COVID-19 and the Peculiar Case of 4 the Missing Myocardial Infarction Are Doctors Obligated to Treat During a Pandemic?
The Gendered Impact of COVID-19
AJGH 2020 Volume 14 Issue 2
ADVISORY BOARD Consists of academic mentors who provide guidance for the
Between The Lines
present and future direction of AJGH
Dr Claudia Turner Consultant paediatrician and clinician scientist with the University of Oxford and chief executive officer of Angkor
With borders closed,
Hospital for Children
social distancing in place,
Professor David Hilmers
we see the world from
Professor in the Departments of Internal Medicine and Pediatrics, the Center for Global Initiatives, and the Center for
Between the Lines;
Space Medicine at the Baylor College of Medicine.
Associate Professor Nicodemus Tedla Associate Professor in the School of Medical Sciences at the
They mark the fronts of our masks;
University of New South Wales.
trace the placement of our feet;
Dr Nick Walsh
depict muffled expressions;
Medical doctor and regional advisor for viral hepatitis at the Pan American Health Organization / World Health Organization
And predict crippling recessions;
Regional Office for the Americas.
PEER REVIEWERS Dr Evie Kendal Dr Emma Tumilty Dr Mariana Galrao Dr Julie Hennegan Dr Mariana Galrao Prof Christopher Fisher Prof Hugh Taylor Dr Henry Drysdale
EDITOR-IN-CHIEF Terra Sudarmana
SENIOR EDITORS Stephanie Kirkby Marisse Sonido
ASSOCIATE EDITORS Masrur Joarder Anandita Soundappan John Koh Sophia Moshegov Rosemary Kirk Joy Drieberg Thompson
Placements and conferences, birthdays and weddings; lines strike through unfulfilled plans and predict trajectories for change; Locked within borders, excluded from bubbles; today’s prospects, tomorrow’s realities, are all on the line; In these unprecedented times, AMSA’s Journal of Global Health will guide and enlighten you beyond the words, Between the Lines.
The AJGH Team
Kit Lindgren Tara Kannan
Pabasha Nanayakkara Christine Manuel Design and layout © 2020, AJGH Australian Medical Students’ Association Ltd, 42 Macquarie Street, Barton ACT 2600 firstname.lastname@example.org,au ajgh.amsa.org.au Content © 2020, The Authors Cover design by Stephanie Kirkby and Terra Sudarmana
AJGH is the official student-run, peer-reviewed journal of AMSA Global Health. Responsibility for article content rests with the respective authors. Any views contained within articles are those of the authors and do not necessarily reflect the views of AJGH or the Australian Medical Students’ Association.
COVID-19 and the peculiar case of the missing myocardial infarction A drastic drop in heart attack presentations
How family planning can help with tackling cli-
amidst the COVID-19 pandemic has been ob-
served across the globe – the question is why?
Ethics in short-term medical volunteerism
Knowledge, attitudes, and practices regarding menstruation
Parinda Shah, Sapna Dilgir, Torres Woolley, Ajay Rane
This piece aims to humanise and bring to life
Are doctors obligated to treat during a pandemic?
Rural North India. It also aims to provide a ‘life
In this paper, we explore the moral obligation
al, to inspire the reader.
for healthcare professionals to care for those af-
lesson’ or takeaway from the featured individu-
The good guy one crusader of the drug and alcohol crisis in
fected by SARS-CoV-2.
Public health approaches to addressing trachoma Sally Boardman
A look into telehealth’s ascent during COVID-19
A literature review
A study on final year medical students at an
The Doctor will ring you now Allen Gu
More harm than good? Kishaini Baskararao, Aurelne Thian
Climate Change and sexual and reproductive health: impacts and solutions
PPE in low and middle-income countries during COVID-19
The fight against gender based violence
Strategies to protect healthcare workers in re-
A first-hand look at what it takes to end violence
source limited settings
against women, with Dr Emma Fulu
Dilini Imbulana, Anushree Loyalka, Dominic
Under the microscope AJGH Team
The gendered impact of COVID-19 How the COVID-19 pandemic has disproportionately impacted women
COVID-19 and the peculiar case of the missing myocardial infarction
A drastic drop in heart attack presentations amidst the COVID-19 pandemic has been observed across the globe â€“ the question is why? Jeremy Hunt 4
n recent months, the COVID-19 pandemic has swept across the world, overwhelming hospitals in all corners of the globe, with China, the United States of America, Italy, India, Brazil, and South Africa among the worst hit. Amongst the chaos in many of these hospitals, cardiology teams found the number of people receiving emergency treatment for myocardial infarction (MI) and other cardiovascular conditions was strangely plummeting. Even in areas where COVID-19 has been seemingly well-controlled, such as Australia, the same phenomenon has been noted.  In May, the Spanish Society of Cardiology published a preliminary publication which estimated that levels of Percutaneous Coronary Intervention (PCI ) procedures for ST-elevated myocardial infarction (STEMI) during the pandemic were down as much as 40% from pre-pandemic levels across Spain. In Northern California, the weekly rates of hospitalisation for acute MI decreased by up to 48% during the COVID-19 period.  Further, a 38% decrease in primary percutaneous coronary interventions (PPCI), the American College of Cardiology recommended standard treatment of STEMI patients, has been observed in US catheterization laboratories. Admissions for acute MI were significantly reduced during the COVID-19 pandemic across Italy; in one study daily hospital admissions for acute coronary syndrome (ACS) (which includes STEMI, Non-STEMI (NSTEMI) and unstable angina) decreased from 18.0 in the pre-COVID-19 control period to 13.3 in the COVID-19 period, another found a 48.4% reduction in MI presentation across different centers. WHAT UNDERLIES THIS PHENOMENON? Most concerningly, according to interventional cardiologist Associate Professor Dion Stub, is the “real possibility that patients are avoiding coming to hospital… [and] are potentially afraid even to see their GP”. If this is the case, it suggests that the COVID-19 pandemic has resulted in a fear of face-to-face medical care. With people more likely to overlook symptoms and remain at home, it would follow that, when they do seek help, it is likely to be when their condition
is far more critical. This hypothesis is supported by observations from the Queen Mary Hospital in Hong Kong that, during the COVID-19 pandemic, patients have been presenting to the hospital late in the course of heart attacks, when treatment is far less effective. In the aforementioned latter Italian study, there was an accompanying rise in STEMI case fatality rate compared with the same 2019 period and a parallel increase in complications was also registered. A similar phenomenon was observed during the 2003 SARS epidemic, where a study found almost two thirds of lung cancer patients were afraid of visiting the Taipei Veterans General Hospital in Taiwan during the outbreak, while more than a third felt SARS was more dangerous than their cancer. Although it must be noted that patient behaviour may be altered if they believe they are more susceptible to complications of respiratory disease due to pre-existing lung cancer, the patient sentiment captured by this study is pertinent to the current outbreak. It is important to consider other possible explanations for the reduced cardiac presentations. In the age of social distancing, human behaviours, such as social interaction, diet, sleep, and physical activity have been considerably modified. It is possible that some of the risk factors for MI, like high-cholesterol diets, excessive alcohol consumption, or lack of physical exercise, have been removed. Although this cannot be excluded as a contributing factor to the dramatic changes being observed across the world, it seems an unlikely explanation, especially since data from activity tracker users has demonstrated a significant decline in steps taken during COVID-19.  WHY IS THIS IS SO PERPLEXING? Since respiratory infections typically increase the risk of MIs, it would follow that a higher incidence of emergency cardiac presentations should be observed. Indeed, the influenza vaccine is a key
THE VECTOR AWARD The Vector Award is voted on by our editorial team. An article deemed most outstanding among our fine selection of works
intervention to prevent against MI. The risk of increased MI follows shortly after the development of respiratory infection, so a rise in heart attacks should correlate strongly with increased respiratory illness; however, this has not been the case.
islation and medicine and has consulted on projects for international health non-for-profits. Correspondence email@example.com Acknowledgements None
Further, psychosocial stress, often associated with depression and anxiety, is a strong independent risk factor for adverse cardiovascular events; the mind-heart connection likely accounts for a substantial portion of the attributable risk. Thus, with the significant mental health burden resulting from the COVID-19 pandemic and associated lockdowns, it stands to reason that there would be an accompanying increase in MIs. COVID-19 can have a direct cardiotoxic effect, which should be increasing the number of patients presenting with heart problems.
Conflicts of Interest None declared References 1. Zitelny E, Newman N, Zhao D. STEMI during the COVID-19 Pandemic - An Evaluation of Incidence. Cardiovasc Pathol. 2020;48:107232. 2. Hendrie D. Drastic drop in cancer and heart attack patients linked to COVID-19. newsGP. April 14, 2020. https://www1.racgp.org.au/newsgp/ clinical/drastic-drops-in-cancer-and-heart-attackpatients. 3. Rodríguez-Leor O, Cid-Álvarez B, Ojeda S, Martín-Moreiras J, Rumoroso JR, López-Palop R, et al. Impacto de la pandemia de COVID-19 sobre la actividad asistencial en cardiología intervencionista en España. 2020;2:82-9. 4. Solomon MD, McNulty EJ, Rana JS, Leong TK, Lee C, Sung SH, et al. The Covid-19 Pandemic and the Incidence of Acute Myocardial Infarction. N Engl J Med. 2020. 5. Garcia S, Albaghdadi MS, Meraj PM, Schmidt C, Garberich R, Jaffer FA, et al. Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States During COVID-19 Pandemic. J Am Coll Cardiol. 2020;75(22):2871-2. 6. De Filippo O, D’Ascenzo F, Angelini F, Bocchino PP, Conrotto F, Saglietto A, et al. Reduced Rate of Hospital Admissions for ACS during Covid-19 Outbreak in Northern Italy. N Engl J Med. 2020;383(1):88-9. 7. De Rosa S, Spaccarotella C, Basso C, Calabro MP, Curcio A, Filardi PP, et al. Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era. Eur Heart J. 2020;41(22):2083-8. 8. Mackee N. COVID fears drive patients to avoid doctors, hospitals. InSight. May 4, 2020.https:// insightplus.mja.com.au/2020/17/covid-19-avoidingdoctors- clinicians-brace -for-wave - of-severe illnesses/. 9. Tam C-CF, Cheung K-S, Lam S, Wong A, Yung A, Sze M, et al. Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on STSegment–Elevation Myocardial Infarction Care in Hong Kong, China. 2020;13(4):e006631. 10. Chen YM, Perng RP, Chu H, Tsai CM, WhangPeng J. Impact of severe acute respiratory syndrome
In the interim, there is an important message to convey to patients: don’t delay seeking help. Professor Garry Jennings, Senior Director at the Baker Heart and Diabetes Research Institute, recently wrote in the Medical Journal of Australia about his worry that ‘some people with heart disease are abandoning the usual medical advice at a time when they may need it the most’. There is a very real risk, especially in Australia, that despite being successful in minimising the effect of COVID-19 on our health system so far, we risk seeing an increase in deaths from preventable illnesses in the coming months. As the global community continues to fight COVID-19, it is crucial to combat the perception that people must stay away from hospitals or that hospitals are not safe places to seek treatment. The pandemic toll will be much worse if it leads people to avoid care for life-threatening, yet treatable, conditions.
Whilst we remain in the midst of the global COVID-19 pandemic, it is hard to draw causality and understand the full picture of this intriguing occurrence. There are ongoing studies to provide more clarity to these findings and to ascertain the underlying reasons for decreased emergency cardiovascular presentations at hospitals across the globe. Further, a number of publications have emerged describing similar declines in presentations to emergency for stroke, or mental health emergencies, among other conditions. Evidently, this phenomenon is not limited to cardiac problems.
Jeremy Hunt is a first year medical student at the University of Queensland, who majored in computer and biomedical sciences as part of his undergraduate BSc. Within the global and public health spheres, Jeremy is interested in the interplay between business, leg6
on the status of lung cancer chemotherapy patients and a correlation of the signs and symptoms. Lung Cancer. 2004;45(1):39-43. 11. Fitbit. The Impact Of Coronavirus On Global Activity. Fitbit News. March 23, 2020. https://blog. fitbit.com/covid-19-global-activity/. 12. Ruane L, Buckley T, Hoo SYS, Hansen PS, McCormack C, Shaw E, et al. Triggering of acute myocardial infarction by respiratory infection. Intern Med J. 2017;47(5):522-9. 13. MacIntyre CR, Mahimbo A, Moa AM, Barnes M. Influenza vaccine as a coronary intervention for prevention of myocardial infarction. Heart. 2016;102(24):1953-6. 14. Rosengren A, Hawken S, Ounpuu S, Sliwa K, Zubaid M, Almahmeed WA, et al. Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):953-62. 15. Huang Y, Zhao N. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: a web-based crosssectional survey. Psychiatry Res. 2020;288:112954. 16. Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, et al. Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020. 17. Uchino K, Kolikonda MK, Brown D, Kovi S, Collins D, Khawaja Z, et al. Decline in Stroke Presentations During COVID-19 Surge. Stroke. 2020;51(8):2544-7. 18. Hoyer C, Ebert A, Szabo K, Platten M, MeyerLindenberg A, Kranaster L. Decreased utilization of mental health emergency service during the COVID-19 pandemic. Eur Arch Psychiatry Clin Neurosci. 2020. 19. Jennings GL. Coronavirus disease 2019 (COVID-19): angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and cardiovascular disease. Med J Aust. 2020;212(11):5023 e1.
Ethics in short-term medical volunteerism Kishaini Baskararao Aurelne Thian
More harm than good?
The sharing of knowledge also has beneficial impacts on the professional development of volunteers. Medical volunteerism is widely encouraged as a learning opportunity for medical professionals, as well as students.[7-9] Placed in different and often challenging clinical scenarios, medical students develop personal, professional, and practical skills; are exposed to diseases would otherwise not encounter in their home country; and are made more aware of the inequities of global health. An exposure to different cultures accentuates the importance of culturally sensitive healthcare practises. These experiences are invaluable for future practice.[10-11] Being exposed to and learning how to practice culturally responsive medicine early on is an extremely valuable skill for medical students. Students are forced to consider how to manage and educate patients on mental health issues, such as depression, in various cultural contexts. This often includes being aware of the stigma and lack of patient knowledge associated with mental health disorders, as well as learning how to address cultural beliefs regarding mental illnesses.[12-16]
“Saving our planet, lifting people out of poverty, advancing economic growth – these are one and the same fight.” - Ban Ki-Moon
ver the past decade, there has been an increase in the number of medical students and clinicians undertaking humanitarian aid trips to rural and remote communities in order to provide basic medical access and support to vulnerable communities. For the longest time, medical volunteerism has been focused on developing countries with the aim of providing health access in areas of limited resources to improve health and social outcomes. However, the increased interest in medical volunteerism has seen a surge in the number of organisations that arrange such humanitarian aid trips and, as a result, such programs and travel plans have become increasingly commercialised.  While the various programs retain that initial core principle of giving aid to the vulnerable, we cannot ignore the shift in focus towards less pure intentions. These include boosting one’s curriculum vitae or using these trips as a chance to travel and enjoy oneself. In fact, the recent popularity of medical volunteerism has somewhat created a bandwagon effect; medical students feel obliged to participate for fear of missing out.
Medical volunteerism also benefits the communities who receive this help. Volunteers often bring with them a set of skills, ideas, and expertise that can be shared with local medical staff and community members, who can then integrate these techniques into their own healthcare as they see fit even after these short volunteerism trips have ended. The communities are able to receive healthcare and resources that are not typically available to them.
So many student volunteers offer their time and money to ‘give back’, and while these intentions are to be applauded, the question must still be asked: are these well-meaning efforts actually improving people’s lives? We will discuss the ethics of short-term medical volunteerism through the four main ethical pillars: beneficence, non-maleficence, justice, and autonomy.
However, beneficence is not simply to ‘do good’ but also to ‘serve the best interests of the patients and their family’. Despite providing communities with healthcare they may not otherwise have access to, several issues have been raised regarding whether or not these efforts are acting in the community’s best interests. For example, is the care provided by medical volunteers actually empowering these communities, or are they, in fact, pulling resources away from more needed local activities without increasing their capacity?[17-18]
BENEFICENCE The discussion of beneficence in the context of global health can be rather straightforward since medical volunteerism is, at its heart, based on principles of equity aiming to address the lack of healthcare resources and care available to the less advantaged. In fact, the rising interest in global health has greatly contributed to the popularity of medical volunteerism, especially among medical students. There are many pathways to undertake medical volunteerism. The most commonly discussed are disaster relief or short trips to less developed countries, which are ideally undertaken to improve quality of life and healthcare for vulnerable populations. These easily fall in line with doing good and acting in the patient’s best interest.
NON-MALEFICENCE The pillar of non-maleficence refers to ‘doing no harm’. While certainly not an endeavour which actively seeks to ‘do harm’, there have been increasing concerns over the ethics of medical volunteerism. These concerns generally revolve around themes of power imbalances and exploitation, a perpetuation of paternalistic healthcare, cultural insensitivity, a focus on self-serving benefits (e.g., tourism), and even criminal activities.[3,20] 9
between competing claims and is linked to fairness, entitlement, and equality. In healthcare ethics, distributive justice refers to the fair distribution of scarce resources while rights-based justice encompasses respect for people’s rights.
Other ethical concerns and harms have been described; these include vulnerable populations being used as ‘practise’, taking away local jobs and resources from other local activities that may be more necessary. This does little in improving capacity of these populations and only further increases their vulnerability and dependency on foreign aid.
Another concern that has been raised regarding medical volunteerism is the shift in focus towards boosting one’s curriculum vitae. Organisations may utilise medical volunteerism as an opportunity to create an industry for profit. International medical student electives have particularly been criticised for this, wherein student volunteers end up spending more time recreationally than in the clinical setting. The focus is thus less on improving the health outcomes of these populations, and this wastes resources that could be more needed elsewhere.
In many underdeveloped settings, certain resources—including medications and treating equipment—are more limited than in a resourced practice setting, presenting several ethical challenges. Clinical resource and staff limitations can often result in the need for challenging decisions to be made regarding triaging patients of the community, with only those deemed most ‘in need’ receiving access to healthcare.  Rooted in the ethical principle of justice, triage is a necessary part of every health system whenever there is a mismatch between demand for care and availability of resources, which can be significantly bigger in underdeveloped settings.
Further, medical students are often given freer rein to undertake procedures. They may not have the qualifications in their home country to do so independently but may have that responsibility placed upon them due to lesser regulations and resource strain from staff shortages. There may also be the perception that they are there to help a more vulnerable population that requires ‘any help that they can get’. Whether or not they may, in fact, be causing more harm both to the patient and by wasting resources is a major concern.
It is difficult to manage the ethical challenges that come with balancing the welfare of the patient, maintaining efficiency within a short period of time, and providing equitable distribution with special considerations for vulnerable populations. Short-term medical trips can involve having a limited number of medications, surgical apparatus, and aseptic materials (such as gloves and under-pads) brought along.  This often limits the number of people that can be helped, especially in terms of minor surgeries/ procedures or when managing chronic conditions like diabetes and hypertension, which often require months-worth of supplies to be distributed during a single trip.
Volunteers may also unintentionally practice in a way that is culturally inappropriate.[24,26] Culturally inappropriate care results in poorer patient outcomes and the development of negative attitudes towards healthcare. Thus, developing an awareness of one’s own culture, developing the ability to remain non-judgemental, and learning to respond to different attitudes and cultures is important in practicing culturally appropriate medicine.[27,28]
Furthermore, many volunteer groups, especially those with students, often choose to target certain communities—perhaps those deemed safer or more accessible. This alters the equity of care received amongst differing villages in the same country. For example, medical student electives are often restricted to Level 1 and Level 2 countries that are deemed ‘safe’, leaving out the most vulnerable populations and exacerbating the inequity that medical volunteerism aims to resolve. More thought should go into expanding the service capacity of existing resources in a way that is consistent with the context and needs of remote communities.
Volunteers therefore need to remember to be aware of one’s own cultures and beliefs and be sensitive, responsive, and respectful towards differences in culture—especially when volunteering in a culture different to one’s own. JUSTICE
The pillar of justice requires that healthcare professionals ‘seek to equitably distribute the life-enhancing opportunities afforded by health care’. The principle of justice has been described as the moral obligation to act on the basis of fair adjudication
The ethical principle of respect for each person’s rights regarding their own healthcare and to be respectful of cultural differences is pivotal. When volunteering overseas, cultural sensitivity and respecting a 10
patient’s right to choose, to maintain privacy, and to speak their own truth is a critical component of global health ethics.
ical issues and, in the near future, allow medical volunteerism to flourish as a means to improving global health.
The effectiveness of medical volunteerism would have to be decided by all stakeholders, including the treating team volunteers and local community members, with measures to ensure appropriate defences are in place. These measures should also be designed to suit the cultural values of a community or family, as well as have flexibility for the patient’s individual preferences regarding their healthcare. [5,34] There is argument as to whether certain cultural and/or religious beliefs, especially within the Asian community where doctors are regarded as ‘healers’ and ‘gods’, play a role in their preference for an authoritative approach as opposed to a more collaborative one. The concept of rights-based justice often overlaps with the ethical pillar of autonomy, which highlights respecting the rights and preferences of the patient.
Although this remains an ethical pillar that is less easily met with short-term medical trips, it is worth keeping in mind that student volunteers can still play an active role in educating patients on different aspects of health care (including nutrition and oral hygiene), which still provides a significant contribution towards patients learning to take control of their own healthcare.
The pillar of autonomy refers to respecting the right of the (competent, informed) patient to make his or her own decisions.[5,36]
Foreign medical aid is increasingly seen as our ethical duty as global citizens. As future healthcare workers, it is our duty to alleviate suffering and to protect the health of our worldwide community. The ultimate goal of these medical trips is to provide local residents with greater access to quality healthcare and to reduce the burden of disease. However, to properly achieve this requires recognition that this is a multi-factorial, complex issue and necessary consideration should be done, as addressed in this article.
The education of locals is a key element in ensuring sustainable, lasting benefit. However, this will require time that short-term missions often do not have. As the definition requires, patients should be competent and informed of the situation and management plan and this requires upskilling and competency development of local members of the community.[5,39]
Often, in developed, high-income country settings, the shared healthcare decision making model is adopted, whereby the patient and clinician work together to devise an approach that is often effective and tailored to the patient’s values and preferences.  However, in low- to middle-income countries, there is a lack of patient education and understanding regarding what treatment they are receiving and the significance of their medication in the treatment of disease.
Kishaini is a Doctor of Medicine student at the University of Western Australia. She is passionate about global health, with particular interest in migrant, refugee, and asylum seeker health, and has been involved in WAMSS’ Interhealth for the last 2 years.
Vulnerable populations often require help and likely have lower health literacy. Local healthcare workers and patients are often forced to accept help from these medical volunteers who are likely to have had more training and are equipped with more resources. However, medical students with limited knowledge may have limited roles.
Aurelne Thian is a Doctor of Medicine student at the University of Western Australia. She has an interest in many areas of medicine and global health, particularly in child and paediatrics health. Correspondence firstname.lastname@example.org
The points raised in the context of medical ethics ultimately lead us to question whether medical volunteerism, if not conducted within well-described ethical guidelines, could possibly be working against the initial agenda of improving global health inequities. Despite the increasingly popular critique on medical volunteerism, the good news is that the increasing discussion of ethics in medical volunteerism means that student volunteers are made more aware of the potential impacts of their actions. We can work towards mediating these eth-
Acknowledgements None Conflicts of Interest None declared References 1. Asgary R, Junck E. New trends of short-term humanitarian medical volunteerism: profession11
graphic by Hyun Jae Nam
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al and ethical considerations. J Med Ethics. 2013;39(10):625-631. 2. Heck JE, Bazemore A, Diller P. The shoulder to shoulder model-channeling medical volunteerism toward sustainable health change. Fam Med. 2007;39(9):644. 3. Bauer I. More harm than good? The questionable ethics of medical volunteering and international student placements. Trop. Dis. Travel Med. Vaccines. 2017;3(1):1-12. 4. Smith JK, Weaver DB. Capturing medical students’ idealism. Ann Fam Med. 2006;4(suppl 1):S32-S37. 5. DeCamp M, Lehmann LS, Jaeel P, Horwitch C. Ethical obligations regarding short-term global health clinical experiences: an American College of Physicians position paper. Ann Intern Med. 2018;168(9):651-657. 6. Toole MJ. Volunteering to help those less fortunate: Pathways for Australian GPs to acquire helpful knowledge and skills. Aust Fam Physician. 2016;45(1/2):26. 7. Keelan E. So you want to be a medical volunteer. Ulster Med J. 2015;84(3):220. 8. Jarman BT, Cogbill TH, Kitowski NJ. Development of an international elective in a general surgery residency. J Surg Educ. 2009;66(4):222224. 9. Cole DC, Plugge EH, Jackson SF. Placements in global health masters’ programmes: what is the student experience? J Public Health. 2013;35(2):329-337. 10. Yeomans D, Le G, Pandit H, Lavy C. Is overseas volunteering beneficial to the NHS? The analysis of volunteers’ responses to a feedback questionnaire following experiences in low-income and middle-income countries. BMJ open. 2017;7(10):e017517. 11. Mitchell RD, Jamieson JC, Parker J, Hersch FB, Wainer Z, Moodie AR. Global health training and postgraduate medical education in Australia: the case for greater integration. Med J Aust. 2013;198(6):316-319. 12. Ng CH. The stigma of mental illness in Asian cultures. Aust N Z J Psychiatry. 1997;31(3):382-390. 13. Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. The International Health Program: the fifteen-year experience with Yale University’s internal medicine residency program. Am J Trop Med Hyg. 1999;61(6):1019-1023. 14. Haq C, Rothenberg D, Gjerde C, Bobula J, Wilson C, Bickley L, et al. New world views: preparing physicians in training for global health work. Fam Med. 2000;32(8):566-572. 15. Thompson MJ, Huntington MK, Hunt DD, Pinsky LE, Brodie JJ. Educational effects of international health electives on US and Canadian medical students and residents: a literature re-
view. Acad Med. 2003;78(3):342-347. 16. Godkin MA, Savageau JA. The effect of medical students’ international experiences on attitudes toward serving underserved multicultural populations. Fam Med. 2003:26. 17. Snyder J, Dharamsi S, Crooks VA. Fly-by medical care: conceptualizing the global and local social responsibilities of medical tourists and physician voluntourists. Global Health. 2011;7(1):1-14. 18. DeCamp M. Scrutinizing global short-term medical outreach. Hastings Cent Rep. 2007:21-23. 19. Andersson GB, Chapman JR, Dekutoski MB, Dettori J, Fehlings MG, Fourney DR, et al. In: Do no harm: the balance of “beneficence” and “non-maleficence”. 2010 LWW. 20. Stone GS, Olson KR. The ethics of medical volunteerism. Med Clin. 2016;100(2):237-246. 21. Organization WH. Guidelines for health care equipment donations. 1997. 22. Miranda JJ, Yudkin JS, Willott C. International health electives: four years of experience. Travel Med Infect Dis. 2005;3(3):133-141. 23. White MT, Cauley KL. A caution against medical student tourism. AMA J Med Ethics. 2006;8(12):851-854. 24. McCall D, Iltis AS HEC forum: Springer p. 285-297 25. Welling DR, Ryan JM, Burris DG, Rich NM. Seven sins of humanitarian medicine. World J Surg. 2010;34(3):466-470. 26. Dowell J, Blacklock C, Liao C, Merrylees N. In: Boost or burden? Issues posed by short placements in resource-poor settings. 2014 Br J Gen Pract. 27. Association AIDs. Cultural safety for Aboriginal and Torres Strait Islander doctors, medical students and patients: position paper. Canberra, AIDA. 2013. 28. Branch E. Review of Cultural and Linguistic Diversity (CaLD) Data Collection Practices in the WA Health System. 2018. 29. Snyder L. American College of Physicians ethics manual. Ann Intern Med. 2012;156(1_ Part_2):73-104. 30. Gillon R. Medical ethics: four principles plus attention to scope. BMJ. 1994;309(6948):184. 31. Strasser R. Rural health around the world: challenges and solutions. Fam Pract. 2003;20(4):457-463. 32. Sykes KJ. Short-term medical service trips: a systematic review of the evidence. Am J Public Health. 2014;104(7):e38-e48. 33. Lasker JN. Hoping to help: the promises and pitfalls of global health volunteering. Cornell University Press; 2016. 34. Pezzella AT. Volunteerism and humanitarian efforts in surgery. Curr Probl Surg. 2006;43(12):848. 12
35. Tseng W-S, Streltzer J. Cultural Competence in Healthcare Specialties. Cultural Competence in Health Care. 2008:15-25. 36. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: a practical approach to ethical decisions in clinical medicine. 1982. 37. Hoffmann TC, Legare F, Simmons MB, McNamara K, McCaffery K, Trevena LJ, et al. Shared decision making: what do clinicians need to know and why should they bother? Med J Aust. 2014;201(1):3539. 38. Bernheim SM, Ross JS, Krumholz HM, Bradley EH. Influence of patientsâ€™ socioeconomic status on clinical management decisions: a qualitative study. Ann Fam Med. 2008;6(1):53-59. 39. Wilson JW, Merry SP, Franz WB. Rules of engagement: the principles of underserved global health volunteerism. Am J Med. 2012;125(6):612-617.
