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The Lancet Commission on 21st-Century Global Health Threats

Via The Lancet, December 15, 2022: The Lancet Commission on 21st-Century Global Health Threats. 

The world has lived through an extraordinary global health threat, the COVID-19 pandemic, leading to nearly 20 million deaths, staggering economic losses, a generational decline in human capital, and the first decline in global life expectancy since 1950 (the first year when UN estimates were published). Another major threat, climate change, now has broad scientific, political, and social recognition. The spectre of nuclear confrontation has re-emerged as a serious threat during the ongoing Russian invasion of Ukraine. 

The three Cs—COVID-19, climate change, and conflict—highlight that the steady global health progress of the past 70 years will not necessarily continue in the next 70 years. But there are many other threats beyond the three Cs that threaten to undermine future global health progress, including rising antimicrobial resistance, increasing obesity, inverted population pyramids, eroding sexual and reproductive rights for women, food insecurity, and fraying multilateralism. How global health advances or retreats will depend crucially on the multiplicity of these threats and how they intersect. 

The global community and many nations have launched commissions, task forces, and panels to draw lessons from the COVID-19 pandemic. The Pan-European Commission on Health and Sustainable Development explored the post-pandemic world for Europe and made far-reaching recommendations based on a One Health lens. The Independent Panel for Pandemic Preparedness and Response and the G20 High Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response called for the creation of new institutions and financing mechanisms to prepare the world for new pandemics and other threats. 

Multiple commissions, task forces, and panels have addressed climate change, including two Lancet Commissions, and the Intergovernmental Panel on Climate Change produces regular multistakeholder assessments. These global convenings have been mirrored by multiple national reviews. Although there are high-profile initiatives for pandemics and climate change, other threats have received less widespread attention or have been debated largely in academic subdisciplines.  

Governments, international organisations, and local communities will need to manage multiple threats at the same time. Many of these threats interact and lead to complex health, economic, social, and geopolitical consequences. Climate change, population growth, and political fragility may coincide leading to large-scale migration. Food systems can be designed to improve health, reduce poverty, and slow climate change, or the reverse.  

Specific and cross-cutting technologies and policies are needed to reduce the risk of emerging threats or to decrease the harms from threats as they unfold. The most important strategies for risk and harm reduction are unlikely to emerge if each threat is examined in isolation from the others.  

We have established the Lancet Commission on 21st-Century Global Health Threats to examine the broad set of threats facing the world over the rest of the century. This long perspective is needed since threats such as climate change, food systems, antimicrobial resistance, or inverted population pyramids require many decades for actions to alter future trajectories. The Sustainable Development Goal focus on 2030 is an important motivator for immediate policy action, but a longer-term perspective is needed to fully assess and respond to emerging threats.

This Commission's work will be informed by diverse expertise. The Commission members are drawn from many distinct groups: current and former heads of state, intergovernmental organisation leaders, leaders of public health institutions, global health funders, global health thought leaders, and civil society and youth organisations. The Commission represents a diverse group with gender parity and regional balance so that many perspectives are brought to bear on finding cross-cutting tools and solutions for future threats. The Commission will meet over the next 2 years to assess the evidence produced by various working groups and will release its analysis and recommendations by the end of 2024.

Why are women more prone to long Covid?

Via The Guardian: Why are women more prone to long Covid? Excerpt:

In June 2020, as the first reports of long Covid began to filter through the medical community, doctors attempting to grapple with this mysterious malaise began to notice an unusual trend. While acute cases of Covid-19 – particularly those hospitalised with the disease – tended to be mostly male and over 50, long Covid sufferers were, by contrast, both relatively young and overwhelmingly female. 

Early reports of long Covid at a Paris hospital between May and July 2020 suggested that the average age was around 40, and women afflicted by the longer-term effects of Covid-19 outnumbered men by four to one. 

Over the past 12 months, a similar gender skew has become apparent around the world. From long Covid patients monitored by hospitals in Bangladesh and Russia to the Covid Symptom Tracker app, from the UK-wide Phosp-Covid study assessing the longer-term impact of Covid-19, to the medical notes of specialist post-Covid care clinics across both the US and the UK, a picture has steadily emerged of young to middle-aged women being disproportionately vulnerable. 

