20 age group. There are 120 deaths from traffic accidents per year in the same age group. The fact that despite this loss of life, we continue to use motor vehicles, suggests that whilst society will try to mitigate these risks, they are acceptable. Similarly there are about 500 traffic accident associated deaths per year in the 20-39 age group, whilst there have been less than 200 corvid-19 deaths.
If we suppose such a death rate is socially acceptable in the UK, it makes me wonder why we are quite clearly damaging the health of our young, physically, socially and psychologically, for the potential benefit of the more elderly of us? For me this seems morally wrong.
Competing interests: No competing interests
Dear Editor
Douglas et al. describe the “profound consequences” due to the measures taken in order to get rid of the COVID-19 pandemic [1]. During this global emergency, a terrible disaster of unimaginable dimensions, we are called upon to: prepare and be ready,[2] detect, protect and treat,[2] reduce transmission,[2] innovate and learn,[2] stand together,[2] and look out for each other.[2] With our knowledge, skills and capabilities, we as doctors shall do the right things with calm and protect the citizens of the world.[2] We see people struggling with limited capacity, limited resources and limited resolve.[2] Witnessing so many people fighting for and losing their lives, moves us to tears.
In 1948, the General Assembly of the United Nations ratified the Universal Declaration of Human Rights (Resolution 217a) .[3] “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including (…) medical care [3] and (…) security in the event of (…) sickness or (…) disability”.[3] The Second General Assembly of the World Medical Association purposefully also adopted the Declaration of Geneva in 1948.[4] As doctors, we pledged ourself to consecrate our lives to the service of humanity.[4]
With deep fear,[5] we observe the rapid erosion of the rules of Resolution 217a [3] and the Declaration of Geneva,[4] in this pandemic.[2]
COVID-19 patients are triaged due to the lack of capacity and resources [2] to achieve the best possible treatment outcomes. This does not entitle us to let terminally ill patients suffer without relief, redemption and help.[6]
The health and well-being of my patient will be my first consideration.[4]
All available and unavailable resources are shifted towards patients with COVID-19 while transplantation programs, for example, are stopped. While this may be rationally justifiable, it may deprive other individual patients of their last chance of recovery.
I will not permit any considerations to intervene between my duty and my patient.[4]
We should also not deprive or abandon for example any patients of treatment for age-related macular degeneration and their preventable vision loss. Since most ophthalmologists are not involved in the treatment of COVID-19 patients, this does not tie up any resources. Hence, we ask why constrain therapies: Potential infection risks? The masks and the gloves we use?
And we have called every day for countries to take urgent and aggressive action. We have rung the alarm bell loud and clear.[2]
Not all followed the early advice of the World Health Organization. Masks, consumables and ventilators were not ordered in time nor in sufficient amounts, though corporate “just-in-time” inventory management was well executed. Generous stockpiling and cost efficiency are mutually contradictory. In future, physicians should be jointly responsible for the business administration of hospitals and health policy counseling. Presently, there is no rule on preparedness in the Declaration of Geneva.
Those patients with diseases other than COVID-19 have much to lose. Seeing so many patients’ health deteriorate from restricted access to care, despite the available treatment options, moves us to tears.
With deep anxiety, we note existing rules[3,4] and warnings[2] being undermined and flouted. We must not ignore the Declaration of Geneva and call on all medical professionals to analyze the present ethical emergency in order to establish additional rules in preparation for future crises.
Authors
Anna Lena Huber, MD 1, 2
Reinhard Angermann, MD 1
Alexander Loizides, MD (alexander.loizides@i-med.ac.at) 3
Bernhard Glodny, MD 3
Claus Zehetner, MD 1
1 Department of Ophthalmology and Optometry, Medical University of Innsbruck, Austria
2 Department of Neuroradiology, Medical University of Innsbruck, Austria
3 Department of Radiology, Medical University of Innsbruck, Austria
All authors declare no competing interests according to the BMJ policy on declaration of interests.
References
1. Douglas M, Katikireddi SV, Taulbut M, McKee M, McCartney G. Mitigating the wider health effects of covid-19 pandemic response. BMJ. 2020 Apr 27;369:m1557. doi: 10.1136/bmj.m1557.