Knowledge, attitudes, and practices regarding menstruation A study on final year medical students at an Australian university Parinda Shah Sapna Dilgir Torres Woolley Ajay Rane
BACKGROUND arious taboos and myths exist in different cultures surrounding menses and these have contributed to lifestyle restrictions and induced preventable stresses for many women. Several studies have highlighted that it is important we promote education, so future doctors have a holistic understanding of this topic and are able to provide destigmatising care. There is currently minimal literature describing medical students’ knowledge, attitudes, and practices regarding menstruation.
Menstrual health and menstrual hygiene are evolving concepts in the developed world. Unfortunately, various negative misconceptions exist in different cultures surrounding menses. The resulting shame and social stigma have contributed to lifestyle restrictions and high levels of psychosocial distress for many women.[1-8]
Research has been conducted in high income countries outlining the impact of menstrual disorders, such as endometriosis, dysmenorrhoea, and heavy menstrual bleeding, on women. These conditions impact all areas of a woman’s life—social, physical, emotional, sexual, and occupational—preventing them from carrying out activities of daily living.[3,9,10] Despite this large burden of disease, there are minimal studies assessing the knowledge, attitudes, and practices regarding menstruation in high income societies. Like many Western countries, disparities surrounding menstruation are also present in Australia—mainly amongst Indigenous communities, low socio-economic backgrounds, and rural communities. Globally, a lack of knowledge is a major barrier to menstrual health management as it can lead to misconceptions, negative cultural and social norms, and negative menstrual experiences. [7,8,11] Several studies have highlighted that we must promote menstrual health education, especially amongst adolescents and healthcare providers, to prevent these outcomes.[1,2,5,12-15] Currently menstrual health represents a low priority in health education amongst remote regions of Australia.
MATERIALS AND METHODS A cross-sectional questionnaire study was conducted to explore the current knowledge, attitudes, and practices surrounding menstruation among final year medical students at James Cook University (JCU). Quantitative analysis was applied to closed questions, and open-coded questions were thematically grouped. RESULTS The overall findings (n=65; response rate=35%) highlight that while misconceptions on menstruation exist in Australian society, university is a vital source of menstrual health knowledge. Approximately half of the students felt that studying medicine normalised menstruation, while the rest felt there was no change in their attitudes as they were comfortable with this topic prior to medical school. Studying medicine also contributed to changes in 20% of female students’ menstrual practices.
The forms of social stigma identified by students were grouped into 4 themes (n=24): (1) religious and lifestyle restrictions, (2) stigma stemming from males in society, (3) the use of degrading language when referring to menstruation, and (4) unwillingness to discuss the topic. There were also varying views towards the use of medical interventions for the cessation of periods.
Medical practitioners, particularly female practitioners, are in an ideal position to promote menstrual health as they are menstruators themselves, allowing them to empathise with the difficulties faced by menstruating women while administrating care to their patients. Hence, doctors, as influencers of menstrual health amongst females, must be both knowledgeable and comfortable with the subject so they can provide compassionate and destigmatising care. Incorrect practices, inaccurate knowledge, and negative attitudes amongst those implementing menstrual health interventions, such as healthcare professionals, can interfere with patients receiving correct information.[5,7,15] Therefore, it is important to assess doctors’ knowledge, attitudes, and practices regarding menstruation. This, in turn, can improve education at a medical student level, to ensure a solid platform is provided from which future doctors can effectively manage menstrual disorders, reinforce correct menstrual practices, and
Recommendations from students for improvements to the JCU medical curriculum included providing more information on (1) different cultural perceptions of menstruation, (2) practical elements linked with menstruation, and (3) medical knowledge relating to menstruation and menstrual health conditions. CONCLUSION Studying medicine is reported by medical students to improve knowledge, promote positive attitudes, and enforce hygienic practices regarding menstruation. This, in turn, can help reduce misconceptions and promote menstrual hygiene in the wider community.
serve as advocates for women.[15,16]
One of the suggested ways to improve menstrual health management is to increase research on menstruation.[4,5,11] However, there is limited literature exploring medical students’ knowledge about menstruation. The few studies that exist are conducted in Asia and Africa,[2,17,18] with no studies focused on menstrual knowledge, attitudes, and practices in high-income countries. Hence, this study aims to
The responses were downloaded into SPSS 23 for Windows (International Business Machine, Australia). The data was coded into dummy variables and analysed using frequencies and Chi square tests. p<0.05 was considered statistically significant. Thematic analysis was carried out on student responses to the open-ended questions, which involved manually coding the data into common themes.
1. Explore the current knowledge, attitudes, and practices surrounding menstruation among final year medical students at an Australian university. 2. Identify any educational gaps in the university’s medical program regarding this topic.
RESULTS Out of the 185 students enrolled in the final year of the university’s MBBS degree in 2019, 65 students (35%) completed the survey.
DEMOGRAPHICS OF PARTICIPANTS
James Cook University (JCU) Human Ethics approval (H7473) and a letter of support from the College of Medicine and Dentistry at JCU were obtained prior to commencing this low-risk study.
The demographics of the 65 students that participated in this study are outlined in Figure 1. Overall, majority of students were female (75%) and 18-25 years old (80%). This was somewhat reflective of the 2019 medical cohort at JCU which has more females (61%) and students aged 18-25 years (68%). In terms of ethnicity, Caucasians constituted a small majority (51%) of respondents. With regards to religion, majority of respondents were Christian (34%), followed by atheists (28%).
SURVEY A cross-sectional survey was developed in collaboration with 4 subject matter experts (i.e., specialist obstetricians and gynaecologists). This consisted of open- and close-ended questions covering five main areas: demographics, knowledge, attitudes, practices, and potential improvements to the JCU Bachelor of Medicine, Bachelor of Surgery (MBBS) curriculum. For the full survey, please see Appendix A (available at https://www.ajgh.amsa.org.au).
KNOWLEDGE The main three sources of knowledge about menstruation were university (57%), followed by family (45%), and school (35%). Friends (25%), Internet/media (25%), books (3%), and health professionals (2%) were other sources of knowledge. Most male students obtained their menstrual knowledge from university, whilst female students obtained their knowledge not only from university but also family and school (Table 1). Caucasian students were more likely, and Asian students less likely, to have family as a source of menstrual knowledge (Table 2a and 2b). This was supported by student quotes such as ‘[Sri Lankan] grandparents refusing to talk about [menstruation] openly’.
PARTICIPANTS AND DATA COLLECTION The survey (Appendix A), with an attached information sheet and consent form, was distributed via e-mail to all final year students enrolled in JCU’s MBBS program in 2019. The survey was voluntary and anonymous. The participants’ demographics in terms of age and gender were representative of the 2019 JCU medicine cohort, according to data obtained from the JCU medicine administration department.
The MCQ-based knowledge quiz consisted of questions related to the menstrual cycle, dysmenorrhoea, toxic shock syndrome, and heavy menstrual bleeding. Most students outlined the role of progesterone in the menstrual cycle (72%), defined secondary dysmenorrhea (77%), identified the cause of toxic shock syndrome (74%), and outlined the treatment of heavy menstrual bleeding (89%). A score of 100% (4/4) was obtained by only 39% of students despite being final
A brief medical curriculum review was conducted to understand the topics taught in the current JCU MBBS curriculum. This was completed by liaising with relevant lecturers involved in teaching this topic throughout the 6-year degree.
said, ‘for a very common/natural occurrence for females, I was surprised about how taboo the topic is’. When asked if they felt comfortable conducting a consultation and managing patients from various cultural backgrounds who present with menstrual health issues, 89% of students felt comfortable. The remaining felt uncomfortable, as they were unfamiliar with different cultural and religious differences surrounding menstruation or would have difficulty in discussing the topic with paediatric patients.
year medical students, while 37% scored 75%, 20% scored 50%, and 3% scored 25%. Overall, 82% of students agreed studying medicine significantly improved their understanding of menstruation. ATTITUDES The main factors influencing attitudes towards menstruation were knowledge (95%), demographics (54%), and opinions of family, friends, and colleagues (46%). Most students stated knowledge influenced their attitude towards menstruation, with students reporting they were now more empathetic towards menstruating women and increased knowledge had built open mindedness regarding the topic. Other factors influencing attitudes were culture and religion (42%), media (29%), and personal experience (2%).
Attitudes towards using medical interventions for menstrual control, such as intra-uterine devices, the oral contraceptive pill, or other forms of contraception, were varied as evident through their responses to the open-ended question. Majority (69%) of students stated that cessation of periods should be a patient’s choice, that this gave them control over their body, or that it can reduce the inconvenience menstruation poses. All students aged 25-34 years largely held this view (p=0.022). A student clearly outlined the impact of studying medicine on changing her views on this topic, ‘I have seen women become functionally impacted by dysmenorrhea and heavy menstrual bleeding that requires medical intervention to enable them to function in society. Prior to this I believed we should all be menstruating’. Interestingly, 42% of students believed menstruation should only be ceased for a medical indication such as dysmenorrhoea, anaemia, or disruption of a patient’s quality of life. Forty-six percent of students aged 18-24 years (p=0.043) and 59% of Christian students (p=0.037) held this notion. Lastly, 14% of students viewed menstruation to be a natural process that should not be ceased.
Students were asked to identify forms of social stigma regarding menstruation, and their answers could be grouped into 4 reoccurring themes. The first theme was religious or lifestyle restrictions, such as not being able to enter places of worship, being unable to sit on furniture, or not being able to attend a funeral due to cultural beliefs. The other themes included stigma stemming from males in society, the use of de-grading language when referring to menstruation, and unwillingness to discuss the topic. The latter theme was common, with 19% of students, both males and females, stating they felt uncomfortable talking about menstruation with their peers. The main notion was summarised by a student who stated discussing menstruation is like ‘discussing defecation/urination’. Additionally, female students felt uncomfortable when discussing the topic with male peers. There was no correlation between feeling uncomfortable and age, gender, ethnicity, or religion, though this may be due to the small sample size available to test these relationships. Furthermore, 22% of female students felt they were treated differently at least 50% of the time whilst menstruating. Two students from those who participated specifically mentioned that social stigma, either through dismissive attitudes or religious associations between menstruation and impurity, was a barrier to women acquiring medical treatment for menstrual health issues.
PRACTICES Sixteen percent of female students currently followed cultural or religious restrictions while menstruating, including not entering religious places or being isolated in separate rooms whilst visiting their home country. Asian students were more likely, and Caucasian students less likely, to follow such restrictions (Table 2a and 2b). Of the female students, 45% felt menstrual symptoms significantly impacted their lives. For instance, menstruation resulted in taking time off from educational duties or work commitments and even interfered with relationships. Furthermore, 43% of female students found sanitary products posed a significant expense.
Regarding the impact of studying medicine on students’ menstrual attitudes, 46% of students felt medicine had normalised menstruation. Fifty-four percent of students stated there was no change in their attitude, as they had previously been open or indifferent to the topic (Table 3). Five students also noted that studying medicine had highlighted the stigma towards menstruation in today’s society. One student
When asked if medicine had contributed to a change in their menstrual practices, 20% of female students stated that it had instilled some changes. These included changing their choice of sanitary products 17
and they would not necessarily require discussions on the topic with family members. Interestingly, Caucasian students were more likely to state family members as a source of knowledge than Asian students. This could be explained by the fact that the same degree of openness in discussion of such matters might not exist in some Asian cultures.[1,2,19] These findings clearly demonstrate the importance of teaching menstruation to university students, especially as males and students from Asian backgrounds may not receive this knowledge during their younger years.
from tampons to menstrual cups, increasing their frequency of changing the products, or commencing contraception to obtain menstrual control. The reasons for these changes are outlined in Table 4. Male students were asked if they were aware of specific menstrual practices. Most (81%) male students mentioned practices related to sanitary products, such as type of product, frequency of change, and risk of overflow. They also mentioned the need for analgesia and cultural or religion-enforced practices, such as the use of menstrual huts or not being able to enter religious areas while menstruating. As outlined in Table 5, when asked if studying medicine had impacted how they treat women who are menstruating, 75% of male students stated there was no change, with the remaining 25% stating they were now more empathetic towards menstruating women.
Our study highlights that the current curriculum may be effective in levelling studentsâ€™ understanding of menstruation, despite pre-university knowledge and influences on menstruation, as there were no gender, age, or cultural-based discrepancies on knowledge performance in this study. In medicine, where all doctors will be responsible for managing menstrual-related health issues, it is important that physicians have a solid platform of knowledge on the topic, despite their demographic factors. Gaps amongst certain demographics of doctors, such as those highlighted in a study where male paediatricians had significantly lower knowledge than their female colleagues for certain menstruation-related topics, can be a barrier to adolescents receiving medical care for an important component of female health. In our study, a quarter of male students expressed they were more empathetic and had a greater appreciation for the difficulties faced by women during menstruation due to their medical education. Despite this, students felt the curriculum could be improved by incorporating practical elements for male students, including types of sanitary products, how to utilise them, and how often they should be changed.
IMPROVEMENTS TO THE JCU MBBS PROGRAM The curriculum review outlined the menstruation-related topics taught in each year level of MBBS at JCU and the methods used to teach the topics (Table 6). Overall, 37% of students believed the JCU MBBS could be improved. Recommendations for improvements could be grouped into 3 themes: more information on different cultural perceptions of menstruation, more information on practical elements linked with menstruation, and more medical knowledge relating to menstruation and menstrual health conditions (Table 7).
DISCUSSION This study highlights the knowledge, attitudes, and practices regarding menstruation among Australian final year medical students, and it is the first of this kind in a high-income nation. Students reported that studying medicine positively influenced their knowledge, attitudes, and practices regarding menstruation.
A POSSIBLE GAP IN THE CURRICULUM The current literature shows that, globally, a lack of knowledge is a major barrier to menstrual health management, as it can lead to misconceptions, negative cultural and social norms, and negative menstrual experiences.[7,8,11] An inability to discuss menstruation in an informed and comfortable way may interfere with identifying abnormal menstrual patterns, comprehensively evaluating patient health, and impact female preparedness for menarche.
MEDICAL EDUCATION: A NECESSITY AND ITS IMPACT Our study demonstrates that medical students have varying sources of information regarding menstruation, reflecting the variety in their cultural and social backgrounds. For female students, as supported by the current literature, school and family members (especially mothers) are a key source of menstrual information.[5,15] Our findings that university is more likely to be the main source of knowledge for males is not surprising given boys would receive minimal education about menstruation at school,
Given students in our study were final year medical students, it was surprising that 23% of students had a score â‰¤50% on the MCQ-based knowledge quiz. The questions that were most answered incorrectly were regarding the role of progesterone in the menstrual cycle and the causative organism 18
of toxic shock syndrome. This may indicate a gap in knowledge regarding normal menstrual physiology and pathophysiology of menstrual conditions that is not being addressed sufficiently in the university curriculum.
open-minded about the topic. It is thought better understanding and openness on this subject is naturally created as both genders are taught simultaneously with a scientific approach. MEDICAL STUDENTS’ VIEWS AND PRACTICES – THE IMPACT ON THEIR FUTURE PATIENTS
Menstrual cycle physiology and the pathophysiology of menstrual health conditions is taught in detail in Year 1 of the JCU MBBS degree and re-visited briefly in Years 4 and 5. It is possible that students performed at a level below that expected for final year medical students due to the vast volume of content they are expected to know at the completion of their degree, making it difficult to remember specific details on this subject. Retaining this information could be helped by teaching younger students, explaining the information to volunteer patients via role-play, or greater interaction with patient’s presenting with menstrual health issues during the General Practice and Obstetrics and Gynaecology rotations in Year 5.
Medical students hold varying views regarding menstruation and related topics. One such topic is that of menstrual control using medical interventions. Our findings that over two thirds of students, including all students aged 25-34 years, felt menstrual cessation using contraception was a patient’s choice suggests older students recognise the importance of menstrual control in a world where more women are studying and working. Furthermore, studying medicine exposes students to the difficulties of menstruation through their interaction with patients, highlighting the need for menstrual control. In our study, 14% of students felt menstruation should not be ceased as it is natural. This was significantly lower than Szucs et al. (2017), where 69-75% of female health science students considered monthly menstruation necessary for their health. Underlying cultural factors in the differing settings of these studies may explain the differences in results.
MEDICAL CURRICULUM VS. MENSTRUAL STIGMA
Our study revealed that medical students were aware of social stigma regarding menstruation, such as religious or lifestyle restrictions, stigma stemming from males in society, the use of de-grading language when referring to menstruation, and unwillingness to discuss the topic. Some medical students admitted to being affected or influenced by this social stigma themselves. Specifically, some female students felt they were treated differently whilst menstruating, currently practised cultural restrictions, or felt their menstrual symptoms were not recognised as legitimate medical conditions. There is evidence that due to social stigma and taboos, women may feel embarrassed, ashamed, afraid, or may not be able to identify abnormal menstruation, hindering their ability to seek medical care.[4-6,8,20] This notion was also recognised by students in our study.
Furthermore, 43% of female students in our study found menstrual products to be a considerable expense. Studies conducted in America and the UK also demonstrated that women were unable to afford the required menstrual hygiene supplies, resulting in use of unhygienic products.[16,20] Despite living in high income countries, these women faced some of the same menstrual challenges as women living in low-resource countries. A significant development in improving access to menstrual health products has been the removal of the tampon tax in many countries, with Australia leading the way. A suggestion to improve the current medical curriculum mentioned that the topic of new reusable feminine hygiene products should be included. This would allow students to be more empathetic to the practical and financial challenges of menstruating and enable them to provide cost-effective options to their future patients.
In the past decade, involvement of international activists, non-governmental organisations, UN organisations, and researchers have contributed to major developments in menstrual health, paving the way for huge social movements on this topic.[5-7] To support this movement and improve menstrual health management, medical schools need to promote awareness and education, eliminate stereotypical views of women surrounding menses, and outline the impact of sociocultural factors on patients.[2,7,12,17] Our study demonstrates that JCU’s MBBS program was effective in reducing stigma by encouraging open-mindedness and addressing misconceptions regarding this topic. This was evident from the 46% of students who stated studying medicine had normalised menstruation and made them more comfortable with discussing the topic. The remaining students felt they were already
Practices and beliefs of health practitioners may influence how they deliver patient care. Although there are no studies assessing this in regard to menstrual health, studies have been conducted in other medical fields such as palliative care and general practice which demonstrate that ethnicity and religion, as well as personal health behaviours impact provision of care to patients. 19
[21,22] Hence, a wide awareness of various cultural and social views regarding menstruation, as well as hygienic menstrual practices, are vital in providing open-minded and safe care to patients. This is particularly important as patients will have different needs and cultural beliefs in a multicultural society such as Australia. The JCU medical curriculum exposes students to different perspectives on menstruation during the first year of the degree. Although 89% of students stated they felt comfortable managing patients from various cultural backgrounds who present with menstrual health issues, students felt the curriculum could be improved by exploring perspectives by listening to menstrual experiences of women from different cultural backgrounds and role playing.
Dr Torres Woolley is an evaluation coordinator involved in evaluating graduate outcomes and curriculum learning activities across the undergraduate programs of Medicine, Dentistry, and Pharmacy at James Cook University. He has over 20 years’ experience in research and evaluation methods, analyses, and software for both quantitative and qualitative methods, with a strong focus on the use of complexity-aware techniques in impact evaluations. Professor Ajay Rane is a world renowned urogynaecologist who has acquired an Order of Australia for his aid work in helping women with pelvic floor dysfunction in developing countries including India, Bangladesh, Papua New Guinea, and Fiji. He remains passionate about education of medical students and is the director of the obstetrics and gynaecology training program at James Cook University. Correspondence email@example.com
The results were limited by 2 main factors. Firstly, only 35% of the JCU MBBS cohort participated in the survey, lending to an increased risk of bias in the data. Whilst the participant demographics represented that of the overall cohort in terms of age and gender, greater participation in the survey may have resulted in a wider variety of views on the topic. Secondly, the study was only conducted at one university and only on a single year level; hence, the results cannot be generalised to all medical students in Australia.