Dr Sarah Jolley, who runs the UCHealth post-Covid care clinic in Aurora, Colorado, told the Observer that about 60% of her patients have been women. In Sweden, Karolinska Institute researcher Dr Petter Brodin, who leads the long Covid arm of the Covid Human Genetic Effort global consortium, suspects that the overall proportion of female long Covid patients may be even higher, potentially 70-80%. 

“This pattern has been seen in other post-infectious syndromes,” says Dr Melissa Heightman, who runs the UCLH post-Covid care clinic in north London. “Around 66% of our patients have been women. A lot of them were in full-time jobs, have young children, and now more than a quarter of them are completely unable to work because they’re so unwell. Economically, it’s a bit of a catastrophe.” 

As Heightman points out, this is not a new trend when it comes to infectious diseases, rather one which has historically been neglected. Women are known to be up to four times more likely to get ME/CFS (myalgic encephalomyelitis, or chronic fatigue syndrome), a condition believed to have infectious origins in the majority of cases, while studies have also shown that patients with chronic Lyme disease are significantly more likely to be female.

But despite this, there have been relatively few attempts to drill down into why this is the case. Instead, because these conditions predominantly affect women, they have more often been dismissed as being psychological in origin. Over the years, both ME/CFS and chronic Lyme disease have been ridiculed by sectors of the medical community as forms of hypochondria. 

“In general, there’s not as much research money and attention on conditions that primarily affect women,” says Julie Nusbaum, an assistant professor at NYU Long Island School of Medicine. “That’s just a general disparity in medical research. I think certain biases persist that when women present with a lot of body aches or pains, there’s more often an emotional or personality component to it than medical origin.” 

Worryingly, signs of these age-old biases have crept in over the past year with long Covid. There are anecdotal reports of female patients complaining that their persistent symptoms have been dismissed or attributed to anxiety. Dr Janet Scott, an infectious diseases specialist at the University of Glasgow, says that there remains a school of thought within the academic community that the long Covid gender skew may simply be an artefact of women being more likely to report symptoms than men. 

“I don’t buy it myself,” says Scott. “I think it plays into the narrative of, ‘Don’t worry about long Covid, it’s just a bunch of hysterical, middle-aged women.’” 

But Scott and other scientists around the world are trying to delve into the different factors which make women more prone to developing long Covid. Understanding them could be crucial to shedding a light on this mysterious condition in general, as well as other illnesses which can be triggered by an infection.

Pan-Canadian survey reveals long-term harm of COVID to brain health

Via newswire.ca: Pan-Canadian Survey Reveals Long-term Harm of COVID to Brain Health. Excerpt:

VANCOUVER, BC and MONTREAL, June 3, 2021 /CNW/ - A pan-Canadian survey of more than 1,000 COVID long-haulers, individuals with COVID-19 symptoms that last weeks or months, reveals the impact of Long COVID on brain health. From coast to coast, cognitive impairment or "brain fog" was among the top reported symptoms, along with fatigue and shortness of breath. Additional brain-related symptoms included headaches, dizziness, and anxiety. 

Over 80% of respondents experienced symptoms for more than three months, and almost 50% experienced symptoms for 11 months or more. While vaccines and physical distancing are important to prevent and mitigate COVID-19, the survey suggests the impact of COVID-19 on brain health will last beyond the pandemic. 

A detailed report on the survey is forthcoming and will be available on the website of the alliance members listed below. Survey results are consistent with other scientific findings, including that Long COVID is disproportionately impacting women in their middle years. This is the largest publicly available survey of people living with Long COVID in Canada to date. 

"It is our hope that the data collected from this survey will highlight the implications of Long COVID on brain health. Creating awareness through lived experiences and patient collaboration will magnify the urgency to act on funding for research and rehabilitation of long-haulers," said COVID Long-Haulers Support Group Canada Founder Susie Goulding. 

The survey is the result of an alliance between Viral Neuro Exploration (VINEx), COVID Long Haulers Support Group Canada, and Neurological Health Charities Canada (NHCC) to build awareness and increase funding for research and care on Long COVID. The alliance leverages science, clinical research, and lived experiences from patient groups, and is reaching out to other organizations with an interest in the lasting and long-term impacts of COVID-19. 

