Juxtaposition 14.1 by Juxtaposition Global Health Magazine

politicization politicization of Health: of Health: Yearofof TheThe Year pandemic TheThe pandemic Volume 14 Issue 1 | 2021

Illustration by Riya Razdan

JUXTAPOSITION MAGAZINE VOLUME 14 ISSUE 1 | 2021

C O N T R I B U T O R S

T E A M

Blessing Nkennor

Sanaya Rau

Shatabdy Zahid

Blessing is an undergraduate student at the University of Toronto currently completing her studies in Molecular Biology, Health Studies and International Development Studies. She has significant health research experience on the intersections between public health, politicaleconomy, and community mobilization.

As Co-Editor in Chief for two years, Sanaya launched Juxtaposition’s exclusive interview series, “JuxtaTalks” and podcast, “JuxtaPod”. She graduated from the University of Toronto with a double major in Global Health and Environment and Health. Her most recent publication on neonatal care can be found in the Journal of Pediatrics.

Shatabdy completed her Master of Public Health in Epidemiology from the University of Toronto’s Dalla Lana School of Public Health and is currently working as a research analyst. She is interested in using data to understand health inequities experienced by underrepresented populations.

Simisola Johnson

Hayley Asling

Matilda Dipeiri

Simisola is a graduate from the University of Toronto with a BSc in psychology and neuroscience. Currently, she has been busy writing on topics relating to public health. Her most recent publications can be found at the Harvard Public Health Review and the University of Toronto Medical Journal.

Hayley is currently pursuing her MPH in Social and Behavioural Health Sciences from the Dalla Lana School of Public Health at the University of Toronto. Her interests include women’s health equity, sexual and gender-based violence, and global reproductive and maternal health.

Matilda is a 4th-year undergraduate student at the University of Toronto. Her areas of focus are health studies and geography, with a keen interest in the built environment’s influence on health and how infrastructure can be conducive to health equity.

Vaishnavi Bhamidi

Jocelyn Tamura

Farihah Khan

Vaishnavi is a second-year undergraduate student studying Medical Sciences at Western University. She is incredibly passionate about health journalism, epidemiology, and global health.

Jocelyn studied Global Health and Anthropology at the University of Toronto. She is deeply interested in learning and writing about health and human rights, the political economy of health, and health equity.

Farihah graduated from the University of Toronto with a HBSc in Global Health and Physiology. Farihah is interested in creating a positive impact in people's lives through public policy advocacy and community program planning.

Editors-in-Chief Blessing Nkennor Sanaya Rau

Editorial Matilda Dipieri Vaishnavi Bhamidi Farihah Khan Jocelyn Tamura Lucas Penny Suha Sagheer

Communications

Min Jung Hannah Nie

Podcasters Mariam Zaidi Tosha Henry-Adams

Illustrators Riya Razdan Yeasmin Sultana Angela Niu Jocelyn Tamura Jessica Liu

C O N T E N T S

Letter from the Editors

COVID-19 and Prisons:

The COVID-19 Pandemic:

The Global Gag Rule:

Preventing the Next Pandemic:

Improving Maternal Health using Technology:

New Website Launch

Juxtapod

A Call for Correctional Health Care Reform By Simisola Johnson

An Opportunity for Reform for the World Health Organization By Jocelyn Tamura

A Neocolonial Sanction on the Sexual and Reproductive Rights of Millions of Women in the Global South By Hayley Asling

All for One and One (Health) for All By Shatabdy Zahid

The Flourishing Frontiers of Telemedicine in Pregnancy Care By Vaishnavi Bhamidi

Letter from the editors

We are pleased to present Volume 14, Issue 1 of Juxtaposition, the University of Toronto’s premiere student-run global health magazine. As we write this letter, Ontario is slowly beginning to reopen following a ravaging third wave of the COVID-19 pandemic, new coronavirus variants and a disjointed vaccine rollout campaign. People are tired, frustrated and scared for the health of their loved ones. In many ways, the politicization of health - a seemingly nonpartisan, science-based topic - has exposed the inequities in the social determinants of health within our communities. Juxtaposition creates space for multidisciplinary discussion about complex global health issues through political, social, economic, legal and biomedical lenses. This year’s theme “The Politicization of Health: The Year of the Pandemic” explores various topics including the evolving role of the World Health Organization in responding to global crises, the rise of telemedicine and the need to apply a One Health approach to public health governance. These stories and others in this Issue reflect the successes and failings in managing the COVID-19 pandemic as we strive to return to some semblance of normalcy, or at least a new normal. As Editors, we have a particular responsibility to shine a light on how the politicization of health has affected those on the margins. Thus, in this Issue, you will also find articles that discuss the absence of correctional settings in vaccine rollout plans. In our exploration of these issues, we are proud to celebrate diversity. Our contributors come from diverse backgrounds and walks of life. This diversity brings nuance and heart to our story-telling. This year, we are delighted to feature an almost exclusively female team of writers, editors, public relations associates, podcasters and illustrators, many of whom are BIPOC. Diversity and inclusion are at risk during this crisis, and we are proud to do our part in ensuring that every voice is heard and every story is respected. This year also brought with it the launch of JuxtaPod - our exclusive Juxtaposition podcast now available on Spotify. Through a series of intimate conversations with multidisciplinary experts, JuxtaPod aims to highlight (1) the implications of the COVID-19 pandemic across Ontario and (2) the innovative research underway to address health inequities. We are also excited to launch our new website, juxtamagazine.org, where you will have access to inhouse articles, JuxtaTalks interviews and much more! A sincere thank you to our team who have exhibited tremendous resilience and dedication to this publication. And to you, our readers. Your continued support of this publication energizes and inspires us. Stay safe and stay well. We hope you enjoy this year’s print edition.

Blessing Nkennor Editor-in-Chief 2020-2021

Sanaya Rau Editor-in-Chief 2020-2021

KEEP IN TOUCH juxtamagazine.org | @juxtamagazine | facebook.com/juxtamagazine

covid-19 & prisons

A Call for Correctional Health Care Reform

Simisola Johnson

n the wake of the COVID-19 pandemic, we have seen congregate settings such as long-term care homes, shelters, and other workplaces flounder at the behest of the SARS-CoV-2 virus. While facial masking and quarantine requirements have been critical public health strategies to combat the virus, vaccine administration in cramped living and work spaces remains a top priority. Yet, with over 5 million doses of the COVID-19 vaccine administered as of March 29, 2021, and a national plan to only inoculate about five per cent of the federal prison population, it is clear that correctional settings —which are also congregate settings— are lowly prioritized in Canada [1, 2]. Certainly this a major human rights issue but also, a public health concern. As of June 17th, 2021, the latest live update from Correction Services Canada (CSC), six federal inmates have died as a result of the virus [3]. The United Nations Office of the High Commissioner for Human Rights states that “prisoners shall have access to…. health services available… without discrimination on the grounds of their legal situation” [4]. Conversely, the impact of COVID-19 outbreaks among Canada’s prison populations reveals our lack of resolve to establish policies and practices aimed to fulfill this obligation [4]. Prisons have existed in societies for centuries. However, the widespread abuses of human rights and freedoms throughout the 1930s, and during World War II, put an end to the idea that individual states should have sole authority over the treatment of their citizens —including prisoners [5]. By June 1945, through the signing of the United Nations Charter, human rights entered the realm of international law. Three years later, Member States solidified their commitment to protecting their citizens by

adopting the Universal Declaration of Human Rights (UDHR) [5]. Not only do international human rights documents such as the UDHR, The Standard Minimum Rules for the Treatment of Prisoners, and the International Covenant on Civil and Political Rights, establish a legal ground for basic human welfare, they also link international human rights law and national policies to public health practice by establishing the human right to food, clothing, social services, and medical care. Unfortunately, international agreements are often overlooked. In 2006, the United Nations (UN) followed up with the Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment of Punishment (OPCAT) to hold countries accountable [6]. Through OPCAT, governments are required to adopt prevention mechanisms for inspections, regulations, and oversight of state detention facilities, including senior homes and psychiatric institutions [7]. Interestingly, Canada has yet to sign this treaty [6]. No matter the legal status of an individual, their right to adequate health care must be fulfilled. At the onset of the pandemic, governments around the globe enacted minor changes to their standards of practice in response to explosive transmission rates occurring in prisons. For example, correctional facilities in the US, the UK, Israel and various parts of Asia have authorized the temporary release of people in custody who are considered at low risk to reoffend, close to the end of their sentence, or have a pre-existing medical condition [811]. Likewise, Canada has suspended interregional transfers, switched personal/legal visitations to video format, and increased confinement protocols to limit physical contact [12, 13]. However, these temporary reforms are not adequate long-term public health strategies for infectious disease prevention for a group that is four times more likely to catch infection [49]. Indeed, the devastating impact of COVID-19 in correctional settings highlights an urgent need for additional mitigation strategies such as vaccination programs and raises the question of why prison populations have been widely excluded from COVID-19 vaccine trials [14]. In general, incarcerated people have poor health. The causes behind these health

Illustration

P A G by E

Yeasmin Sultana

No matter the legal status of an individual, their right to adequate health care must be fulfilled.

prisons [30]. According to the most recent 2017-18 data, over 50% of individuals occupying provincial or territorial jails were yet to be convicted [31, 32]. Lastly, overcrowding is a longknown contributing factor of contagious disease transmission in prisons [33]. Though advocates have called for the temporary release of some inmates amid COVID-19 outbreaks, early release strategies do not significantly reduce spiking infection rates [34]. Moreover, weaknesses in our national response to COVID-19 in correctional facilities highlight the importance of increasing testing measures, improving hygiene practices, and strengthening policies regarding bail and remand (e.g.,

disparities are multifactorial and complex, as they are anchored in shifting demographic variables such as gender, age, ethnicity, and the enforcement of discriminatory policies (e.g., Medicaid Inmate Exclusion Policy). For example, incoming federal offenders in Canada are getting older. According to the most recent 2017-18 data, one quarter of federal inmates in Canada are over the age of 50 [15]. Not only is advanced age a major risk factor for COVID-19, but it also increases financial strain on the carceral system, as greater spending is required to accommodate other complex needs such as dementia or impaired mobility [15-17]. Furthermore, compared to the general Canadian population, people in prison typically demonstrate a higher prevalence of underlying, serious, and sometimes life-threatening conditions [4]. The most common underlying health condition among incarcerated individuals is cardiovascular disease —a major risk factor for COVID-19 and a leading cause of death in prison [18, 19].

