Introduction

By Harpreet Kaur & Chaitra Dinesh – kaur@doctors.org.uk & chaitracd@outlook.com 

Whilst the COVID-19 pandemic has brought global health to the forefront, discussions around how different aspects of global health are affected are only now starting to arise. There is a realisation that the burden of disease isn’t shared equally among the global population and we need to put a spotlight on this once again. 

Global health can be defined as an area for study, research and practice that places a priority on improving health and achieving health equity for all people worldwide (1). There are various topics that come under global health, and this two-part blog addresses a few of these. It is not possible to cover each topic in the depth it requires – however, the aim of this blog is to give you a starting point to engage with the ongoing discussions and to think about how we can build back better (2) following this pandemic. 

Women’s Health

Family planning 

By Anna Martin – k1598627@kcl.ac.uk 

Millions of women and girls in the UK rely on family planning clinics for contraceptive advice. As the UK finds itself in lockdown, this includes strict travel restrictions and only allowances for what is defined as ‘necessary’ outings. Women have found themselves struggling to attend services to collect contraceptives, get vital family planning advice and have access to safe abortion. Marie Stopes International (MSI) predicts “up to 9.5 million vulnerable women and girls risk losing access to our contraception and safe abortion services in 2020 due to the COVID-19 pandemic” (1). Why is this a problem? Both the decreased access to contraception and the increased cases of domestic violence while houses are in lockdown is leading to more unwanted pregnancies and consequently the need for abortions. Abortion is a time-sensitive procedure and delaying it increases mortality (2). 

Access to safe abortion globally is already severely poor, and the COVID-19 pandemic has only seen an increase in this problem. Travel bans will also mean that women who live in countries where abortion is banned, such as Poland (3), cannot seek the service elsewhere. 

In England, the requirement to attend abortion clinics in order to take the first abortion pill with the possibility of taking the second pill at home has been suspended, allowing women to take both pills at home (4) – a practice which has also been adopted in Scotland and Wales (5).This ensures vulnerable women who are unable to leave their homes can still access safe abortion. This has the power to minimise unnecessary contact in-person and the pressure on an already overburdened NHS. 

Contraception and access to safe abortion is not a luxury and goverments should not categorise them as one. Women should be able to be able to access these services, safely, even during lockdown measures, in order to decrease preventable deaths and unwanted pregnancies.

Domestic violence

By Oliver Moore – olivermoore@outlook.com 

Globally, 243 million (18%) women and girls aged 15-49 have reported either physical and/or sexual violence from an intimate partner in the previous 12-months (6). This harrowing figure rises to 30% when considering physical or sexual violence from a partner over a women’s lifetime (7). This violence can often have horrific consequences, as over ⅓ of women who are intentionally killed are killed by either a current or previous partner (8).

These figures are only getting worse in light of the current COVID-19 global pandemic. Over 90 countries are currently in lockdown, meaning 4 billion people are trapped in the confinements of their own home (9). UN Women describe this situation as a “perfect storm for controlling, violent behaviour behind closed doors” (9). Sadly, this statement seems to be the truth for many women, both locally, here in the UK, and worldwide. In the UK, at least 16 women have died from suspected domestic abuse between 23rd March and 12th April, compared to an average of 5 deaths over the same period in the last 10 years (10) – a threefold increase.

However, this issue is not confined to the UK alone. In France, reports of domestic violence have increased by 30% since the lockdown was commenced (11). In Cyprus (12) and Singapore (13), registered domestic abuse hotlines have seen a 30% and 33% increase in calls, respectively. Argentina has seen a 25% increase in emergency calls for domestic violence since their lockdown was imposed (14).

This mass violence against women is not just a humanitarian issue but an economic one too. UN Women estimate that the global cost of violence against women and girls is 2% of global GDP, or $1.5 trillion annually – this figure includes direct costs (such as loss of productivity at work) and indirect costs (such as child and welfare support and counselling) (15). In the light of COVID-19, this figure will only increase.