"The survey underlines earlier observations that COVID-19 can cause neurological damage which persists months after the initial infection. It clearly indicates that Canada needs action on brain health in COVID and post-COVID contexts," said Neurological Health Charities Canada Manager Deanna Groetzinger. 

According to the survey, nearly half of respondents received care for long-lasting symptoms in a healthcare clinic more than five times. Nearly a third received care more than 10 times. Six out of 10 had to take leave from work as a consequence of living with Long COVID, for weeks or months at a time, sometimes leading to early retirement. The responses suggest ongoing economic, health and societal costs with ripple effects into the public health sector and labour force.

Women in 40s, 50s who survive COVID-19 more likely to suffer persistent problems: UK studies

Via Reuters: Women in 40s, 50s who survive COVID more likely to suffer persistent problems: UK studies. Excerpt:

LONDON (Reuters) - Women in their 40s and 50s appear more at risk of long-term problems following discharge from hospital after COVID-19, with many suffering months of persistent symptoms such as fatigue, breathlessness and brain fog, two UK studies found on Wednesday.

One study found that five months after leaving hospital, COVID-19 patients who were also middle-aged, white, female, and had other health problems such as diabetes, lung or heart disease, tended to be more likely to report long-COVID symptoms. 

“Our study finds that those who have the most severe prolonged symptoms tend to be white women aged approximately 40 to 60 who have at least two long term health conditions,” said Chris Brightling, a professor of respiratory medicine at Leicester University who co-led the study known as PHOSP-COVID

A second study led by the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) found that women under 50 had higher odds of worse long-term health outcomes than men and than older study participants, even if they had no underlying health conditions. 

“It’s becoming increasingly clear that COVID-19 has profound consequences for those who survive the disease,” said Tom Drake, a clinical research fellow at Edinburgh University who co-led the ISARIC study.

COVID-19: A heavy toll on health-care workers

An important comment in The Lancet Respiratory Medicine: COVID-19: a heavy toll on health-care workers. Excerpt:

Health-care workers are known to be at risk for anxiety, depression, burnout, insomnia, moral distress, and post-traumatic stress disorder. Under usual working conditions, severe burnout syndrome affects as many as 33% of critical care nurses and up to 45% of critical care physicians. Extrinsic organisational risk factors—including increased work demands and little control over the work environment—and the trauma of caring for patients who are critically ill have been heightened by the COVID-19 pandemic and represent important exacerbating factors for poor mental health among health-care workers. 

Following the outbreak of severe acute respiratory syndrome in 2003, health-care workers reported chronic stress effects for months to years. Among health-care workers treating patients with COVID-19, a Chinese study reported high rates of depression (50%), anxiety (45%), insomnia (34%), and distress (72%). These findings were supported by a systematic review of 13 studies including more than 33 000 participants. 

Studies from Italy and France reported a high prevalence of depressive symptoms, post-traumatic stress disorder, and burnout; risk factors for adverse psychological outcomes included younger age, female sex, being a nurse, and working directly with patients with COVID-19. The long-term effect on the health of those working in health care remains to be seen. 

The COVID-19 pandemic is a stark reminder of racial and socioeconomic disparities, with disproportionate infection and death rates among migrants, the poor, and racialised groups. COVID-19 has also had a disproportionate effect on women health-care workers. Women comprise 70% of the global health and social care workforce, putting them at risk of infection and the range of physical and mental health problems associated with their role as health professionals and carers in the context of a pandemic. The pandemic exacerbated gender inequities in formal and informal work, and in the distribution of home responsibilities, and increased the risk of unemployment and domestic violence. 

While trying to fulfil their professional responsibilities, women had to meet their families' needs, including childcare, home schooling, care for older people, and home care. Burdened by these obligations, women had reduced academic productivity relative to men, as evidenced by fewer women being part of the cohort producing new knowledge about the pandemic. There was a disconnect between the demands of parenting and the expectations of the scientific community, as shown by ultra-short timelines for COVID-19-related grant proposals, which further deepened the divide between women and men. 