2. Ghebreyesus TA. WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020. New York, March 11th, 2020 https://www.who.int/dg/speeches/detail/who-director-general-s-opening-re... (last access March 11th, 2020)
3. Universal Declaration of Human Rights, G.A. res. 217A (III), U.N. Doc A/810 at 71 (1948). Article 25, 1. University of Minnesota. Human Rights Library. http://hrlibrary.umn.edu/instree/b1udhr.htm (last access March 25th, 2020)
4. WMA Declaration of Geneva, Adopted by the 2nd General Assembly of the World Medical Association, Geneva, Switzerland, September 1948, and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968, and the 35th World Medical Assembly, Venice, Italy, October 1983, and the 46th WMA General Assembly, Stockholm, Sweden, September 1994, and editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005, and the 173rd WMA Council Session, Divonne-les-Bains, France, May 2006 and amended by the 68th WMA General Assembly, Chicago, United States, October 2017 https://www.wma.net/policies-post/wma-declaration-of-geneva/ (last access March 25th, 2020)
5. Ratti AAD (Pius XI). Mit brennender Sorge. Encyclical of Pope Pius XI on the Church and the German Reich. Libreria Editrice Vaticana, Rome 1937. http://www.vatican.va/content/pius-xi/en/encyclicals/documents/hf_p-xi_e... (last access March 25th, 2020)
6. Micalessin G. “È uno tsunami. E muoiono lucidi.” Viaggio tra i medici eroi nella terapia intensiva del San Carlo. Il Giornale 2020 (Mar 11th) https://www.ilgiornale.it/news/politica/tsunami-e-muoiono-lucidi-1838892..., (last access March 25th, 2020)
Competing interests: No competing interests
Dear Editor
The article discusses the wider health effects of the pandemic response. However, there is one very wide issue that hasn't been discussed in any media at all is the frequent breach in confidentiality.
Confidentiality is a fundamental right and is of paramount importance in our healthcare system. People take this matter stringently when it involves patients, but unfortunately this doesn’t always appear to apply to the healthcare staff especially in the current pandemic.
When a healthcare worker takes time off due to suspected Covid-19 symptoms or proven Covid-19 illness, it would be very difficult to conceal this information in the area they work as it impacts other professionals working in the same area. However, very soon this message gets discussed openly and casually at all levels with little concern about protecting one’s privacy and confidentiality. If it was due to any other medical illness before this pandemic, I doubt whether anyone would openly discuss such matters.
A more worrying situation is when healthcare professionals are advised to shield or isolate themselves due to their underlying medical conditions that would make them vulnerable to Covid-19. In such a situation some may volunteer to share the information themselves to justify their absence from work because they feel guilty for not being at the frontline. Even if they don’t, somehow the information spreads widely and very soon the entire workplace gets to know about their medical problems.
Lack of confidentiality could have other negative consequences, intended or otherwise, to the individual, including a perception of being accused of spreading the disease or feeling distanced or being discriminated by colleagues and others at the workplace.
Everyone has a right to privacy in relation to their own health matters and we all have to be mindful that we do not breach someone’s confidentiality at the workplace and beyond. Otherwise there is a risk that this unhealthy practice could continue even after the pandemic is over.
Competing interests: No competing interests
Covid-19: Social Distancing or Social Isolation?
Dear Editor,
Douglas et al comment on social distancing measures to control the spread of covid-19 and highlight its adverse consequences on health and health inequities [1]. On the other hand, governments all over the globe as well as in low and lower-middle income countries have promoted this intervention as part of multipronged strategies to tackle the pandemic. Adverse consequences of social distancing are important in the elderly, people with chronic diseases and the poor, who all are at the receiving end of this pandemic.
There is a short path from social distancing to social isolation [2]. In the English Longitudinal Study of Aging loneliness and social isolation were associated with increased risk of being inactive, smoking and multiple risk behaviors leading to greater incidence of cardiovascular diseases [3]. Other adverse consequences of social isolation include higher risk of premature mortality, greater depression, introversion, poor social skills and dementia [2]. In developed countries it affects about a third of people and leads to 26% increased risk of premature mortality [4].
