climate & health

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Sushrutajnl.net Volume:13 Issue:2 JULY 2020 2

SUSHRUTA July 2020 Journal of Health Policy & Opinions BAPIO Publications

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BAPIO Publications Journal of Health Policy & Opinions SUSHRUTA July 2020

Volume:13 Issue:2 JULY 2020 Sushrutajnl.net

Contents SushrutaPage Number

Editorial5 Climate Change & Health6 Health Professionals & Climate Change

Policy9 HowtoBuildClimateResilientHealthSystems12 ClimateChangeandNutrition

Articles15 AnOnlineSurveyofHealthcareProfessionalsintheCOVID-19PandemicintheUK26 TheBushfiresDownUnder28 COVID-19&ClimateChange30 RemoteConsultations35 MeltingIceandMalaria

Essay 36 Climate Change & Health

Opinions39 ClimateChange&Childhood41 Air Pollution43 GoingVirtual–‘Nogoingbackinthecave….’

Reviews46 ClimateChangePolicy

The Coronavirus Collective49 AStudent'sPerspective49 BetterNewWorld50 HiddenTalents50 BehindtheMask50 AStudentoftheMind51 WhenaPandemicStrikes52 Perspective52 TheOneWhoMustnotbeNamed



SUSHRUTA

PUBLICATION TEAM

BAPIO Executive

President: Ramesh Mehta OBE MD FRCPCHChairman: JS Bamrah CBE FRCPsych MDSecretary: Parag Singhal MD MPhil FRCP

Chief Editor: Indranil CHAKRAVORTY PhD FRCPManaging Editor: Buddhdev PANDYA MBE

Editorial Board (2019-2021)[email protected]

Abhay CHOPADA MS FRCS,LondonAnantha Krishnan RAGHURAM MD FRCP MScAntonia HARRIS MSc, StGeorge’sUniversityHospital,LondonArun K GUPTA MD Psych,NorthumberlandTyneandWearNHSFoundationTrustAshok Kumar JAINER FRCPsych,Coventry&WarwickshirePartnershipNHSTrustCatherine DOMINIC,QueenMary’sUniversityofLondonDhananjaya SHARMA MS,GeneralSurgeon,NSCBMedicalCollege,Jabalpur,IndiaDhananjay RAJE MSc PhD Statistics, CSTAT(RoyalStatisticalSociety,London)Cielito CANEJA BSN-RN, MSN, PgDipHed BScINP, MSc, DipClinMed;Chel&WestHospLondonFarica PATEL MBBS, Guys&StThomas’sHospital,LondonGeeta MENON MS FRCOpth,HealthEducationEnglandSouthLondonGodwin SIMON MD FRCP,BasildonandThurrockUniversityHospitalsJudith GOWER LLM FRSA,HertfordshireLawSocietyJyothi SRINIVAS MRCPCH, MiltonKeynesUniversityHospital,MiltonKeynesDame Parveen KUMAR DBE, BSc, MD, DM, DEd, FRCP, FRCP(L&E), FRCPath, FIAPRamyadevi RAVINDRANE MBBS BSc,LondonSchoolofHygiene&TropicalMedicineSahana RAO MRCPCH,OxfordUniversityHospitals,Oxford,EnglandSoumit DASGUPTAMBBS MS FRCS FRCPSubarna CHAKRAVORTY PhD FRCPath MRCPCH,KingsCollegeHospitalsNHSTrust,LondonSuparna DASGUPTA FRCPCH PgDip (MedEd),MacclesfieldGeneralHospital,MacclesfieldTriya CHAKRAVORTY BA (Oxon), OxfordVeena DAGA MD, FCAI, FRCA, LeedsTeachingHospitals,LeedsVipin ZAMVAR MS FRCS,RoyalInfirmaryofEdinburgh

ISSN2732-5156(Print)2732-5164(Online)PublishedbyBAPIOPublicationsonbehalfofBritishAssociationofPhysiciansofIndianOrigin.Copyright(R)byBAPIOLtd,UK.

Scope;SushrutaJournalofHealthPolicy&Opinionisajournalforamulti-professionalaudienceintheUKandglobally,establishedin2007inprintandonlinefrom2020.

Disclaimer:Theopinionsandviewsexpressedbytheauthorsarenotnecessarilythoseoftheeditororthepublishers.Although,careistakeninpreparationofthispublication,theeditorsandthepublishersarenotresponsibleforanyinaccuraciesinthearticles.Greatcareistakenwiththeregardstoartworksupplied,thepublisherscannotbeheldresponsibleforanylossordamageincurred.