These factors put Indigenous, Black and other racialized prison populations at a disproportionate risk for poor health outcomes—the same population groups at higher risk of dying by COVID-19 due to impacts of the social determinants of health.

Existing human rights declarations make it clear that incarcerated individuals should have adequate space to live, with access to enough air, light, and healthcare to remain healthy. However, structural determinants of prison health, notably cramped dwelling spaces, unsanitary living conditions, shared showering, and inadequate access to health care services, have made prisons and jails a groundswell for infectious diseases. These factors put Indigenous, Black and other racialized prison populations at a disproportionate risk for poor health outcomes —the same population groups at higher risk of dying by COVID-19 due to impacts of the social determinants of health [20, 21]. Though health disparities in mass incarceration are nothing new, there is hope. To truly make amends, we must seek to understand why Canadian prisons are failing to keep infections out and what can be done differently [1, 22, 23].

presumption of innocence), if we are to build a more resilient and equitable carceral system post-pandemic. In advancing the shared goals of human rights and public health, we must remember that beyond vaccine efficacy and safety, public health is vital to the promotion, restoration, and maintenance of health for communities [35]. Too often is prison health viewed as an isolated matter, but the reality is that most incarcerated individuals will eventually re-enter society with unmet physical and mental health needs [36]. In 2019, Moazen and colleagues criticized the UN’s policy brief on HIV prevention in prisons, saying that omitting the sexual partner(s) of a prisoner from sexually transmitted infection testing protocols is a “costly mistake” for both prison environments and society at large [37]. Similarly, in a report recently published in Health Affairs, researchers revealed that jail cycling, the process of moving people in and out of jail for arrests and pre-trials, was a significant predictor of COVID-19, accounting for nearly 16% of all community infections in Chicago [38, 39]. Jails and prisons are not enclosed systems. When correctional facilities fall short of targeted testing protocols, are excluded from public health efforts, and continue to enforce discriminatory policies that

First and foremost, the emergence and re-emergence of zoonotic diseases are on the rise [24, 25]. Reliance on simple lockdown protocols, as opposed to having effective pre- and post-exposure management and infection-control strategies (to diagnose, control, and interrupt transmission) as well as adequate access to personal protective equipment, pose a grave health risk to correctional facilities [26, 27]. Secondly, systemic inequities, such as inadequate access to clean water and personal hygiene products [28], hinder compliance with ‘frequent hand-washing directives’ to prevent disease transmission. During COVID-19, there has been limited room for inmates to practice social distancing [29]. The excessive and prolonged use of pre-trial detention and imprisonment for minor, petty offences are critical drivers of overcrowded

contribute widely to health disparities in prison populations, correctional employees, families, and communities bear the brunt [40].

poverty, conflict, discrimination and disinterest. Prison is an environment that concentrates precisely these issues” [46]. Breaking cycles of disadvantage in correctional settings is no easy feat, as it requires the dismantling of tactics used to impede health promotion in prisons. For instance, institutional neglect (e.g., budget cuts, low health care provisions, and inadequate rehabilitative opportunities) also contributes to the inequalities of prison health, which further normalizes unhealthy prison environments. According to the WHO, a prison environment supportive of health promotion initiatives is an efficient approach to addressing the physical, mental, social and spiritual health of prison populations [47]. Therefore, adopting a whole prison approach (i.e., system-wide strategy focused on creating supportive prison environments) is worth considering for reform efforts [47]. Most importantly, what is correctional health care reform without a close examination of prison health governance?

The time for correctional health care reform is now. Existing guidelines often spotlight behavioral factors affecting health outcomes, and seldom emphasize the role of upstream, structural determinants to the same degree [41]. For example, decades of public health research has shown that overcrowding and poor ventilation are among the major environmental risk factors for infectious disease transmissions in correctional settings, but a lack of political commitment in the prevention of transmission of infectious diseases in correctional settings is a major hindrance to substantial change [42]. We also know that prolonged solitary confinement can further exacerbate mental health illnesses and delay reporting and treatmentseeking behaviors. Despite a wealth of evidence revealing how solitary confinement poses mortality risk among currently and formerly incarcerated people, amid the current COVID-19 crisis, Canadian prisons have increased their use of solitary confinement as a mitigation strategy [43, 44, 50]. Undoubtedly, links between incarceration and health disparities warrant a systemic, community-based and equity-informed approach to improving public health opportunities. Canada could start by tackling the social determinants of incarceration, through increased investments in affordable housing, employment opportunities, mental health programs, community programs and reducing gender-based violence [45]. As the World Health Organization (WHO) declares, “ill-health thrives in settings of

Currently, correctional health care professionals report to correctional leadership as opposed to health care, which may hinder public health goals and impede their clinical independence [45]. Described as “the processes under which individual physicians have the freedom to exercise their professional judgment in the care and treatment of their patients without undue or inappropriate influence by outside parties or individuals,” the World Medical Association, affirms that clinical independence is “a critical component of high-quality medical care” [48]. Ultimately, prisoners bear the burden if unreasonable restraints or administrative control are imposed on health care professionals. This is not to say that correctional administrators cannot collaborate effectively alongside health care professionals to provide high-quality health care in prisons. Rather, there is no path forward without eliminating persisting ethical and organizational barriers to quality health care in prisons. For this reason, correctional health care reform could also benefit greatly from reforming existing correctional leadership and health governance structures altogether.

When correctional facilities fall short of targeted testing protocols, are excluded from public health efforts, and continue to enforce discriminatory policies that contribute widely to health disparities in prison populations, correctional employees families, and communities bear the brunt.

The colossal effect of the COVID-19 pandemic on incarcerated individuals reinforces the importance of advancing health equity in criminal justice reform. Threats can be alleviated, and health disparities reduced, only if discriminatory practices and systems are abolished. As viral variants circumnavigate the globe, posing an even greater threat for those most structurally disadvantaged, Canada must double down on interventions known to fight disease in congregate settings and change the course of history for incarcerated populations —starting with an equitable vaccination policy.

References [1] Harris, K. (2021, January 06). Conservatives slam VACCINE rollout plan that prioritizes some federal PRISONERS | CBC News. Retrieved February 5, 2021, from https://www.cbc.ca/news/politics/covid19-vaccine-rollout-cscprisoners-1.5863435 [2] Little, N., 2021. COVID-19 Tracker Canada - Vaccination Tracker. [online] Covid19tracker.ca. Available at: <https://covid19tracker.ca/ vaccinationtracker.html> [Accessed 29 March 2021]. [3] Government of Canada, C. (2021, April 09). Testing of inmates in federal

correctional institutions FOR COVID-19. Retrieved June 20, 2021, from https://www.csc-scc.gc.ca/001/006/001006-1014-en.shtml [4] Kouyoumdjian, F., Schuler, A., Matheson, F. I., & Hwang, S. W. (2016). Health status of prisoners in Canada: Narrative review. Canadian family physician Medecin de famille canadien, 62(3), 215–222. [5] Human rights and prisons: A manual on human rights training for prison officials. (2005). New York, New York: United Nations. [6] Khaikin, L. (2020, September 18). Canada drags its feet on international convention against torture. Retrieved March 29, 2021, from https:// canadiandimension.com/articles/view/canada-drags-its-feet-oninternational-convention-against-torture [7] Preventing Torture: The Role of National Preventive Mechanisms. (2018). New York City, New York: United Nations. [8] Covid-19 prisoner releases too few, too slow. (2020, October 28). Retrieved March 29, 2021, from https://www.hrw.org/news/2020/05/27/ covid-19-prisoner-releases-too-few-too-slow [9] ICRC: Urgent Intervention needed to protect Palestinian prisoners and detainees in ISRAELI prisons FROM Covid-19 exposure. (2020, April 16). Retrieved March 30, 2021, from https://ccrjustice.org/icrc-urgentintervention-needed-protect-palestinian-prisoners-and-detainees-israeliprisons-covid-0 [10] Taylor, D., & Grierson, J. (2020, April 04). Up to 4,000 inmates to be temporarily released in England and Wales. Retrieved March 30, 2021, from https://www.theguardian.com/society/2020/apr/04/up-to-4000-inmates-tobe-temporarily-released-in-england-and-wales?fbclid=IwAR2kHYdOFLKzP 3jpTT00F_JXjz9juRut30rS4xeFxvuk2X9p_B_9EolhExs [11] Asia: Reduce prison populations facing covid-19. (2020, October 28). Retrieved March 29, 2021, from https://www.hrw.org/news/2020/04/06/ asia-reduce-prison-populations-facing-covid-19