Taking the above statistics into account, much more must be done to stop global violence against women, especially when imposed mass travel and social restrictions can seriously hinder access to help. It is imperative that we check-in with the women and girls in our lives and communities to ensure their well-being and safety are maintained. There are many organisations worldwide that can help women at risk of domestic violence (16).

Find out more about SfGH’s stance on women’s health by reading the relevant policies online at: https://medsinblog.files.wordpress.com/2019/11/access-to-legal-and-safe-abortion-in-the-uk.pdf https://medsinblog.files.wordpress.com/2018/01/domestic-abuse-policy-statement-sga-17.pdf

Housing/homelessness 

By Isobel Francis – issyfrancis1000@gmail.com 

Most people would say that coronavirus has had a massive impact on their life and that the thought of having to quarantine for weeks to months is a scary prospect. Even those who are quarantining with their family, friends, housemates or alone in a safe space that they can call home find the lockdown difficult and even distressing. Quarantine has a whole different meaning and impact on those who don’t have stable accommodation to rely on. We are all too familiar with the social distancing rules, advice to regularly wash our hands for 20 seconds and to only travel for essential items (1). These rules become difficult if you are currently sofa surfing and are unable to keep to one place or living on the streets and have no easy access to running water. One can see that the viral transmission rate among this population could potentially be very high (2).

It was reported that 91% of the coronavirus deaths in England and Wales in March 2020 happened in people with at least one pre-existing condition (3). Rough sleepers are three times as likely to have chronic health conditions than the general population and the prevalence of infectious diseases such as TB/HIV/Hep C is significantly higher (4). Moreover A&E attendance is at least eight times higher than the general population. These facts illustrate the alarming added risk the coronavirus has for this vulnerable population and points towards some of the health inequalities present at a surface level in the UK. 

The government released a statement to local authorities on the 26th March, a few days after lockdown began, asking them to ‘urgently accommodate rough sleepers’ (5). The homeless can apply online for emergency interim accommodation. This could be in places such as hotels or holidays homes that would otherwise be closed for social distancing. Whilst a good attempt to reduce viral transmission and support this population in this challenging time, it is known that preventative medicine is the best medicine and with a 165% increase in rough sleepers in the UK since 2010 (6), it can’t be helped but to look towards the wider issue. There have been prominent issues over the last ten years with universal credit, the amount of social housing available and the increasing rent costs (7). This swift action by the government to quickly house rough sleepers proves that homelessness is a key public health issue. It can only be hoped that more sustainable, long term solutions to tackle homelessness will continue to be sought for the future. 

Find out more about SfGH’s stance on homelessness and health by reading our policy online at: https://medsinblog.files.wordpress.com/2019/11/homeless-health.pdf

Mental Health

By Antonis Tofias

“Man is by nature a social animal,” wrote Aristotle and from there on, this became a phrase quoted countless times in scientific literature1). We also have a hardwired response protocol to changing environments, as they may pose threats; that of anxiety, uneasiness and cortisol – the stress hormone(2). How is this pandemic any compatible with the way the human brain is built? This blog post aims to spark a discussion on the impact of the pandemic on our emotions and mental health. 

The environment that the pandemic has instigated affects everyone, both children and adults. Everyone is experiencing some sort of fear; fear of our loved ones dying, fear of ourselves contracting the virus, or fear of what will happen to us after we contract the virus. Elderly and vulnerable groups people are faced with a new form of stigma – they are the ‘vulnerable groups’. The population is also faced with social isolation and working from home (3). I am certain that all of us have experienced people who walk over to the other side of the street after spotting us from 100 yards away. That is of course ‘social distancing’, this is being careful, this is respecting that someone might be vulnerable and this is definitely an act of solidarity. But I always wondered how it makes other people feel – beyond the rational. It makes me feel ‘infected,’ as if from some new type of ‘modern day leprosy.’