During the pandemic, there have been glimmers of hope and solace. We were buoyed by support from institutional and government leadership, the spirit of teamwork, the celebration of lives saved, and the acknowledgement of our value by the public. Social media was a venue for health-care workers to share their anxiety, insomnia, and fatigue, which reduced the sense of isolation and normalised conversations about mental health. 

To effectively support health-care workers—the greatest assets of our health-care systems—we must understand their challenges and needs. Burnout and other forms of work-related psychological distress are unavoidable occupational health issues. By acknowledging the commonality of psychological distress related to caring for patients with COVID-19, we can destigmatise work-related mental health issues and appropriately attend to the mental health needs of all health-care workers affected by the pandemic. 

Finally, we hope that the COVID-19 pandemic will prompt a redefinition of essential support workers, with recognition of the contribution of all health-care workers and appropriate education, protection, and compensation.

Melinda Gates: COVID-19's toll on women

Via Foreign Affairs: Melinda Gates: COVID-19's Toll on Women. Excerpt:

By nearly every measure, there had never been a safer time to be pregnant in Sierra Leone than February 2014. The country’s health system had historically been one of the world’s worst, but the maternal death rate had dropped more than 50 percent since 1990, and some level of antenatal care was almost universal. 

Then in March, the World Health Organization declared an Ebola outbreak in the region, and progress started to unravel. By November, you could plot the story with two terrible and mirrored curves: one that showed an exponential rise in Ebola cases; another that showed a corresponding crash in the number of pregnant women receiving care.  

When the crisis ended, the silent death toll of women and babies was even higher than its official one: 3,589 people in Sierra Leone had been killed by the Ebola virus itself. The number of additional newborns and mothers who died during childbirth was somewhere between 3,593 and 4,936.  

That is what epidemics do: they not only overwhelm immune systems but also overwhelm health systems. And because the parts of those systems devoted to caring for women are often the most fragile and underfunded, they collapse first and fastest. Early data suggest that in low- and middle-income nations, the cutback in maternal care during COVID-19 could claim the lives of up to 113,000 women. 

There is still time to avert such an outcome. In every country—and for every woman—sexual and reproductive health care must be classified as “essential” services. Even during a pandemic, someone suffering a heart attack would never be told that a trip to the emergency room was optional. Yet the message millions of pregnant women receive during a crisis is that it’s okay to deliver at home, alone. 

It isn’t. During the 2014 Ebola outbreak, by far the biggest driver of maternal mortality was the fact that women were increasingly giving birth without medical assistance. Health ministers need to find ways to provide safe maternal care even in pandemic conditions. 

In some countries, that might mean designating separate health facilities—some for those suffering from COVID-19, others for mothers and newborns who are COVID-free. In other places, it may be easier and safer to bring the expertise of the clinic to the mothers themselves. 

Protecting the contraceptive supply chain is crucial, too. Early estimates also suggest the pandemic will cause 49 million additional women to go without contraceptives, leading to 15 million additional unplanned pregnancies. Part of the responsibility for addressing this rests with the international community. A small group of countries manufactures most of the active primary ingredients for generic contraceptives, and since the pandemic hit, they’ve been stockpiling those ingredients, even though there’s no evidence they are running short on them. It’s a heartless trade policy—and a senseless one.  

A health system isn’t just a network of supply chains or a bundle of essential services. It’s made of people. Health workers on the frontlines need tools to keep themselves safe. Eventually that will require giving them first priority to a COVID-19 vaccine. For now, it requires supplying them with personal protective equipment that fits. 

The PPE that’s delivered to hospitals and clinics is often designed for men, even though 70 percent of health workers worldwide are female. Manufacturers should ensure they’re making enough PPE that will fit the people who need to use it, and health systems should make sure they’re buying enough.

Leaders should also use the pandemic as a forcing mechanism to integrate women’s health care. In many low-income countries, a random calendar dictates how people receive care: Monday is for vaccinations, Tuesday for antenatal care, Wednesday for family planning. Instead of scheduling one appointment, a woman is expected to show up at the same time as everyone else who needs some service, spend all day awaiting her turn, and then come back again the next morning to do it all over. This block scheduling never made much sense, and it makes even less during a pandemic, when no one should be spending any more time in a crowded waiting area than necessary.