[20] Richardson, L., & Crawford, A. (2020). COVID-19 and the decolonization of Indigenous public health. Canadian Medical Association Journal, 192(38). https://doi.org/10.1503/cmaj.200852 [21] Betancourt, J. R. (2020, November 23). Communities of color devastated by COVID-19: Shifting the narrative. Harvard Health Blog. https://www.health.harvard.edu/blog/communities-of-color-devastated-bycovid-19-shifting-the-narrative-2020102221201. [22] Burki, T. (2020). Prisons are “IN no Way equipped” to deal With covid-19. The Lancet, 395(10234), 1411-1412. doi:10.1016/s01406736(20)30984-3 [23] Wildra, E. (2021, December 21). Since you asked: Just how overcrowded were prisons before the pandemic, and at this time of social distancing, how overcrowded are they now? Retrieved March 29, 2021, from https://www. prisonpolicy.org/blog/2020/12/21/overcrowding/ [24] McArthur D. B. (2019). Emerging Infectious Diseases. The Nursing clinics of North America, 54(2), 297–311. https://doi.org/10.1016/j. cnur.2019.02.006 [25] Spickller, A. R. (2015, May 15). Emergence and reemergence of zoonotic diseases - public health. Retrieved March 29, 2021, from https:// www.merckvetmanual.com/public-health/zoonoses/emergence-andreemergence-of-zoonotic-diseases [26] Bhatnagar, T., Mandal, S., Arinaminpathy, N., Agarwal, A., Chowdhury, A., Murhekar, M., . . . Sarkar, S. (2020). Prudent public health intervention strategies to control the CORONAVIRUS disease 2019 transmission in India: A Mathematical model-based approach. Indian Journal of Medical

[12] Canada, C. (2020, December 17). Heightened COVID-19 measures in

Research, 0(0), 0. doi:10.4103/ijmr.ijmr_504_20

the Ontario region. Retrieved February 25, 2021, from https://www.canada.

[27] Why COVID-19 testing is the key to getting back to normal. (2020,

ca/en/correctional-service/news/2020/12/heightened-covid-19-measures-

September 4). Retrieved March 28, 2021, from https://www.nia.nih.gov/

in-the-ontario-region.html

news/why-covid-19-testing-key-getting-back-normal

[13] Ricciardelli, R., & Bucerius, S. (2020, June 26). Canadian prisons in

[28] About 100 inmates to Stage hunger strike AT lindsay jail over inhumane

the time of covid-19: Recommendations for the pandemic and beyond.

CONDITIONS | CBC News. (2020, June 15). Retrieved February 11, 2021,

Retrieved April 10, 2021, from https://www.ualberta.ca/folio/2020/06/

from

commentary--canadian-prisons-in-the-time-of-covid-19-recommendationsfor-the-pandemic-and-beyond.html

[29] von Seidlein, L., Alabaster, G., Deen, J., & Knudsen, J. (2021). Crowding

[14] Kinner, S. A., Young, J. T., Snow, K., Southalan, L., Lopez-Acuña, D.,

has consequences: Prevention and management of COVID-19 in informal

Ferreira-Borges, C., & O'Moore, É. (2020). Prisons and custodial settings are

urban settlements. Building and environment, 188, 107472. https://doi.

part of a comprehensive response to covid-19. The Lancet Public Health,

org/10.1016/j.buildenv.2020.107472

5(4). doi:10.1016/s2468-2667(20)30058-x

[30] Prison overcrowding. (2020, August 06). Retrieved April 12, 2021,

[15] Government of Canada, O. (2019, February 28). Aging and dying in

from

Prison: An investigation into the experiences of older individuals in federal March

30,

2021,

from

https://www.penalreform.org/issues/prison-conditions/key-facts/

overcrowding/#:~:text=Prison%20overcrowding%20is%20one%20of%20

custody - February 28, 2019 - office of the CORRECTIONAL Investigator. Retrieved

https://www.cbc.ca/news/canada/toronto/hunger-strike-central-east-

correctional-centre-lindsay-jail-inhumane-conditions-1.5611936

the%20key%20contributing,best%20prevent%20prisons%20from%20

https://www.oci-bec.gc.ca/cnt/rpt/

fulfilling%20their%20proper%20function.

oth-aut/oth-aut20190228-eng.aspx#:~:text=Currently%2C%20in%20

[31] John Howard Society's 5-POINT plan to Improve corrections. (2021,

Canadian%20federal%20penitentiaries,for%2040%20years%20or%20

February 18). Retrieved March 27, 2021, from https://johnhoward.ca/

resources/changing-laws-policies/john-howard-societys-5-point-plan-

[16] Mueller, A. L., McNamara, M. S., & Sinclair, D. A. (2020). Why does

improve-corrections/

COVID-19 disproportionately affect older people?. Aging, 12(10), 9959–

[32] Malakieh, J. (2019, May 09). This Juristat article provides a Statistical

9981. https://doi.org/10.18632/aging.103344

overview of adults and Youth admitted to and released from custody and

[17] McKillop, M., & Boucher, A. (2018, February 20). Aging prison

community supervision in Canada in 2017/2018. analysis is presented at

populations drive up costs. Retrieved April 1, 2021, from https://www.

the national as well as the provincial and territorial LEVELS. Average counts

pewtrusts.org/en/research-and-analysis/articles/2018/02/20/aging-prison-

and the incarceration rates are presented. admissions and the characteristics

populations-drive-up-costs

of adults and youth in the correctional system (such as age, sex and

[18] Wang, E. A., Redmond, N., Dennison Himmelfarb, C. R., Pettit, B.,

ABORIGINAL identity) are also discussed. Retrieved March 29, 2021, from

Stern, M., Chen, J., Shero, S., Iturriaga, E., Sorlie, P., & Diez Roux, A. V.

https://www150.statcan.gc.ca/n1/pub/85-002-x/2019001/article/00010-

(2017). Cardiovascular Disease in Incarcerated Populations. Journal of the

eng.htm

American College of Cardiology, 69(24), 2967–2976.

[33] Gaes, G. (1985). The Effects of Overcrowding in Prison. Crime and

[19] Thomas, E. H., Wang, E. A., Curry, L. A., & Chen, P. G. (2016). Patients’

Justice, 6, 95-146. Retrieved April 12, 2021, from http://www.jstor.org/

experiences managing cardiovascular disease and risk factors in prison.

stable/1147497

Health & Justice, 4(1). doi:10.1186/s40352-016-0035-9

[34] Ouellet, V., &amp; Loiero, J. (2020, July 17). COVID-19 infection

RATES 5-9 times higher in prisons than in general population, CBC news analysis suggests | CBC News. Retrieved April 11, 2021, from https://www. cbc.ca/news/canada/prisons-jails-inmates-covid-19-1.5652470 [35] Bloland, P., Simone, P., Burkholder, B., Slutsker, L., &amp; De Cock, K. M. (2012). The role of public health institutions in global health system Strengthening Efforts: The Us Cdc's Perspective. PLoS Medicine, 9(4). doi:10.1371/journal.pmed.1001199 [36] Macmadu, A., & Rich, J. D. (2020, June 02). Correctional health is community health. Retrieved April 12, 2021, from https://issues.org/ correctional-health-is-community-health/ [37] Moazen, B., Assari, S., Neuhann, F., & Stöver, H. (2019). The guidelines on infection control in prisons need revising. The Lancet, 394(10195), 301302. doi:10.1016/s0140-6736(19)30279-x [38] Reinhart, E., & Chen, D. L. (2020). Incarceration and Its DISSEMINATIONS: Covid-19 Pandemic lessons From CHICAGO’S Cook county jail. Health Affairs, 39(8), 1412-1418. doi:10.1377/hlthaff.2020.00652 [39] Siliezar, J. (2020). Harvard Study Links Jailing Practices to COVID-19 Spread. Harvard Gazette. Retrieved from https://news.harvard.edu/gazette/ story/2020/08/harvard-study-links-jailing-practices-to-covid-19-spread/. [40] Kinner, S. A., & Wang, E. A. (2014). The case for improving the health of ex-prisoners. American Journal of Public Health, 104(8), 1352-1355. doi:10.2105/ajph.2014.301883 [41] Li, M. (2018, March). From prisons to communities: Confronting re-entry challenges and social inequality. Retrieved March 27, 2021, from https:// www.apa.org/pi/ses/resources/indicator/2018/03/prisons-to-communities [42] Niveau, G. (2006). Prevention of infectious disease transmission in correctional settings: A review. Public Health, 120(1), 33-41. doi:10.1016/j. puhe.2005.03.017 [43] Desson, C. (2020, April 25). Prison watchdog criticizes 'EXTREME' confinement as COVID-19 cases SURGE | CBC News. Retrieved March 29, 2021, from https://www.cbc.ca/news/canada/montreal/canada-prisonconditions-covid-19-human-rights-1.5545303 [44] Government of Canada, O. (2021, March 18). Home. Retrieved March 28, 2021, from https://www.oci-bec.gc.ca/index-eng.aspx [45] Nowotny, K. M., & Kuptsevych-Timmer, A. (2018). Health and JUSTICE: Framing incarceration as a social determinant of health for black men in the United States. Sociology Compass, 12(3). doi:10.1111/soc4.12566 [46] Bone, A. (2000). Tuberculosis control in prisons: A manual for programme managers. Geneva, Switzerland: World Health Organization. [47] Møller, L. (2007). Health in prisons: a Who guide to the essentials in prison health. Regional Office for Europe, World Health Organization. [48] WMA - the world Medical ASSOCIATION-WMA declaration of Seoul on professional autonomy and Clinical Independence. (2020). Retrieved February 25, 2021, from https://www.wma.net/policies-post/ wma-declaration-of-seoul-on-professional-autonomy-and-clinicalindependence/ [49] Prashar, A. (2020, December 26). We need to Prioritize incarcerated people as the COVID vaccine is distributed. Retrieved February 11, 2021, from

https://www.businessinsider.com/need-to-prioritize-incarcerated-

people-as-covid-vaccine-is-distributed-2020-12

The COVID-19 Pandemic: An Opportunity for Reform for the

World Health Organization Jocelyn Tamura

ince COVID-19 emerged in late 2019, the world has looked to the World Health Organization (WHO) for its guidance and leadership. The WHO endeavours to be an independent voice of technical expertise on public health. However, elements of its response to the COVID-19 pandemic have highlighted afresh the need for reform if the WHO is to respond effectively to global health threats. With concerns of global health security at the forefront of minds around the world, now is the time to think about what role we want — and need — the WHO to play when the next pandemic arrives.