Conflicts of Interest None declared References 1. Chothe V, Khubchandani J, Seabert D, Asalkar M, Rakshe S et al. Students’ perceptions and doubts about menstruation in developing countries: a case study from India. Health Promot Pract. 2014;15(3):319-326. https://www.ncbi.nlm.nih.gov/ pubmed/24618623. Accessed August 2019 2. Chang Y, Hayter M, Lin M. Pubescent male students’ attitudes towards menstruation in Taiwan: implications for reproductive health education and school nursing practice. J Clin Nurs. 2012;21(3-4):513-521. https://www.ncbi.nlm.nih. gov/pubmed/21457380. Accessed August 2019 3. Schoep M, Nieboer T, Van Der Zanden M, Braat D, Nap A (2019). The impact of menstrual symptoms on everyday life: a survey among 42,879 women. Am J Obstet Gynecol. 2019;220(6):569. https:// www.ajog.org/article/S0002-9378(19)30427-2/abstract. Accessed July 2020. 4. Krusz, E, Hall N, Barrington D, Creamer S, Anders W et al. Menstrual health and hygiene among Indigenous Australian girls and women: barriers and opportunities. BMC Women’s Health. 2019;19(1):146. https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-019-0846-7#citeas. Accessed July 2020. 5. UNICEF, Poirier P ed. Guidance on Menstrual Health and Hygiene. New York, USA: Program Division/WASH;2019. https://www.unicef.org/wash/ files/UNICEF-Guidance-menstrual-health-hygiene-2019.pdf. Accessed July 2020. 6. Simavi. The Global Menstrual Health and Hygiene Collective statement. Simavi. https://
IMPLICATIONS OF THIS STUDY AND FUTURE DIRECTIONS Overall, this study suggests that certain demographic and sociocultural factors influence students’ knowledge, attitudes, and practices regarding menstruation. Conducting comparative studies in other Australian medical schools, as well as other countries, would provide a deeper understanding of factors which influence this and allow for the development of more relevant and culturally appropriate medical curricula. More studies on this subject will raise awareness on the social stigma towards menstruation that exists in the Western world and encourage research into strategies to overcome negative attitudes regarding women’s reproductive concerns. Parinda Shah studied at James Cook University and is currently an intern at Blacktown Hospital, NSW. She is passionate about women and children’s health, in particular addressing the inequity between developing and developed countries. Dr Sapna Dilgir is an obstetrician and gynaecologist who has completed a fellowship in pelvic floor and advanced laparoscopic surgery. She is a previous adjunct lecturer at James Cook University and is currently involved in teaching medical students at Griffith Base University. 20
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simavi.org /quick-read/the - global-menstr ual-health-and-hygiene-collective-statement/. Published March 2020. Accessed July 2020. 7. Tellier S, Hyttel M. Menstrual Health Management in East and Southern Africa: a Review Paper. UNFPA. https://esaro.unfpa.org/sites/default/files/ pub-pdf/UNFPA%20Review%20Menstrual%20 Health%20Management%20Final%2004%20 June%202018.pdf. Published 2018. Accessed July 2020. 8. Hennegan J, Shannon A, Rubli J, Schwab K, Melendez-Torres. Women’s and girls’ experiences of menstruation in low- and middle-income countries: a systematic review and qualitative metasynthesis. PLoS medicine. 2019;16(5): e1002803. https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002803. Accessed July 2020. 9. Young K, Fisher J, Kirkman M. Women’s experiences of endometriosis: a systematic review and synthesis of qualitative research. J Fam Plann Reprod Health Care. 2015;41(3): 225-234. https:// pubmed.ncbi.nlm.nih.gov/25183531/.Accessed July 2020. 10. Garside R., Britten N, Stein K. The experience of heavy menstrual bleeding: a systematic review and meta‐ethnography of qualitative studies. J Adv Nurs. 2008;63(6): 550-562. https://pubmed. ncbi.nlm.nih.gov/18808575/. Accessed July 2020. 11. Tull K. Period poverty impact on the economic empowerment of women. Gov.Uk. www. gov.uk/dfid-research-outputs/period-poverty-impact-on-the-economic-empowerment-of-women. Published Jan 2019. Accessed July 2020. 12. Atif K, Naqvi S, Naqvi S, Ehsan K, Niazi S et al. Reproductive health issues in Pakistan; do myths take precedence over medical evidence? J Pak Med Assoc. 2017;67(8):1232-1237. Available from: https:// www.ncbi.nlm.nih.gov/pubmed/28839310. Accessed August 2019 13. Garg R, Goyal S, Gupta S. India moves towards menstrual hygiene: subsidized sanitary napkins for rural adolescent girls – Issues and challenges. Matern Child Health J. 2012; 16(4):767774. Available from: https://www.ncbi.nlm.nih.gov/ pubmed/21505773. Accessed August 2019 14. Upashe S, Tekelab T, Mekonnen J. Assessment of knowledge and practice of menstrual hygiene among high school girls in Western Ethiopia. BMC Women’s Health. 2015; 15(84). Available from: https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-015-0245-7#citeas. Accessed August 2019 15. Singer M, Sood N, Rapoport E, Gim H, Adesman A et al. Pediatricians’ knowledge, attitudes and practices surrounding menstruation and feminine products. Int J Adolesc Med Health. 2020;20190179. https://www.degruyter.com/view/journals/ijamh/ ahead-of-print/article-10.1515-ijamh-2019-0179/ar-
ticle-10.1515-ijamh-2019-0179.xml?language=en. Accessed July 2020. 16. Kuhlmann A, Bergquist E, Danjoint D, Wall L. Unmet menstrual hygiene needs among low-income women. Obstet Gynecol. 2019;133(2):238-244. https://pubmed.ncbi.nlm. nih.gov/30633137/. Accessed July 2020. 17. Wong W, Li M, Chan W, Choi Y, Fong CA et al. A cross-sectional study of the beliefs and attitudes towards menstruation of Chinese undergraduate males and females in Hong Kong. J Clin Nurs. 2013;22(23-24):3320-7. Available from: https:// www.ncbi.nlm.nih.gov/pubmed/24580786. Accessed August 2019 18. Szucs M, Bito T, Csikos C, Parducz Szollosi A, Furau C et al. Knowledge and attitudes of female university students on menstrual cycle and contraception. J Obstet Gynaecol. 2017;37(2):210214. Available from: https://www.ncbi.nlm.nih. gov/pubmed/27923286. Accessed August 2019 19. Chote V, Khubohandani J, Seabert D, Asalkar M, Rakshe S et al. Students’ Perceptions and Doubts about menstruation in developing countries: A case study from India. Health Promot Pract. 2014; 15(3):319-26. Available from: https:// www.ncbi.nlm.nih.gov/pubmed/24618653. Accessed August 2019 20. Plan International UK. Plan international UK’s research on period poverty and stigma. Plan UK. https://plan-uk.org/media-centre/ plan-international-uks-research-on-period-poverty-and-stigma. Published Dec 2017. Accessed July 2020. 21. British Medical Journal. Doctor’ religious beliefs strongly influence end-of-life decisions, study finds. Science Daily. https://www.sciencedaily.com/releases/2010/08/100825191656.htm. Published Aug 2010. Accessed July 2020. 22. Oberg E, Frank E. Physicians’ health practices strongly influence patient health practices. J R Coll Physicians Edinb. 2009;39(4):290-291. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3058599/. Accessed July 2020.
Figure 1: Participant demographics
Table 1: Bivariate relationships between gender and participants’ main source of menstrual knowledge. Variable – Main source of Female knowledge n (%) University 22 (45%) Family 28 (57%) School 21 (43%) *Calculated using 2-sided Chi-square Test
Male n (%) 15 (94%) 1 (6%) 2 (13%)
p-value* 0.001 <0.001 0.027
Table 2a: Bivariable relationships between Caucasian ethnicity and participants’ main source of menstrual knowledge and the current practice of menstrual restrictions amongst female participants. Caucasian n (%) Family as main source 20 (61%) of menstrual knowledge Female students 1 (7%) currently practising cultural or religious restrictions *Calculated using 2-sided Chi-square Test
Non-Caucasian n (%) 8 (26%)
Table 2b: Bivariable relationships between Asian ethnicity and participants’ main source of menstrual knowledge and the current practice of menstrual restrictions amongst female participants. *Note: Due to the limited number of participants, students who identified as from the Indian subcontinent, South-East Asian, or Chinese were grouped into the umbrella term of ‘Asians’ for ethnicity.
Asian n (%)
Family as main source of 6 (25%) menstrual knowledge Female students currently 6 (43%) practising cultural or religious menstrual restrictions *Calculated using 2-sided Chi-square Test
Non-Asian n (%) 22 (55%)
Table 3: Selected student responses to ‘How has studying Medicine changed your attitudes towards menstruation?’. n (%) 30 (46%)
Examples ‘I understand it better now and am able to make more informed decisions about my own health, as well as feel more confident to explain and give advice to others.’ ‘I’m by far more comfortable with discussing and understanding the female reproductive cycle now than before starting medicine.’ ‘Medical education tends to normalize a lot of human physiology for us and a lot of students get desensitised. It makes it easier for us to normalize this for patients and explain what is needed for their education.’
‘Previously it was an awkward topic, now I just see it as a natural occurrence. Nothing to be shy about.’ ‘No, I had liberal views about menstruation previously and I still hold the same.’
‘I don’t think I had an attitude towards it beforehand. I studied at an all-boys school and so I had limited exposure outside a biology class. Indeed, my only experiences have either been in a patient or academic setting, so I feel I have no “attitude” or stigma towards the topic.’ ‘Not really. I have obviously gained a lot of knowledge surrounding the different conditions that surround menstruation and the way they affect women across the world, but my individual attitude towards menstruation has not personally changed.’
‘Menstruation has never been a taboo topic for me, my family, or my social circle.’
Table 4: Selected female student responses for reasons why menstrual practices changed after studying medicine. Why menstrual practices changed after studying medicine
Female student quotes ‘Common myths were put to rest, i.e., I now know that it is safe to skip through sugar pills in order to not have a period.’ ‘More knowledgeable about the different types of contraception and how they can manage heavy and painful periods.’ ‘Learning about contraindications of the COCP (which apply to me)… which led me to decide that the Mirena is the best option for myself.’ ‘More confident’
Table 5: Selected male student responses to ‘Has studying Medicine impacted how you treat females when they are on their periods?’. n (%) 12 (75%)
More empathetic towards women
Examples ‘Whether or not a woman is on her period has no bearing on her ability to interact or function. Studying medicine has not changed this understanding for me.’ ‘Prior to medicine it was not something I discussed so was often oblivious to the fact. I don’t think I treat females any differently when they are on their period nowadays either.’ ‘I have a greater appreciation for the difficulty that menstruating involves.’ ‘Given I know the physiology more, I am more empathetic.’
Theme No impact, still treat women the same
Table 6: The menstrual-related topics taught in JCUâ€™s MBBS degree and the strategies used to teach them. MBBS year First year
Menstrual cycle physiology
Videos & media
Social-cultural context of menstruation
Contraception options Menopause and HRT Second year Fourth year
PCOS Hormonal contraception and HRT
Uterine anatomy and menstrual cycle physiology
Q&A workbooks Lectures
Pathology: Abnormal uterine bleeding, PCOS, endometrial disorders: malignancy, inflammation Menstrual cycle physiology Lectures Contraception options
Amenorrhea Menorrhagia Endometrial malignancy
Note: These topics were covered in the Obstetrics & Gynaecology and General Practice rotations
Table 7: Selected student responses to ‘In terms of the knowledge and perspective of menstruation you have received, do you think that the JCU MBBS degree could be improved in any way to better prepare you for internship?’ Themes More education on cultural differences
n (%) 15 (63%)
Examples ‘More info around cultural differences and practices and ways in which these can be overcome’ ‘How to conduct consultations to provide more culturally appropriate care. Hearing from women of different cultural backgrounds would be beneficial’ ‘Discussions about cultural issues and stigma regarding menses could be beneficial’
More educa- 8 (33%) tion on practice elements
‘Separate the biological explanation from the social one, as well as showing some understanding of cultural values.’ ‘More information about real things—what a tampon looks like, how often it should be changed. The males in the class don’t really know these things.’ ‘Possibly a lecture in either 3/4/5/6th about essentially what to do if a young girl came to you and asked, “How do I menstruate?”. As a male, I would ask a female colleague about this because I couldn’t tell her about tampon insertion.’
More educa- 3 (13%) tion on medical elements
‘It would be interesting to maybe introduce topics such as reusable feminine hygiene products such as the menstrual cup/period underwear, as these have become more popular in recent years.’ ‘A revision of the basic science of menstruation in 4th year and how it related to contraceptives; this felt very rushed in 5th year when contraceptives are such a big part of everyday clinical practice for GPs. More knowledge about menstrual pharmacology and risks, benefits, etc.’
Asking the question ‘are we doing enough’ regularly and repeatedly is critical.
Dr. Maria Van Kerkhove Technical lead, WHO
Are doctors obligated to treat during a pandemic? In this paper, we explore the moral obligation for healthcare professionals to care for those affected by SARSCoV-2. Monique Lam
making in times of crisis relies on these foundations of medicine, which are essential to arrive at compromise during times of limited resources. Whilst healthcare workers are morally bound to treat, it is essential to recognise the potentially damaging consequences that may result for both doctors and future medical practice.
he rapid spread of virus SARS-CoV-2 (severe acute respiratory syndrome corona virus 2) has resulted in a global pandemic. Hospitals and intensivists around the world have faced ethical challenges with many countries facing limited access to ICU beds, mechanical ventilators and protective personal equipment. These unprecedented times have revealed the vulnerabilities within healthcare systems, creating confusion and disarray among health care workers as protocols and indications to test evolve daily, roles and responsibilities remain uncertain, and guidelines for treatment continue to change. These challenges include the moral obligation for healthcare professionals to care for those affected by SARS-CoV-2. Ethical dilemmas arise as treatment standards can be compromised, resulting in professional and personal hardship. There is a need for clear guidelines guided by a strong ethical framework for both medical practitioners and the public. It is necessary to approach this issue holistically to examine the effects of compromised healthcare on medical practitioners during a time limited resources. Rather than a moral obligation bound by social contract, there is an opportunity to promote altruism for others. This requires guidelines framed by ethical decision making, full transparency and clear communication.
The SARS-CoV-2 pandemic has resulted in a shift in priority from the individual to a utilitarian view, which aims to maximise the overall good for the greatest number of people. This has resulted in a number of ethical dilemmas, firstly that of restricted autonomy for health care practitioners/professionals (HCPs), as they have an ethical duty to provide treatment to patients despite the risk to their own health and the health of their family and friends. There has been significant difficulty in maximising benefit and minimising harm as SARS-CoV-2 is a new manifestation of disease, without efficacious treatment or cure. This creates uncertainty regarding prognosis, leading to restrictive criteria to treat in resource poor settings. Equitable distribution of resources is challenged in the context of limited supplies and guidelines regarding the allocation of supplies during a pandemic. NEED FOR GUIDELINES
The SARS-CoV-2 pandemic has demonstrated the need for guidelines founded in an ethical framework to establish guidelines for best practise decision making. Guidelines dispel uncertainty regarding professional rights and responsibilities, and increase the awareness and comfort levels of both the public and healthcare workers. In addition, clear communication with the public will foster trust and solidarity in doctors and the healthcare system. Guidelines based on an ethical framework allows HCPs to safeguard the standard of patient centred care and moral equality afforded outside of a pandemic. It further helps to alleviate psychological distress experienced by clinicians who are forced
As the world finds itself caught in the midst of a pandemic, complexities around the ethics of health care delivery have come to the forefront alongside the need for a vaccine and efficacious treatment. It is necessary to examine health ethics in a global pandemic as they determine the expectations of our healthcare workers and how to distribute scarce resources in a fair and equitable way. Doctorâ€™s face the ethical dilemma behind the â€œmoral obligationâ€? of healthcare professions to provide care for those with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). The moral obligation to treat is guided by the four pillars of medical ethics; autonomy, beneficence, non-maleficence and justice. Decision Recommendations
Quantifying the expected risk that HCPs are required to take The moral duty to care for both the sick as well as themselves in order to continue providing care
Expectations to do no harm to others by reducing transmission of the disease Exceptions for HCPs not required to assist (i.e. immunocompromised/pregnant) Table 1: Recommendations outlining expectations for health care workers during a pandemic.
Recommendations Clear guidelines for indications to treat, criteria for treatment and triage Regularly reviewed guidelines by a monitoring committee to ensure equitable distribution of limited resources without prejudice Treatment and triage criteria to be regularly reviewed as knowledge regarding the disease evolves Separate clinicians providing care to patients with those making triage decisions Decisions should be made by a triage officer and a team of expert respiratory physicians and infectious disease consultants Communication to the patient and family regarding treatment should be a team-based approach Table 2: Recommendations for guidelines and quality control to facilitate health care professional safety.
to make difficult decisions regarding patient care by guiding them with current evidence-based protocols.
The absence of guidelines can lead to loss of trust in healthcare professionals and reduced presentations to hospital. Healthcare workers have faced insecure housing and prejudice as a result of their occupation. Risk of exposure to SARS-CoV-2 has also lead to reduced health care access for medical and emergent conditions. The United Kingdom observed that presentations for suspected heart attacks halved since March 2020. Uncertainty about HCP roles and availability of intensive care resources such as mechanical ventilators has lead to public uncertainty which has the potential to prevent compliance with legislation and may instil a reluctance to practice reciprocity and put the needs of others above the individual. Thus, a fair decision making process with equitable distribution of scarce human resources is imperative to generate public trust and ensure the best standard of care is provided to all patients during these times. MORAL OBLIGATION TO TREAT The practitioners “duty of care” to the sick is an inherent moral obligation for HCPs. As stated by Upshur R et al. the medical knowledge and skill of physicians and health care practitioners is superior to those of the general public, it is an assumed risk taken by freely choosing a profession devoted to caring for the ill and there is a binding social contract that requires HCPs to be available and assist during times of emergency. The dilemma of a moral obligation to treat arises from the tension between a HCP’s autonomy versus their duty to “do no harm.” The SARS-CoV-2 has challenged practitioners to maintain standards of care and remain true to the ethical foundations 30
that would normally frame treatment. RESTRICTED AUTONOMY It is through restriction of individual autonomy during a pandemic that public health is preserved and protected. In addition to this, HCPs have a moral and social obligation to treat, which in itself can limit autonomy by requiring that practitioners set aside conflicting liberties. HCPs must balance the demands of their role which necessitates treating patients during a pandemic, with the risks of compromising their own health and the wellbeing of their families. Although it is easy to say that HCPs are required to treat, the dilemma arises in establishing the extent to which this obligation binds them. This includes the degree to which HCPs must risk their health to care for sick patients. The CMA Code of Ethics states that HCPs have an obligation to treat. “when pestilence prevails, it is their (physician’s) duty to face the danger and to continue their labours for the alleviation of suffering, even at the jeopardy of their own lives.”  Conversely, Upshur et al. questions whether HCPs should have “minimal self-regard” and “pursue their duties at the cost of their own lives.”  Dr James Mahoney, a 62 year-old Pulmonologist from New York, delayed his retirement to assist in the ICU at University Hospital Brooklyn.  Due to the severe lack of medical equipment, and limited supplies of PPE, Dr Mahoney contracted SARS-CoV-2 and passed away. It is clear that in a resource poor setting, assumptions of a moral duty of care can imply that the life of a healthcare worker is less valued than that of
a member of the general public. On May 23rd 2020, the death toll of healthcare workers in England and Wales alone had surpassed 300 deaths, three times more than the number of deaths in Australia. With such high risk posed HCPs, it is essential to clarify roles and responsibilities, increasing the likelihood that HCPs will altruistically contribute to the crisis.
ern Italy, however, was one of the first countries to experience the crisis. Hospitals lowered the age cut off for treatment from 80 to 75, and doctors were forced to decide who received potentially life-saving treatment. In response, the Italian College of Anaesthesia, Analgesia, Resuscitation and Intensive care issued recommendations for critically ill patients in the ICU, urging “clinical reasonableness” and a “soft utilitarian approach in the face of resource scarcity.” Thompson et al. argues that not only do we need to consider the ethics when establishing practise guidelines, but also to reflect on the “moral obligation to demonstrate transparency, accountability, fairness and trustworthiness in allocation of scarce resources.” These guidelines should aim to fairly allocate resources and be directed by a utilitarian framework to maximise the best possible outcome for the most people.
RESOURCE ALLOCATION DURING TIMES OF SCARCITY Whilst HCPs strive to deliver the same standard of care to all patients, during a pandemic resource limitations can result in inequities in health care delivery. HCPs are further limited in their ability to exercise their clinical judgement as they are bound by treatment criteria. Patient centred care and the “responsibility of acting for the benefit of the patient is… a sacred duty that all physicians owe to their patients.” To choose who receives treatment thus violates the obligation to do no harm and transgresses deeply held moral beliefs.
PHYSICAL AND PSYCHOLOGICAL IMPACTS
“Fifty years ago, US doctors could be charged with crime for rationing health care. It was considered murder or manslaughter. Treating everyone equally was a matter of both law and ethics. Even when survival chances were uncertain, ethical and legal mandate was to continue treatment.”
Not only do physicians face the trauma of violating ethical standards by withholding or withdrawing treatment, but it is compounded by patients dying alone and away from family and loved ones. Neil Shortland, Professor of criminology and justice studies likened the moral anguish caused by such a decision to the psychological trauma occurring in soldiers who are forced to witness or engage in acts that “transgress their own morals and beliefs.”(8) To base
Australia has had the benefit of geographical isolation, reduced community transmission and time to prepare for an influx of SARS-CoV-2 patients. North-
Physical impacts · Overwhelming amount of critical cases leads to physical and mental exhaustion and impaired decision. This causes HCPs to be more prone to making errors, thus creating more guilt. Eventually, this becomes a vicious cycle affecting the doctor’s ability to function, let alone to treat. · Physical exhaustion and the neglect of self needs as doctors place the needs of patients above their own, prevent HCPs from providing treatment in the long term as the crisis continues (burn out)
Psychological impacts · Decreased self-esteem as doctors, emphasising feelings of imposter syndrome · Creating doubt regarding their current knowledge, thus affecting treatment of other patients regardless of disease · Causing a profound sense of helplessness as they must “let patients die.” This helplessness is worsened by the fact that the disease currently has no known treatment or prevention · Anxiety and depression as a result of helplessness increasing suicidal ideation and suicide attempts · Post Traumatic Stress Disorder (PTSD) · Mental exhaustion also affects HCP’s relationships with families and co-workers. Conflict decreases morale and can also lead to decreased trust and solidarity
Table 3: The physical and psychological impact of delivering health care during a pandemic.
decisions on making the “least-worse” decision creates a psychological trauma known as “moral injury.” This psychological harm is so great that it can damage one’s sense of right and wrong and cause severe traumatic grief and long-term trauma. The consequences of these decisions can physically and psychologically impact physicians. CONCLUSION HCPs face a multitude of challenges regarding their moral obligation to treat and providing optimal care during a pandemic in a resource finite setting. Establishing practice guidelines fosters solidarity and trust in the hospital system, creating sustainable and equitable environments with a patient centred focus. These guidelines must be transparent and inclusive to foster public trust and cooperation and define HCPs scope of practice. It is through guidelines and codes developed within an ethical framework that we are able to create this environment, and the burden faced by HCPs can be significantly lessened. Monique Lam is a final year medical student from Bond University, Gold Coast. She is incredibly passionate about global health particularly around refugee and maternal health as well as international aid. Throughout her medical degree, she has been actively involved in organising and attending events run by the Bond University Making a Difference Global Health group. Quality is her middle name. Acknowledgements Nil Conflicts of Interest Nil Correspondence firstname.lastname@example.org
References 1. Ruderman C, Shawn T, Benismon C, Bernstein M, Hawryluck L, Zlotnik Shaul R et al. On pandemics and the duty to care: whose duty? who cares?. BMC Med Eth. 2006;7(5):1-6 2. Thompson A, Faith K, Gibson J, Upshur R. Pandemic Influenza preparedness, an ethical framework to guide decision making. BMC Med Eth. 2006,7(12):111 3. Uibu K. Doctor evicted over coronavirus fears after she refused to stop ‘essential’ hospital work [Internet]. ABC News [cited 2020 June 03]. Available from: https://www.abc.net.au/news/2020-04-22/coronavirus-fears-doctor-evicted-during-crisis/12162880 4. Wood J. COVID-19 is causing people with other serious illnesses to avoid hospital [Internet]. World Economic Forum [cited 2020 May 27]. Available from: https://www.weforum.org/agenda/2020/04/ 32
covid-19-hospitals-empty-cardiac-emergencies-pandemic/ 5. Upshur R, Faith K, Gibson J, et al. Stand On Guard For Thee Ethical considerations in preparedness planning for pandemic influenza. Toronto; University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group; 2005 6. Coleman J. Doctor who delayed retirement to fight pandemic at low-income hospital dies of COVID-19. The Hill [cited 2020 May 21]. Available from: https://thehill.com/blogs/blog-briefingroom/news/498354-doctor-who-delayed-retirement-to-fight-pandemic-at-low-income?fbclid=IwAR3kyPdfDh-kn7kvJiKwTk1uA3NzvHK6K-h56DrvjXnpCyn3zhxCHGm_p5Y 7. Reference Worldometer. Coronavirus cases. Worldometer Web site [cited 2020 May 23]. Available from: https://www.worldometers.info/ coronavirus/coronavirus-cases/ 8. Shortland N. Doctors are making life-anddeath choices over coronavirus patients – it could have long-term consequences for them. The Conversation [cited 2020 May 18]. Available from: https://theconversation.com/doctors-aremaking-life-and-death-choices-over-coronavirus-patients-it-could-have-long-term-consequences-for-them-134728 9. Shurkin J. COVID-19: The ethical anguish of rationing medical care. Discover Magazine [cited 2020 May 18]. Available from: https://www.discovermagazine.com/health/covid-19-the-ethical-anguish-of-rationing-medical-care 10. Rosenbaum L. Facing Covid-19 in Italy – ethics, logistics, and therapeutics on the epidemic’s front line. N Engl J Med. 2020;382(1):18731875 11. Coronavirus lockdown protest: What’s behind the US demonstrations? BBC News [cited 2020 May 17]. Available from: https://www.bbc. com/news/world-us-canada-52359100
We need to learn the lessons that are being shown from this virus.
Dr. Michael J. Ryan, WHO
The fight against gender based violence A first-hand look at what it takes to end violence against women, with Dr Emma Fulu
or most of us, the idea of eliminating worldwide violence against women is well and truly in the ‘too hard’ basket; but not for feminist icon Dr Emma Fulu.
countries, we have an office in Timor-Leste and I’ve since set up a charity in New York. COULD YOU TELL ME A LITTLE BIT MORE ABOUT WHAT YOU DO AT THE EQUALITY INSTITUTE?
Dr Emma Fulu is a feminist activist, social entrepreneur and one of the world’s leading experts on violence against women. She is the founder and Executive Director of the Equality Institute, a global feminist agency dedicated to the prevention of violence against women and girls. She is also the co-founder of VOICE, a non-profit organisation that works with women and girls in conflict and disaster settings to amplify their solutions to violence in their own communities.
We’re a global feminist agency and our priority is advancing gender equality and ending violence against women. We do that through three core areas – research, creative communication, and policy and advocacy work. So for example, we do a lot of research to try to understand violence against women and also to evaluate programs and policies to see what’s working in different settings. We then work with a lot of global organisations like the UN and Word Bank to help set the policy agenda, and then we also do work on social media to ignite the conversation around feminism and gender equality and how to end violence.
In August 2020 she was interviewed by Kate Maddams. They discussed Dr Fulu’s work, the gendered impacts of the COVID-19 pandemic and how medical students can help end violence against women. COULD YOU GIVE US SOME INSIGHT INTO HOW AND WHY YOU STARTED THE EQUALITY INSTITUTE?
IT SOUNDS LIKE EXTREMELY REWARDING WORK YET AT THE SAME TIME THE CONTENT OF THE WORK IS ALSO DEEPLY UPSETTING, HOW DO YOU MANAGE THE NATURE OF THE WORK?
I’m a researcher by background, and have been researching in the field for almost 20 years now. I initially was doing a degree in International Development Studies at university where I became interested in the gender dimensions of international development. My family is actually from the Maldives, so when I finished my honours degree I went to the Maldives to work at the Ministry of Gender. One of the first things they asked me to do was look into the issue of violence against women. They had anecdotal evidence that the problem existed but didn’t really know the scale of the problem so they asked if I could try to do some research.
That’s a good question. The focus of our work is predominantly on primary prevention, so trying to address the root causes, and we take a very positive, strength based, empowerment approach. So even though the content of the work is very heavy, because we are working to create positive change, that keeps the work positive and engaging and it feels like you’re doing something meaningful. For me, I feel like I’d be more depressed if I wasn’t doing anything towards the issue. It’s a deep passion for me and for members of my team so I think as hard as it is some days, we all feel better for actually trying to do something to end violence against women.