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TheChapel,TrinityGardens9-11BromhamRoad,BedfordMK402BPUnitedKingdomEmail:[email protected]:(+44)01234363272CoverpicturebySubarnaChakravorty

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Editorial

Climate Change & Health Ramya Ravindrane 1 & Catherine Dominic 21LondonSchoolofHygiene&TropicalMedicine&2QueenMary’sUniversityofLondonGuestEditors

Article InformationSubmitted14June2020Published22June2020

Key words:Climatechange;healthinequalities;pandemic

Wearelivingthroughatimeofhugeuncertaintyandformany great hardships. The COVID-19 pandemic has

changedsocietyperhapsirreversibly.Ithasrevealedcracksinourhealthandwelfaresystems,stimulatedconversationandtriggeredinnovationandchange,throughthedisruptionofmanyareasoflife.

TheJulyeditionofSushrutawasinitiallyintendedtofocusonclimatechangeandhealth,butasweslowlymovetowardanewnormalinthepost-COVIDeraitbecameclearwe needed to widen the scope of this issue. This editionlooksatthevariouswaysinwhichplanetaryhealthinteractswithhumanhealth.Topicscoveredrangefromairpollutionandchildhealth,changesinvectorbornediseasepatterns,sustainable nutrition and the winner of our internationalessaycompetitiononclimatechangeandhealth.

We also include important articles focusing onthe Covid-19 pandemic, such as original research on thedifferential susceptibility among Black Asian & MinorityEthnic(BAME)groups.

Thismixtureoftopicsbroughtustoreflectontheconnectionsbetween climate change and COVID-19 and what it canteachusgoingforward.TheresponsetoCOVID-19,thoughvaried between countries and not without controversy,demonstrates the capacity for social and cultural changethat,post-COVID,needtobedrivenandharnessed.

This gives hope for climate change mitigation.Thedrasticchangestogovernment,economyandindustryrequiredcanbeachievedifpoliticalandpublicwillispresent.Covid-19 has highlighted extreme health inequalitieswiththosefromBAMEandlowersocio-economicgroupsseemingtosuffermoresevereformsoftheillnessandahigherdeathrateamongsthealthprofessionals.

Thisissomethingthat,asthejournaloftheBritishAssociation for Physicians of Indian Origin, has hit closeto home. Particularly as we work to ensure equality anddiversityintheNHSforBAMEdoctors.Similarly,itispoorerpopulations of countries in the southern hemisphere that

will face thegreatesthardship fromclimatechangedue toextreme heat and weather events, unstable food systems,conflict,andmigration.TheseinequalitiesmustcontinuetoberecognisedandaddressedasnewhealthpolicyiscreatedandevenastheWestbeginstomoveoutofthemosttragicphaseofthedisease,wemustnotleaveLMICsbehind.

We want this edition of Sushruta to provide anoptimistic view of the future. Throughout the pandemicimagesofnatureregeneratinghavecometobeasymbolofhopesuchasfishinthecanalsofVeniceorsatelliteimagesofskiesfreeofpollution.AsweemergefromtheCOVID-19pandemicwemusttaketheconceptof ‘anewnormal’andapply it to the way our society addresses climate change.Reductionsincarbonemissionscancontinueaswecontinuetoworkfromhomeandlimittravel.Thegovernmentshouldaim to support a ‘green economy’ promoting economicrecoverywithalowcarbonfootprint.Itwillbedifficult,butwehaveprovedourselvestoberesilientandadaptableinthefaceofacrisis.q



HealthProfessionalsandClimateChangeRichard SmithChairoftheUKHealthAllianceonClimateChangeandformereditor,BMJ

Article InformationSubmitted:22June2020Published:24June2020

BoththeWorldHealthOrganisation(WHO)andtheLan-cethavecalledclimatechangetheworld’smajorthreat