restrictions. Since then, it has gone on to publish guidelines to manage COVID-19 and established COVAX, a global program that aims to distribute vaccines equitably globally [8]. These moves have attracted equal parts praise and criticism in their execution. To begin, the WHO has exhibited deference to the interests of its member-states throughout its management of COVID-19 — particularly to China. For example, in January 2020, as mounting evidence pointed towards Chinese efforts to conceal the scale of the virus, WHO Director-General Tedros Adhanom Ghebreyesusm praised China for its “commitment to transparency and to supporting other countries” [9]. In fact, a study in the World Development journal found that all the nonneutral statements made by the WHO about China framed the country in a positive light [10]. It was only in February 2021 that a WHO team was able to conduct research in Wuhan, China to investigate the origins of COVID-19. Even still, the team experienced difficulties entering the country and is expected to be highly reliant upon Chinese officials for access to key locations and data [11,12].

The WHO is a branch of the United Nations that is focused on protecting global health. Established in 1948, it is composed of over 190 member-states and operates in regional offices around the world [1]. Its role is normative, whereby it collects data and provides technical guidelines and expertise on health topics for global leaders [2]. While it attends to nearly 200 health issues, the WHO has played a particularly significant role in the management of pandemics [3]. Its International Health Regulations (IHR), borne out of the SARS pandemic in 2005, are a legally binding set of agreements that serve to improve the detection and reporting of emerging public health threats [4]. Under the IHR, the Director-General has the authority to convene an Emergency Committee to assess if a threat merits the declaration of a public health emergency of international concern (PHEIC) [5]. A PHEIC is defined as an “extraordinary event” which may threaten the international community and require a global response to address [6]. In essence, it catalyzes global action, galvanizing funding and attention towards a health threat [7].

Nevertheless, the WHO’s partiality to the political interests and sovereignty of its member-states is a strategic choice; memberstates are a major source of WHO funding [13]. Memberstates pay annual dues, while 80-85% of the WHO’s funding is derived from voluntary contributions from countries, nongovernmental organizations, and private funders [3]. These contributions amounted to a budget of 4.84 billion in 20202021, a number comparable to the budgets of some major U.S. hospitals [14, 15]. Given this limited budget, the WHO must uphold a balancing act between pleasing its funders and retaining its independence.Health Organization declares, “illhealth thrives in settings of poverty, conflict, discrimination and disinterest. Prison is an environment that concentrates precisely these issues” [46].

The WHO has played a critical leadership role during the COVID-19 pandemic. It declared COVID-19 a PHEIC in January 2020, prompting countries around the world to implement social distancing measures, mask-wearing policies, and travel

Illustration by Riya Razdan

All the same, the WHO’s deference to its member-states is not without consequences. The WHO’s tolerance to misinformation and data restriction has raised concerns over its capacity to investigate emerging threats under the IHR, should countries fail to assess or report them [16]. A lack of adequate data from China towards the beginning of the pandemic contributed to the delayed pronouncement of COVID-19 as a PHEIC [5]. Indeed, experts agree that the PHEIC announcement came a week late; at the time of its pronouncement, the virus had already spread to over 100 countries [2,7]. These actions reduced the time that countries could prepare for the oncoming threat and likely cost millions of lives [8].

action. Many countries, particularly outside of Asia, delayed the implementation of public health measures for six to eight weeks after the PHEIC declaration [5]. Furthermore, many countries ignored WHO’s early recommendations to minimize the use of travel bans [5]. As it stands, the responsibility for protecting global health security does not lie solely within the hands of the WHO; it is also individual countries that must recognize their roles. While the WHO promises to promote global solidarity, expertise, and coordination to effectively manage global health threats, the COVID-19 pandemic has made it clear that, in its current state, the WHO is limited in its ability to provide this leadership. This challenge, and much more, will be discussed in the upcoming World Health Assembly. The future of the WHO lies in the hands of these leaders.

Recognizing these gaps in the WHO’s response to COVID-19, countries around the world have convened to propose reforms. In November 2020, G7 members converged to draft proposals for WHO reforms. In January 2021, the WHO Executive Board met to put forward their proposals for their visions of a future WHO. So far, over 20 countries have participated in reform discussions [8]. These proposals will be formally considered and implemented at the next World Health Assembly in May 2021 [3].

References [1] WHO. (2021). About WHO. https://www.who.int/about [2] Clinton, C., Friedman, E., Gostin, L. O., & Sridhar, D. (2020). Why the WHO? Think Global Health. https://www.thinkglobalhealth.org/article/why-who [3] Stevens, P. (2020). Towards a more focused, less divisive World Health Organization. Geneva Network. https://geneva-network.com/research/towards-amore-focused-less-divisive-world-health-organization/ [4] WHO. (2005). International Health Regulations. WHO. https://www.who.int/ health-topics/international-health-regulations#tab=tab_1 [5] Mullen, L., Potter, C., Gostin, L. O., Cicero, A., & Nuzzo, J. B. (200 C.E.). An analysis of International Health Regulations Emergency Committees and Public Health Emergency of International Concern Designations. BMJ Glob Health, 5, 1–10. [6] Maxmen, A. (2021). Why did the world’s pandemic warning system fail when COVID hit? Nature News In Focus. [7] Durrheim, D. N., Gostin, L. O., & Moodley, K. (2020). When does a major outbreak become a Public Health Emergency of International Concern? Lancet, 20(8), 887–889. [8] WHO. (2020). Rolling updates on coronavirus disease (COVID-19). WHO. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-asthey-happen [9] Bremmer, I. (2020). Why We Need the World Health Organization, Despite Its Flaws. Time. https://time.com/5836602/world-health-organization-coronavirus/ [8] Pratnaik, P. (2021). Competing visions for W.H.O. reforms. Geneva Health Files. https://genevahealthfiles.substack.com/p/competing-visions-for-whoreforms [9] Roberts, L. (2020). Institutional Failures in COVID-19. Think Global Health. https://www.thinkglobalhealth.org/article/institutional-failures-covid-19 [10] Ho, J.-M., Li, Y.-T., & Whitworth, C. (2021). Unequal discourses: Problems of the current model of world health development. World Development, 137. [11] Brant, R. (2020). Covid: WHO team probing origin of virus arrives in China. BBC. https://www.bbc.com/news/world-asia-china-55657781 [12] WHO. (2021). WHO Director-General’s opening remarks at the media briefing on COVID-19 – 5 January 2021. WHO. https://www.who.int/directorgeneral/speeches/detail/opening-remarks-for-the-media-briefing-on-covid-19-5january-2021 [13] Posner, E. A. (2020). The Limits of the World Health Organization. Lawfare. https://www.lawfareblog.com/limits-world-health-organization [14] Gostin, L. O. (2015). The future of the World Health Organization: lessons learned from Ebola. The Milbank Quarterly, 93(3), 475. [15] World Health Organization. (2019). (rep.). Programme Budget 2020-2021. Retrieved from https://www.who.int/about/finances-accountability/budget/ WHOPB-PRP-19.pdf?ua=1 [16] Barna, M. (2020). WHO process for declaring health emergencies scrutinized: COVID-19 response shows limitations. The Nation’s Health. https:// www.thenationshealth.org/content/50/2/1.3 [17] Paun, C. (2020). Countries plot changes to World Health Organization once pandemic recedes. Politico. https://www.politico.com/news/2020/10/02/ countries-plot-changes-at-the-world-health-organization-once-pandemicrecedes-425072

Among these proposals include ways to improve the WHO’s ability to assess and report potential health threats. Countries including Germany, France and Australia recommend enhancing the WHO’s ability to monitor compliance with IHR requirements, particularly the obligation to rapidly and transparently report emerging health threats [8]. When a threat becomes apparent, the WHO Director-General argues for the creation of a multi-level system with scope for nuance in the assessment of risk [8]. As it stands, Emergency Committee members are hesitant to “flip the switch” on global action through the declaration of a PHEIC [16]. The proposed system would create several risk levels, each defined by objective criteria and associated with recommended public health responses. These reforms would improve countries’ abilities to react in a proportionate manner and encourage early action to address global health threats before they become widespread [7]. Countries including France and Germany have urged the WHO to modify their funding system. In particular, they argue for increases in assessed contributions and the designation of funds for crises to ensure that the WHO can respond quickly to threats without the need to wait for additional donations [8]. While easing the WHO’s ability to fulfil its agenda, increases in funding will also make it less susceptible to influence by its individual funders and better able to maintain its independence [17]. The WHO hopes to implement these reforms — and many more — in May. Nevertheless, reforms are only half the battle; the WHO would still rely heavily on compliance by its member states. For example, even if improved health risk assessment and reporting were to be established, it would be up to the individual countries to follow the accompanying WHO guidelines [5]. During the COVID-19 pandemic, the WHO’s declaration of a PHEIC was not immediately followed by commensurate

The Global Gag Rule:

A Neocolonial Sanction on the Sexual and Reproductive Rights of Millions of Women in the Global South

Hayley Asling

n January 28, 2021, President Biden signed a presidential memorandum revoking the global gag rule – an unsurprising move in what has become a predictable back-and-forth between liberal and conservative politicians. Since its development in 1984, the gag rule – a policy which bans international groups from receiving US funding if they provide, or even mention, abortion – has been reinstated by every Republican president and rescinded by every Democratic president in an attempt to signal, early in a new administration, the government’s stance on abortion politics [1]. This most recent recession comes at a critical time, as global sexual and reproductive health services become further undermined by the COVID-19 pandemic and global inequities in health service capacity are glaring [2].