MMWR: Characteristics of women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status

MMWR has published Characteristics of Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status — United States, January 22–June 7, 2020. The summary:

What is already known about this topic?  

Limited information is available about SARS-CoV-2 infection in U.S. pregnant women. 

What is added by this report?  

Hispanic and non-Hispanic black pregnant women appear to be disproportionately affected by SARS-CoV-2 infection during pregnancy. Among reproductive-age women with SARS-CoV-2 infection, pregnancy was associated with hospitalization and increased risk for intensive care unit admission, and receipt of mechanical ventilation, but not with death.  

What are the implications for public health practice? 

Pregnant women might be at increased risk for severe COVID-19 illness. To reduce severe COVID-19–associated illness, pregnant women should be aware of their potential risk for severe COVID-19 illness. Prevention of COVID-19 should be emphasized for pregnant women and potential barriers to adherence to these measures need to be addressed.

WHO concerned over COVID-19 impact on women, girls in Africa

A news release from WHO AFRO: WHO concerned over COVID-19 impact on women, girls in Africa.

Brazzaville, 18 June 2020 – Humanitarian crises, including health emergencies affect men and women differently. As COVID-19 continues to spread in Africa, there are concerns over its impact on women and girls, with vulnerabilities feared to worsen as the pandemic overwhelms health systems.    

Although overall in the African Region, women account for around 40% of COVID-19 cases, this ranges from 35% in some countries to over 55% in South Africa.   

“We are already seeing that the impact of COVID-19 on women and girls is profound. Women are disproportionately affected by lockdowns and this is resulting in a reduced access to health services,” said Dr Matshidiso Moeti, World Health Organization (WHO) Regional Director for Africa.  

As efforts are focused on curbing the spread of COVID-19, essential services such as access to sexual and reproductive health services have been disrupted. According to preliminary data, in Zimbabwe, the number of caesarean sections performed decreased by 42% between January and April 2020 compared with the same period in 2019. The number of live births in health facilities fell by 21%, while new clients on combined birth control pills dropped by 90%. In Burundi, initial statistics show that births with skilled attendants fell to 4749 in April 2020 from 30 826 in April 2019.    

Recent analysis published in the Lancet Global Health suggests that a reduction in maternal health services of between just 9.8-18.5% could lead to as many as 12 200 additional maternal deaths over six months in low- and middle-income countries.    

The economic hardship due to COVID-19 is also greater for women according to a World Bank report. Informal workers, most of whom are women, account for more than 90% of the labour force in sub-Saharan Africa. Informal sector jobs are particularly at risk during the pandemic.   

In addition, women face a higher risk of gender-based violence in the wake of the COVID-19 outbreak. A recent study by UN Women found that reports of violence against women, and particularly domestic violence, have increased in several countries as security, health, and financial worries create tensions and strains accentuated by the cramped and confined living conditions of lockdown.   

“We are working with governments and partners to find ways to continue to deliver essential services safely, including the provision of personal protective equipment to health workers, many of whom are nurses and are women,” said Dr Moeti.   

The burden of caring for the sick is also largely borne by women. Most health workers in Africa are women. Over the past four months, with the Colleges of Nursing in Africa WHO has provided targeted virtual trainings to over 1000 nurses and midwives. In West Africa, this training has been cascaded sub-nationally using virtual platforms – thus allowing as many nurses as possible to be trained in case management for COVID-19 and infection prevention and control.   

WHO works to improve the health of women and girls in Africa by developing guidance on the implications of gender, gender-based violence, and access to sexual and reproductive health.

Women make up over half of COVID-19 deaths in Canada, counter to trends in most of world

Via The Globe and Mail, a report by The Canadian Press: Women make up over half of COVID-19 deaths in Canada, counter to trends in most of world. Excerpt:

Women account for more than half the COVID-19 cases and deaths in Canada, making the country an outlier running counter to the overwhelming trend that sees the disease killing more men than women in most of the world.  

Women represent 53 per cent of Canadian deaths linked to the disease, the highest proportion in any country, according to numbers compiled by a research initiative at the University College London’s Centre for Gender and Global Health. The nearest among countries that report gender data are Portugal and Finland, at 51 per cent. In the United States, Sweden, France and England, the proportion of female deaths is between 40 and 44 per cent. 