There is growing recognition that social isolation and loss of socio-economic status have important implications on disability in older individuals [2]. In India too, loneliness is a risk factor for a variety of psychological conditions [5]. Most of the elderly in developing countries are frail and dependent for activities of daily living on community services [4]. These social services are usually not available in these countries and most of the people live in a cohesive joint family system and depend on their young ones. Socially isolating or shielding them away from their kin could have deleterious effects on physical, psychological and social well-being. This is even more important in older adults with cognitive impairment and ambulation. Many of these seniors have no access to technology or are not conversant with its use. Social isolation and distancing also leads to economic hardship as observed during the universal lockdown due to covid-19 in India and other developing countries [6].
It has been suggested that multidisciplinary research is needed to evaluate interventions to decrease deleterious consequences of social isolation and loneliness, especially among the elderly [7]. These have also been highlighted by Douglas et al [1]. A meta-review has reported that interventions include employing community components for greater accessibility and acceptability of care, greater clinical effectiveness through ongoing contact and use of trusted local providers, family involvement, and economic benefits [8]. It can be done at homes and quarantine camps and must include technology-aided delivery. The Commonwealth Fund has suggested activities to address social isolation during the covid-19 pandemic [9]. These include screening for isolation and referring to digital support, expanding access to telehealth for mental health care with access to internet and smartphones.
Digital technology is widely available and could be gainfully employed in India too. Specific interventions for India and other resource limited countries include better use of widely available e-application services (e.g., e-chaupals). This would lead to better point-of-care services in rural and urban areas, better treatment compliance, proper data collection and disease surveillance and appropriate distant health education [10]. Other interventions include counselling, emotional disclosures, adequate physical activities as well as maintaining social interactions. We believe that social cohesion and not social distancing, while maintaining physical distancing, is the way forward for the covid-19 pandemic.
REFERENCES
1. Douglas M, Katkireddi SV, Taulbut M, McKee M, McCartney G. Mitigating the wider health effects of covid-19 pandemic response. BMJ. 2020; 369:m1557.
2. National Academies of Sciences, Engineering and Medicine. Social isolation and loneliness in older adults: opportunities for the healthcare system. Washington. National Academies Press. 2020.
3. Shankar A, McMunn A, Banks J, Steptoe A. Loneliness, social isolation, and behavioral and biological health indicators in older adults. Health Psychol. 2011; 30:377-385.
4. Fried L, Prohaska T, Burholt V, Burns A, Golden J, Hawkley L, et al. A unified approach to loneliness. Lancet. 395; 114.
5. India State-level Disease Burden Initiative Mental Disorders Collaborators. The burden of mental disorders across he states of India: The Global Burden of Disease Study 1990-2017. Lancet Psychiatry. 2020; 7:148-161.
6. Sen A, Rajan R, Banerjee A. Huge numbers may be pushed into dire poverty or starvation …. we need to secure them. New Delhi. Indian Express. 17 April 2020. Available at: https://indianexpress.com/article/opinion/coronavirus-india-lockdown-eco.... Accessed 20 April 2020.
7. Holmes EA, O-Connor RC, Perry VH, Tracey I, Wessely S, Arsenault L, et al. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. Lancet Psychiatry. 2020. EPub 15 April 2020.
8. Kohrt BA, Asher L, Bhardwaj A, Fazel M, Jordans MJD, Mutamba BB, et al. Th role of communities in mental health care in low- and middle-income countries: a mea-review of components and competencies. Int J Env Res Public Health. 2018; 15:1279.
9. Lewis C, Shah T, Jacobson G, McIntosh A, Abrams MA. How the COVID 19 pandemic could increase social isolation and how providers and policymakers can keep us connected. To the Point. Commonwealth Fund. 8 Apr 2020. Available at: https://www.commonwealthfund.org/blog/2020/how-covid-19-pandemic-could-i... . Accessed 19 April 2020.
10. Jaroslawski S, Saberwal G. In eHealth in India today, the nature of work, the challenges and the finances: an interview based study. BMC Med Inform Decis Mak. 2014; 14:1.