The development of the global gag rule mirrors a general surge in anti-abortion sentiment and the politicization of women’s reproductive rights throughout the US, following the legalization of abortion in 1973 [5]. Up until the early 1970s, the US government invested heavily in the research, development, and distribution of contraception for population control initiatives in the Global South, which included abortion technologies [1]. In typical Cold War fashion, the US capitalist society feared that the resource strain caused by overpopulation in newly selfgoverning nations would render them sympathetic to socialism, pushing President Johnson to deem population control a matter of US national security [1]. However, throughout the early 1980s, President Reagan increasingly introduced antiabortion policies into international development initiatives, an effort that included the global gag rule [1]. The introduction of these policies coincided with the initiation of abortion as a distinct partisan issue in the US around the 1976 presidential election [5]. This politicization – which shifted abortion access from an issue of sexual and reproductive health and rights to one of political allegiance – established a new mechanism of obtaining power among conservative voters: by promoting antiabortion policy.

The global gag rule, known officially as the Mexico City Policy, was initially conceived by the Reagan administration in 1984 as a means of imposing oppressive anti-abortion rules on international family planning programs [3]. The policy prohibits foreign non-governmental organizations (NGOs) who receive US funding from providing abortion services, information, or referrals, while also barring advocacy for abortion law reform [1,4]. This prohibition holds universally, even if abortion services are provided with non-US funds, and/or abortion is legal in the recipient country [1,4]. The gag rule, which received its nickname from reproductive health advocates due to its attempts at silencing abortion services and advocacy [1], is a radical intrusion on the rights and autonomy of recipients of US funding in the Global South [4]. In essence, it forces NGOs to choose between complying with the policy and ending the provision of abortion services or declining significant US funding and risking the efficacy and reach of their work [3,4].

Fast forward 32 years to January 23, 2017: On his third day in office, former President Donald Trump reinstated the global gag rule under a new painfully ironic title: Protecting Life in Global Health Assistance (PLGHA), which expanded the reach of the rule by applying the policy to recipients of any US global health funding. Where the gag rule previously only included family planning NGOs, the most recent iteration included everything from maternal health and paediatrics, to HIV/AIDs and reproductive health, to infectious disease and vaccination programmes, implicating an unprecedented $8.8 billion in

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Illustration by Jessica Liu

B M D D I G I TA L .C O M

withdrawn funds and endangering the lives of millions [4,5]. Considering the ideological nature of his political base (indeed, Trump was the first presidential candidate to ever speak at the anti-abortion March for Life in Washington, DC [6]), the former President’s decision to expand the global gag rule illuminates the transient nature of health politicization; it can shift opportunistically depending on who is in power.

The pervasive reach and devastating impacts of the gag rule – now compounded by the COVID-19 pandemic – are predicated on the very structure of global health systems today. Highlighting a darker history of neocolonialism1 in global health institutions, the current structure of global health is one where states in the Global South are dependent on foreign aid from wealthier countries in the Global North to meet their basic health needs, leaving them vulnerable to exploitation by foreign powers [5]. In the case of the global gag rule, the US utilizes this financial dependence to impose its anti-abortion ideology on financially poorer countries for political gain back in the US. This speaks to a power dynamic whereby powerful actors can monopolize global health agenda-setting through their financial position.

Despite the narrative spun by its supporters, the global gag rule, like other restrictive anti-abortion policies, does not stop women from seeking abortions [7]. On the contrary, during periods when the policy is in effect, abortion rates rise as other forms of family planning are defunded [1,8]. By reducing women’s access to contraceptive services, the gag rule increases the probability of unintended pregnancy and, due to the loss of trusted health services, also increases reliance on secretive and unsafe abortions that are a major cause of maternal injury and death in low-income settings [7,9]. For example, Marie Stopes International, an NGO for international reproductive health, estimated that cuts to their services due to Trump’s PLGHA policy would give rise to an additional 6.5 million unintended pregnancies, 2.1 million unsafe abortions, and more than 21,000 maternal deaths [10]. This impact is compounded by the COVID-19 pandemic, which alone is predicted to cause 7 million unintended pregnancies and thousands of unsafe abortions and birth-related deaths worldwide [11]. These changes in reproductive health outcomes are driven by multiple factors, including disruptions in access to already precarious sexual and reproductive health services, the closure or re-purposing of reproductive health clinics, and lockdown measures that curtail free movement and lead to ‘skyrocketing’ rates of gender-based violence [11,12].

By reducing women’s access to contraceptive services, the gag rule increases the probability of unintended pregnancy and, due to the loss of trusted health services, also increases reliance on secretive and unsafe abortions that are a major cause of maternal injury and death in low-income settings.

This politicization – which shifted abortion access from an issue of sexual and reproductive health and rights to one of political allegiance – established a new mechanism of obtaining power among conservative voters: by promoting antiabortion policy.

Here, the US government leverages its position as the largest donor of global health programs in the world to push an antiabortion agenda to secure domestic power through lobbyist support, funding, and conservative votes [3, 13]. Given the impact this policy has on maternal injury and death, the lives of millions of women in poorer countries reliant on US aid are deemed fair collateral in a political fight closer to home. The reliance on foreign aid for progress on health service delivery in the Global South – and the resulting ability of powerful actors to co-opt global health agenda setting for their own vested interests – effectively destabilizes Global South health systems. This is particularly problematic during

Neocolonialism refers to the use of economic, political, cultural, or other pressures to control or influence other countries, especially those which are former dependencies.

“When I heard about this, the result of the [2016 US Presidential] election, I thought, how are we going to turn all these women away? How are we going to deny them, again, the access to family planning and birth control they used to get from our organization?” Lalaina Razafinirinasoa Country Director, Marie Stopes Madagascar, contraception and safe abortion NGO

Given the impact this policy has on maternal injury and death, the lives of millions of women in poorer countries reliant on US aid are deemed fair collateral in a political fight closer to home.

and that in fights for global health equity – particularly those which have been made apparent throughout this pandemic – we continue to question why the basic well-being and health security of the global majority are reliant on precarious, internationally funded NGOs. If we maintain the current global health status quo – whereby women’s reproductive health is continuously politicized, and the Global North can exploit the Global South for financial or political gain at the expense of millions of lives – we are sure to see yet another version of the global gag rule implemented by whichever Republican president comes next.

References [1] WHO. (2021). About WHO. https://www.who.int/about [2] Clinton, C., Friedman, E., Gostin, L. O., & Sridhar, D. (2020). Why the WHO? Think Global Health. https://www.thinkglobalhealth.org/article/whywho [3] Stevens, P. (2020). Towards a more focused, less divisive World Health Organization. Geneva Network. https://geneva-network.com/research/ towards-a-more-focused-less-divisive-world-health-organization/ [4] WHO. (2005). International Health Regulations. WHO. https://www. who.int/health-topics/international-health-regulations#tab=tab_1 [5] Mullen, L., Potter, C., Gostin, L. O., Cicero, A., & Nuzzo, J. B. (200 C.E.). An analysis of International Health Regulations Emergency Committees and Public Health Emergency of International Concern Designations. BMJ Glob Health, 5, 1–10. [6] Maxmen, A. (2021). Why did the world’s pandemic warning system fail when COVID hit? Nature News In Focus. [7] Durrheim, D. N., Gostin, L. O., & Moodley, K. (2020). When does a major outbreak become a Public Health Emergency of International Concern? Lancet, 20(8), 887–889. [8] WHO. (2020). Rolling updates on coronavirus disease (COVID-19). WHO. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/ events-as-they-happen [9] Bremmer, I. (2020). Why We Need the World Health Organization, Despite Its Flaws. Time. https://time.com/5836602/world-healthorganization-coronavirus/ [8] Pratnaik, P. (2021). Competing visions for W.H.O. reforms. Geneva Health Files. https://genevahealthfiles.substack.com/p/competing-visionsfor-who-reforms [9] Roberts, L. (2020). Institutional Failures in COVID-19. Think Global Health. https://www.thinkglobalhealth.org/article/institutional-failurescovid-19 [10] Ho, J.-M., Li, Y.-T., & Whitworth, C. (2021). Unequal discourses: Problems of the current model of world health development. World Development, 137. [11] Brant, R. (2020). Covid: WHO team probing origin of virus arrives in China. BBC. https://www.bbc.com/news/world-asia-china-55657781 [12] WHO. (2021). WHO Director-General’s opening remarks at the media briefing on COVID-19 – 5 January 2021. WHO. https://www.who.int/ director-general/speeches/detail/opening-remarks-for-the-media-briefingon-covid-19-5-january-2021 [13] Posner, E. A. (2020). The Limits of the World Health Organization. Lawfare. https://www.lawfareblog.com/limits-world-health-organization [14] Gostin, L. O. (2015). The future of the World Health Organization: lessons learned from Ebola. The Milbank Quarterly, 93(3), 475.