tohealth.(I12)ItisunfortunatelyamuchmoreseriousthreatthantheCovid-19pandemic.Althoughthepandemicislike-lytokillmillions,itwilleventuallypass.Humanshaveexpe-riencedpandemicssincetheymovedintocitiessome5000yearsago.Incontrast,althoughtheEarthhasexperiencedwideswingsintemperature,humanshavenotexperiencedtheglobalwarmingthatisunderway. Climatechange isalreadycausingsufferingandprematuredeathasaresultofextremeweather,sea-levelrises,extensionof infections intonewareas, crop failure,water shortages,forced migration and the air pollution that accompaniesclimatechange.(3)Thisisallsettobecomedramaticallyworseifwe do notmanage to reduce greenhouse gas emissions.TheIntergovernmentalPanelonClimateChange(IPCC),aninstinctively cautious body, warned in 2018 that we havelessthan15yearslefttoreducegreenhousegasemissionsto keep global temperature to less than 1.5°C above pre-industriallevels,alevelthatshouldavoidwhattheIPCCcalls“extremeclimatechange.”(4) In order to keep the global temperature below the 1.5°Cincrease the world has needed to reduce greenhousegas emissions by about 7% a year. (4) But they have beenincreasing by about 7% a year, (5) meaning that we areheadingtowardsatemperatureincreaseof4°C,alevelthatcouldhavecatastrophiceffectsonhealth.(6) As a result of thepandemic and consequent lockdownsofeconomiesitisestimatedthatgreenhousegasemissionswillfallbyabout8%in2020.(7)Thisisgoodnewsinthatitshowsthat reductions are possible, but it also shows the extentof change necessary: shutting down the global economyis not possible, but equally dramatic changes must bemade—bytheinternationalcommunity,andeverycountry,organisation,andindividual. It’s important to recognise that the vast majority of thegreenhousegasesemittedintotheatmospheresincethestartof the industrial revolution have come from high-incomecountries.Yet themostseriousconsequences fromclimatechangewillbeinlowincomecountries.Thishasledtotheidea of Contraction andConvergence inmitigating climatechange. (8)All countriesneed toconverge towardsnet-zeroemissions, but high emitting countries need to make thebiggestreductionswhilesomelowincomecountriesmight

temporarily increase emissions to aid development beforecontractingtonetzero. TheUKHealthAllianceonClimateChange (which I chair)has spelt outwhat thismeans for a high emitting countrylike Britain (present average per capita emission 5.6 tonsof carbon dioxide) is each person rapidly converging totheglobalaverage(4.8 tons/capita),andthenreducingtozeroby2040.Theallowance forBritain isabout0.5 tons/per capitabetweennowand2040.Yet theaverageBritishhomeemits2.7tonsofcarbondioxideayearfromdomesticheating, and a return flight from London to New Yorkemitting1.0tonofcarbondioxide.Theseexamplesillustratethedramaticchangesweneedtomakeinhowwelive,eat,travel,andworktokeepbelowaglobaltemperatureincreaseof1.5degrees.

Improving health and mitigating climate change

Fortunatelybutunsurprisingly,what isgoodformitigatingclimate change is also good for human health. (3) The Australians have a phrase “Healthy planet, healthy places,healthy people”: it is difficult if not impossible for peoplewho live in unhealthy places to be healthy. To mitigateclimatechangeweneed todriveand fly lesswhichmeansexercisingmore,whichisgoodforthehealthofindividuals(transportation accounts for just over a quarter ofgreenhousegasemissions).Wealsoimproveourhealthbyeatinglessmeatandmoreplant-basedfoods,whichinturnreduces greenhouse gas emissions from food (about 14%ofglobalemissions).Recognisingthatwearepartofnatureandcherishingitmoreisgoodforourmentalhealth.

It’s importantmake clear, however, that, althoughwewillneedtochangehowwelive,themostimportantchangesneedtobemadeatapoliticallevel.Weneedglobalcooperation,commitmentsbygovernmentstoreducingcarbonemissionsthattheydeliver,andashiftfromaneconomythatpursuesgrowth to one that promotes wellbeing. Individuals alonechangingwill not be enough to avoid climate catastrophe,and political changes in transport, agriculture, trade, andurbandesignmake it easier for individuals to live healthylivesinwhichweconsumelesscarbon.

Health systems and climate change

The recognition of the huge threat to health from climate changemightbeexpectedtomeanthathealthsystemswould

Editorial

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beintheforefrontofreducingcarbonconsumption.Infact,astheLancetCountdowninClimateChangehasshownalmostallhealthsystemshaverisingnotfallingcarbonemissions.(5)TheUShealthsystemsaccountsforabout12%ofemissions,whiletheNHSproduces5-6%ofBritain’semissions.Healthsystemsmayhavebeensoslowtoreducecarbonemissionsbecause of what’s been called “moral offsetting”—thoseworking at what they see as socially beneficial activitieslike treating thesickdonot think that theyhave thesameobligationasotherstoreducetheircarbonconsumption.(9) There is, however, something absurd and paradoxical forhealthsystemsnottobeactingonwhatisdeemedthemajorthreattohealth.TheNHSinEnglandhasnowcommitteditselftogetting tonet-zeroemissionsasquicklyaspossibleandhasanet-zeroadvisorycommittee(onwhichIsit)advisingonhowfastnet-zerocanbeachievedandthestepsthatwillneed to be taken to get there. (10) (It’sworth explaining atthispointthat“net-zero”acceptsthatitwillnotbepossibletoreducecarbonconsumptiontozero,andsosomecarbonemissions will have to be removed from the atmospherethrough natural methods like planning trees or enrichingsoil or through technologies, although those technologiesarenorcurrentlyabletoworkatscale.) AlmostthreequartersoftheNHScarbonfootprintarisesfromprocurement of goods and services with pharmaceuticalsalone counting for about 20% and medical equipmentanother10%.(11)Travelaccountsforanother13%ofthetotalNHSfootprint,andaboutonein20journeysonBritishroadsarises from deliveries and patients and staff travelling tohealthfacilities.TheNHSusesabout2billionplasticglovesayear,andanaestheticgasesandinhalersmakeamaterialcontributiontogreenhousegases.