Moving beyond the status quo, what effect is the global emergency going to have on our mental health in the future; for communities, families, and vulnerable individuals. Will we be able to ‘reboot’ normality? Are our support systems, interactions and social networks going to feel the same, or are they going to feel ‘rusty’? Does that mean that people with existing mental health conditions will find it even harder to readjust? Are the survivors of COVID-19 going to be faced by social stigma, that will predispose them to mental health conditions (4)?  The UK’s largest domestic abuse charity, Refuge, has reported a 700% increase in calls to its helpline in a single day (5). Will family dynamics ever return to normal? There are indeed a lot of questions; and with every one answered, more uncertainty arises.

At the moment we have an important role to play in order to mitigate for the current and future effects the pandemic will have on our mental health.

With the disruptive effects of COVID-19 – including social distancing – currently dominating our daily lives, it is important that we check on each other, call and video-chat, and are mindful of and sensitive to the unique mental health needs of those we care for. Our anxiety and fears should be acknowledged and not be ignored, but better understood and addressed by individuals, communities and governments,” Dr Hans Kluge (3).

Racial inequalities

By Sana Hasan – sanahasan59@hotmail.com 

In April 2020, the UK government announced that they would launch an investigation into the impact of COVID-19 on black, Asian and minority ethnic (BAME) populations (1). Current data shows that 34% of those critically ill with COVID-19 are of BAME backgrounds, with Asian patients composing 14.4% of this number and black patients another 11.9%. All this in a country where, according to the 2011 census, only 14% of the population identify as BAME. In simple terms, BAME Britain was dying from COVID-19 at a rate 27% higher than representation in the population would suggest (2).

Calls from the British Medical Association a few days earlier cited concerns about BAME healthcare professionals. The first 10 doctors who died were BAME. The story is sadly not unique to the UK. Similar trends are seen in America, which consistently shows across state lines that black populations are dying disproportionately of COVID-19 (3, 4). Of course, race is not an island. Poverty rates in BAME populations are double that of white populations and, as such, the former will be hit harder by the impact on the economy (5). Alternative suggestions have been overcrowding, vitamin D deficiency and some other alleged causes. However, accounting for socio-economic and demographic factors is not sufficient. As stated starkly by Afua Hirsch, “For every 10% increase in minority residents, there are an additional unexplained 2.9 COVID-19 deaths per 100,000 people” (2).

The pandemic has not caused the disparity in statistics for BAME populations. It has only added to them. In the UK, we don’t collect ethnicity statistics for those contracting the new coronavirus. We don’t record it on death certificates either. We need the data for coronavirus and its impact on BAME populations, because without reliable statistics we simply cannot know the reason for these deaths. But we already have data that shows BAME groups overall suffer worse health compared to their white counterparts (2, 6, 7). Life expectancy, infant mortality and maternal mortality are all notable measures worse in BAME populations. We have known this for decades, and solutions have been proposed time and time again. One may argue that we are long overdue to have a national discussion about this  – and, after all, there’s no better time.

More news is emerging everyday, but here are a few interesting stories to start reading into. Obviously, race is  a complicated subject with many different approaches, and as such it is worth seeking out a variety of opinions.

Conclusion

By Harpreet Kaur & Chaitra Dinesh – kaur@doctors.org.uk & chaitracd@outlook.com 

During this global pandemic it is vital that we don’t forget other determinants of health and other global health issues. These issues are likely to either exacerbate or be exacerbated by the effects of the pandemic itself on individuals and on health systems. It is important that those who have power to make or influence decisions, look at these issues in a more holistic manner, work on reducing these inequalities in the longer term and also ensure when we are building back that we plan ahead for the future. 

It is also important that as individuals we do not underestimate our power to influence decisions; it can certainly seem like decisions are being made in isolation and without consultation, but by joining up our voices and ensuring concerns are heard we can affect change. In this article itself we have linked to many ways that we as individuals can do this, so make sure to have a look and to comment below with any other actions that you are aware of. In the next part of this blog we will delve deeper into other global health issues in a similar fashion – keep an eye out for it.