the current COVID-19 pandemic. Historically, transnational global health efforts have been driven largely by the interests of ‘philanthropic’ funders and major global health agencies – including the Bill & Melinda Gates Foundation and the World Bank – which has resulted in a narrow focus on technologybased, disease specific global health interventions rather than on strengthening local health systems [14, 15]. By choosing not to invest in local health service capacity-building, or improved social conditions (which are more directly associated with mortality and morbidity declines), this approach to global health development has left many countries in the Global South vulnerable to the pandemic due to significant underresourcing, economic precarity, and fragmented health system governance [14, 15, 16]. Indeed, the COVID-19 pandemic has revealed glaring inequities in global health system capacity, as poorer countries throughout the world deal with chronic shortages in basic health supplies and equipment, human and capital resources, and most recently, vaccine development and distribution [14, 17]. And despite these disparities, at a time when coordinated global responses are needed most, the pandemic has been leveraged as another opportunity for health politicization at the expense of poorer countries reliant on foreign aid. In the US, former President Trump went as far as suspending US funding to the World Health Organization in the middle of the pandemic, after downplaying and ignoring initial warnings about the crisis, in an attempt to shift blame for his handling of the outbreak [18, 19]. This decision further highlights the capacity for powerful actors to prioritize financial or political interests over the health security needs of the globalized world – the same capacity that underpins the global gag rule. While it is worth acknowledging with some relief that Biden’s presidency brings a hiatus to the global gag rule, Dr. Arianne Shahvisi brilliantly notes that Biden’s presidential memorandum is “also a devastating reminder of where we are: the bodily autonomy of millions of women in the Global South hangs on the stroke of a white man’s signature, and we count it as a success when the whims of a bullish superpower swing the right way” [20]. It is important that this perspective not be lost,

Preventing the Next Pandemic: All for One and One (Health) for All

Shatabdy Zahid

Illustration by Jocelyn Tamura

OVID-19, caused by the SARS-CoV2 virus, is believed to be a zoonotic disease – meaning that the virus originated in an animal and can now be transmitted to humans [1]. Early inquiries showed that the virus likely emerged from the Huanan Seafood Market in Wuhan, China, where horseshoe bats and/or ant-eating pangolins carrying the disease were sold as live animals in the wet market and spread to customers [1, 2]. However, at the time of writing, the investigation is ongoing. SARSCoV2 virus is considered to be the most recent example of a zoonotic disease, but it is not the first to exist. West Nile Virus is transmitted from mosquitoes, Ebola is spread from contact with infected bats and primates, and Lyme disease is hosted in rodents and transmitted to humans from tick bites [3]. Of the various infectious pathogens that are known to affect humans, about 60% have zoonotic origins, and up to 75% of emerging infectious diseases are zoonotic [4]. These estimates are particularly worrying when we consider how much of our lives, from where we live to what we eat, have become interwoven with the lives of animals. To potentially prevent the next pandemic, we need policies and strategies that understand the interconnection of the health and wellbeing of humans, animals, and the environment, such as the One Health approach. One Health is a multi-level collaborative and transdisciplinary approach that addresses urgent health issues, such as housing, employment, and food security, at the humananimal-environment interface [5].

Similarly, the 2014 West African Ebola epidemic is believed to be connected to habitat encroachment as local forests were cut down and urbanized for mining and timber operations [7]. The index case for the deadly Ebola virus outbreak was a young boy who was playing in a tree that housed infected bats [8]. Some reports suggested that urbanization in local areas may have contributed to the influx of wild animals, especially the Ebola disease-carrying bats, and allowed for more contact with local residents [7]. For both the spread of Ebola and Lyme disease, there was a lack of coordinated housing, environmental and health policies, and strategies that could have prevented the transmission of these deadly diseases. Another area of our lives that is inherently linked to animals is our consumption and demand for animal products, particularly in high-income countries [9]. The increased demand for animal products has led to greater use of factory farming, wet markets, and exotic animal trading, and has been consequently identified as contributing to the development of recent pandemics [10]. Factory farming is the practice of streamlining the breeding and slaughter of livestock to maximize production and minimize costs [11]. To keep costs low, species of animals that do not naturally interact (i.e. pigs, chickens, ducks, turkeys, cattle and fish) are kept in cramped quarters, creating the perfect environment for new pathogens to mix and emerge [10, 11]. Further, livestock are bred quickly with little genetic diversity, which increases the chances of animals having weaker immune systems [10]. Due to the miserable living conditions, poor nutrition, weakened immune responses and overuse of antibiotics, animals often have poor health and are distressed, causing them to cough and defecate in abundance [10, 11]. Harmful pathogens, like the H1N1 influenza (“Swine flu”) virus or other strains of bird flu, are then spread around, infecting other animals and employees [10]. Factory farm employees often work in crowded and unsafe areas, interact heavily with the potentially disease-carrying animals and may not be compensated for sick leave, thus forcing them to work while ill and further contributing to the spread of diseases [12, 13]. In order to maximize production to meet consumer demands and minimize spending, agricultural and labour policies and strategies routinely place profits over employee environmental and animal protections, which in turn permits more deadly diseases to appear and spread in communities.

Of the various infectious pathogens that are known to affect humans, about 60% have zoonotic origins, and up to 75% of emerging infectious diseases are zoonotic.

Along similar lines, live animals sold in markets or for trading are also kept in stressful and unhygienic conditions. It is important to note that most “wet” markets in Asia – where COVID-19 is believed to have originated – refer to markets for locals to buy fresh foods, such as chicken, fish, pork, and produce, at accessible prices, though there are some wet markets that trade and sell more exotic wildlife as a delicacy and for traditional medicines [14]. After the 2003 SARS outbreak, which was believed to have started from interactions between customers and infected exotic animals at Chinese wet markets, there was pressure on the Chinese government to ban exotic animal trading, and increase the safety standards of these markets or shut them down completely [15]. However, banning exotic animal trading pushed the practice towards underground crime

To meet rising housing demands, we have been clearing forests, disturbing local fauna and encroaching on animal spaces to urbanize land and create new, at times fatal, meeting points with animals and organisms [6]. In Canada and the US, suburbs are developed by breaking up forests into smaller patches and crisscrossing them with concrete and brick homes, thereby creating the perfect environment for Lyme disease-carrying deer and small-footed mice to inhabit. With their old habitats destroyed, the deer and mice roam freely in our backyards and parks and are the premier food choice of Lyme disease infected ticks. More frequent interaction with the disease-carrying ticks in our backyards and parks raises our chances of contracting the debilitating disease [6].

circles that continuously evade international law enforcement and safety regulations [16]. Wet markets were also closed down temporarily and there was an attempt to implement safety measures. However, once the spread was under control, the markets re-opened and the safety standards began to lighten over time. The move to permanently close down markets also raised concerns about its effect on people’s livelihood and the availability of affordable and nutritious food options [17]. Even after the SARS outbreak, there continue to be gaps in policies and strategies that protect market employees, customers, animals, the environment and the global community at large. After the 2003 SARS outbreak, the World Health Organization (WHO) offered guidelines of constant vigilance and global communication to prevent the next pandemic. Guidelines included increased laboratory testing, surveillance, reporting, and multi-level global cooperation [17]. Without consistent local and international support and collaboration for health infrastructure, surveillance and policy development, any new infectious diseases that emerge will not be dealt with quickly enough and with minimal casualties [16]. Once SARS was no longer dominating headlines, the health and safety policies created post-SARS continued to be short-sighted and unidimensional [17]. An approach to making sure future strategies and policies are multidimensional is to implement the principles of the One Health approach [16, 18]. The One Health approach to public health governance recognizes that the health and wellbeing of humans, animals and the environment are intertwined [5, 18, 19]. According to the WHO, the One Health approach is particularly relevant to issues surrounding food safety, controlling emerging zoonoses, and preventing potentially pandemic-causing diseases from developing, all of which were seen in the housing, agricultural, labour and food safety issues discussed earlier [5, 19]. For example, with regards to housing and urbanization relating to the spread of Lyme disease and Ebola, the housing, environmental and public health sectors would need to combine their expertise and communication to ensure that homes and communities are developed in a way that prevents the spread of fatal diseases in populations, while still meeting housing demands. Additionally, to ensure that the next pandemic does not originate in factory farms or wet markets, policies and strategies need a multifaceted approach that provides environmental regulations and safety standards for employees, customers and animals on farms, in markets and animal living spaces, while still ensuring that nutritious, affordable and culturally traditional foods remain accessible. As recommended by the One Health approach, this complex undertaking would involve multiple sectors and disciplines working together: agricultural, labour, public health, justice and global trade, just to name a few.

The One Health approach to public health governance recognizes that the health and wellbeing of humans, animals and the environment are intertwined. Agricultural Organization of the United Nations and the World Organisation for Animal Health to promote multi-sectoral responses to emerging zoonotic threats, food safety concerns and other public health issues that may develop as humans and animals continue their interconnection [19]. The Center for Disease Control and Prevention in the US implements the One Health approach by allowing relevant sectors and disciplines to be involved in learning how diseases spread among humans, animals, plants and the environment [20]. Our lives have become more and more interconnected with animals and the environment. We build our homes near their homes and we rely on them to feed us and allow our cultural practices to continue. However, this interconnectedness, when unregulated, also allows for the emergence of infectious diseases that may very well become the next pandemic. The transdisciplinary, multi-level, and multi-faceted One Health approach to designing and implementing policies and strategies allows for a wide network of key actors to work together and ensure optimal health and wellbeing for humans, animals and the environment and will hopefully prevent the next pandemic from ever occurring.