Competing interests: No competing interests
Dear Editor,
The analysis by Margaret Douglas and colleagues resonate with me and many other people in Hong Kong.
Following months of social unrest and violence arising from pro-democracy movements, Hong Kong—a former British colony off the coast of South China—is facing one of the most severe blows to the city’s economy in our lifetime, probably worse than that during the SARS epidemic in 2003. As local government officials hastily launch an economic relief package amid the covid-19 crisis, popular opinion remains sceptical about the usefulness of these relief efforts in helping out the most vulnerable grassroots. (1)
The social determinants of health are literally visible. I work in a district general hospital situated in Yau Ma Tei, undoubtedly one of the busiest areas in our city, yet also home to the poor and homeless. (2) I have witnessed how patients had poorly controlled diabetes just because they could not afford blood glucose testing kits at home. I often see patients staying in the hospital much longer than they should, due to lack of accessible housing or caretakers. All these moments were heartbreaking for me as a junior doctor, and I can only see everything getting worse as the covid-19 pandemic lingers on.
Several weeks ago, one popular fast food chain in Hong Kong decided to suspend overnight service at its 24-hour outlets, in compliance with the social distancing policy imposed by the government. As a result, people who take shelter in these fast food outlets at night, colloquially known as “McRefugees”, were forced to sleep on the street. (3) While the “McRefugees” and other issues of homelessness existed long before covid-19 was known to the world, we are now seeing the breadth and depth of our city’s social problems being neglected in the past. This is an unforgiving examination of every aspects of our population health.
On the other hand, a number of “non-essential” services at my hospital have been put on hold in order to conserve manpower and resources at the height of the outbreak. At present, various elective procedures such as total joint replacement (TJR) surgery for osteoarthritis are postponed indefinitely. (4) Like the UK, most Hong Kong people rely on publicly funded healthcare. The median waiting time for elective TJR surgery in Hong Kong’s public healthcare system is now up to 42 months. (5)
On more than one occasion, my patient has burst into tears in the recovery room after a TJR operation, not due to pain or anxiety, but out of gratitude and relief. “Doctor, I have been looking forward to this moment for many years.” It is through these narratives and personal encounters that I have learnt every single bit of our clinical care can be life-transforming for our fellow human beings. But now, all these stories are set aside to save our city from covid-19.
There is no question that protecting healthcare systems from being overwhelmed by covid-19 should be our first priority at this moment. However, the sheer optimism that things will spontaneously go back to normal is probably nothing more than wishful thinking. We must carefully identify the most vulnerable groups and individuals affected by the covid-19 pandemic response and implement the necessary interventions as promptly as we can before the resulting health inequalities become more dangerous than covid-19 itself.
References:
(1) Leung A. Jobless thousands wait for government help, training courses. South China Morning Post 2020 Apr 18. https://www.scmp.com/news/hong-kong/hong-kong-economy/article/3080524/co...
(2) Tsang H. Poverty amid plenty; Hong Kong's increasing homeless. Journalism and Media Studies Centre, The University of Hong Kong, 16 November 2015. https://jmsc.hku.hk/2017/02/poverty-amid-plenty-hong-kongs-increasing-ho...
(3) Westbrook L. No shelter for Hong Kong's homeless 'McRefugees' amid coronavirus horror. South China Morning Post 2020 Apr 5. https://www.scmp.com/news/hong-kong/society/article/3078447/no-shelter-m...
(4) Cheung EHL, Chan TCW, Wong JWM, et al. Sustainable response to the COVID-19 pandemic in the operating theatre: we need more than just personal protective equipment. British Journal of Anaesthesia Published Online First: 2020. doi:10.1016/j.bja.2020.04.002
(5) Hospital Authority. Elective Total Joint Replacement Surgery, 31 March 2020. https://www.ha.org.hk/visitor/ha_visitor_text_index.asp?Content_ID=22122...
Competing interests: No competing interests
Dear Editor
The recommendations in this paper are very important for mitigating the wider health effects of covid-19 pandemic response. Besides them, is there any role for aspirin?
The health effects of covid-19 are new and not well known yet.
The widespread inflammatory reaction and deadly vascular thrombosis affect key organs, included vessels, lung, heart, brain and kidney.