I ended up working with the World Health Organisation (WHO) to do the study – the first national prevalence study in the Maldives. From then on I kept working in the space, I’d found my passion. I worked with the United Nations (UN) and then moved to South Africa to lead another global program on violence prevention. In the midst of that I had three kids. So I was doing a crazy job, travelling a lot, and the truth is I burnt out. I knew I was still passionate about the work but was struggling to do the career. So I moved back to Australia to be closer to my family and to re-assess, and that’s when I started the Equality Institute.
I think we also see change happening, so while from a distance it can look like this issue is overwhelming, that’s not true. We are actually seeing rates of violence decrease in some countries, we are seeing programs that are actually having an impact on the ground, and we are seeing women and girls all over the world leading that change which is really inspiring. So most of the time I feel inspired more than I feel upset, but we do have to take care of ourselves as well because it is hard work.
I started it with the idea that I wanted to combine research with policy and create a space where there was nurturing and I could balance my career with my family. It started small but it has grown now to be a global agency. We’ve worked in more than 20
You know, when I started in this field about 20 years ago, no one was talking about violence against women and now it’s on the global agenda. there’s the sustainable development goals which all countries have to report on. In my 35
career I have seen massive change, and that’s motivating.
THERE’S BEEN SOME CONCERNING REPORTS OF INCREASED VIOLENCE IN THE HOME DURING COVID-19 LOCKDOWNS AROUND THE WORLD. CAN YOU EXPAND UPON THIS?
At this point, we really need to focus on violence against women, and we also need women to be leading this response because they know the issues that they are facing. It’s a really challenging time for many, many people.
Sure. There definitely is, and while we still don’t have all of the data, what we do know is that in Australia we’re seeing increased rates of reporting around violence against women. We know that during the lockdown, home unfortunately isn’t always the safest place for some women and children. It also makes it harder for these people to seek support. We’re seeing diversity in the types of violence that women are experiencing, for example technology facilitated abuse and more controlling behaviour.
DO YOU THINK THE GOVERNMENT IS RESPONDING TO THIS APPROPRIATELY? I think there is definitely more that could be being done. Importantly, ensuring that response services are well funded, but also looking at other ways to protect women in vulnerable circumstances. I think there’s the opportunity for using this time to create long term changes. It’s a complicated issue but we have some lessons from a humanitarian context, that when things fall apart, as challenging as the situation is, it also offers opportunities.
The pandemic is also impacting gender equality through risk of catching the virus. In the vast majority of countries, a higher percentage of front-line workers (health workers for example) are women, putting these women at a higher risk of being infected with COVID-19.
In Australia we currently have the chance to think about long term systemic and structural changes, and to improve gender equality through this process. That could be things like restructuring childcare and thinking about existing child caring responsibilities as well as norms around men and women’s work. It’s a time when all of these norms are being disrupted and I would like to see more of that long term change and investment in transformation rather than just responding to the crisis. I think we need to be thinking more holistically about what’s possible to create in the post-COVID world.
On top of this there have been interruptions of supply chains for medical products. For example, women’s access to contraception is being impacted because the world’s largest IUD factory has shut down. Shipping interruptions are also worsening the issue. So there’s a huge number of effects that we’re just starting to get a sense of, but we really need to collect more data to get a better understanding of the
AS JUNIOR DOCTORS AND FUTURE DOCTORS, IS THERE ANYTHING IN RELATION TO GENDER BASED VIOLENCE THAT YOU THINK WE SHOULD BE AWARE OF?
Violence against women is now defined very clearly as a global public health issue. The evidence is clear that it has an impact on women’s physical, mental and reproductive health. We also know that in Australia it’s the greatest health risk factor for women in their reproductive years - greater than smoking, alcohol and obesity. What we know is that women
Image 1. Caption: Dr Emma Fulu
who experience violence are engaging with doctors and health professionals more often. So doctors are inevitably going to be seeing women who have experienced violence. Globally, one in three women will experience sexual or physical abuse. So you will be seeing those women. The issue is that they don’t always present as experiencing violence through injuries - they may be presenting with a variety of other health consequences and concerns.
player in a big ecosystem and we’re trying to contribute in areas that we feel like we can. Personally, I tend to be a big dreamer. I’ve always been interested in pushing things further. I have a vision of supporting people to be themselves, because I really feel that everyone benefits from gender equality - it’s really about people having the freedom to live the lives they want to live. I personally feel like feminism is for everyone and feminist leadership can help transform the world. So I guess my big vision is expanding the reach of that type of work and broadening the people who feel engaged in this issue. For us at The Equality Institute, that manifests in lots of different forms and I’m really open to seeing where that takes us as an organisation.
There’s a lot of work being done globally to help health workers identify and be able to provide the right treatment for people who are experiencing violence. So I would say it’s being aware. Alongside this awareness though, there really needs to be a whole health system response. It has one of the highest health burdens of any health issue facing people in this country.
The WHO has some great guidelines on this for healthcare professionals. And it does really require training. It’s not just about asking the basic questions, it’s also about noticing the subtle signs and symptoms that might indicate experiences of violence. It’s also about being able to ask in sensitive and safe ways and then knowing ways to support women. I think it’s an area that should definitely be introduced into medical training.
Conflicts of Interest Nil References Nil
As MEDICAL STUDENTS WHO ARE PASSIONATE ABOUT FEMINISM AND GENDER EQUALITY, DO YOU HAVE ANY SUGGESTIONS FOR HOW YOUNG PEOPLE CAN ADVOCATE IN THESE AREAS?
A few ways! There’s a public health approach. A lot of the work globally being done in the field of violence against women is being completed by public health experts who are medically trained. So there’s always the opportunity to combine being a doctor with a public health focus and then potentially have an influence on policies and health promotion in that regard. But I also think it doesn’t necessarily have to be through the health space, it can be through talking about these issues in your families and communities or finding local organisations working on gender issues. I recommend trying to identify the space that you’re most passionate about, finding like-minded people and going from there. We [The Equality Institute] will also be starting to develop more resources and support for people to engage with these issues. WHAT’S YOUR VISION FOR THE EQUALITY INSTITUTE? Within our organisation, we envision a world where diversity is celebrated, all people are respected, and resources are shared. We recognise that we are one 37
Under the microscope
t is safe to say that 2020 has been a significant year for global health. The pandemic has changed the world in ways we could never have imagined. Borders have closed. New borders have been built. As social distancing becomes the norm, our lives become increasingly virtual. In a time of muddled and murky misinformation, we will rely heavily on peer-reviewed scientific research to guide us through the noise. The need for transparent and open scientific debate has never been more critical. As students learning these skills, it will be up to us to shape the future of our global health.
The time has come for us to read Between the Lines, appreciating todayâ€™s issues in order to craft tomorrowâ€™s solutions.
The AJGH Team
Climate change and sexual and reproductive health: impacts and solutions
How family planning can help with tackling climate change Betrice Walker 40
ductive health. In consideration of these findings, this review discusses how strengthening efforts to achieve SRH outcomes through family planning may offer a dual benefit of improving health whilst assisting with mitigation of and adaptation to climate change.
lobal climate change represents a grave threat to the future of human health and our natural environment. Progress towards achieving universal access to sexual and reproductive health services, family planning, maternal and neonatal healthcare, is likely to be affected in the absence of urgent and significant action. New challenges associated with a changing environment are likely to arise and further impact maternal and infant health outcomes, fertility, rates of sexually transmitted infections and risks of sexual violence. At the same time sexual and reproductive health is inherently linked to sustainable population growth, a contributing factor to climate change. Maintaining ongoing progress towards improving sexual and reproductive health outcomes, and strengthening existing health services to adapt to climate related changes, offers a dual benefit of improving health outcomes and mitigating one of the key drivers of climate change, population growth.
METHODS Keyword searches of Medline, CINAHL and Scopus databases were used (searched June-July 2020), supplemented by manual searches of relevant journals and reference lists of primary articles. Keywords included: “climate change”, “sexual health”, “reproductive health”, “maternal health”, “maternal-child health”, “women’s health” and “sexually transmitted diseases”. Studies were included if they detailed the impact of climate change on sexual and reproductive health, population-based strategies and family planning in the context of the environment. Key outcomes included: maternal and child health, fertility, menarche, HIV infections, mother-tochild transmission of HIV, vector borne diseases, access to SRH healthcare and gender-based and sexual violence. All study designs and settings were included to provide breadth to the discussion. The field was narrowed based on publication date after 2007, peer review, English language and relevance. The initial search yielded 181 results. Title and abstract screening identified 91 eligible articles. Full text screening identified 51 articles which were included in the narrative review synthesis.
SUMMARY This narrative review aims to explore the impact of climate change on sexual and reproductive health. It will discuss how the realisation of sexual and reproductive rights and the advancement of gender equity through voluntary family planning could contribute to sustainable population changes as a part of a comprehensive climate change strategy.
THE EFFECT OF CLIMATE CHANGE ON SEXUAL AND REPRODUCTIVE HEALTH OUTCOMES Climate change impacts on SRH through increased frequency of natural disasters, increased average seasonal temperatures, food insecurity, poor air quality and altered geographic distribution of vector borne diseases as described in Figure 1. In the wake of natural disasters, direct damage to healthcare infrastructure threatens existing services whilst human displacement and migration bring many new challenges. Changes to SRH outcomes are also mediated through indirect pathways, including changes in crop yields, distribution of infectious disease, and violent conflict. Consequently, climate change acts as a health-threat multiplier, impacting on health and healthcare systems to broaden already existing health and social inequalities. Due to the close relationship between SRH, gender equity and environmental health, as van Daalen et al suggests, the effects of climate change on health are overwhelmingly negative, with women often bearing
INTRODUCTION Global climate change has been declared the greatest health threat of the 21st century. Increased frequency of natural disasters, extreme temperatures, pollution, food insecurity and altered distribution of vector borne disease threaten all aspects of human health, including sexual and reproductive health (SRH). New SRH challenges posed by climate change, in combination with ongoing rapid population growth, places strain on existing health services, perpetuates environmental degradation, and impairs the ability of communities to adapt to climate change. As such, voluntary family planning has been identified as a strategy to mitigate rapid population expansion and its associated environmental impacts, as a part of a broad approach to climate change.[2-6] This narrative review summarises available evidence regarding the impacts of climate change on sexual and repro41
Figure 1 Sexual and Reproductive Health Impacts of Climate Change [9-23]
the brunt of both morbidity and mortality.  Those living in the low-income and middle-income (LMICs), where SRH outcomes are poorest, currently are, and will continue to be disproportionately affected. DIRECT HEALTH EFFECTS MATERNAL AND NEONATAL HEALTH There is a growing literature base linking environmental changes such as extreme heat and air pollution with poor neonatal and maternal outcomes. A recent systematic review found that temperature extremes adversely impact birth outcomes including gestational length, birth weight, stillbirth and neona42
tal stress. Heat waves during pregnancy have also been associated with an increased risk of maternal complications such as hypertension, uterine bleeding, eclampsia and incompetent cervix. Exposure to ambient air pollutants including nitrogen oxides, particulate matter and ozone has also been linked to an increase in the risk of hypertensive disorders in pregnancy and exposure to high concentrations of fine outdoor particulate matter has been associated with low birthweight. However, there is insufficient evidence to conclude if air pollution is associated with preterm birth. There is also a body of epidemiological literature
which supports the contention that experiencing stress during pregnancy from direct or indirect exposure to disasters can adversely affect reproductive outcomes.[11,23,24] A recent systematic review concluded that the major concerns for pregnant women exposed to disasters relate to decreased foetal growth and maternal mental health problems, especially in the most directly exposed women. Given that natural disasters are predicted to occur more frequently and with higher intensity with climate change, poor pregnancy and birth outcomes could increase in accordance.
 Climate change impacts on the health of HIV patients directly, but also on socioeconomic determinants of HIV transmission, such as migration, gender inequities and poverty. Chersich argues that climate change could undo considerable gains made by programs aiming to prevent MTCT of HIV through reduced access to antiretroviral medications in the aftermath of disasters or due to migration, wastage of heat sensitive medication, and increased liquid requirements for infants during heatwaves resulting in high viral load exposure as a consequence of increased breastmilk consumption.
A mother’s health during pregnancy impacts their future health and birth outcomes, and as such, the effects of extreme heat, air pollution and natural disasters are likely to persist. Growth restriction and prematurity have lasting health implications for the child and significantly contribute to infant morbidity and mortality. This illustrates the potentially long-lasting effect of climate change on maternal and neonatal heath. The magnitude of these effects is significant when considering these issues at a population level.
MENARCHE Menarche, the first occurrence of a woman’s menstrual period, indicates the onset of reproductive capacity and the transition from childhood to womanhood. Age of menarche is associated with a country’s fertility and female mortality rates, and is often delayed by high mortality and fertility rates. Timing of menarche is likely to be influenced by numerous factors, including the environment and therefore may be impacted by climate change.  A recent systematic review by Canelón and Boland explored the potential for climate change events to alter the age of menarche by disrupting food availability or via increased toxin/pollutant release. They concluded that perturbations in the timing of menarche secondary to climate change are likely to increase the disease burden for women in four key areas: mental health, fertility-related conditions, cardiovascular disease and bone health. There have been no further studies assessing the impact of climate change on menarche, so further research in this area may identify other risks to women’s health.
FERTILITY There is mixed evidence regarding the impact of climate change on fertility biology and behaviours. A study utilising US natality files and climate data found no statistically significant impact of heat waves on birth rates, concluding heat waves do not influence fertility decisions.  However, this literature review found three other studies which would indicate otherwise. Firstly, a longitudinal household survey utilising climate data in Indonesia observed reduced fertility following abnormally high temperatures, particularly amongst women living on farms.  Secondly, a Korean study estimating the effects of temperature on birth rates found that an additional day with a maximum temperature of 30-32oC, relative to 28-30oC, decreased the birth rate 9 months later by 0.24% or 92 babies per month.  Finally, a study in the US observed a similar drop in birth rates at 9-10 months, but also found a partial rebound at 11, 12 and 13 months. This study was the only study to include analysis of the underlying cause of reduced fertility. They attributed the reduced birth rates to the high temperatures affecting reproductive health rather than reducing sexual activity. Due to the complex and interrelated nature of fertility behaviour and biology, future studies are necessary to confirm the potential impact of climate change on fertility.
VECTOR BORNE DISEASES Vector borne diseases often exhibit seasonal patterns, or year to year variation and are likely to be sensitive to climate change. In particular malaria, dengue and zika pose substantial risks for the pregnant woman, foetus and newborn child. As seen in Figure 1, pregnant women have a higher risk of severe malaria, resulting in anaemia, acute respiratory distress syndrome, hypoglycaemia and coma. Malaria infection during pregnancy is associated with miscarriage, stillbirth and LBW, and it is suspected to be an underreported cause of maternal mortality. Dengue virus during pregnancy is associated with increased risk of caesarean, eclampsia and growth restriction, while Zika primarily poses a risk to the foetus of microcephaly and impaired cognitive develop-
HIV INFECTION AND MOTHER-TO- CHILD TRANSMISSION (MTCT) OF HIV Existing literature acknowledges numerous bidirectional interactions between HIV and climate change. 43
ment.  Changing distribution and increased burden of these diseases therefore pose a threat to SRH. INDIRECT HEALTH EFFECTS LACK OF ACCESS TO HEALTHCARE SERVICES Key sustainable development strategies targeting sexual health rely on strengthening existing healthcare services, however access to healthcare services is threatened during natural disasters. Lack of access to essential contraceptive and abortion services may increase the risk of unplanned pregnancies, sexually transmitted diseases and unsafe abortion, while reduced access to maternal healthcare impacts on maternal mortality rates. A case study exploring disruption to maternal healthcare during annual flooding in rural Bangladesh found a lack of planning for the management of maternal complications directly impacted on maternal outcomes, with a female to male death ratio of 3:1 and an increase in inadequate antenatal care from 1.3% to 3.9%. Planning for natural disasters in climate change strategies must include SRH services in order to allow provision of essential medical care. FOOD INSECURITY AND MALNUTRITION Many LMIC families depend on small-scale rainfed agriculture and livestock systems whose food production will be impacted by environmental changes with climate change. Lack of food availability results in nutritional deficits that disproportionately affect women, impacting on pubertal development, pregnancy outcomes and breastfeeding.
GENDER-BASED AND SEXUAL VIOLENCE Physical and sexual violence increases following disasters and evidence indicates that the propensity for interpersonal violence may increase in uncomfortably hot temperatures.[20, 22] As such, there is a general consensus that climate change will correlate with increased violence against women. Sexual violence has both short- and long-term consequences on women’s physical, mental, and SRH, including; unwanted pregnancy, abortion, sexually transmitted infections (STIs), HIV/AIDS, recurrent urinary tract infection, pelvic pain, pelvic inflammatory disease and genital injury.[33, 34] THE IMPACT OF POPULATION ON CLIMATE CHANGE AND SRH OUTCOMES By 2050, the population is expected to increase to 10.9 billion people, from today’s 7.7 billion, with the expansion primarily taking place in sub-Saharan Africa and South Asia. In these countries, population growth 44
is driven by high fertility rates where women have on average 4-7 children.  The effect of rapid population growth is three-fold in resource poor settings. Firstly, rapid population expansion brings unsustainable consumption and production, resource scarcity and places stress on natural infrastructure. Secondly, an increasing number of fertile and pregnant women places strain on already struggling maternal health services; requiring existing strategies targeting maternal mortality to increase in proportion with population growth. Thirdly, population expansion increases vulnerability to climate change and impairs the ability of countries to adapt to climate change. The collision between global warming and rapid population growth has the potential to precipitate a major humanitarian disaster. Yet population dynamics have not been effectively integrated into climate change science.[38, 39] FAMILY PLANNING AS A COST EFFECTIVE SOLUTION Integrating family planning (FP) into broader climate policy could offer a dual benefit of assisting with mitigation of climate change and improving SRH outcomes. It will also enhance the capacity of LMIC to adapt to climate change, and in doing so, reduce the risk that climate change poses to SRH. FP is defined as the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and time of births. FP offers a unique solution among medical interventions as seen in Figure 2. It reduces poverty, maternal mortality and increases community resilience, women’s education and empowerment in addition to mitigating climate change through stabilisation of global populations. [2-6, 39-41] In countries which continue to experience a high fertility rate, there is a high level of unmet need for FP services. Consequently, in their latest report, the Intergovernmental Panel on Climate Change (IPCC), identified voluntary FP as an important climate change mitigation and adaptation strategy. FP is also a cost-effective investment. According to the Guttmacher Institute, an investment of $8.56 per person per year would ensure that all women in developing regions receive essential maternal and newborn care and effective contraceptive services.  PRACTICALITIES TO IMPROVE UPTAKE AND EFFECTIVENESS OF FAMILY PLANNING CLIMATE STRATEGIES COMBINING HEALTH WITH OTHER MESSAGES Multiple studies have found that combining
health and environmental or economic messages has the potential to reach a wider audience than single sector interventions.
The argument for female education is strengthened by its documented contribution to resilience in the face of the climate change. From a SRH perspective enhancing female education is associated with positive maternal health outcomes, including reduced maternal mortality, unwanted pregnancy and increased antenatal healthcare usage. Educated and empowered women with improved health, increased financial capacity, and smaller, more prosperous families will also be better equipped to recover from environmental and economic shocks that are likely to increase with climate change.
A qualitative study in rural Northern Kenya, where families depend on natural resources found that relating family size to the environment is a compelling strategy to improving support for FP among Samburu men. Another project in eastern Ethiopia combined efforts to promote sustainable land practices, land rehabilitation and modern FP and HIV/ AIDS awareness, by inviting professionals from local health facilities to partake in environmental training sessions. By integrating SRH awareness, the project has helped to ensure that the environmental benefits are sustainable, protected from being eroded by rapid population growth and complemented by improved SRH. Further, a community based study in Uganda suggested that promotion of FP to time births according to the most optimal seasonal conditions for pregnancy might also be also be considered as an initiative to enhance perinatal health in the light of a changing climate.
INCORPORATION IN GENDERED POLICY The impacts of climate change are not the same across genders, and as such Sorensen et al suggest including gender in climate policies is essential to addressing the complex interactions between poverty, gender-based discrimination and climate change. This sentiment is echoed in the UN women’s guidebook “Leveraging Co-Benefits Between Gender Equality And Climate Action For Sustainable Development”, which provides a practical guide to help stakeholders integrate gender equality considerations in climate projects. Given that the relationship between SRH rights and gender inequality is bidirectional and self-reinforcing, efforts to improve gender equality through gendered climate change strategies will inevitably benefit SRH outcomes.
ENHANCING FEMALE EDUCATION The relationship between FP and girls’ education is mutually reinforcing; when girls have access to FP, they have greater access to education and when girls are more educated they desire contraceptive use, further advancing their time in school and economic opportunities. Wheeler found in countries where female schooling rates are particularly low, greater attention to female education increases FP productivity and carbon emissions abatement more rapidly.
Figure 2 Family planning: impacts on fertility rates, maternal morbidity, female empowerment and climate change (Adapted from Marie Stopes International)
Although population based approaches are not the only strategies to confronting the climate change challenge, slowing population growth could reduce global emissions by 40% in the long term. FP, integrated with environmental strategies, enhanced by female education and gendered climate policies has the potential to improve SRH outcomes, gender inequality and slow population growth. It therefore acts as both a climate change mitigation and adaptation strategy. Though prior literature has iterated the controversial nature of “population control” as an approach to climate change,  this idea undermines the very nature of FP, which is voluntary and rightsbased at its core, serving to empower individuals and couples’ control over becoming pregnant and birth spacing. Given that many women cite that they have an unmet need for contraception, it is hard to argue that meeting this need would limit their choice in the matter, particularly in the light of the SRH benefits FP offers. Challenges limiting the success of population-based climate change strategies and access to FP are complex and often intertwined with social and economic factors. Incorporating health messages with economic and environmental messages, promoting female education and gender equity may assist in overcoming these challenges. Further, recognising that neo-liberalism relies on population growth to maintain wealth and power is instrumental in understanding resistance to effective climate action and population-based strategies.