References [1] Cyranoski, D. Mystery deepens over animal source of coronavirus. Nature, (2020). [2] Mackenzie, J.S. & Smith, D.W. COVID-19: a novel zoonotic disease caused by a coronavirus from China: what we know and what we don’t. Microbiology Australia, (2020). [3] Center for Disease Control and Prevention. 8 Zoonotic Diseases Shared Between Animals and People of Most Concern in the U.S. Center for Disease Control and Prevention Newsroom Release, (2019). [4] Woolhouse, M.E.J. & Gowtage-Sequeria, S. Host range and emerging and reemerging pathogens. Emerging Infectious Diseases 11, 1842–1847 (2005).

To identify, respond to, and stop disease outbreaks, the One Health approach insists on the collaboration of professionals and experts from a wide breadth of departments and disciplines to monitor and mitigate public health threats. These experts can include medical professionals, epidemiologists, health, social and environmental researchers, and government actors [5, 18, 19]. For example, currently, the WHO works with the Food and

[5] Mackenzie, J.S. & Jeggo, M. The One Health approach—why is it so important? Tropical Medicine and Infectious Disease 4, 1-4 (2019). [6] Li, S. et al. Consequences of landscape fragmentation on Lyme disease risk: a cellular automata approach. PLoS One 7, 1-12 (2012). doi:10.1371/ journal.pone.0039612 [7] Saéz, A. M. et al. Investigating the zoonotic origin of the West African Ebola epidemic. EMBO Molecular Medicine 7, 17-23 (2015).

[8] World Health Organization. “Origins of the 2014 Ebola epidemic” in One year into the Ebola epidemic. (World Health Organization, 2015). [9] OECD/FAO. “Meat”, in OECD-FAO Agricultural Outlook 2020-2029 (OECD Publishing, 2020). [10] Graham, J.P. et al. The animal-human interface and infectious disease in industrial food animal production: rethinking biosecurity and biocontainment. Public Health Reports 123, 282-299 (2008). [11] Food and Water Watch. Factory farm nation: 2020 edition. (2020). [12] Turner, J. Factory farming and the environment. UN/AAC Subcommittee on Nutrition. (1999). [13] FoodPrint. Sustainable Agriculture vs. Industrial Agriculture. FoodPrint News. (n.d https://foodprint.org/issues/sustainable-agriculture-vs-industrialagriculture/#easy-footnote-bottom-1-1820 [14] Wescott, B. & Wang, S. China's wet markets are not what some people think they are. CNN.com. (2020). https://www.cnn.com/2020/04/14/asia/ china-wet-market-coronavirus-intl-hnk/index.html [15] Library of Congress. Regulation of Wild Animal Wet Markets. Library of Congress. (2020). https://www.loc.gov/law/help/wet-markets/china.php [16] Aguirre, A. A., et al. Illicit wildlife trade, wet markets, and COVID‐19: preventing future pandemics. World Medical & Health Policy 12, 256-265 (2020). [17] Institute of Medicine. Forum on Microbial Threats: Learning from SARS: Preparing for the Next Disease Outbreak: Workshop Summary. (National Academies Press, 2004). [18] El Zowalaty, M.E., & Järhult, J.D. From SARS to COVID-19: a previously unknown SARS- related coronavirus (SARS-CoV-2) of pandemic potential infecting humans – call for a One Health approach. One Health 9, 1-6 (2020). [19] World Health Organization. One Health. World Health Organization Newsroom https://www.who.int/news-room/q-a-detail/one-health (2017). [20] Center for Disease Control and Prevention. One health basics. (2018).

The Flourishing Frontiers of

Telemedicine in Pregnancy Care Vaishnavi Bhamidi

elemedicine has been a lesser-known, but recently burgeoning component of healthcare systems, both in North America and internationally. Its application to prenatal and postnatal care is one of growing significance, especially when it comes to ensuring maternal and child health, improving healthcare access, and allowing patients and physicians to adapt to rapidly changing pandemic circumstances. A 2017 article analyzing 71 international studies of telemedicine interventions for pregnancy care found that women of reproductive age seem to be highly interested in such care and most of the evaluated health outcomes for postpartum telemedicine interventions were largely positive, with patient and provider satisfaction rates of up to 95% [1].

Telemedicine in North America Although many telemedicine application initiatives have been steadily developing since the late 2000s, the demand and need for such services have been relatively low. In Canada, telemedicine represented merely 15% of all billable healthcare services in 2014 [3]. That said, there has been a swelling demand for such services due to considerations of convenience, accessibility, and time and transportation savings. A 2018 survey by Ipsos, a French market research company, found that 9% of Canadians have used telehealth and that more than 44% would be willing to try telehealth [4]. However, it can be argued that nothing has compelled this transition more than the present pandemic. Lockdown and physical distancing measures have exceeded any naturally-growing demand for telemedicine services by necessitating rapid modification of healthcare infrastructure. This shift has completely modified what pregnancy care looks like for women in Canada and the United States. Now, in the post-pandemic era, rather than abiding by the general schedule of 11-14 prenatal clinic visits, an increasing number of telehealth check-ins are being incorporated [5]. What’s more, pregnant women must now get involved in their own care like never before. They are being taught to self-monitor their own and their child’s vitals using blood pressure cuffs, fetal heart rate Doppler monitors, and smartphone tools [5]. To provide further support to new parents, many clinics are also substituting the customary six week postpartum check-in with virtual check-ins happening 2-3 weeks after birth [5]. Additional pregnancy-related services such as mental health care, online teleconsultations, lactation support, and at-home monitoring of blood sugar are also being considered or implemented by various physicians and clinics [6].

Telemedicine, eHealth, and mHealth are often used interchangeably and generally differ in their definition depending on the context. However, there are subtle differences that distinguish these terms. Telemedicine is broadly known as the remote provision of healthcare services using information and communication technologies via strategies like remote diagnosis, monitoring, intervention, and education [2]. On the other hand, electronic health (eHealth) and mobile health (mHealth) refer more specifically to digital applications installed on portable mobile devices that aid the provision of healthcare [1]. This article will examine the scope, impacts, and risks associated with implementing telemedicine, eHealth, and mHealth practices (henceforth clubbed together as telehealth), specifically for pregnancy care. In addition, this article will also detail three examples of grassroots telehealth initiatives being developed around the world: WawaRed in Peru, ImTeCHO in India, and RapidSMS in Rwanda.

These ample opportunities to supplement existing in-person pregnancy care with remote monitoring and self-administered care represent a new frontier in managing maternal and infant health in North America. There is a growing notion that telemedicine can improve healthcare access and reduce maternal mortality rates, especially in rural populations [6,7]. However, there are also emerging risks that need to be mitigated in order to ensure effective and productive integration of telehealth into pregnancy care in the North American context. One of the largest related issues is the lack of national telemedicine platforms that integrate electronic health record (EHR) information across different information systems. For example, in Canada, many health technology companies have created apps that allow the use of private consultation services.

geographical locations, many miles away from hospitals or clinics. Low-to-middle income (LMIC) countries are also experiencing an unprecedented increase in smartphone users, especially due to decreasing prices [9,10]. These devices are being leveraged to innovate new ways to ensure robust maternal and child health. As of 2014, the WHO reported that 56% of countries employ telemedicine initiatives supporting major women’s and children’s health [8]. With the pandemic modifying the nature of pregnancy care internationally, the continuum of maternal and newborn healthcare needed to be modified. A 2020 online survey that analyzed 1060 responses by international maternal and newborn health professionals found that telemedicine was distinctly useful for applications such as online group birth preparedness classes, postnatal care by video or phone, setting up a COVID-19 helpline at maternity wards, and online psychosocial counselling [11]. As such, telemedicine is a tool that can address challenges faced by resource-constrained health markets in terms of the availability, quality, and financing of health care [10]. This article examines three successful grassroots telemedicine pregnancy interventions that have been piloted and expanded in Peru, India, and Rwanda.

What’s more, pregnant women must now get involved in their own care like never before. They are being taught to self-monitor their own and their child’s vitals using blood pressure cuffs, fetal heart rate Doppler monitors, and smartphone tools.

WawaRed in Peru WawaRed is a Peruvian healthcare application that was piloted in all 15 health centers inVentanilla, a district an hour’s drive from Peru’s capital, Lima [12,13]. Wawa means ‘baby’ in the Quechua, an Andean language, while red means ‘network’ in Spanish. The application was developed to support healthcare providers and soon-to-be mothers so that they have the necessary information to ensure a healthy pregnancy, safe childbirth, and effective prenatal care. The WawaRed system includes two components: centralized prenatal EHR information and health information text messages. The former component simplifies and standardizes information collection by midwives during prenatal care visits [14]. In the past, midwives needed to fill up to 10 different non-digitized forms (each of which fed into a different health system) during prenatal visits, which unnecessarily took up large amounts of time during visits and contributed to significant data entry errors [12,14]. Moreover, this information used to take anywhere from days to weeks to be registered by the Ministry of Health, which was inefficient and made it difficult to monitor disease outbreaks such as the Zika virus [13]. However, with a centralized EHR repository, information entry is standardized and processing is instantaneous. The latter component sends both general information about diet and exercise, as well as personalized motivational messages to the cellphones of pregnant women, which can lessen feelings of isolation, helplessness, and supplement additional healthcare information [14].