Many hospitals are using anticoagulants, in both preventive and therapeutic dosages, with variable results.
Aspirin is well known and successful for decades as antiplatelet drug for cardiovascular prevention in low dosages.
In higher dosages is also antipyretic and anti-inflammatory. It has also anticoagulant effects inhibiting prothrombin synthesis.
It is very effective for the prevention of venous thrombosis in orthopedic surgery.
It is an interesting question to investigate the potential benefits of the use of aspirin in Covid-19, either in low doses combined with standard anticoagulants, or alone, in high dosages.
Always give under gastric protection, with Proton Pump Inhibitors.
Prof. Enrique Sánchez-Delgado, MD
Internal Medicine-Clinical Pharmacology and Therapeutics
Hospital Vivian Pellas, Managua, Nicaragua
Competing interests: No competing interests
Re: Mitigating the wider health effects of covid-19 pandemic response
Dear Editor,
Being homeless means much more than being without a home. The initial government message of ‘Stay Home’ was meaningless to the estimated 280,000 citizens in the UK who don’t have a permanent roof over their heads (1). Worryingly, 4,266 of these are estimated to be sleeping rough on any given night (2).
Similarly, the message to ‘wash your hands more often’ is decidedly more difficult without easy access to washing facilities, especially with the sudden closure of fast-food outlets and leisure centres. Hunger has set in for many owing to the lack of access to food charities and the kind commuters who donate sandwiches or small change are no longer passing by. Apply this situation to someone who may already be in compromised physical or mental health, malnourished or struggling with addiction and it is easy to see why a virus would see this population as an easy target.
And COVID was quick to take hold amongst those in London hostels with 38% of inhabitants becoming symptomatic of COVID in March 2020 and a death rate 25 times higher than within the general population (3).
The homeless charity Crisis runs the ‘Everybody In’ scheme which aims to help homeless people find and keep accommodation. Never before has this been such an imperative message. City councils across the UK have stepped up their services to accommodate this vulnerable group of people. This is inclusive of those individuals whom habitually use alcohol and drugs, or have previously not been eligible for housing support.
As part of the national action plan, empty hotels have been used as emergency safe spaces to accommodate the homeless. The plan to re-home rough sleepers in en-suite hotel rooms with the provision for cooked meals appears expensive but would be considerably more cost-efficient compared to admission to hospital. This plan is estimated to save the NHS 2,624 COVID-19 related hospital admissions and prevent 164 deaths within the first six months (4).
But what happens now that lockdown rules have started to ease? The £3.2bn cash injection from the government will not be enough to sustain the councils’ efforts indefinitely and Boris Johnson was unable to confirm if support measures would remain in place. In London, the COVID-CARE hotel which had been set up specifically to house those who are exhibiting symptoms, is facing pressure to close as the rate of infection within the general population continues to decline (5). Hotels are understandably keen to reopen for business but turfing thousands of homeless people back out on to the streets is a sure-fire way to increase rates of transmission once again. COVID-19 aside, there has been many incidental successes found from housing this population of people. This includes vast improvements in both physical and mental health, adherence to rehabilitation programmes and the sense of belonging to a family unit. This is all now in jeopardy and people are instead fearful of returning to an old way of life and exposure to the very infection they have been protected from (6).
COVID-19 has changed the way we live, work, travel and socialise. It has also proven to be a golden opportunity for change in systems which were previously not favourably managed. Imagine if this were our chance to change the trajectory for the homeless. Or far worse, imagine if we reverted back to old habits and missed this chance altogether.
References
1.https://england.shelter.org.uk/media/press_releases/articles/280,000_peo...
2.https://www.homeless.org.uk/facts/homelessness-in-numbers/rough-sleeping...
3.https://www.wlm.org.uk/news/fears-of-catastrophic-coronavirus-outbreak-a...
4.https://www.medrxiv.org/content/10.1101/2020.05.04.20079301v1
5.https://blogs.ucl.ac.uk/iehc/2020/05/13/inclusion-health-and-covid-19/
6.https://www.theguardian.com/society/2020/may/16/rough-sleepers-must-not-...
Competing interests: No competing interests