Quebec and Ontario are driving the trend in Canada. In Quebec, 54.9 per cent of novel coronavirus deaths have been among women, 54.4 per cent in Ontario. Women account for 59.3 per cent of infections in Quebec and 56.9 per cent in Ontario, according to numbers compiled by the provinces as of Friday. 

Experts say the trend in infection and death rates among men and women has important implications for how the disease is managed, particularly because the people who care for the sick are also mostly women. 

“The response needs to be gendered,” said Kirsten Fiest, an epidemiologist at the University of Calgary. “We have these socially constructed and prescribed roles where women are both the sick and the caregivers. This has to inform the response.” 

Likely explanations for why more women are contracting the disease and dying from it in Canada are relatively clear. Long-term care homes are the hotbeds of infection in this country. The illness is particularly hard on people over the age of 70, and Canadian women outlive men by an average of four years. More than 70 per cent of Ontario and Quebec long-term care residents are women, and more than 80 per cent of personal support workers and nurses working at high risk of infection in long-term care homes are also women.

However, it is too early to reach any final conclusions: The course of the pandemic so far is that it moves among vulnerable populations while testing lags and methods shift for counting cases and deaths.

COVID-19: A public health approach to manage domestic violence is needed

Via The Lancet Public Health: COVID-19: a public health approach to manage domestic violence is needed.

The negative consequential effects of the measures adopted by the UK and other countries to tackle the spread of coronavirus disease 2019 (COVID-19) on society are beginning to unfold. An area of concern is the impending crisis of domestic violence—gender-based violence and child abuse and neglect, due to movement restrictions, loss of income, isolation, overcrowding, and stress and anxiety, all which put women and children at a disproportionally increased risk of harm. 

This increased risk is not surprising. Previous epidemics, such as the Ebola virus disease outbreak in west Africa, but also cholera and Zika virus disease outbreaks, led to regional environments where domestic violence became more prevalent; there were reductions in funding for specialist gender-based violence public health services; and, for survivors of gender-based violence, there was reduced access to health-care services. 

Although we are not aware of published studies to date that have tracked the national trends in gender-based violence related to COVID-19, initial reports from UK support services such as the National Domestic Abuse helpline have already shown increases in service use, a pattern seen elsewhere (with notable examples in China, Spain, and France). 

In the UK, before the coronavirus crisis, gender-based violence was already deemed as highly prevalent, associated with substantial negative downstream social, psychological, and physical outcomes. Therefore, any resultant increases in the rates of domestic violence would not only be a further travesty of human rights but also be associated with further long-term costs to society, which might be irreparable beyond the immediate threat of COVID-19. It has never been more important than now to implement a public health approach to gender-based violence in the UK.

Similar to an approach that has been put in use to improve the management of physical violence in cities such as Cardiff, Glasgow, and London, the principles of a public health approach should be implemented to support survivors of gender-based violence. The WHO public health approach consists of four steps, which we have suggested the adaptation of to aid in the prevention of domestic violence during this pandemic (appendix). 

Without adequate surveillance, it is not possible to capture the burden of domestic violence during this pandemic. Because of selection biases, administrative datasets have consistently shown underestimates in the expected rates of domestic violence. Potential approaches to improve the surveillance of domestic violence could include the routine inquiry (feasibly integrated into remote primary care consultations or active syndromic surveillance from local health protection teams) and the urgent implementation of linked datasets between police and health records datasets to identify individuals at risk. Enhancing surveillance would also provide the opportunity to offer targeted support and interventions. 

Though formal evaluations of current interventions have not yet taken place during the pandemic, national charities (such as, but not limited to, Women's Aid, Safelives, and the National Society for the Prevention of Cruelty against Children) have produced guidance for how survivors can both report violence, abuse, and neglect and keep themselves safe, including information on remote reporting and support mechanisms. 

There are substantial gaps in the literature relating to the surveillance and evaluation of effective interventions to support those at risk of domestic violence, child abuse and neglect during this pandemic. The medical profession has a duty to provide support in overcoming these problems—to provide a public health approach to supporting those most vulnerable in society.