A downfall is that they risk leading to episodic, fragmented care from different professionals rather than the cultivation of sustained relationships with a single provider [3]. Moreover, many clinics are currently using teleconferencing platforms, but the lack of embedded EHR may reduce the efficiency of visits and require physicians to record patient data in multiple places [3]. Telemedicine Around the World It can be useful to expand the discussion of pregnancy telemedicine interventions from the West to the entire world. Considering the international context increases the nature and scope of how telemedicine can be applied while revealing remarkable innovations in countries around the world. A 2014 report by the World Health Organization (WHO) dubbed the transition from bulky technologies to portable devices as a ‘quiet revolution’ in information communications technology [8]. This ‘quiet revolution’ has widely impacted how healthcare can be delivered, particularly for pregnant women in remote

Throughout the pilot, 54,000 pregnant Indigenous women were registered on the system, 100 midwives were trained in data entry, and 28 ministry statisticians were trained in data analysis [12]. The success of this system prompted the national government to expand the program. A Peruvian ministerial order was signed on January 16, 2017, that officially supported WawaRed to be scaled up to 350 centres countrywide [12].

Illustration by Jocelyn Tamura

P A G E

B M D D I G I TA L .C O M

were regarding life-threatening complications. The number of women giving birth at local hospitals was reported to have risen from 68% to about 95%. Moreover, there was a 48% decrease in newborn death and a 69% decrease in in-utero death. Based on these results, the Rwandan government scaled the program nationally. It now includes 60,000 community health workers and there are plans to expand the system to aid case management of malaria, diarrhoea, and pneumonia [18].

Since then, 2,240 midwives from 646 health facilities in 18 of Peru’s 25 regions have been enrolled [14]. ImTeCHO in India Innovative mobile-phone technology for community health operations (ImTeCHO) is a mobile application that was developed to help government-accredited social health activists (ASHAs) and primary health center (PHC) staff in improving coverage of maternal, neonatal, and child health [15]. The study included 22 PHCs, catering to 476,943 Bhil or Vasava tribal people of Baruch and Narmada districts in Gujarat, India. ASHAs were given Samsung smartphones to review their schedule of home appointments for the day, conduct procedures based on a task list, and submit a digital form summarizing each visit from Feb 2016 to Jan 2017.

Conclusion These three examples demonstrate the monumental potential of telemedicine’s application in pregnancy care around the world. At the same time, it’s important to mention the potential risks and challenges of applying telemedicine to an international context. Telemedicine services often require sustained funding in order to persist as long-term healthcare strategies, which can result in an over-reliance on donors. Additionally, the use of such resources assumes universal access to electricity, the internet, and mobile devices, which is still a work in progress for many countries. Moreover, simply having access to such infrastructure isn’t enough. Patients also need to be technologically literate so that they can install and effectively use such tools. From the provider perspective, due to the nascence of telemedicine applications, there is an inadequate understanding of how telemedicine visits should be invoiced and who should pay for data coverage required by teleconsultations. Nevertheless, by keeping these considerations in mind and creating healthcare telemedicine infrastructures that robustly cater to the linguistic, cultural, and technological specificities of locales around the world, there is a huge benefit that countries stand to gain.

The ImTeCHO application performs a variety of functions including, but not limited to: showing health video clips, housing a checklist to screen for pregnancy complications, having a decision support-system to show patient risk stratification based on information entries, and suggested names and doses of approved drugs. The app was largely successful, with the coverage of maternal health services significantly improving in the intervention (as compared to the control). Usage was also high, with ASHAs logging in on 85% of days. Observing this study’s benefit, the state government of Gujarat picked up this technology and rebranded ImTeCHO to TeCHO+ for state-wide use [15-17]. They expanded its services to create an integrated health IT platform [15]. As of Feb 2019, 58,000,000 citizens, 490,000 pregnant women, and 640,000 infants under the age of 1 have been enrolled [16].

Moreover, simply having access to such infrastructure isn’t enough. Patients also need to be technologically literate so that they can install and effectively use such tools.

RapidSMS in Rwanda RapidSMS is an alert tool conjointly developed by Unicef and the Rwandan Ministry of Health in order to improve maternal and child health monitoring [8]. It functions to track the health status of pregnant women, provide guidance in cases of complicated pregnancy, and improve communication of EHR information throughout the healthcare system [18]. RapidSMS was piloted from June 2010 to May 2011 with 432 village-level community health workers from the Musanze district, which is a two hour drive from Rwanda’s capital, Kigali. This tool facilitates real-time communication between community health workers and the medical community to organize pregnancy care. If the system determines that the information inputted by the mother constitutes a normal pregnancy, it sends automated reminders for upcoming clinical appointments to the community health worker’s phone. On the other hand, if the system determines that there is a case of complicated pregnancy, it triggers an emergency response system that calls ambulance transport from the closest hospital, calls the hospital facility manager to inform them about the incoming patient, and instructs the community health worker on how to manage the event and prepare the patient for transfer.

References [1] Van den Heuvel, J. F., Groenhof, T. K., Veerbeek, J. H., Van Solinge, W. W., Lely, A. T., Franx, A., & Bekker, M. N. (2018). EHealth as the NextGeneration Perinatal Care: An overview of the literature. Journal of Medical Internet Research, 20(6). doi:10.2196/jmir.9262 [2] Combi, C., Pozzani, G., & Pozzi, G. (2016). Telemedicine for developing countries. Applied Clinical Informatics, 07(04), 1025-1050. doi:10.4338/ aci-2016-06-r-0089 [3] Mahal, I. (2021, January 14). Coronavirus has sped up Canada's adoption

Throughout the pilot, 11,502 pregnancies were monitored. A total of 35,734 SMS were sent and 1% of these messages

of Telemedicine. Let's make that change permanent. Retrieved March 22, 2021, from https://theconversation.com/coronavirus-has-sped-up-canadasadoption-of-telemedicine-lets-make-that-change-permanent-134985 [4] Khalid, A. F. (2021, January 14). How to build a better Canada after COVID-19: Make telehealth the primary way we deliver health care. Retrieved March 22, 2021, from https://theconversation.com/how-tobuild-a-better-canada-after-covid-19-make-telehealth-the-primary-way-wedeliver-health-care-140702 [5] Goligoski, E. (2020, April 28). Prenatal care may look very different after coronavirus. Retrieved March 22, 2021, from https://www.nytimes. com/2020/04/28/parenting/pregnancy/coronavirus-prenatal-care.html [6] Jercich, K. (2020, June 25). How telemedicine can help close the maternal health gap. Retrieved March 22, 2021, from https://www.healthcareitnews. com/news/how-telemedicine-can-help-close-maternal-health-gap [7] Use of telemedicine to increase access to maternal health care. (2020, December 31). Retrieved March 21, 2021, from https://nciom.org/use-oftelemedicine-to-increase-access-to-maternal-health-care/ [8] eHealth and innovation in women's and children's health: A baseline review (Rep.). (2014, March). Retrieved March 20, 2021, from WHO Global Observatory for eHealth website: https://apps.who.int/iris/bitstream/hand le/10665/111922/9789241564724_eng.pdf?sequence=1 [9] Silver, L. (2020, August 25). Smartphone ownership is growing rapidly around the world, but not always equally. Retrieved March 19, 2021, from https://www.pewresearch.org/global/2019/02/05/smartphone-ownership-isgrowing-rapidly-around-the-world-but-not-always-equally/ [10] Lewis, T., Synowiec, C., Lagomarsino, G., & Schweitzer, J. (2012, April 30). E-health in low- and middle-income countries: Findings from the Center for Health Market Innovations. Retrieved March 22, 2021, from https://www.who.int/bulletin/volumes/90/5/11-099820/en/ [11] Galle, A., Semaan, A., Huysmans, E., Audet, C., Asefa, A., Delvaux, T., . . . Benova, L. (2021). A double-edged Sword - Telemedicine for maternal care during COVID-19: Findings from a global mixed-methods study of healthcare providers. BMJ Global Health, 6(2). doi:10.1136/ bmjgh-2020-004575 [12] Sinha, C. (2019, January 22). WawaRed. Retrieved March 19, 2021, from https://www.comminit.com/health/content/wawared [13] Owens, B. (2017, January 27). Maternal health enters the information age in Peru. Retrieved March 20, 2021, from http://idrc.canadiangeographic. ca/blog/maternal-health-information-age-peru.asp [14] Pérez-Lu, J. E., Bayer, A. M., & Iguiñiz-Romero, R. (2018). Information = equity? How increased access to information can enhance equity and improve health outcomes for pregnant women in Peru. Journal of Public Health, 40(Suppl_2), 64-73. doi:10.1093/pubmed/fdy177 [15] Modi, D., Dholakia, N., Gopalan, R., Venkatraman, S., Dave, K., Shah, S., . . . Shah, P. (2019). MHealth intervention “IMTECHO” to improve delivery OF maternal, neonatal, and child Care services—A Clusterrandomized trial in tribal areas OF Gujarat, India. PLOS Medicine, 16(10). doi:10.1371/journal.pmed.1002939 [16] Mobile app ImTeCHO helps ASHA workers provide better maternal and child care services. (2019, February 24). Retrieved March 20, 2021, from https://ahmedabadmirror.indiatimes.com/ahmedabad/others/mobileapp-helps-asha-workers-provide-better-maternal-and-child-care-services/ articleshow/68137228.cms [17]Saha, S., Kotwani, P., Pandya, A., Saxena, D., Puwar, T., Desai, S., . . . Ravi, J. (2020). TeCHO+ program in Gujarat: A protocol for health technology assessment. BMJ Innovations, 6(4), 209-214. doi:10.1136/ bmjinnov-2019-000363 [18] Byishimo, B. (2019, December 29). Rapid SMS: 10 years Of e-health. Retrieved March 22, 2021, from https://www.newtimes.co.rw/lifestyle/ rapid-sms-10-years-e-health

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