Additionally, while population growth is occurring more rapidly in developing countries, FP also has a role to play in higher income countries. The richest 10% of the world’s population are responsible for almost half the total lifestyle consumption emissions and amongst the high income countries, up to one third of pregnancies are unintended, hence, ongoing efforts to promote FP in these countries will also contribute to reduced carbon emissions. Further research is essential to fully understand the impact of climate change on SRH, and population on climate change, and in turn, to evaluate the efficacy of any population-based strategies which are implemented. Areas for future research identified in this narrative review include: the effect of air pollution exposure on neonatal outcomes, the impact of natural disasters on maternal and neonatal health, changes to fertility behaviour and biology secondary to climate change as well as climate related changes to timing of menarche. Merging population and climate data will be vital in this process. Due to the interconnected relationship of many aspects of SRH with behaviour and the environment, confounding factors must be accounted for in future research methodologies. As 46
such, Grace suggests research strategies for conducting micro-level empirical research, expanding on existing social research frameworks, to ensure that research on the links between climate, fertility and reproductive health outcomes in developing countries is an accurate reflection of the situation. Outside of FP, other strategies to protect SRH will be necessary as environmental shocks and climate change occurs. These include emergency plans for maternal health to address the immediate needs of pregnant women during disasters, contingency plans to ensure access to essential medications such as antivirals, misoprostol and magnesium sulphate, enhancing access to skilled birth attendants and management programs for vector borne diseases. Sorensen et al provides a comprehensive summary of multisectoral solutions to climate change impacts on women’s health. CONCLUSION Slowing population growth, through voluntary FP, will allow countries vulnerable to climate change to develop appropriate adaptive policies, as well as slow the climate change process. This has positive repercussions on health as well as economic and social impacts due to the interdependence of SRH outcomes, environmental health and gender inequality. Climate change and SRH remain urgent global priorities and merging strategies to combat these issues, may allow the global community to reap multiple benefits, in a way which is cost-effective and human rights focused. The global community will rely on political will, ongoing research efforts and evidence-based policy decisions to mitigate and adapt to climate change to ensure future advances are made towards achieving SRH and rights. Betrice Walker is a final year medical student, and Masters of Public Health student at James Cook University. She is currently an Advocacy Officer for the AMSA Sexual and Reproductive Health Project and is passionate about sexual and reproductive rights. Correspondence email@example.com Acknowledgment Nil References 1. Watts N, Amann M, Arnell N, Ayeb-Karlsson S, Belesova K, Berry H, et al. The 2018 report of the Lancet Countdown on health and climate
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change: shaping the health of nations for centuries to come. The Lancet. 2018;392(10163):2479-514. 2. Adedze M, Osei-Yeboah R. Underuse of modern contraception in sub-Saharan Africa: are there implications for sustainable development and climate change? A review of the literature. Eur J Contracept Reprod Health Care. 2019;24(4):314-8. 3. Coombes R. Climate Change. Population: the forgotten priority. BMJ. 2009;339:b3750. 4. Hawkins KE. Comment on ‘Climate change and contraception’. BMJ Sex Reprod Health. 2020;46(2):156. 5. Bongaarts J, Sitruk-Ware R. Climate change and contraception. BMJ Sex Reprod Health. 2019;45(4):233. 6. Newman K, Fisher S, Mayhew S, Stephenson J. Population, sexual and reproductive health, rights and sustainable development: forging a common agenda. Reprod Health Matters. 2014;22(43):53-64. 7. Watts N, Amann M, Ayeb-Karlsson S, Belesova K, Bouley T, Boykoff M, et al. The Lancet Countdown on health and climate change: from 25 years of inaction to a global transformation for public health. Lancet. 2018;391(10120):581-630. 8. van Daalen K, Jung L, Dhatt R, Phelan AL. Climate change and gender-based health disparities. Lancet Planet Health. 2020;4(2):e44-e5. 9. Homer CSE, Hanna E, McMichael AJ. Climate change threatens the achievement of the millennium development goal for maternal health. Midwifery. 2009;25(6):606-12. 10. Kuehn L, McCormick S. Heat Exposure and Maternal Health in the Face of Climate Change. Int J Environ Res Public Health. 2017;14(8):853. 11. Cil G, Cameron TA. Potential Climate Change Health Risks from Increases in Heat Waves: Abnormal Birth Outcomes and Adverse Maternal Health Conditions. Risk Anal. 2017;37(11):2066-79. 12. Sorensen C, Murray V, Lemery J, Balbus J. Climate change and women’s health: Impacts and policy directions. PLoS Med. 2018;15(7):e1002603. 13. Hu CY, Huang K, Fang Y, Yang XJ, Ding K, Jiang W, et al. Maternal air pollution exposure and congenital heart defects in offspring: A systematic review and meta-analysis. Chemosphere. 2020;253:126668. 14. Fleischer NL, Merialdi M, van Donkelaar A, Vadillo-Ortega F, Martin RV, Betran AP, et al. Outdoor air pollution, preterm birth, and low birth weight: analysis of the world health organization global survey on maternal and perinatal health. Environ Health Perspect. 2014;122(4):425-30. 15. Pedersen M, Stayner L, Slama R, Sørensen M, Figueras F, Nieuwenhuijsen MJ, et al. Ambient air pollution and pregnancy-induced hypertensive disorders: a systematic review and meta-analysis. Hypertension. 2014;64(3):494-500. 16. Rylander C, Øyvind Odland J, Manning Sandanger T. Climate change and the potential effects on ma-
ternal and pregnancy outcomes: an assessment of the most vulnerable – the mother, fetus, and newborn child. Glob Health Action. 2013;6(1):19538. 17. Rogerson SJ. Management of malaria in pregnancy. Indian J Med Res. 2017;146(3):328-33. 18. Chibueze EC, Tirado V, Lopes KdS, Balogun OO, Takemoto Y, Swa T, et al. Zika virus infection in pregnancy: a systematic review of disease course and complications. Reprod Health. 2017;14(1):28. 19. Pouliot SH, Xiong X, Harville E, Paz-Soldan V, Tomashek KM, Breart G, et al. Maternal dengue and pregnancy outcomes: a systematic review. Obstet Gynecol Surv. 2010;65(2):107-18. 20. International Federation of the Red Cross and Red Crescent. World Disasters Report.; 2007. 21. Abdullah ASM, Dalal K, Halim A, Rahman AF, Biswas A. Effects of Climate Change and Maternal Morality: Perspective from Case Studies in the Rural Area of Bangladesh. Int J Environ Res Public Health. 2019;16(23):4594. 22. Nour NN. Maternal health considerations during disaster relief. Rev Obstet Gynecol. 2011;4(1):22-7. 23. Harville E, Xiong X, Buekens P. Disasters and perinatal health:a systematic review. Obstetrical & gynecological survey. 2010;65(11):713-28. 24. ACOG Committee Opinion No. 457: Preparing for disasters: perspectives on women. Obstet Gynecol. 2010;115(6):1339-42. 25. Sellers S, Gray C. Climate shocks constrain human fertility in Indonesia. World Dev. 2019;117:357-69. 26. Cho H. Ambient temperature, birth rate, and birth outcomes: evidence from South Korea. Popul Environ. 2020;41(3):330-46. 27. Barreca A, Deschenes O, Guldi M. Maybe Next Month? Temperature Shocks and Dynamic Adjustments in Birth Rates. Demography. 2018;55(4):1269-93. 28. Talman A, Bolton S, Walson JL. Interactions between HIV/AIDS and the environment: toward a syndemic framework. Am J Public Health. 2013;103(2):253-61. 29. Chersich M. Will global warming undo the hard-won gains of prevention of mother-to-child transmission of HIV? S Afr Med J. 2019;109(5):2878. 30. Šaffa G, Kubicka AM, Hromada M, Kramer KL. Is the timing of menarche correlated with mortality and fertility rates? PLoS One. 2019;14(4):e0215462. 31. Canelón SP, Boland MR. A Systematic Literature Review of Factors Affecting the Timing of Menarche: The Potential for Climate Change to Impact Women’s Health. Int J Environ Res Public Health. 2020;17(5):1703. 32. Haines A, Kovats RS, Campbell-Lendrum D, 47
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Corvalan C. Climate change and human health: Impacts, vulnerability and public health. Public Health. 2006;120(7):585-96. 33. Grose RG, Chen JS, Roof KA, Rachel S, Yount KM. Sexual and Reproductive Health Outcomes of Violence Against Women and Girls in Lower-Income Countries: A Review of Reviews. The Journal of Sex Research. 2020:1-20. 34. Campbell J, Jones AS, Dienemann J, Kub J, Schollenberger J, Oâ€™Campo P, et al. Intimate partner violence and physical health consequences. Arch Intern Med. 2002;162(10):1157-63. 35. New population projections underline the need for voluntary family planning programmes [press release]. 11 March 2009 2009. 36. Potts M, Henderson CE. Global warming and reproductive health. Int J Gynaecol Obstet. 2012;119(S1):S64-S7. 37. Sexual and reproductive health and climate change. Lancet. 2009;374(9694):949. 38. Page A, Larsen M. The empowerment of women and the population dynamics of climate change. J Public Health (Oxf). 2010;32(4):590-1. 39. Stephenson J, Newman K, Mayhew S. Population dynamics and climate change: what are the links? J Public Health (Oxf). 2010;32(2):150-6. 40. Hardee K. Population, gender, and climate change. BMJ. 2009;339:b4703. 41. Hardee K, Patterson KP, Schenck-Fontaine A, Hess S, Leisher C, Mutunga C, et al. Family planning and resilience: associations found in a Population, Health, and Environment (PHE) project in Western Tanzania. Popul Environ. 2018;40(2):204-38. 42. Singh S et al. Adding It Up: The Costs and Benefi ts of Investing in Family Planning and Maternal and Newborn Health. New York: Guttmacher Institute and United Nations Population Fund; 2009. 43. Smith KR, A.Woodward, D. Campbell-Lendrum, D.D. Chadee, Y. Honda, Q. Liu, J.M. Olwoch, B. Revich, and R. Sauerborn,. Human health: impacts, adaptation, and co-benefits. In: Climate Change 2014: Impacts, Adaptation, and Vulnerability. Part A: Global and Sectoral Aspects. Contribution of Working Group II to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge, United Kingdom and New York, NY, USA: Cambridge University Press; 2014. 44. Marie Stopes International. Climate Change Solutions: Empowering Women and Girls through Reproductive Choices. 2017. 45. Kock L, Prost A. Family Planning and the Samburu: A Qualitative Study Exploring the Thoughts of Men on a Population Health and Environment Programme in Rural Kenya. Int J Environ Res Public Health. 2017;14(5):528. 46. Bryant L, Carver L, Butler CD, Anage A. Climate change and family planning: least-developed countries define the agenda. Bull World Health Organ. 48
2009;87(11):852-7. 47. MacVicar S, Berrang-Ford L, Harper S, Steele V, Lwasa S, Bambaiha DN, et al. How seasonality and weather affect perinatal health: Comparing the experiences of indigenous and non-indigenous mothers in Kanungu District, Uganda. Soc Sci Med. 2017;187:39-48. 48. Slaymaker E, Scott RH, Palmer MJ, Palla L, Marston M, Gonsalves L, et al. Trends in sexual activity and demand for and use of modern contraceptive methods in 74 countries: a retrospective analysis of nationally representative surveys. Lancet Glob Health. 2020;8(4):e567-e79. 49. Wheeler D, Hammer D. The economics of population policy for carbon emissions reduction in developing countries. Center for Global Development Working Paper. 2010(229). 50. Glemarec Y, Qayum S, Olshanskaya M. Leveraging co-benefits between gender equality and climate action for sustainable development. Mainstreaming Gender Considerations in Climate Change Projects. UN Women; 2016. 51. Bongaarts J, Oâ€™Neill BC. Global warming policy: Is population left out in the cold? Science. 2018;361(6403):650-2. 52. Grace K. Considering climate in studies of fertility and reproductive health in poor countries. Nat Clim Chang. 2017;7(7):479-85. 53. Lu MC. The Future of Maternal and Child Health. Matern Child Health J. 2019;23(1):1-7.
The doctor will ring you now October 2020
A look into telehealthâ€™s ascent during COVID-19
ace-to-face consultations between patient and doctor, once the mainstay of healthcare delivery, suddenly presented a potential transmission risk due to the COVID-19 pandemic. One of the Australian healthcare system’s adaptations to the pandemic was an increase in the remote delivery of healthcare services, commonly known as telehealth. While telehealth has been a part of healthcare for decades, its use was limited prior to the pandemic, with utilisation restricted to rural and remote patients. Numerous barriers prevented its widespread adoption across medical services.
It is important to note that prior to the COVID-19 pandemic, the Medicare Benefits Schedule (MBS), a list of services for which the Government offers rebates, had limited coverage for telehealth services. Specifically, only some third-party services (the former of the two above models) were listed under the MBS since July 2011. This meant that only telehealth eligible (ie. rural and remote) areas of Australia had access to specialist video consultations under Medicare prior to 2020.
However, the pandemic accelerated telehealth’s implementation, with a sharp increase in usage since March 2020. While this was driven by the necessity of preventing transmission, it was also partly facilitated by policy decisions such as introducing Medicare subsidies for telehealth services. It is possible that as telehealth’s benefits become apparent and systemic barriers are overcome, telehealth’s increased uptake will remain post-pandemic, allowing it to become a central component of standard healthcare delivery in the future.
Within the narrow range of telehealth services available under the MBS, previous years had nonetheless witnessed an increase in telehealth usage. For example, in the 2016-17 financial year, 115,000 Medicare-subsidised video conferences with specialists were claimed by 65,000 patients, along with 55,000 items of patient-end services. This represented an approximately seven-fold increase in telehealth use compared to 2011-12, when 16,000 specialist video consultations and 10,000 patient-end services were claimed.[6, 7]
To comprehend these benefits and to appreciate the systemic barriers previously preventing telehealth utilisation, this article aims to provide a broad overview of telehealth use prior to COVID-19. Furthermore, publicly available data about telehealth usage during COVID-19 will be examined to understand how usage evolved in 2020 and the factors driving this evolution.
THE TRADITIONAL CALCULUS FOR TELEHEALTH FACTORS SUPPORTING TELEHEALTH UPTAKE
WHAT IS TELEHEALTH?
Collaborative third-party services, further divided into specialist-end services (video conferencing between patient and specialist) and patient-end services (where a GP or nurse is present physically with a patient during a remote consultation with a specialist). On-demand telehealth services between patient and providers such as GPs.
In the pre-COVID-19 context, proponents of telehealth framed its benefits in terms of cost, care, choice and convenience. Significant stakeholders were remote and rural patients, including those experiencing relative isolation such as prisoners, workers at sea and those in war zones.  Studies reported that telehealth increased standards of care for rural patients through indicators such as shorter wait times, more timely patient transfers in emergency care, access to familiar community and support at home and information dissemination. [9-12] Another study found that significantly fewer rural Queensland patients incurred costs when attending consultations via video than in-person as much of those costs were travel-related.
The concept of remote healthcare delivery dates back to the telegraph and telephone, through which doctors have held remote consultations since the 19th century. Remote healthcare delivery evolved with technology throughout the decades since; today, telehealth may take the form of telephone or video consultations across a wide array of medical and clinical disciplines. Specifically, the Australian Department of Health defines telehealth services as using “information and communications technologies (ICTs) to deliver health services and transmit health information over both long and short distances. It is about transmitting voice, data, images and information rather than moving care recipients, health professionals or educators”. The Royal Australian College of General Physicians (RACGP) further describes two models of telehealth services in operation within Australia:
From the providers’ perspective, telehealth “[promoted] enhanced local service provision, more rapid specialist clinical assessment, reinforcement of local health professionals’ clinical assess50
ments and increased access to specialists and their resources”. Access to specialist support was particularly relevant in disciplines such as dermatology, psychiatry, cardiology and non-critical chronic disease, with several studies concluding that greater telehealth coverage was needed to harness specialist support.[8, 9, 14-19] Furthermore, practitioners who were able to work from the comfort of their own homes found telehealth to be convenient. Additionally, the installation of video infrastructure had the side-effect of enabling medical professionals to network and access professional development such as web-based education and courses through video-conferencing.  While this was not a direct patient-related benefit, there nonetheless existed an indirect benefit if providers successfully upskilled through electronic means.
to seek help further prevented engagement with telehealth.[23, 24] On a systemic level, the government was also disincentivised from facilitating telehealth adoption.  Financially, there existed a significant capital cost associated with establishing infrastructure necessary for telehealth, expended mostly through funding for public hospitals and subsidies. In return, the government stood to raise no revenue; thus, there existed little incentive to bear this financial cost.[25, 26] Policy-wise, Australia’s state-level regulation of medical practices created difficulties for implementing binding nation-wide policies such as Medicare schemes for telehealth. Appropriate federal-level regulation and licensing was thus also challenging to implement, which posed a problem as telehealth often involved consultations that crossed state lines. [22, 25, 26]
BARRIERS PREVENTING TELEHEALTH UPTAKE
While telehealth appeared to offer a simple solution to the question of remote health access, a survey of patients and providers published in 2007 found telehealth remained “underused and poorly integrated into their practice”. This sentiment is echoed today, with experts such as Prof. Anna Peeters of Deakin University expressing that telehealth had been extremely underutilised in Australia prior to COVID-19.  The late RACGP President Dr. Harry Nespolon similarly remarked, in reference to telehealth’s slow adoption, that the medical system was “languishing back in the 1970s” until the pandemic’s onset.
HOW COVID-19 CHANGED THE CALCULUS The cost-benefit analysis outlined above was in practice for years until the COVID-19 pandemic altered the calculus. Suddenly, the salient benefits of choice and convenience dwarfed in comparison to telehealth’s potential to save lives by avoiding the risk of contact transmission. A strong incentive now existed to overcome the barriers preventing telehealth’s use.
Clearly, there existed barriers preventing a wider uptake of telehealth. A 2011 study identified a number of these barriers from the providers’ perspective: lack of funding for consultations (disincentivising providers from offering telehealth), increased teleconsultation time compared to traditional consultations, technological expertise, available infrastructure like internet access, and an innate preference for the traditional approach. These concerns were echoed by the respondents to the aforementioned 2007 survey, who pointed to technological literacy and access, confusing funding arrangements, timetabling issues between urban specialists and rural practitioners as well as disruption to practices as reasons for their hesitancy to embrace telehealth.
TELEHEALTH IN PREVIOUS PANDEMICS Increased use of telehealth during a pandemic was not novel to 2020. During the 2002-04 SARS outbreak, one study explored teleconferencing between doctors and an isolated SARS patient, which resulted in lower infection risk and lower cost while maintaining adequate delivery of care.  During the Ebola outbreak of 2014-16, a study investigated contact tracing performed digitally and remotely as opposed to paper-based forms, ultimately concluding that their data was more accurate and complete while minimising the risk from transmission.[28, 29] AUSTRALIA’S TELEHEALTH RESPONSE TO COVID-19
These barriers paralleled those seen from the patients’ perspective. Inability to pay medical bills due to the lack of subsidy for teleconsultations posed a significant financial barrier. Furthermore, remote patients often lacked funding to buy expensive video-conferencing equipment such as computers and cameras.[22, 25] Technological issues were exacerbated by unreliable internet availability and speed. [22, 25, 26] Similarly to in-person consultations, cultural barriers such as medical literacy and willingness
Before COVID-19, telehealth’s value lay in its ability to provide service to rural and remote communities; in fact, one needed to satisfy criteria of remoteness in order to receive MBS subsidies for telehealth. The restrictions enacted to control COVID-19 spread, however, created an artificial remoteness between patients and providers; telehealth has been increasingly used to bridge the divide. 51
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In recognition of the demand and necessity for telehealth, the Australian Government added a number of temporary items to the MBS on 13th March 2020, widening the scope of reimbursable and bulkbilled telehealth services beyond the services provided for rural and remote patients. This was part of a $2.4 billion COVID-19 health package announced by the Government on 11th March, of which $100 million was dedicated to “a new Medicare service for people in home isolation or quarantine… to receive health consultations via the phone or vidFigure 1. Monthly number of claims of telehealth items that existed before the COVID-19 paneo such as FaceTime or Skype”. demic. Sourced from Service Australia’s Medicare Item Reports tool and publicly available item  Three weeks later, on 29th numbers.[7, 34] March, the Government unveiled a further $669 million to “expand health’s permanent funding by Medicare. Medicare-subsidised telehealth services for all Australians”, materialised in the form of more temporary Interestingly, the vast majority of telehealth aptelehealth items added to the MBS. In that same pointments were conducted over phone as oppackage, bulk-billing incentives for GPs were douposed to video: 96% of GP and 81% of non-GP bled. These temporary arrangements are due to consultations in April 2020. This possibly be reviewed on 30th September 2020. reflects the aforementioned technological barrier where video use requires higher technological litHere, it is important to recall that prior to COVID-19, eracy, as well as both patients and providers bea principal barrier cited by patients and providers ing more familiar with telephone infrastructure alike was the lack of funding for consultations. The as opposed to video infrastructure. Government’s COVID-19 response directly worked to counter this barrier by covering services such as TELEHEALTH USAGE DATA FROM THE MBS primary care that were previously unsubsidised. Furthermore, the very existence of government-funded telehealth packages implied that the urgency had At the time of writing, no comprehensive nanow outweighed the systemic disincentives preventtion-wide report about pandemic-related teleing the government from fully embracing telehealth. health usage had been made available by the The breakdown of these barriers resulted in increased Government. However, monthly data about MBS exposure of telehealth to patients and practitioners, item usage up to June 2020 is publicly available possibly overcoming hesitancy while allowing the on the Services Australia website via a search tool. community to experience telehealth’s benefits for the  It is also possible to access a comprehensive first time. list of telehealth item numbers currently in operation.[34, 35] Querying these item numbers in the SURVEY OF MEDICAL PRACTITIONERS search tool returns the monthly claim numbers for those items. The immediate impact of the MBS changes was a EXISTING TELEHEALTH SERVICES sharp increase in the number of doctors offering consultations by telehealth. A report compiled from an A search of item numbers corresponding to teleonline survey of medical practitioners conducted in health services that existed prior to COVID-19 reMay 2020 found that 36% of all consultation items vealed that those items were claimed significantwere provided by telehealth, compared to just 1.3% ly more after March 2020. At the peak in April pre-pandemic. Telehealth was used by “almost 2020, the total claims for these item numbers all GPs” and 76% of non-GP specialists, with GPs and approximately doubled the figures recorded for specialists bulk-billing 96% and 76% of their conthe months immediately prior to the pandemic. sultations respectively. As a further indication The majority of the rise in these claims was acof telehealth’s growing popularity among medical counted for by specialist video consultations (see practitioners, 84% of the respondents supported tele52
Figure 1). TEMPORARY TELEHEALTH SERVICES As aforementioned, one of COVID-19’s greatest impacts on telehealth in Australia was the raft of temporary telehealth items added to the MBS in March 2020. Specifically, many existing item numbers for face-to-face consultations received temporary telehealth counterparts; these telehealth item numbers were further divided into telephone and video items. In total, almost 17.5 million temporary telehealth items were claimed between their introduction in March and 30th June. Of these, 16 million (92%) were by telephone while the remaining 1.5 million were video conferences. The peak monthly telehealth use occurred in April, when approximately 5.4 million telephone and 490,000 video conferences were held (see Figure 2i). In contrast, face-to-face consultations experienced a significant decrease after the introduction of temporary telehealth items, sinking to a nadir of 11 million consults in April from a high of 15 million just two months earlier in February. However, this trend reversed slightly as telehealth use decreased over May and June while face-to-face consults increased (see Figure 2i). This was possibly due to a relative abatement in COVID-19 concern after the “first wave” passed by late April. Dissecting the aggregate values, there were various out-of-hospital services that received temporary telehealth item numbers which can be grouped as follows:
» » » » » »
28 GP services 31 other medical practitioner (OMP, eg. dermatologists, emergency medicine specialists, obstetricians and gynaecologists, ophthalmologists, pathologists, diagnostic and interventional radiologists, and radiation oncologists) services  40 specialist services 20 allied health services 8 mental health services excluding GP/OMP services 8 obstetrician and midwifery services 4 nurse practitioner services 2 dental services, specifically for oral and maxillofacial surgery
Out of these services, the general trend observed above was reflected within GP, OMP, specialist, nurse practitioner and obstetrician/midwifery services; this trend featured a significant increase in telehealth use by April with a corresponding decrease in face-to-face consultations. GP services constituted the majority of 53
all temporary telehealth item claims, accounting for 14 million (80%) of the 17.5 million total claims from March to June, while specialist claims came a distant second at 2 million (11%). This marked a shift away from the pre-pandemic paradigm, where the only telehealth items claimable were specialist appointments. Mental health services deserve a special note here, as it was the one group where telehealth claims far outstripped face-to-face consultations, and also where video conferencing predominated over telephone (see Fig. 2c). A simple explanation could be that physical clinical examinations might not be as important in mental health services, leading naturally to the adoption of telehealth. Patients and practitioners alike might also prefer video over telephone due to the additional intimacy provided by visual contact. CONCLUSION Telehealth has been hailed as a revolutionary step in medical care, yet its adoption has been slow. This could be attributed to several identifiable barriers despite telehealth’s recognised benefits. In the COVID-19 pandemic of 2020, however, telehealth’s ability to provide care without an increased transmission risk became incredibly valuable. To promote increased telehealth use, the Australian Government and healthcare sector implemented measures to overcome these barriers. Specifically, newly introduced temporary telehealth MBS items and GP bulk-billing incentives contributed to a significant reduction in financial barriers. This led to a sharp increase in telehealth use, with monthly items claimed peaking at 5.9 million (of which 4.5 million were GP services) in April 2020, compared to fewer than 25,000 in the pre-pandemic months (see Figures 1,2). The extraordinary current circumstance is further illustrated by noting that the vast majority of all MBS telehealth items claimed since April were non-specialist services unsubsidised prior to COVID-19. While it is too early to know whether the Government’s support for telehealth will persist beyond the 30th September review date, it is nonetheless true that many systemic barriers preventing telehealth’s adoption have already been overcome. This allowed telehealth’s benefits of safety, convenience, and care to accrue and gain recognition. Thus, it is entirely possible that if there is sufficient demand for telehealth, its utilisation will persist even after transmission risk ceases to be a pressing concern post-pandemic. This will ensure telehealth’s ascension to a mainstream role
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publishing.nsf/Content/e-health-telehealth. 4. Royal Australian College of General Practitioners. On-demand Telehealth Services. 2017. 5. Department of Health. Telehealth: Specialist video consultations under Medicare 2014 [updated 8 May 2014. Available from: http://www.mbsonline. gov.au/telehealth. 6. Australian Institute of Health and Welfare. Australia’s health 2018. Canberra: AIHW; 2018. Contract No.: AUS 221. 7. Medicare Item Reports [Internet]. 2020 [cited 14 August 2020]. Available from: http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp. 8. Moffatt JJ, Eley DS. The reported benefits of telehealth for rural Australians. Australian Health Review. 2010;34(3):276-81. 9. Buist AC, Greg; Silvas, Arlene. An evaluation of the telepsychiatry programme in Victoria, Australia. Journal of Telemedicine and Telecare. 2000;6(4):216-21. 10. Westwood JD. The ViCCU Project–achieving virtual presence using Ultrabroadband internet in a Critical Clinical application–initial results. MedFigure 2. Monthly item claims of various services that received temporary telehealth item icine Meets Virtual Reality 13: The Magnumbers in March 2020. Sourced from Service Australia’s Medicare Item Reports tool and publicly available item numbers.[7, 35] ical Next Becomes the Medical Now. 2005;111:94. in healthcare, allowing the community wider access 11. D’Souza R. Telemedicine for intensive supto its benefits. port of psychiatric inpatients admitted to local hospitals. Journal of Telemedicine and Telecare. Allen is a second-year Doctor of Medicine student at the University 2000;6(1_suppl):26-8. of Melbourne and incoming AMSA Secretary for 2021. He is inter12. Doessel DP, Travers H, Hunter E. The Use ested in novel applications of technology as tools in medicine and of Touch-Screen Technology for Health-Related bioscience. Information in Indigenous Communities: Some Economic Issues. Prometheus. 2007;25(4):373-92. Correspondence 13. Smith AC, Youngberry K, Christie F, Isles A, firstname.lastname@example.org McCrossin R, Williams M, et al. The family costs of attending hospital outpatient appointments via Acknowledgments videoconference and in person. Journal of TeleNil medicine and Telecare. 2003;9(2_suppl):58-61. 14. Abbott LM, Miller R, Janda M, Bennett H, References Taylor ML, Arnold C, et al. A review of literature supporting the development of practice guidelines 1. Fisk M, Livingstone A, Pit SW. Telehealth in the for teledermatology in Australia. Australasian Context of COVID-19: Changing Perspectives in AusJournal of Dermatology. 2020;61(2):e174-e83. tralia, the United Kingdom, and the United States. J 15. Muir J. Telehealth: the specialist perspective. Med Internet Res. 2020;22(6):e19264. Australian Family Physician. 2014;43(12):828. 2. Eikelboom RH. The telegraph and the beginnings 16. Liu N, Huang R, Baldacchino T, Sud A, of telemedicine in Australia. Global Telehealth 2012: Sud K, Khadra M, et al. Telehealth for NoncritDelivering Quality Healthcare Anywhere Through ical Patients With Chronic Diseases During the Telehealth: Selected Papers from Global Telehealth COVID-19 Pandemic. Journal of Medical Internet 2012 (GT2012). 2012;182:67. Research. 2020;22(8):e19493. 3. Department of Health. Telehealth 2015 [Available 17. Sorinmade OA, Kossoff L, Peisah C. COVID-19 from: https://www1.health.gov.au/internet/main/ 54
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Research; 2020. 34. Department of Health. Telehealth quarterly statistics update. 2016. 35. Department of Health. MBS changes factsheet: COVID-19 Temporary MBS Telehealth Services. 2020. 36. Department of Health. Coronavirus (COVID-19) current situation and case numbers. 2020. 37. Australian Bureau of Statistics. Unit Group 2539 Other Medical Practitioners. 2009(Australian and New Zealand Standard Classification of Occupations, First Edition, Revision 1 ).
and Telehealth in Older Adult Psychiatry-opportunities for now and the Future. International journal of geriatric psychiatry. 2020. 18. Zhou X, Snoswell CL, Harding LE, Bambling M, Edirippulige S, Bai X, et al. The role of telehealth in reducing the mental health burden from COVID-19. Telemedicine and e-Health. 2020;26(4):377-9. 19. Wade V, Stocks N. The use of telehealth to reduce inequalities in cardiovascular outcomes in Australia and New Zealand: A critical review. Heart, Lung and Circulation. 2017;26(4):331-7. 20. Mauldon E. The Use of and Attitude Towards Telehealth in Rural Communities. Australian Journal of Primary Health. 2007;13(3):29-34. 21. Warriner J. The rise of telehealth in the coronavirus pandemic could lead to a permanent shift in healthcare. ABC News. 2020 5 May 2020. 22. Moffatt J, Eley DS. Barriers to the up-take of telemedicine in Australia-a view from providers. 2011. 23. Jang J, Jang Jaccard J, Nepal S, Alem L, Li J. Barriers for Delivering Telehealth in Rural Australia: A Review Based on Australian Trials and Studies. Telemedicine and e-Health. 2014;20(5):496-504. 24. Winterton R, Warburton J. Models of care for socially isolated older rural carers: barriers and implications. 2011. 25. NICTA, Hanlen L, Robertson P. Telemedicine in the context of the National Broadband Network: Department of Broadband, Communications and the Digital Economy; 2010. 26. Rogove HJ, McArthur D, Demaerschalk BM, Vespa PM. Barriers to telemedicine: survey of current users in acute care units. Telemedicine and e-Health. 2012;18(1):48-53. 27. Chang T, Lee J, Wu S, editors. The telemedicine and teleconsultation system application in clinical medicine. The 26th Annual International Conference of the IEEE Engineering in Medicine and Biology Society; 2004: IEEE. 28. Innovations for Poverty Action. Reducing Ebola Virus Transmission: Improving Contact Tracing in Sierra Leone. 2014. 29. Keshvardoost S, Bahaadinbeigy K, Fatehi F. Role of telehealth in the management of COVID-19: lessons learned from previous SARS, MERS, and Ebola outbreaks. Telemedicine and e-Health. 2020. 30. $2.4 Billion Health Plan to Fight COVID-19 [press release]. 11 March 2020 2020. 31. $1.1 Billion to Support More Mental Health, Medicare and Domestic Violence Services [press release]. 29 March 2020 2020. 32. RACGP secures $500m to help general practice fight coronavirus [press release]. 29 March 2020 2020. 33. Scott A. The impact of COVID-19 on GPs and non-GP specialists in private practice. The Melbourne Institute of Applied Economic and Social 55
A literature review
October 2020 Volume 14
Public health approaches to addressing trachoma Sally Boardman 56
and trichiasis and eventually results in blindness.[1,2] It is the leading cause of preventable blindness globally. Trachoma is classified as a ‘neglected tropical disease’ (NTD) and is a prominent public health issue due to its high prevalence, morbidity, significant economic burden, and preventability. Addressing trachoma has been part of a concerted global effort to reduce the human, social, and economic burden of NTDs on the worlds most disadvantaged and vulnerable populations.
rachoma is a neglected tropical disease (NTD) caused by infection with Chlamydia trachomatis (C. trachomatis) and is the leading cause of preventable blindness globally. It is a disease rooted in poverty and remains endemic in several low- and middle-income countries, predominantly in the tropics, where determinants of health—including poor hygiene, sanitation, and living conditions—favour disease transmission. This paper aims to critically appraise the public health approaches addressing trachoma, namely implementation of the WHO ‘SAFE’ strategy, with reference to trachoma control in Tanzania.