References:

Introduction

  1. Koplan, J.P., Bond, T.C., Merson, M.H., Reddy, K.S., Rodriguez, M.H., Sewankambo, N.K., & Wasserheit, J.N. (2009). Consortium of Universities for Global Health Executive Board. Towards a common definition of global health. Lancet, 373(9679),1993-1995.
  2. https://buildbackbetteruk.org/

Women’s Health

  1. https://www.mariestopes.org/covid-19
  2. Risk factors for legal induced abortion-related mortality in the United States.
  3. ‘How will the coronavirus affect access to abortion?’. 20 march 2020. https://www.ippf.org/blogs/how-will-coronavirus-affect-access-safe-abortion 
  4. Temporary approval of home use for both stages of early medical abortion. Department of Health and Social Care. 30 March 2020. https://www.gov.uk/government/publications/temporary-approval-of-home-use-for-both-stages-of-early-medical-abortion–2 
  5. ‘Early home abortions approved in Scotland during coronavirus outbreak’. The Press and Journal. 31 March 2020. https://www.pressandjournal.co.uk/fp/news/politics/scottish-politics/2115019/early-home-abortions-approved-in-scotland-during-coronavirus-outbreak/ 
  6. Report of the Secretary General. Special edition: Progress towards the Sustainable Development Goals. 8 May 2019 (E/2019/68). https://undocs.org/en/E/2019/68
  7. WHO, Global and Regional Estimates of Violence against Women: Prevalence and Health Effects of Intimate Partner Violence and Non-Partner Sexual Violence (Geneva, 2013).
  8. United Nations Office on Drugs and Crime (UNODC), Global Study on Homicide: Gender Related Killing of Women and Girls 2018 (Vienna, 2018).
  9. United Women. Violence against women and girls: the shadow pandemic. 2020. https://www.unwomen.org/en/news/stories/2020/4/statement-ed-phumzile-violence-against-women-during-pandemic
  10. The Guardian. Domestic abuse killings ‘more than double’ amid Covid-19 lockdown. 2020. https://www.theguardian.com/society/2020/apr/15/domestic-abuse-killings-more-than-double-amid-covid-19-lockdown
  11. ”Domestic violence cases jump 30% during lockdown in France”. 2020. https://www.euronews.com/2020/03/28/domestic-violence-cases-jump30-during-lockdown-in-france
  12. “Lockdowns around the world bring rise in domestic violence”. 2020. https://www.theguardian. com/society/2020/mar/28/lockdowns-world-rise-domestic-violence
  13. “Commentary: Isolated with your abuser? Why family violence seems to be on the rise during the COVID-19 outbreak”. https://www.channelnewsasia.com/news/commentary/coronavirus-covid-19-family-violence-abuse-women-self-isolation-12575026
  14. “During quarantine, calls to 144 for gender violence increased by 25%”. 2020. http://www.diario21.tv/notix2/movil2/?seccion=desarrollo_nota&id_nota=132124
  15. UN Women. The economic costs of violence against women. 2020. Available here: https://www.unwomen.org/en/news/stories/2016/9/speech-by-lakshmi-puri-on-economic-costs-of-violence-against-women
  16. https://www.befrienders.org/

