Mitigating the wider health effects of covid-19 pandemic response

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.

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.

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)

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.