In 1997, the World Health Organisation (WHO) established and partnered with the Global Alliance for the Elimination of Trachoma by 2020 (GET2020) to support state implementation of the WHO 1993 ‘SAFE’ strategy. This strategy has formed the basis of the global response to trachoma control and consists of four core components: surgery for trachomatous trichiasis, antibiotics to treat ocular C. trachomatis infection, and facial cleanliness and environmental improvement to reduce C. trachomatis transmission. Despite significant progress, trachoma remains endemic in 44 countries, which are predominantly low- and middle-income (LMIC), and many of these are in the tropics. Africa is the worst affected continent, harbouring 85% of all active cases globally, and Tanzania is one country where, despite implementation of SAFE since 1999, trachoma remains endemic.[3,6,7] The prevalence of trachoma is influenced by a multitude of health determinants, which interact to create an enabling environment that favours C. trachomatis transmission. These determinants and their relationship to relevant policy in Tanzania are outlined in Figure 1.[1,8-11] They illustrate the challenge in implementing trachoma control programs and the need for a broad and holistic approach.
METHODS Online databases were searched for literature containing relevant keywords. Literature sources included published data, peer-reviewed publications, and relevant grey literature. RESULTS The SAFE strategy has been highly effective in reducing the global prevalence of trachoma. However, it has failed to reach its target of global elimination by 2020. Strengths of this approach include the dual focus on preventative and curative aspects of trachoma management and the GET2020 Alliance to aid state implementation. Challenges in trachoma management include the political landscape influencing global health governance and funding, as well as a pressing need for an intersectoral ‘Health in All Policies’ approach to address the social determinants of health perpetuating trachoma transmission.
This paper will critically appraise the global strategies to address trachoma, primarily through implementation of the SAFE strategy, with reference to trachoma control in Tanzania.
An integrated, multisectoral approach to trachoma management with NTDs is required to attain increased and sustainable progress across the spectrum of NTDs, reduce the risk of resurgence, and achieve the United Nations Sustainable Development Goals (SDGs). This progress can be achieved only by continuing to address the underlying determinants of health and utilising integrated management programs.
METHODS Keywords and search terms were developed using the PICO method: population (trachoma, Tanzania), intervention (SAFE strategy, public health), and outcome (epidemiology, prevalence, incidence, disease burden). Inclusion criteria included published data, peer-reviewed publications, and relevant grey literature (e.g., WHO, Global Burden of Disease, International Trachoma Initiative, Trachoma Atlas, and Tanzanian Health Policy) published within 1990-2020
INTRODUCTION Trachoma is a disease caused by repeated episodes of reinfection with the C. trachomatis bacterium. This causes conjunctival inflammation, leading to scarring 57
Socio-economic, political context Governance – global health governance, national, state and local health departments, community health leaders Macroeconomic policies
Context-specific strategies tackling structural and intermediary determinants
Education – health literacy
Social policies – housing, built environment
Public policies – health, water and sanitation (clean water provision, waste disposal, sanitation infrastructure eg. latrines), education, environmental
Culture and societal values – beliefs about illness including perceived severity and aetiology, gender inequity
Structural determinants Social determinants of health inequities
Material circumstances – housing, overcrowding, access to improved water source Behaviours – hygiene and sanitation practices
Key dimensions and directions for policy
Globalization Environment Macro Level: Public policies Mesa Level: Community
Micro Level: Individual interaction
Biological factors – age (children, adults), gender (females), race/ethnicity, health vulnerabilities Psychosocial factors – religious beliefs, cultural practices, perceptions of health, stigma and isolation, mental health
Social participation and empowerment
Policies on stratification to reduce inequalities, mitigate effects of stratification
Not addressed May include global policies to address inequalities in states which result in stratification of ‘developed’ and ‘developing’ countries with consequential impacts on health status
Policies to reduce exposures of disadvantaged people to health-damaging factors
Tanzania National Health Policy 2017 Tanzania NTD Control Programme Trachoma – SAFE Strategy Tanzania National Sanitation and Hygiene Campaign Latrine provision, waste disposal systems, clean water
Policies to reduce vulnerabilities of disadvantaged people
Not addressed May include policies targeted at at-risk groups such as women and children, rural and remote villages
Policies to reduce unequal consequences of illness in social, economic and health terms
Not addressed May include anti-discrimination policies for employees with trachoma-related disability, education targeting stigma and isolation associated with NTDs, economic support to access health services for treatment
Intermediary determinants Social determinants of health
Health system factors Availability of services – hospitals, primary care centres, treatment centres, health professionals, mass drug administration, supply of medicines eg. azithromycin, community health programs for health promotion and education
Equity in Health and Wellbeing Disproportionate burden of trachoma in low and middle income countries, particularly the tropics Evidence for interventions Trachoma prevalence and incidence
Accessibility of services – transportation, distance/time, cultural and linguistic barriers, mistrust of healthcare professionals, cost Quality of care – trust in the healthcare system, perception of treatment benefits and purpose, privacy and confidentiality, training HCWs in trachoma diagnosis and grading
Figure 1. Modified WHO conceptual framework on the social determinants of health applied to trachoma, using Tanzania’s implementation of the SAFE strategy as an example of policy intervention. [1, 8-11]
to account for literature prior to the implementation of the SAFE strategy. The literature was comprehensively reviewed using keyword searches in online databases, including Medline, PubMed, and Google Scholar, with further sources selected and evaluated via handsearching.
EVALUATION OF THE SAFE STRATEGY The SAFE strategy has enabled significant progress towards GET2020’s primary goal: the global elimination of trachoma. As of September 2020, 13 countries have successfully implemented the strategy and eliminated trachoma, 9 of which have been validated by WHO (Figure 2). Furthermore, the number of people at risk of trachoma has reduced dramatically, from 1.5 billion in 2002 to 136.9 million in May 2020, reflecting the declining global prevalence.[2,6] The latest data estimates the total global burden of trachomatous trichiasis to be 2 million, more than a 60% reduction since 2002. However, despite this progress, trachoma remains a public health problem in 44 countries, with only 13% of identified endemic countries achieving elimination, compared to the target of 100% by 2020. Thus, WHO has set a revised date for the target of eliminating trachoma to 2030, as part 58
of the NTD roadmap for 2021-2031 ‘Ending the neglect to attain the Sustainable Development Goals.’ In Tanzania, despite a significant reduction in the prevalence of trachoma from 395.10 per 100,000 in 1999 to 145.45 per 100,000 in 2017, trachoma remains endemic in 4 regions following the introduction of the SAFE strategy (Figure 3).[7,12] The latest reports from 2017 indicated good progress, with only 18 out of 54 endemic councils having active trachomatous inflammation of ≥5% (the threshold for endemicity), and trachoma transmission was estimated to be interrupted in over 90% of endemic districts by 2020.[13,14] The progress made to eliminate trachoma over the past few decades clearly demonstrates that SAFE is an effective public health intervention, which the growing evidence-base supports. The evidence for individual components of the SAFE strategy and their implementation in Tanzania is outlined in Table 1 (available online).[1-4,6,9,11-35] One of the major strengths of the SAFE strategy is the targeting of both medical or curative treatment (e.g., antibiotics and surgery) and key
determinants driving trachoma infection (e.g., facial cleanliness and environmental improvement) as part of an upstream approach to disease prevention. Secondly, the universal nature of the strategy provides a global framework by which nations can implement SAFE and allows for the global mapping and monitoring of progress. Furthermore, the partnership with GET2020 pushes for states to incorporate the strategy into national health policies and infrastructure, with disease mapping and monitoring primarily conducted by health professionals in local areas. This is a significant step towards health system strengthening and empowering states to take ownership over public health initiatives, and it has been re-emphasised as a priority in the 2021-2030 WHO NTD roadmap. Another benefit of GET2020 as part of the public health approach was the development of the Global Trachoma Mapping Project (GTMP). This tool accurately mapped epidemiological data on global trachoma prevalence between 2012-2016 to guide SAFE implementation, particularly the delivery of mass drug administration (MDA), to areas most in need. This has played an integral role in guiding resource allocation for MDA and in monitoring and evaluation efforts. [36,37]
recent study in northern Tanzania demonstrated that there was little understanding of trachoma aetiology and treatment, as well as the links between childhood infection and the development of blindness. This indicates that this is an area of ongoing need. Improvements in hygiene, sanitation, and environmental conditions conducive to good health are all part of a broader need for health system strengthening. This is essential to producing sustainable change and mitigating the risk of recrudescence of infection in populations that have eliminated trachoma. POLICY AND LEADERSHIP CHALLENGES There are a multitude of policy and leadership challenges that impact planning and implementation of a public health intervention. Two primary challenges for addressing trachoma as a public health issue are governance and funding and intersectoral leadership challenges. The approach to eliminate trachoma has required an intensive international effort, with the involvement of WHO, many NGOs, and public-private partnerships, such as the International Trachoma Initiative. The involvement of multiple stakeholders who provide technical and financial support creates an administrative and political challenge due to the reliance on donors to fund health interventions. This enhances their political influence and gives them undue power over the formation and implementation of program activities. This has contributed to a focus on ‘vertical’ (disease-specific) programs, with donors funding specific interventions with shortterm measurable progress (e.g., supplying MDA). 
One of the key limitations of the SAFE strategy is the lack of specific targets and strategies to address its facial cleanliness and environmental improvement components and the lack of evidence-based research to guide these interventions. Increasing the evidence base and extending partnerships to improve delivery of these components to reduce trachoma transmission has been identified as a critical action to reach the 2030 trachoma targets. The neglect of these interventions has led to an over-reliance on medical treatment, despite the fact that trachoma was eliminated as a cause of blindness in most of the developed world largely due to global improvements in water and sanitation in the early 1900s. A reliance on ‘siloed’ or ‘vertical’ disease programs is likely to have perpetuated this, as these programs access funding specifically for antibiotic provision. For example, azithromycin (Zithromax®), the antibiotic of choice to treat trachoma, is largely donated by Pfizer, a multinational pharmaceutical company, through the International Trachoma Initiative. Effecting critical change to basic conditions for health, including sanitation, requires a ‘Health in All Policies’ approach with multisectoral support, of which the support and integration of donor campaigns is more challenging.  A core education component is also needed and would be strengthened by a comprehensive NTD health promotion campaign, with materials to improve health literacy. Education is a vital strategy to empower individuals to understand disease aetiology and symptoms, learn how interventions prevent disease, and to build trust in healthcare providers. A
However, this approach often neglects determinants that are harder to quantify, such as poverty and environmental conditions for hygiene. These programs also hinder integrated approaches to NTD management. For example, in Tanzania, azithromycin donated by Pfizer is kept separate from the general pharmaceutical supply, ‘earmarked’ for MDA in trachoma-endemic districts.[6,16] However, a more effective approach would involve the integration of medicines into the national pharmaceutical supply chain. This would allow antibiotics to be used as part of an integrated approach for multiple NTDs requiring similar treatment, utilising existing primary health infrastructure. The need for multisectoral support is recognised by WHO, identifying that multisectoral action for NTDs across diagnostics, monitoring, and evaluation; access and logistics; and advocacy and funding are required to meet 59
targets for the SDGs and accelerate control and elimination. In its 2021-2030 roadmap for NTD action, WHO has called for further integration of NTD programmes into national health systems by utilising existing health infrastructure and, thus, improving the sustainability and efficiency of interventions, with coordinated action across sectors. Tanzania has recognised the importance of intersectoral collaboration and established a ‘Sector Wide Approach’ to facilitate coordination among health sector stakeholders for all health interventions. This approach is important and seeks to maximise the impact to broader health outcomes, particularly in Tanzania, which has one of the highest NTD burdens in the world.
ETHICAL CONSIDERATIONS Resource allocation is a pertinent ethical consideration in trachoma and NTD management. Whilst trachoma and NTDs cause significant morbidity in LMICs globally, from an epidemiological perspective, other illnesses such as non-communicable diseases are responsible for a greater morbidity and mortality burden, leading to ethical dilemmas around funding priorities. Advocacy for investment into targeting trachoma and NTDs may be considered from a human rights based approach, supporting the right of all humans to an environment that supports health. This approach seeks to advocate for health equity and social justice and is particularly pertinent to NTDs, which largely result from global inequities in social and environmental determinants of health. An ethical consideration in implementation of SAFE is gaining consent for treatments such as antibiotics. A recent study highlighted the lack of understanding of the purpose of azithromycin in treating trachoma, with some believing the drug was being given to terminate pregnancy. This raises some serious ethical concerns about informed consent and educating patients about the interventions.
Implementing an intersectoral approach to trachoma management which utilises the ‘Health in All Policies’ (HiAP) framework is another policy challenge. HiAP recognises the need for sectors outside of health to contribute to policies which seek to optimise co-benefits for health and minimise negative consequences. This is pertinent to trachoma management, where intersectoral collaboration between stakeholders in health, environment and water, and built environment sectors is required to address the determinants of health driving trachoma, particularly hygiene and sanitation and vector control. This challenge has been recognised in Tanzania, with the Ministry of Health reporting 60% of outpatient department diagnoses associated with poor sanitation and hygiene practices, the persistence of which is due to ‘weak coordination among stakeholders’. A specific objective of Tanzania’s revised National Health Policy in 2017 focuses on ‘intersectoral collab-
oration’ for sustainable water safety, sanitation, and hygiene, all of which are linked to its efforts to improve primary health care services and are necessary to achieve long-term improvement.
Figure 2. Status of elimination of trachoma as a public health problem, 2019.
Annex 2. Disease summaries. 2020 [cited Sep 15 2020](WHO/UCN/NTD/2020.01). Available from: https://www.who.int/neglected_diseases/ Ending-the-neglect-to-attain-the-SDGs--NTDRoadmap-Annex2.pdf 3. World Health Organization. Trachoma Epidemiological Situation. 2020 [Sep 16 2020]. Available from: https://www.who.int/trachoma/ epidemiology/en/ 4. World Health Organization. Ending the neglect to attain the sustainable development goals: a road map for neglected tropical diseases 2021–2030. 2020 [cited Sep 15 2020](WHO/UCN/ NTD/2020.01). Available from: https://apps.who. int/iris/handle/10665/332094 5. World Health Organization. Planning for the Global Elimination of Trachoma (GET): report of a WHO Consultation, Geneva, Switzerland, 25 and 26 November 1996. World Health Organization; 1997. 6. World Health Organization. WHO Alliance for the Global Elimination of Trachoma by 2020: progress report, 2019. Weekly Epidemiological Record. 2020 [cited Sep 16 2020];30:349-60. Available from: https://www.who.int/publications/i/item/who-wer9530 7. International Trachoma Initiative. Global Trachoma Atlas. 2020 [cited 2020 Aug 12]. Available from: https://www.trachomaatlas.org/ global-trachoma-atlas 8. Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Geneva: WHO Document Production Services; 2010. 9. Mtuy TB, Burton MJ, Mwingira U, Ngondi JM, Seeley J, Lees S. Knowledge, perceptions and experiences of trachoma among Maasai in Tanzania: Implications for prevention and control. PLoS Negl Trop Dis. 2019;13(6) doi:10.1371/journal.pntd.0007508 10. Mwingira UJ, Kabona G, Kamugisha M, Kirumbi E, Kilembe B, Simon A, et al. Progress of Trachoma Mapping in Mainland Tanzania: Results of Baseline Surveys from 2012 to 2014. Ophthalmic Epidemiol. 2016;23(6):373-80 doi:10. 1080/09286586.2016.1236974 11. Stocks ME, Ogden S, Haddad D, Addiss DG, McGuire C, Freeman MC. Effect of water, sanitation, and hygiene on the prevention of trachoma: a systematic review and meta-analysis. PLoS Medicine. 2014;11(2):e1001605 doi:10.1371/journal.pmed.1001605 12. Institute of Health Metrics and Evaluation. Trachoma prevalence. 2017 [2020 Aug 12]. Available from: https://ourworldindata.org/grapher/trachoma-prevalence-age-standardized-ihme?tab=chart&time=1990.. 13. United Republic of Tanzania. National
Overall, the SAFE strategy has been successful in aiding the elimination of trachoma, however progress has been slower than initially anticipated. Continued implementation of all SAFE components in trachoma-endemic regions is required, with an enhanced focus on delivery of facial cleanliness and environmental improvement and further research to support these interventions. As begun in Tanzania, approaches to trachoma control must move away from vertical disease programs, which are driven by donor-specified outcome targets, and be integrated into national NTD policies and programs. NTDs often share many underlying determinants and have similar treatments, epidemiology, and geographic distribution. Thus, integrated approaches are likely to have beneficial and sustainable effects on reducing trachoma prevalence, whilst also reducing the burden of other NTDs and the risk of re-emergence. Furthermore, this approach will enhance the efficiency and cost-effectiveness of intervention programs.[40,42] A critical aspect of this will be the ability of LMICs to invest in sustainable health systems, which are less reliant on the political influence of external donors. A continued push for greater accountability and transparency for organisations and NGOs in the global health sphere will greatly aid this approach. The effect of this will extend far beyond trachoma control and have a lasting impact on several NTDs and associated diseases of poverty. Sally is a medical student based in Sydney, NSW. She is passionate about social justice and health, both of which have led her into advocacy for global and rural health issues. She has a particular interest in women’s and children’s health, being two groups which often suffer a disproportionate health disadvantage.
Correspondence email@example.com Acknowledgements The author acknowledges James Cook University in which this material was produced as part of the Master of Public Health and Tropical Medicine course requirements. Conflicts of Interest The author declares no conflicts of interest in the publication of this article. References 1. Taylor HR, Burton MJ, Haddad D, West S, Wright H. Trachoma. Lancet. 2014;384:2142-52 doi:10.1016/ s0140-6736(13)62182-0 2. World Health Organization. Ending the neglect to attain the sustainable development goals: a road map for neglected tropical diseases 2021–2030. 61
Figure 3. Map of Tanzania illustrating trachoma-endemic districts and districts where trachoma has been eliminated. Image created using data obtained from the Global Trachoma Atlas.
Health Policy 2017. Ministry of Health CD, Gender, Elderly and Children. United Republic of Tanzania; 2017. 14. United Republic of Tanzania. Health Sector Strategic Plan July 2015 - June 2020. Ministry of Health and Social Welfare. United Republic of Tanzania 2015. 15. Solomon AW, Zondervan M, Kuper H, Buchan JC, Mabey DC, Foster A. Trachoma control: a guide for programme managers. World Health Organization, London School of Hygiene & Tropical Medicine, International Trachoma Initiative; 2006. 16. Envision. Tanzania Work Plan FY 2019. 2018 [cited 15 Sep 2020]. Available from: https://www.ntdtoolbox.org/sites/default/files/content/paragraphs/ resource/files/2019-08/tanzania_fy18_py8_envision_ work_plan.pdf 17. Mecaskey JW, Ngirwamungu E, Kilima PM. Integration of trachoma control into primary health care: the Tanzanian experience. Am J Trop Med Hyg. 2003;69:29-32 doi:10.4269/ajtmh.2003.69.5_suppl_1.0690029 18. Lietman T, Fry A. Can we eliminate trachoma? Br J Ophthalmol. 2001;85(4):385-7 doi:10.1136/ bjo.85.4.385 19. World Health Organization. WHO Alliance for the Global Elimination of Trachoma by 2020: progress report on elimination of trachoma, 2018. Weekly Epidemiological Record. 2019 [cited Sep 16 2020];29:317-28. Available from: https://apps.who.int/ iris/bitstream/handle/10665/325910/WER9429-enfr.pdf?ua=1 20. West SK, Munoz B, Mkocha H, Holland MJ,
Aguirre A, Solomon AW, et al. Infection with Chlamydia trachomatis after mass treatment of a trachoma hyperendemic community in Tanzania: a longitudinal study. Lancet. 2005;366(9493):1296-300 doi:10.1016/s01406736(05)67529-0 21. Evans JR, Solomon AW, Kumar R, Perez A, Singh BP, Srivastava RM, et al. Antibiotics for trachoma. Cochrane Database Syst Rev. 2019;9 doi:10.1002/14651858.CD001860.pub4 22. Emerson PM, Hooper PJ, Sarah V. Progress and projections in the program to eliminate trachoma. PLoS Negl Trop Dis. 2017;11(4):e0005402 doi:10.1371/journal.pntd.0005402 23. Ramadhani AM, Derrick T, Holland MJ, Burton MJ. Blinding trachoma: systematic review of rates and risk factors for progressive disease. PLoS Negl Trop Dis. 2016;10(8) doi:10.1371/ journal.pntd.0004859 24. West SK, MuĂąoz B, Mkocha H, Hsieh Y-H, Lynch MC. Progression of active trachoma to scarring in a cohort of Tanzanian children. Ophthalmic Epidemiol. 2001;8(2-3):137-44 doi:10.1076/opep.18.104.22.16858 25. Ramadhani AM, Derrick T, Macleod D, Massae P, Mafuru E, Malisa A, et al. Progression of scarring trachoma in Tanzanian children: A four-year cohort study. PLoS Negl Trop Dis. 2019;13(8):e0007638 doi:10.1371/journal. pntd.0007638 26. Ramadhani AM, Derrick T, Macleod D, Massae P, Malisa A, Mbuya K, et al. Ocular immune responses, Chlamydia trachomatis infec62
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tion and clinical signs of trachoma before and after azithromycin mass drug administration in a treatment naive trachoma-endemic Tanzanian community. PLoS Negl Trop Dis. 2019;13:e0007559 doi:10.1371/ journal.pntd.0007559 27. Wolle MA, Munoz BE, Mkocha H, West SK. Constant ocular infection with Chlamydia trachomatis predicts risk of scarring in children in Tanzania. Ophthalmology. 2009;116(2):243-7 doi:10.1016/j. ophtha.2008.09.011 28. Cox JT, Mkocha H, Munoz B, West SK. Trachomatous scarring among children in a formerly hyper-endemic district of Tanzania. PLoS Negl Trop Dis. 2017;11(12) doi:10.1371/journal.pntd.0006085 29. West SK, Munoz B, Mkocha H, Gaydos CA, Quinn TC. Number of years of annual mass treatment with azithromycin needed to control trachoma in hyper-endemic communities in Tanzania. J Infect Dis Med. 2011;204(2):268-73 doi:10.1093/infdis/jir257 30. West S, Munoz B, Mkocha H, Gaydos C, Quinn T. The effect on trachoma and ocular C. trachomatis in villages of multiple, yearly, mass antibiotic treatment in Tanzania: charting the course for the Tanzania National Trachoma Control Program. Invest Ophthalmol Vis Sci. 2008;49(13) 31. Hsieh YH, Bobo LD, Quinn TC, West SK. Risk factors for trachoma: 6-year follow-up of children aged 1 and 2 years. Am J Epidemiol. 2000;152(3):20411 doi:10.1093/aje/152.3.204 32. West S, Munoz B, Lynch M, Kayongoya A, Chilangwa Z, Mmbaga B, et al. Impact of face-washing on trachoma in Kongwa, Tanzania. Lancet. 1995;345(8943):155-8 doi:10.1016/s01406736(95)90167-1 33. Ejere HOD, Alhassan MB, Rabiu M. Face washing promotion for preventing active trachoma. Cochrane Database Syst Rev. 2015 (2) doi:10.1002/14651858.CD003659.pub4 34. Ejere HO, Alhassan MB, Rabiu M. Face washing promotion for preventing active trachoma. Cochrane Database Syst Rev. 2012 (4) doi:10.1002/14651858. CD003659.pub3 35. Rabiu M, Alhassan MB, Ejere HO, Evans JR. Environmental sanitary interventions for preventing active trachoma. Cochrane Database Syst Rev. 2012 (2) doi:10.1002/14651858.CD004003.pub4 36. Baker MC, Mathieu E, Fleming FM, Deming M, King JD, Garba A, et al. Mapping, monitoring, and surveillance of neglected tropical diseases: towards a policy framework. Lancet. 2010;375(9710):231-8 doi:doi.org/10.1016/S0140-6736(09)61458-6 37. Solomon AW, Pavluck AL, Courtright P, Aboe A, Adamu L, Alemayehu W, et al. The Global Trachoma Mapping Project: methodology of a 34-country population-based study. Ophthalmic epidemiology. 2015;22(3):214-25 doi:10.3109/09286586.2015.10374 01 38. The Lancet. Progress in sanitation need-
ed for neglected tropical diseases. Lancet. 2012;379(9820):978 doi:10.1016/s01406736(12)60412-7 39. World Health Organization. Health in all policies: Helsinki statement. Framework for country action. 2014. 40. Standley C, Boyce MR, Klineberg A, Essix G, Katz R. Organization of oversight for integrated control of neglected tropical diseases within Ministries of Health. PLoS Negl Trop Dis. 2018;12(11) doi:10.1371/journal.pntd.0006929 41. United Nations General Assembly. Universal declaration of human rights. UN General Assembly 1948;302(2). 42. Armah FA, Quansah R, Luginaah I, Chuenpagdee R, Hambati H, Campbell G. Historical Perspective and Risk of Multiple Neglected Tropical Diseases in Coastal Tanzania: Compositional and Contextual Determinants of Disease Risk. PLoS Negl Trop Dis. 2015;9(8) doi:10.1371/ journal.pntd.0003939
This piece aims to humanise and bring to life one crusader of the drug and alcohol crisis in Rural North India. It also aims to provide a â€˜life lessonâ€™ or takeaway from the featured individual, to inspire the reader. Kaarthikayinie Thirugnanasundralingam
The good guy
THE BATTLE BENEATH THE SNOW RURAL NORTH INDIA IS BATTLING A SUBSTANCE ABUSE EPIDEMIC.
imachal Pradesh or ‘the land of snowy slopes’ is a populous Northern Indian state made up of hundreds of small villages divided into 12 districts. Dharamshala is the centre of the Kangra district and one of two capital cities of the state*. Buried in the foothills of the Himalayas and steeped in a unique blend of culture, Dharamshala effortlessly marries the Tibetan and Indian ways of life. The city is widely known as home to his Holiness the 14th Dalai Lama, and for boasting the world’s highest cricket stadium perched at over 1457 metres above sea level. However, concealed under this breathtaking scenery is a region grappling with a growing alcohol and drug problem that has permeated through its rural agricultural villages.
cohol, tobacco, and cannabis. Alarmingly, the report also placed the prevalence of alcohol use in children aged 10-17 at 1.3% and cannabis-use at 0.9%.