Housing/homelessness

  1. ‘Guidance on social distancing’, Public Health England, 30thMarch 2020, found online at: https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults
  2. Wood L.J., Davies A.P., Khan Z. COVID-19 precautions: easier said than done when patients are homeless, Medical Journal of Australia, 2020
  3. ‘Deaths involving COVID-19, England and Wales’, Office for National Statistics, 16thApril 2020, found at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsinvolvingcovid19englandandwales/deathsoccurringinmarch2020
  4. Gill Leng, The Impact of homelessness on health, Local Government Association, 2018, found at: https://www.local.gov.uk/sites/default/files/documents/22.7%20HEALTH%20AND%20HOMELESSNESS_v08_WEB_0.PDF
  5. Guidance of hostel or day centre providers of services for people experiencing rough sleeping, Public Health England,  25thMarch 2020, found online at: https://www.gov.uk/government/publications/covid-19-guidance-on-services-for-people-experiencing-rough-sleeping/covid-19-guidance-for-hostel-or-day-centre-providers-of-services-for-people-experiencing-rough-sleeping
  6. Number of rough sleepers in England soars by 165% since 2010, Crisis, 31stJanuary 2019, found online at: https://www.crisis.org.uk/about-us/media-centre/number-of-rough-sleepers-in-england-soars-by-165-since-2010/
  7. Why is homelessness increasing, St Martins Trust, 2019, found online at: https://www.connection-at-stmartins.org.uk/facts-about-homelessness/why-is-homelessness-increasing/

Mental Health

  1. Aristotle, Metaphysics
  2. Bruce Duncan Perry, Szalavitz M. The boy who was raised as a dog : and other stories from a child psychiatrist’s notebook : what traumatized children can teach us about loss, love, and healing. Basic Books; 2006.
  3. ‌Mental health and psychological resilience during the COVID-19 pandemic [Internet]. http://www.euro.who.int. 2020 [cited 2020 Apr 24]. Available from:  http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/news/news/2020/3/mental-health-and-psychological-resilience-during-the-covid-19-pandemic
  4. ‌IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings. February 2020 IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings [Internet]. 2020 Feb. Available from: https://interagencystandingcommittee.org/system/files/2020-03/IASC%20Interim%20Briefing%20Note%20on%20COVID-19%20Outbreak%20Readiness%20and%20Response%20Operations%20-%20MHPSS_0.pdf 
  5. Mark Townsend. Revealed: surge in domestic violence during Covid-19 crisis, The Guardian. [cited 2020 Apr 24]. Available from:
    https://www.theguardian.com/society/2020/apr/12/domestic-violence-surges-seven-hundred-per-cent-uk-coronavirus 

Racial Inequalities

  1. Butcher B, Massey J. Are minorities being hit hardest by coronavirus? [Internet]. BBC News. 2020 [cited 25 April 2020]. Available from: https://www.bbc.co.uk/news/uk-52219070
  2. Hirsch A. Britain doesn’t care about health inequalities. For minorities, that ignorance is deadly | Afua Hirsch [Internet]. the Guardian. 2020 [cited 25 April 2020]. Available from: https://www.theguardian.com/commentisfree/2020/apr/23/britain-ignorant-health-inequalities-coronavirus-black-people-dying
  3. Centres for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19) in the U.S. [Internet]. Centers for Disease Control and Prevention. 2020 [cited 25 April 2020]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html
  4. Brooks R. African Americans struggle with disproportionate COVID death toll [Internet]. Nationalgeographic.com. 2020 [cited 25 April 2020]. Available from: https://www.nationalgeographic.com/history/2020/04/coronavirus-disproportionately-impacts-african-americans/
  5. Chowdhury S. Why COVID-19 is far from an equaliser [Internet]. Amnesty.org.uk. 2020 [cited 25 April 2020]. Available from: https://www.amnesty.org.uk/coronavirus/why-covid-19-far-equaliser
  6. Hirsch A. If coronavirus doesn’t discriminate, how come black people are bearing the brunt? | Afua Hirsch [Internet]. the Guardian. 2020 [cited 25 April 2020]. Available from: https://www.theguardian.com/commentisfree/2020/apr/08/coronavirus-black-people-ethnic-minority-deaths-pandemic-inequality-afua-hirsch
  7. Parliamentary Office of Science and Technology. ETHNICITY AND HEALTH [Internet]. Parliament.uk. 2007 [cited 25 April 2020]. Available from: https://www.parliament.uk/documents/post/postpn276.pdf

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