In 2019, a national report was published on the Prevalence and Extent of Substance Use in India. This report compiled data collected from hundreds of thousands of surveys conducted in representative samples across all 36 States and Union Territories. The survey utilised the validated World Health Organisation ASSIST tool to identify harmful use or dependence in the individuals surveyed. It found that nationally, 19% of individuals who consumed alcohol did so in a harmful pattern, meeting the ‘dependence’ threshold that warranted treatment. Men made up the overwhelming majority of these individuals, and the substances most commonly used in included al-
It is worth noting that the true extent of substance abuse in rural India is extremely difficult to quantify as individuals may be reluctant to disclose their usage in government-led surveys due to a fear of authority and the negative repercussions that may follow. Additionally, the significant culturally-rooted stigma associated with psychiatric illness including substance abuse also prevents many people in rural India from reporting the true extent of their use, as they may fear a loss of reputation within their small communities. Thus, the data which has been reported is likely to be an underestimation.
In these small communities, the lack of any meaningful enforcement of alcohol legislation means that there are few barriers to the sale of alcohol even to minors as young as five. Sadly, some of these children grow up witnessing and subject to alcohol fuelled domestic violence. This in turn significantly detracts from their social wellbeing, affecting their educational attainment and subsequently facilitating their own entry into the vicious cycle of substance abuse. It takes immense willpower to navigate these unique challenges, and government high schools remain a crucial point of education for these taboo issues. Among this vulnerable group, science-based prevention strategies aimed at delaying the initiation of substance use and those which involve families, schools and communities have consistently been identified as 65
amongst the most effective. In December 2019, I was fortunate to be one of seven medical students from Monash University’s TeamMED India who travelled to Himachal Pradesh to deliver a school based health promotion program in conjunction with a local non-government organisation, The Chinmaya Organisation for Rural Development (CORD). Our aim was to educate young adolescents about alcohol and drugs, and equip them with skills and strategies they could employ when faced with common drivers of substance use such as peer pressure and anxiety. We also travelled with the organisation to different rural villages to gauge the extent of substance abuse by speaking to members of the community, and in doing so, identify those groups or individuals who may need further support from CORD. I met Mr. Saab# during one of these community visits.
By all measures, Mr Saab is a man who leads a simple life. A delicately embroidered Himachali crown adorns his glistening forehead as he fiddles around in the sun with what appears to be an old dismantled radio. “Aao Aao,” he says, as his grease covered hands welcome our army of 12 into his humble home. It is striking how welcoming members of these communities are, even to complete strangers. In true Indian spirit, Mr Saab makes us feel as though God himself has stumbled upon his doorstep. Despite this warm welcome, it doesn’t take long for us to realise that his kind eyes have seen many a struggle. Mr Saab has lived in a community consumed by a pervasive substance abuse problem since he was a boy. He pensively describes gradually coming to the realisation that his father was more frequently intoxicated than not, leaving a young Saab to witness firsthand the inescapable and destructive nature of alcohol. His eyes begin to well up with tears as he looks into the distance, poignantly recounting how his father would violently unleash his feelings of inadequacy on the very people he should nurture and care for. In bearing witness to this chaos, Mr Saab quickly learnt to distance himself from Sharab (alcohol), and the people who drank it, sometimes even fleeing the family home and the callous father it contained.
THE GOOD GUY
It is a sunny day in Tang, a rural village near Dharamshala, situated beneath the jewel of Kangra - the Dauladhar mountain range. Streaks of dark green and crimson red uniform scurry down the pathway as the clanging of the lunch bell fills our ears. We pass a group of labourers who begin stacking rows of terracotta bricks on their heads. Their bodies are lean from the heavy lifting, and their faces are awash with fatigue. It begs the question; how do these people carry this burden on their head and continue to function effectively? I wonder, perhaps it is because their minds are occupied elsewhere.
On those occasions where he could not physically escape, he began to find refuge in the vast ocean of Indian music. Entranced by the mellifluous tones he quickly discovered that music left him far more intoxicated than any drug ever could. And so began his powerful jour66
ney of self-actualisation. A self-taught flautist, singer, dancer, and actor, Mr Saab taps into the age-old tradition of passing on important lessons through folk song, dance, and drama. He discovered the power of music to hold our every pain and joy, and evoke emotion even in those numbed by years of substance abuse. Armed with his angelic voice, he travels from village to village singing about drugs of abuse and the perils of intoxication, encouraging his fellow brothers and sisters to give up the habit, or better yet, never start.
program would not have been possible. And finally, Mr Saab for sharing his memorable story. References 1. Ambekar A, Agrawal A, Rao R, Mishra AK, Khandelwal SK, Chadda RK on behalf of the group of investigators for the National Survey on Extent and Pattern of Substance Use in India. Magnitude of Substance Use in India [Internet]. New Delhi: Ministry of Social Justice and Empowerment, Government of India; 2019 [cited 2020, Aug 20]. 88p. Report No.: 1. Available from: http://socialjustice. nic.in/writereaddata/UploadFile/Survey%20Report636935330086452652.pdf 2. Gautam S, Jain N. Indian culture and psychiatry. Indian Journal of Psychiatry [Internet]. 2010 [cited 2020, Aug 21];52(7):309-13. Available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3146223/ doi: 10.4103/0019-5545.69259 3. Lander L, Howsare J, Byrne M. The Impact of Substance Use Disorders on Families and Children: From Theory to Practice. Social Work in Public Health [Internet]. 2013 [cited 2020 Aug 21];28(0):194-205. Available from: https://www. ncbi.nlm.nih.gov/pmc/articles/PMC3725219/ doi: 10.1080/19371918.2013.759005
From Mr Saab we learn the importance of keeping oneself occupied. Perhaps he was not tempted down the pathway of intoxication because he felt that he always had something better to do, whether it was preparing a new composition, becoming engrossed in a new art form, or tinkering with household items. Slowly but surely, he carved out a greater purpose for himself. He, just like the bricklayers, demonstrated that you are better equipped with strength to handle the challenges life throws at you if you keep your mind occupied. He blossomed from his adversity to become stronger, wiser, and kinder. In doing so, he embodies the very essence of rural India - resilient, insightful, and humble. Mr Saab is a good guy. From his lived experience, it becomes clear that perhaps the most important asset in a community riddled by alcohol and drugs is a few good people, doing a few good things. In the end, it is a collection of small ripples that eventually culminates in a tide. * #
Shimla is the other Capital City of Himachal Pradesh. This is a pseudonym.
Kaarthikayinie is a 4th year medical student at Monash University and aspires to a career with an emphasis on womenâ€™s health. She is also passionate about global health equity and preventative medicine..
Correspondence firstname.lastname@example.org Conflicts of interest None declared Images Kaarthikayinie Thirugnanasundralingam Acknowledgements I would like to acknowledge Narender Ji, Aishwarya Didi, Manohar Bhai and everyone else at CORD for their inspiring work and invaluable guidance throughout the trip. I would also like to thank the TeamMed India 2019 group: Natasha, Muskan, Alpha, Caitlin, Kartik and Kunal - without whom the 67
Strategies to protect healthcare workers in resource limited settings Dilini Imbulana Anushree Loyalka Dominic Edwards
PPE in low and middle-income countries during COVID-19
Transmission of COVID-19 is primarily through droplet and fomite spread. Droplets are particles of body fluid that can travel only short distances through the air before landing on surrounding surfaces. Virus-containing droplets may cause direct transmission from close contacts or contribute to the contamination of fomites. Fomites are surfaces or objects (e.g., clothing, equipment, furniture) that can become contaminated by a virus, where it may remain active for hours to days. In contrast to droplets, aerosols are composed of much smaller fluid particles that can remain suspended in air for prolonged periods. If a virus can remain stable within aerosolised airway secretions, this increases the risk of transmission. Current evidence suggests that, while it is plausible that coronaviruses can survive in aerosol form within fluid particles under certain conditions, this is not the primary mechanism for transmission in the community.[1,2]
nfection prevention and control in health care settings involves, among other measures, the use of personal protective equipment (PPE), which encompasses all of the specialised equipment worn by health care workers (HCWs) for protection against health and safety hazards. In low- and middle-income countries (LMICs), there is a higher incidence of infectious disease, often attributed to the poor hospital environmental conditions and reduced availability of PPE, especially during the COVID-19 pandemic. AIM We performed a literature review of proposed methods to prolong the use of PPE and additive measures to protect healthcare workers in resource-limited settings during COVID-19.
Adequate protection against risk infection for HCWs is vital to reduce the burden on health care systems. According to the WHO Guidelines for Infection Prevention and Control, standard droplet precautions are to be applied when in contact with patients with confirmed COVID-19, and airborne procedures must be observed when performing aerosol generating procedures (AGP). According to the Centres of Disease Control and Prevention (CDC), under droplet precautions, PPE must be donned upon entry to the patientâ€™s room; this includes gloves, a gown, and a mask. Airborne precautions require HCWs to don gloves, a gown, and a fit tested N95 or higher level respirator upon entry. Additionally, the CDC has recommended a fundamental framework that all healthcare settings should follow to protect HCWs, which can be represented by a hierarchy of controls, ranked from most to least effective: elimination, substitution, engineering controls, administrative controls, and PPE.
METHODS A search was conducted through several databases, including PubMed, Medline, Scopus, and Google Scholar. Articles were included if they discussed strategies to prolong PPE use for healthcare workers in LMICs. RESULTS Although limited evidence-based strategies exist for PPE in LMICs, extended use of PPE may be attained with effective disinfection or sterilisation, proper doffing, and storage techniques. Alternative PPE includes cloth masks, hand hygiene, and use of face shields. Engineering and administration control of healthcare facilities can further minimise viral transmission.
CONCLUSIONS Several measures have been proposed to optimise current protective measures for HCWs. Extended use and limited reuse of PPE, the use of face shields, proper doffing and hand hygiene, and careful consideration of administrative and engineering controls are all possible strategies to reduce the spread of virus particles to HCWs and patients. However, current studies that show the efficacy of PPE, methods to extend its use, and alternatives to PPE in reducing the transmission of COVID-19 are predominantly conducted in high-income countries. Further research of these strategies in LMICs is required to assess its use in reducing the burden of PPE shortage whilst addressing financial concerns.
2. METHODS A literature search was conducted through several databases, including PubMed, Medline, Scopus, and Google Scholar, using the following keywords and MESH terms: (Personal protective equipment OR protective wear OR infection control) AND (COVID-19 OR coronavirus OR pandemic) AND (healthcare worker, front line worker) AND low middle income countries. Articles were included if they discussed strategies to prolong PPE use for healthcare workers in LMICs. Studies were excluded if they were not published in the English language. 3. RESULTS 69
3.1 EXTENDED PPE USE
A potential strategy to mitigate challenges associated with PPE in limited resources is to optimise current stores of PPE, particularly N95 respirators. This may be achieved by sterilising respirators or implementing the extended use and/or limited reuse of respirators. Extended use is defined as the continual use of the same respirator across multiple patient consultations without donning and doffing. Limited reuse is the use of the same respirator across multiple consults with donning and doffing in between.  Techniques for increasing the longevity of PPE include proper disinfection, storage, and removal of PPE.
Several studies suggest the possible viability of respirator use past the recommended time. Moyer et al. found that intermittent use of N95 respirators for several months resulted in a loss of filtration efficacy after 9-13 hours of cumulative use. Additionally, another study reported the filtration efficacy against inert particles less than 200 nm remained adequate after 5 hours of continuous use, with a maximum recommended extended use period of 8-12 hours. This is suitable against SARS-CoV-2 as it has a diameter of approximately 60-140 nm.[14,15] It has been found that the filtration capacity remained acceptable in respirators stockpiled past their shelf life if stored in manufacturer-recommended conditions. However, the duration N95 respirators remain acceptable past shelf life is unknown.
3.1.1 DISINFECTION METHODS Various disinfection strategies have been suggested to prolong the use of N95 masks. High-income countries and the CDC report that the most promising potential techniques for decontaminating respirators are vaporous hydrogen peroxide, ultraviolet germicidal irradiation (UVGI), and moist heat.[5,6] A summary of each decontamination method and effect on respirator fit performance has been outlined online. However, further research to assess respiratory efficacy post-decontamination for COVID-19 is needed. Studies have shown that UVGI can inactivate coronaviruses, including SARS-CoV and MERSCoV.[7,8] However, with limited financial flexibility, the use of moist heat incubation (i.e., 15–30 minutes (60°C)) or microwave generated steam (1100-1250 W microwave models (range: 40 seconds to 2 minutes)) could be cost-effective solutions. Another method of N95 mask sterilisation reported by van Straten et al. is as follows: N95 masks were sterilised in a 15 minute procedure at 121°C, using a dry sterilisation process and a regular steam process, with the masks in sterilisation/laminate bags. This method was reported to not influence the functionality of the masks tested. Physical decontamination methods such as moist heat and UVGI are less destructive to the respirator filter than chemical methods, such as alcohol washing or bleach. In addition, reuse of N95 masks may be prolonged with the proper storage of respirators post-cleansing, including hanging respirators to dry or keeping them inside a clean, breathable container.[7,10]
FIT FACTORS Respirators can remain adequate for up to 5 successive uses [13,16-17], and failure was avoidable if proper donning procedures were carried out. Moreover, facial perspiration and moisture from exhaled breath has not been shown to significantly impact fit factors. TOLERABILITY Several physiological and psychological markers have been evaluated to determine HCWs’ tolerance of extended use. Researchers at the National Institute for Occupational Safety and found that there was no difference between subjects wearing N95 respirators and controls in terms of oxygen saturation levels, core body temperatures, and perceived heat or humidity while performing low to moderate intensity exercise.[19-22] The average duration of respirators worn by HCWs, particularly ICU nurses, is 2.4 to 6.6 hours, with only short interval breaks.[23,24] FURTHER PROPAGATION OF THE VIRUS An important consideration of extended or limited reuse of masks is the potential virus particle transmission via the HCW’s hands when donning and doffing, or the re-aerosolisation of trapped particles. Fisher et al. found that a virus containing droplet nuclei of diameter 0.65-7.0 micrometres had a negligible risk of re-aerosolisation. However, this is significantly smaller than the diameter of SARS-CoV-2, and there is no empirical data on the fomite potential of SARS-CoV-2 from respirators. Chin et al. analysed the stability of SARS-CoV-2 on different surfaces and reported that it persisted on the outer layer of surgi-
3.1.2 EXTENDED USE AND LIMITED REUSE There are several factors that must be considered before implementing the extended use or limited reuse of respirators. This includes the efficacy of the filter, HCWs’ tolerance of extended use, and ability for the mask to propagate further transmission of 70
cal masks for over 7 days. Reassuringly, 2 studies conducted in major tertiary hospitals in Singapore found that no respirators were contaminated after multiple close patient contacts,[27,28] indicating that there may be low contamination potential. Extended reuse of masks needs to be performed with caution to avoid fomite transmission.
include the use of cloth masks in low risk clinical settings, improving hand hygiene compliance, use of face shields, and reducing the risk of exposure for HCWs through well-developed engineering controls.
3.1.3 PROPER DOFFING AND STORAGE AND PPE COMPETENCY
Cloth masks are commonly used in LMICs to prevent the spread of infection. During COVID-19, cloth masks have been used by HCWs in low resource settings as recommended medical face masks when PPE have become exhausted. However, the degree of increased risk of virus exposure for HCWs wearing cloth masks compared with medical face masks remains unclear.
3.2.1 USE OF CLOTH MASKS
PROPER DOFFING During the Ebola virus outbreak, several studies cited the high contamination rates of inner surfaces of PPE and HCWs due to poor handling of PPE, thus illustrating the importance of correct doffing and storage of PPE to reduce rates of self-contamination and further transmission. Several contributory factors were identified, such as inadequate hand hygiene, lack of standardised doffing protocols and training, incorrectly fitting PPE, doffing barriers (e.g., problematic straps on masks), and prioritising doffing efficiency whilst compromising safety, especially when in timepressed or unfamiliar circumstances. Thus it is clear that the implementation of standardised, safe doffing practices are crucial in maintaining the integrity of PPE and protecting HCWs.
A single RCT assessing the use of cloth masks in a healthcare setting suggested HCWs should not use cloth masks. The risk of exposure was reported to be high during AGPs and in high transmission risk environments, such as emergency and intensive care wards. The study proposes the 3 key characteristics that increase infection risk in cloth masks are moisture retention, sustained reuse, and poor filtration. The study noted the need for innovation of effective cloth mask designs that are evidence-based and low cost for LMICs.
Policy makers may adopt a protocol to reduce the burden of incorrect doffing based on existing recommendations by WHO, CDC, or local guidelines. These include frequent hand hygiene, doffing with the supervision of a trained observer, and just in time training if the standard PPE is replaced with a new model on short notice.[29,30] In LMICs, hands-on training may be a more cost-effective method than computerised training, and this confers the additional benefit of allowing real-time feedback and the development of muscle memory.
Ma QX et al.  found that homemade masks consisting of 4-layer kitchen paper (each layer contains 3 thin layers) and 1 layer of polyester cloth can block 95.15% of SARS-CoV-2 virus. However, the relevant Ct values were not of significant difference, and further research should be performed. Studies have suggested that cloth masks were 5 times more effective than not wearing masks, and common fabric materials may provide marginal protection against virus-sized nanoparticles. While the current guidelines do not recommend HCWs wear cloth masks in a healthcare setting, wearing a cloth mask in resource-limited settings may provide more protection than wearing no mask at all.
PROPER STORAGE The WHO discourages re-donning of potentially contaminated PPE items without adequate reprocessing and storage, as environmental contamination is a principal source of risk to health care workers. Additionally, the CDC advises that masks should be folded so that their outer surfaces are turned inwards to reduce contamination of the environment, and they are stored in a clean, sealable paper bag or container.
3.2.2 HAND HYGIENE NOSOCOMIAL TRANSMISSION OF COVID-19 Nosocomial spread is the primary route of transmission through â€˜transientâ€™ contamination between HCW activities. The Chinese health system, as of 12 February 2020, accounted for 3.83% of the total number of COVID-19 infections due to nosocomial transmission. Hand hygiene is often neglected by HCWs in both low- and high-income countries, with compliance rates sometimes dipping below
3.2 ADJUNCTS TO PERSONAL PROTECTIVE EQUIPMENT Techniques for optimising limited reserves of PPE by utilising alternative measures has been suggested to mitigate challenges associated with resource limitation in LMICs. Strategies suggested in the literature 71
bags, and foam for the headpiece. Face shields should be used on top of a respirator mask as an extra protective layer against aerosol transmission.
20%. As recommended by WHO, hand hygiene is the most effective and cost-efficient method of reducing nosocomial transmission and protecting HCWs and patients.[41,42]
3.3 ADMINISTRATIVE AND ENGINEERING CONTROLS
APPLICATION OF WHO HAND HYGIENE STRATEGIES IN LMICS
Healthcare settings can effectively limit or prevent COVID-19 transmission by implementing administrative controls and using environmental and engineering controls. In conjunction with proper PPE for HCWs, primary prevention strategies should include these controls. Implementation of appropriate controls is dependent on the health facility; however, the general principles have been outlined in Table 1.[51-53]
In resource-limited and overcrowded healthcare environments, hand hygiene is crucial in preventing the spread of viruses. LMICs may be better able to follow WHO’s ‘Multimodal Strategy for Hand Hygiene Improvement’  to maintain optimal hand hygiene behaviour. However, if HCWs in resource-limited countries are unable to adhere to the ‘My 5 Moments for Hand Hygiene’ strategy , adaptations such as the ‘“My five moments for hand hygiene” concept for the overcrowded setting in resource-limited healthcare systems’ should be reviewed. ALTERNATIVES TO WHO RECOMMENDED ALCOHOL-BASED HAND RUBS (ABHR)
A simple administration control that can be used in LMICs includes the reduction of staff-to-staff contact. Goh et al. found a significant reduction in virus spread within hospital services by implementing policies of staff segregation and limiting staff-to-staff interaction.
The shortage of PPE has been accompanied with a shortage of ABHR in healthcare facilities, particularly in LMICs. Healthcare facilities that have limited access to ABHR with WHO recommended formulations can use alternatives that remove the SARS-Cov-2 virus. A study found that instant hand wiping using a wet towel soaked in water containing 1.00% soap powder, 0.05% active chlorine, or 0.25% active chlorine from sodium hypochlorite removed 98.36%, 96.62%, and 99.98% of the virus from hands, respectively.
Engineering controls include physical barriers, such as glass or plastic windows that reduce HCW exposure to the virus in locations such as triage and screening areas. Administrative controls may include postponing elective, non-urgent procedures and hospitalisations, as well as the application of telehealth wherever possible to redirect resources, such as PPE and HCWs, to the management of COVID-19 patients. Additionally, staff education on the appropriate use of PPE may help reduce the environmental waste and reserve of PPE.
3.2.3 FACE SHIELDS
The effectiveness of refined management (including engineering and administrative controls) in the prevention and control of nosocomial COVID-19 infections in non-isolated areas found that the implementation of such methods resulted in zero hospital-acquired infections (HAI). This is particularly pertinent for LMICs, where hospital patients are exposed to rates of HAI at least 2 times higher than in high-income countries.
Face shields are recommended for HCWs when performing aerosol-generating procedures. There is a reported compliance issue surrounding the use of face shields, however, it has been shown to have large potential in reducing the short-term exposure to infectious aerosol particles and preserving face masks and eyewear. Lindsley et al. showed that 0.9% of the initial burst of aerosol from a cough can be inhaled by a worker 46 cm (18 inches) from the patient. During testing of an influenza cough aerosol with a volume median diameter of 8.5 μm, wearing a face shield reduced the inhalation exposure of the worker by 96% in the period immediately after a cough. The face shield also reduced the surface contamination of a respirator by 97%. During the 2009 H1N1 influenza pandemic, the CDC recommended that HCWs consider using face shields to reduce the surface contamination of respirators. Face shields can be made from simple, cost-effective materials, such as plastic film from water bottle cutouts, thermoplastic sheets, A4 acetate sheets, Ziploc
4. DISCUSSION This review demonstrates that there is a robust body of evidence supporting the extended use and limited reuse of N95 respirators, particularly in high-income countries. However, there are some discrepancies regarding specific factors, such as the exact number of cumulative hours that the filtration capacity is sufficient for, duration HCWs can tolerate extended use, and the re-aerosolisation rates of SARS-CoV-2 molecules from PPE. Furthermore, it is important to note that, whilst ef72
fective and frequent hand hygiene has been shown to minimise viral transmission, persistent handwashing to preserve PPE may increase likelihood of impaired skin integrity to the hands. Lan et al. conducted a survey of 526 front-line COVID-19 HCWs that showed 74.5% of HCWs reported damage to hand skin from enhanced infection prevention measures. HCWs who washed their hands more than 10 times per day reported more damage to hand skin, which increases pathogen routes of entry. To mitigate this, it has been suggested that HCWs use protective gloves if available and regularly moisturise.
health. Anushree Loyalka is a third-year medical student at University of Western Australia with a special interest in global health, particularly womenâ€™s health and empowerment. She is the AMSA Global Health representative for her university and is on the managerial committee for Global Health Conference 2021. Dominic Edwards is a third-year medical student from Bond University. He is the Sports Officer for Bond Medical Society, Publications Officer for the Bond University Critical Care Interest Group and Secretary for the Bond University Soccer Club. He is passionate about sport and global health.
As most studies identified in this review were conducted in high-income countries, the ability to translate these proposed strategies to minimise viral transmission amongst HCWs in LMIC needs to be further investigated. Nevertheless, as the COVID-19 pandemic has rapidly affected millions of people in dense populations, research for the efficacy of these strategies may not be possible nor reasonable when there is dire need to protect HCWs. As financial viability in LMICs is a significant barrier for implementing new methods, these strategies may be simple and cost-effective alternatives. Future studies should explore the economic impact of extended use or limited reuse of PPE, with a cost-benefit analysis. We acknowledge that optimal hygiene may not be possible to achieve in many LMIC settings. However, where possible, it should be ensured that doffing and storage policies specific for N95 respirators in the context of SARSCoV-2 are maintained to preserve the efficacy of PPE in between uses for HCWs.
Correspondence email@example.com Acknowledgements The authors would like to thank Alexandra Wilson, Terra Sudarmana, and Shehani De Silva for their assistance with this review. Funding None. Conflicts of interests The authors declare that they have no competing interests. Ethical approval Not required. References 1. Jayaweera M, Perera H, Gunawardana B, & Manatunge J. Transmission of COVID-19 virus by droplets and aerosols: A critical review on the unresolved dichotomy. Environ Res. 2020;188, 109819. Advance online publication. doi: 10.1016/j.envres.2020.109819 2. Pyankov OV, Bodnev SA, Pyankova OG, & Agranovski IE. Survival of aerosolized coronavirus in the ambient air. J Aerosol Sci. 2018;115, 158â€“163. doi: 10.1016/j.jaerosci.2017.09.009 3. Infection Control [Internet]. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality Promotion (DHQP). [cited 2020 May 7]. Available from: https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html 4. CDC - Hierarchy of Controls - NIOSH Workplace Safety and Health Topic. Centres of Disease Control and Prevention; 2015 [cited 2020 Apr 20]. Available from: https:// www.cdc.gov/niosh/topics/hierarchy/default.html. 5. Branley JM, Polkinghorne A, Gilbert GL. Can we reuse P2/N95 respirators? Current evidence and urgent research questions. Med J Aust 2020; https://www. mja.com.au/journal/2020/can-we-reuse-p2n95-respirators-current-evidence-and-urgent-research-questions [Preprint, 9 April 2020] 6. Decontamination and Reuse of Filtering Facepiece Respirators [Internet]. Centres for Disease Control and
5. CONCLUSIONS As this pandemic persists, ensuring sufficient supply of PPE for HCWs remains a major challenge for health facilities around the world. In lower resource settings, this challenge is further exacerbated by financial constraints that underpin the decisions of policy makers. Our review summarises the evidence available for extended use or limited reuse, alternative PPE, and strategic use of engineering and administrative controls as potential solutions to reduce the burden of respirator shortage, without compromising the safety of HCWs. It is important to note that the majority of current evidence is from high-income countries and, thus, careful consideration needs to be taken for the implementation of strategies in LMICs. Further research is required to determine the efficacy of these strategies against SARS-CoV-2 transmission, with cost-benefit analysis to determine the viability in LMICs. Dilini Imbulana is a second-year medical student at the University of Notre Dame. She is the AMSA Global Health representative for her university and has a special interest in refugee and asylum seeker 73
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Palmiero AJ. Physiological impact of the N95 filtering facepiece respirator on healthcare workers. Respir Care. 2010;55(5):569–577. 22. Roberge RJ, Kim JH, Benson S. N95 filtering facepiece respirator deadspace temperature and humidity. J Occup Environ Hyg. 2012;9(3):166–171. 23. Radonovich LJ, Cheng J, Shenal BV, Hodgson M, Bender BS. Respirator tolerance in health care workers. JAMA. 2009;301(1):36–38. 24. Rebmann T, Carrico R, Wang J. Physiologic and other effects and compliance with long-term respirator use among medical intensive care unit nurses. Am J Infect Control. 2013;41(12):1218–1223. 25. Fisher EM, Richardson AW, Harpest SD, Hofacre KC, Shaffer RE. Reaerosolization of MS2 bacteriophage from an N95 filtering facepiece respirator by simulated coughing. Ann Occup Hyg. 2012;56(3):315–325. 26. Chin AWH, Chu JTS, Perera MRA, Hui KPY, Yen H-L, Chan MCW, et al. Stability of SARS-CoV-2 in different environmental conditions. Lancet Microbe. 2020. 27. Ong SWX, Tan YK, Sutjipto S, Chia PY, Young BE, Gum M, et al. Absence of contamination of personal protective equipment (PPE) by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Infect Control Hosp Epidemiol. 2020:1-3. 28. Ong SWX, Tan YK, Chia PY, Lee TH, Ng OT, Wong MSY, et al. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient. JAMA. 2020;323(16):1610-12. 29. Baloh J, Reisinger HS, Dukes K, da Silva JP, Salehi HP, Ward M, et al. Healthcare Workers’ Strategies for Doffing Personal Protective Equipment. Clin Infect Dis. 2019;69(Supplement_3):S192-S8 30. Mumma JM, Durso FT, Ferguson AN, Gipson CL, Casanova L, Erukunuakpor K, et al. Human Factors Risk Analyses of a Doffing Protocol for Ebola-Level Personal Protective Equipment: Mapping Errors to Contamination. Clin Infect Dis. 2018;66(6):950-8. 31. Rational use of personal protective equipment for coronavirus disease (COVID-19) and considerations during severe shortages [Internet]. World Health Organisation [cited 20 April 2020]. Available from https:// www.who.int/publications/i/item/rational-use-of-personal-protective - equipment-for- coronavirus- disease-(covid-19)-and-considerations-during-severe-shortages 32. Yang P, Seale H, MacIntyre C, Zhang H, Zhang Z, Zhang Y, et al. Mask-wearing and respiratory infection in healthcare workers in Beijing, China. Braz J Infect Dis. 2011;15(2): 102-108. doi: 10.1016/S1413-8670(11)70153-2. 33. Chughtai AA, Seale H, MacIntyre CR. Use of cloth masks in the practice of infection control—evidence and policy gaps. Int J Infect Control. 2013;9(3):1–12. doi: 10.3396/IJIC.v9i3.020.13 34. MacIntyre CR, Seale H, Dung TC, Hien NT, Nga PT, Chughtai A et al. A cluster randomised trial of cloth masks compared with medical masks in healthcare workers. BMJ Open 2015;5:e006577. doi: 10.1136/bmjopen-2014-006577 35. Ma QX, Shan H, Zhang HL, Li GM, Yang RM, Chen JM. Potential utilities of mask-wearing and instant hand hygiene for fighting SARS-CoV-2. J Med Virol. 2020;1– 5. doi: 10.1002/jmv.25805 36. Davies A, Thompson K, Giri K, Kafatos G, Walker
Prevention. [cited 2020 May 30]. Available from: https:// www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/ decontamination-reuse-respirators.html 7. Chughtai AA, Seale H, Chi Dung T, Maher L, Nga PT, & MacIntyre CR. Current practices and barriers to the use of facemasks and respirators among hospital-based health care workers in Vietnam. Am J Infect Control. 2015;43(1), 72–77. doi: 10.1016/j.ajic.2014.10.009 8. Hamzavi IH, Lyons AB, Kohli I, Narla S, Parks-Miller A, Gelfand JM, Lim HW, Ozog D. Ultraviolet germicidal irradiation: possible method for respirator disinfection to facilitate reuse during COVID-19 pandemic. J Am Acad Dermatol. 2020. doi: 10.1016/j.jaad.2020.03.085 9. Lin H, Chen C, Huang H, Kuo W, Lai Y, & Lin Y. Filter quality of electret masks in filtering 14.6-594 nm aerosol particles: Effects of five decontamination methods. PloS one. 2017;12(10), e0186217.doi: 10.1371/journal. pone.0186217 10. van Straten B, de Man P, van den Dobbelsteen J, Koeleman H, van der Eijk A, Horeman T. Sterilization of disposable face masks by means of standardized dry and steam sterilization processes; an alternative in the fight against mask shortages due to COVID-19. J Hosp Infect. 2020. doi: 10.1016/j.jhin.2020.04.001. 11. Strategies for Optimizing the Supply of N95 Respirators: COVID-19 [Internet]. Centres for Disease Control and Prevention. 2020. Available from: https://www.cdc. gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html. 12. Fisher EM, Shaffer RE. Considerations for recommending extended use and limited reuse of filtering facepiece respirators in health care settings. J Occup Environ Hyg. 2014;11(8):D115-D28. 13. Moyer ES, Bergman MS. Electrostatic N-95 respirator filter media efficiency degradation resulting from intermittent sodium chloride aerosol exposure. Appl Occup Environ Hyg. 2000;15(8):600–608. 14. Cascella M, Rajnik M, Cuomo A. Features, Evaluation and Treatment Coronavirus (COVID-19)[Internet]. StatPearls Publishing; 2020 [cited 2020 Jul 4]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554776/ 15. Haghighat F, Bahloul A, Lara J, Mostofi R, Mahdavi A. Development of a Procedure to Measure the Effectiveness of N95 Respirator Filters Against Nanoparticles Report R-754. [cited 2013 Jun 2]. Available at http://www. irsst.qc.ca/media/documents/PubIRSST/R-754.pdf. 16. Viscusi DJ, Bergman M, Sinkule E, Shaffer RE. Evaluation of the filtration performance of 21 N95 filtering face piece respirators after prolonged storage. Am J Infect. 2009;37(5):381-6. 17. Roberge R, Niezgoda G, Benson S. Analysis of forces generated by N95 filtering facepiece respirator tethering devices: A pilot study. J Occup Environ Hyg. 2012. 9(8):517–523. 18. Hauge J, Roe M, Brosseau LM, Colton C. Real-time fit of a respirator during simulated health care tasks. J Occup Environ Hyg. 2012;9(10):563–571. 19. Kim JH, Benson SM, Roberge RJ. Pulmonary and heart rate responses to wearing N95 filtering facepiece respirators. Am J. Infect. Control. 2013;41(1):24–27. 20. Roberge R, Benson S, Kim JH. Thermal burden of N95 filtering facepiece respirators. Ann Occup Hyg 2012;56(7):808–814. 21. Roberge RJ, Coca A, Williams WJ, Powell JB,
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J, Bennett A. Testing the Efficacy of Homemade Masks: Would They Protect in an Influenza Pandemic? Disaster Med Pub Health Prep. 2013;7(4):413-418. doi:10.1017/ dmp.2013.43 37. Rengasamy S, Eimer B, Shaffer RE. Simple Respiratory Protection—Evaluation of the Filtration Performance of Cloth Masks and Common Fabric Materials Against 20– 1000 nm Size Particles, Ann Occup Hyg. 2010;54(7):789– 798. doi: 10.1093/annhyg/meq044 38. Pittet D, Allegranzi B, Sax H, Dharan S, Pessoa-Silva C, Donaldson L, Boyce J. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Glob Health. 2006;(10), 641-652. doi: 10.1016/s1473-3099(06)70600-4 39. Wang Y, Wang Y, Chen Y, Qin Q. Unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (COVID-19) implicate special control measures. J Med Virol. 2020;92:568– 576. 40. Allegranzi B, Nejad S, Combescure C, Graafmans W, Attar H, Donaldson L, Pittet D. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet. 2011;377(9761), 228-241. doi: 10.1016/s0140-6736(10)614584 41. Bellissimo-Rodrigues F, Pires D, Soule H, Gayet-Ageron A, Pittet D. Assessing the Likelihood of Hand-toHand Cross-Transmission of Bacteria: An Experimental Study. Infect Control Hosp Epidemio. 2017;38(5), 553-558. doi: 10.1017/ice.2017.9 42. Kratzel A, Todt D, V’kovski P, Steiner S, Gultrom M, Thao TTN, et al. Inactivation of severe acute respiratory syndrome coronavirus 2 by WHO-recommended hand rub formulations and alcohols. Emerg Infect Dis. 2020. doi: 10.3201/eid2607.200915 43. Guner R, Hasanoglu I, Akta, F. COVID-19: Prevention and control measures in community. Turk J Med Sci. 2020;50(SI-1), 571-577. doi: 10.3906/sag-2004-146 44. World Health Organization. Guide to implementation of the WHO multimodal hand hygiene improvement strategy [Internet]. World Health Organization, Geneva. 2009 [cited 2020 Apr 18]. Available from: https://www. who.int/gpsc/5may/Guide_to_Implementation.pdf?ua=1 45. Salmon S, Pittet D, Sax H, McLaws M. The ‘My five moments for hand hygiene’ concept for the overcrowded setting in resource-limited healthcare systems. J Hosp Infect. 2015;91(2), 95-99. doi: 10.1016/j.jhin.2015.04.011 46. Infection prevention and control during health care when COVID-19 is suspected: interim guidance. World Health Organization, Geneva [cited 2020 Mar 19]. Available from: https://apps.who.int/iris/rest/bitstreams/1272420/ retrieve, accessed 23 April 2020 47. Loftus M, Guitart C, Tartari E, Stewardson A, Amer F, Bellissimo-Rodrigues F, et al. Hand hygiene in low and middle-income countries. Int J Infect Dis. 2019;86, 25-30. doi: 10.1016/j.ijid.2019.06.002 48. Ma QX, Shan H, Zhang HL, Li GM, Yang RM, Chen JM. Potential utilities of mask-wearing and instant hand hygiene for fighting SARS-CoV-2. J Med Virol. 2020;1– 5. doi: 10.1002/jmv.25805 49. Lindsley WG, Noti JD, Blachere FM, Szalajda JV, Beezhold DH. Efficacy of face shields against cough aerosol droplets from a cough simulator. J Occup Environ Hyg. 2014;11(8): 509-518. 50. Infection prevention and control of epidemic-and
pandemic-prone acute respiratory infections in health care. Geneva: World Health Organization; 2014 [cited 2020 Apr 24]. Available from: https://www.who.int/csr/ bioriskreduction/infection_control/publication/en/ 51. CDC H1N1 Flu Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel. Centres of Disease Control and Prevention; 2009 [cited 2020 Apr 24]. Available from: https://www.cdc.gov/h1n1flu/ guidelines_infection_control.htm. 52. Infection Prevention and Control for COVID-19. Second Interim Guidance for Acute Healthcare Settings - Canada.ca. Government of Canada; 2020 [cited 2020 Apr 24]. Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/infection-prevention-control-covid-19-second-interim-guidance.html. 53. Australian and New Zealand Intensive Care Society. ANZICS COVID-19 Guidelines Version 1 (pp. 16-20). Melbourne: Australian and New Zealand Intensive Care Society; 2020 [cited 2020 Apr 24]. Available from: https:// www.anzics.com.au/wp-content/uploads/2020/03/ANZICS-COVID-19-Guidelines-Version-1.pdf 54. Goh Y, Chua W, Lee J, Ang B, Liang C, Tan C. et al. Operational Strategies to Prevent Coronavirus Disease 2019 (COVID-19) Spread in Radiology: Experience From a Singapore Radiology Department After Severe Acute Respiratory Syndrome. J Am Coll Radiol. 2020. doi: 10.1016/j. jacr.2020.03.027 55. Xu C, Jin J, Song J, Yang Y, Yao M, Zhang Y. et al. Application of refined management in prevention and control of the coronavirus disease 2019 epidemic in non-isolated areas of a general hospital. Int J Nurs Sci. 2020. doi: 10.1016/j.ijnss.2020.04.003 56. Lan J, Song Z, Miao X, et al. Skin damage among healthcare workers managing coronavirus disease-2019. J Am Acad Dermatol. 2020;82(5):1215-1216. 57. Cavanagh G, & Wambier C. Rational hand hygiene during the coronavirus 2019 (COVID-19) pandemic. J Am Acad Dermatol. 2020. doi: 10.1016/j.jaad.2020.03.090
Table 1. Examples of use of a hierarchy of controls to prevent COVID-19 transmission [51-53]
Postpone elective visits and procedures for patients with suspected or confirmed COVID-19 until they are no longer infectious
Elimination of sources of infection
Deny healthcare facility entry to those wishing to visit patients if the visitors have suspected or confirmed to be infected with COVID-19 Minimise outpatient and emergency department visits for patients with mild COVID-19-like illness who do not have risk factors for complications Keep personnel at home while they are ill to reduce the risk of spreading COVID-19 Install partitions (e.g., transparent panels/windows/desk enclosures) in triage areas as physical barriers to shield staff from respiratory droplets Use local exhaust ventilation (e.g., hoods, tents, or booths) for aerosol-generating procedures Use hoods for the performance of laboratory manipulations that generate infectious aerosols Point-of-care alcohol-based hand rub (ABHR) Install hands-free soap and water dispensers, as well as notouch waste receptacles for garbage and linen, to minimise environmental contact
Conduct aerosol-generating procedures in an airborne infection isolation room (AIIR) to prevent the spread of aerosols to other parts of the facility Use closed suctioning systems for airway suction in intubated patients Use high-efficiency particulate filters on mechanical and bag ventilators
Designated hand washing sinks for HCWs A sufficient supply of and ready access to all PPE at point of care for all HCWs Personal protective equipment
Wear appropriate gloves, gowns, facemasks, respirators, eye protection, and other PPE
Ensure effective general ventilation and thorough environmental surface hygiene
Vaccinate as many healthcare workers as possible (once a vaccine is available) Identify and isolate patients with known or suspected COVID-19 infections Implement respiratory hygiene/cough etiquette programs Respiratory program for all HCWs (e.g., N95 respirator fit testing) Use of N95 respirator, in addition to routine practices, as well as droplet and contact precautions for all AGMP Training, testing, and monitoring for compliance for all HCW education, surveillance, and auditing practices Set up triage stations, manage patient flow, and assign dedicated staff to minimise the number of healthcare personnel exposed to those with suspected or confirmed COVID-19. Screen personnel and visitors for signs and symptoms of infection at clinic or hospital entrances or badging stations, then responding appropriately if they are present
Adhere to appropriate isolation precautions Limit the number of persons present in patient rooms and during aerosol-generating procedures Arrange seating to allow 1.8 metres between chairs or between families when possible Ensure compliance with hand hygiene, respiratory hygiene, and cough etiquette Increase availability of tissues, facemasks, and hand sanitizer in waiting areas and other locations in healthcare facility
Establish protocols for cleaning of frequently touched surfaces throughout the facility (e.g., elevator buttons, work surfaces, etc.) Locate signage in an appropriate language and at the appropriate reading level in areas to alert staff and visitors of the need for specific precautions Place facemasks on patients, when tolerated, at facility access points (e.g., emergency rooms) or when patients are outside their rooms (e.g., diagnostic testing) Place facemasks on patients during transport, when tolerated; limiting transport to that which is medically necessary; and minimising delays and waiting times during transport Visitor restriction policies 77
The gendered impact of COVID-19 How the COVID-19 pandemic has disproportionately impacted women Jasmine Davis
for ill elderly family members. Alongside this, women are predominantly left with the responsibility to take on increased cleaning duties expected during an infectious disease outbreak.
OVID-19 has undoubtedly been one of the most devastating crises in modern history. Early on, the pandemic was labelled as ‘the great equalizer’, however ongoing research has illustrated that COVID-19 is in fact bringing to light the underlying inequalities in our world. These inequalities are vast and complex, and this piece will not be able to fully explore the disproportionate impacts on racial and ethnic minorities and low-income populations.
DOMESTIC VIOLENCE AND FAMILY VIOLENCE The exacerbation of violence against women and girls during COVID-19 has been termed a ‘Shadow Pandemic’ by UN Women. Stay-at-home orders, although necessary to decrease the spread of COVID-19, are likely to increase domestic and family violence, and reduce women’s access to healthcare and social supports. Travel restrictions may limit women’s ability to stay with loved ones, and fear of contracting COVID-19 is stopping some women from seeking medical care after experiencing abuse. Women’s shelters worldwide have reported increased demand and overcrowding, and some have had to shut their doors for fear of an outbreak within the facility. As early as February, China saw a threefold increase in domestic violence cases reported to the local police compared with the previous year. In Kazakhstan, where domestic violence is not a criminal offence, helplines have registered an increase in calls by more than 30%.
A publication by the ‘Gender and COVID-19 Working Group’ in the Lancet in March explored the unequal impact of the global pandemic between men and women. Despite worldwide discussion of these impacts, by organisations such as the WHO and UN Women, representation of women in leadership positions pertaining to decisions about COVID-19 continues to be low. HEALTH CARE WORKERS Up to 70% of the world’s healthcare workers (HCWs) are female. This is placing women at high risk of contracting COVID-19. In the Hubei province of China, where the outbreak started, more than 90% of HCWs are women. This has been exemplified in outbreaks in many other countries, including in Italy, where 66% of HCWs infected with COVID-19 were female.
Women are known to be over-represented in the casual workforce, due to unequal opportunity for full time work worldwide. This places women in a more vulnerable position during an economic fallout. For those women who do have stable work, their pay is on average 11% less than their male counterparts, again putting them at risk of economic hardship during the COVID-19 crisis. Alongside this, women’s economic vulnerability means they have reduced ability to build up supplies against shortages, or for periods of quarantine, a pattern that has been exacerbated by panic buying worldwide.
Past infectious diseases outbreaks have seen expenditure and investment in sexual and reproductive health decrease, reducing women’s reproductive autonomy and access to family planning and obstetric care. In the 2014 Ebola outbreak in West Africa, resources were continually diverted from obstetric care, and led to avoidable morbidity and mortality. Marie Stopes International has predicted that travel restrictions and lockdowns as a result of COVID-19 could result in as many as 3 million additional unintended pregnancies, 2.7 million unsafe abortions and 11,000 pregnancy related deaths. These statistics take into account reduced access to healthcare, interruptions to family planning services, reduced access to contraceptives and abortion, alongside reduced government expenditure on reproductive services.
It is well known that the majority of domestic duties and unpaid care work worldwide is done by women.  Infectious disease outbreaks and their containment measures are shown to further increase this burden. In particular, the closure of schools exacerbates caregiving duties on women, who are often expected to limit their work and economic opportunities to undertake home schooling requirements. Women are also frequently left with the role to care
Despite the clear unequal impacts COVID-19 is having, and will continue to have on women, there is a clear inequality in representation of women globally in decisions pertaining to the pandemic. Despite being the majority of HCWs on the frontline, and despite being the most negatively impacted by the economic and social fallout of the pandemic, only 25% of global leaders are female. This lack of women at the table, and the lack of power in decision making,
8. Godin M. As cities around the world go on lockdown, victims of domestic violence look for a way out. Time [Internet]. 2020; Available From: https:// time.com/5803887/coronavirus- domestic-vio lence-victims/ 9. Smailova D. From where I stand. UN Women [Internet]. 2020; Available From: https://www.unwomen.org/en/news/stories/2020/4/from-where-i-standdina-smailova-on-covid-19 10. Ford L. Coronavirus crisis may deny 9.5 million women access to family planning. The Guardian [Internet]. 2020; Available From: https://www. theguardian.com/global-development/2020/apr/03/ coronavirus-crisis-may-deny-95-million-women-access-to-family-planning
is further exacerbating inequalities and resulting in womenâ€™s needs going largely unmet. The discussions presented in this article are merely a starting point that should prompt further research. As COVID-19 continues to highlight inequalities, in gender or otherwise, it provides an opportunity for those of us with a voice and a platform to speak up, and use this moment to strive for change. Jasmine Davis is a third year post-graduate medical student at the University of Melbourne. She is part of the rural clinical school and currently placed in Echuca. She is the current leader of the AMSA COVID-19 Global Health Taskforce and was the co-lead author on the 2020 Pandemics and Epidemics policy. Correspondence firstname.lastname@example.org Acknowledgements Nil
Conflicts of Interest Nil References 1. The Lancet Public Health. COVID-19 puts societies to the test. The Lancet Public health. 2020 May;5(5):e235. 2. Wenham C, Smith J, Morgan R. COVID-19: the gendered impacts of the outbreak. Lancet. 2020;(10227):846. 3. Farrar J, Gupta GR. Why we need womens leadership in the COVID-19 response. World Economic Forum [Internet]. 2020; Available From: https:// www.weforum.org/agenda/2020/04/women-female-leadership-gender-coronavirus-covid19-response/ 4. UN Women. COVID-19: Emerging gender data and why it matters. UN Women [Internet]. 2020; Available From: https://data.unwomen.org/resources/covid-19-emerging-gender-data-and-why-it-matters 5. Haddad A. COVID-19 is not gender neutral. Broad Agenda [Internet]. 2020; Available From: http://www.broadagenda.com.au/home/covid-19is-not-gender-neutral/ 6. Asia-Pacific Gender in Humanitarian Action Working Group. The COVID-19 Outbreak and Gender. UN Women [Internet]. 2020; Available From: https://www2.unwomen.org/-/media/field%20office%20eseasia/docs/publications/2020/03/ap-giha-wg-advocacy.pdf?la=en&vs=2145 7. UN Women. Infographic: The Shadow Pandemic. UN Women [Internet]. 2020; Available From: https://www.unwomen.org/en/digital-library/multimedia/2020/4/infographic-covid19-violence-against-women-and-girls 80
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