Health professionals acting on climate change

Far from being laggards in mitigating climate change,healthprofessionalsshouldbeleaders.Theyhavescientifictraining, which means they are better able than many tounderstandthesciencethatunderpinsclimatechange.Theyare more trusted than any other group, particularly afterthe bravery they have shown in countering the pandemic,and they interactwithmillionsof citizenseveryday.Thenthethreattohealthandthepositivebenefitstohealthfroma lowcarbon lifeareprobably thebestway for citizens tobemotivated to act on climate change. Inmany countrieshealthworkers outnumber andother groupof employees,and the actions they and their families take as individualscanhaveasizeableimpact—andtheyprovideleadershipbyexample.Finally,healthprofessionalshaveglobalnetworks,andmitigatingclimatechangedemandsglobalaction. When trying to influence international organisations andgovernments health professionals have a stronger voiceif they speak together. That was the thinking behind theformation of the Global Health and Climate Alliance, (12)theUKHealth Alliance on Climate Change (UKHACC), andsimilarbodies.UKHACCisfiveyearsoldandincludesmostof the royal college in the UK, including those of nurses,physicians,surgeons,andgeneralpractitioners,andtheBMA,theLancet,andtheBMJ.(13)Altogether the members of the

Alliancehavesome650000members,asizableproportionoftheworkforceofNationalHealthService. SomeothercountrieshavesimilarorganisationstoUKHACC,(12) but most do not. It seems to me that every countryshould have some organisation of health professionals,and preferably the organisations should include theexisting respected professional bodies. TheWorldMedicalOrganisation, which is made up by medical associationsfromaround theworld, has declared a climate emergencyandcalledontheinternationalhealthcommunitytojoinitsmobilisation.(14) The Global Health and Climate Alliance campaigns at theannual United Nations meeting on climate change—theConference of the Parties (COP). COP26 was due to beheld in Glasgow in November 2020 but has been delayeduntil November 2021 because of the pandemic. It will bea particularly important meeting because countries arerequiredtorenewtheirNationallyDeterminedContributions(NDCs).ThecurrentNDCs,agreedinParisin2015,willnotbe enough to keep the temperature increase below1.5°C(and,asI’vesaid,arenotbeingachievedbymostcountries).It may be that the pandemic will lead to countries actingmore strongly on the threat of climate change. TheGlobalHealthandClimateAllianceisworkingwithWHO,UKHACC,and the British government to try and ensure that healthfeaturesprominentlyinCOP26.Asthenumberimplies,therehavebeen25previousmeetingsofCOP,andformanyyearshealthdidnotfeatureatall.

The UKHACC was part of pressuring the Britishgovernment into committing the country to achieve netzero by 2050, and we are currently campaigning on theEnvironmentBill,airpollution,andeconomicrecoveryfromthepandemicbeingarecovery that issustainableand lowcarbon. Mitigatingclimatechangerequiresorganisationstochange,andUKHACCandanysimilarorganisationspeakswithmoreauthority if its members are putting their own houses inorder. The attached list shows actions thatwe have askedour 21members to take, ranging from the relatively easylikepromotingvegetarianfoodintheircanteenstothemorecomplex likedisinvesting in fossil-fuelcompanies. (table I)Theseareactionsthatcouldbetakenbymostorganisations.Some members of UKHACC have taken all the actions,whereasothersareatthebeginning.MembersoftheAlliancehelpeachother.

Therearearound40millionhealthworkersintheworld, and the demand for healthworkers is predicted toincreasetosome80millionby2030.(15)Theseworkerscanplayaleadingroleinmitigatingtheworld’smajorthreattohealth.Firstly,theycancampaignfortheirgovernments,cit-ies,communities,healthsystems,professionalorganisations,andanyotherorganisationstowhichtheybelongtoacttomitigateclimatechange.Secondly,theycanactthemselves,andI’vepostedablogintheBMJlistingactionsthatindivid-ualscantake.(16)Thirdly,theycanworkwiththeirpatientstoencouragethemtotakethesesameactions—andthehealthprofessionalscandosoknowingthattheywillalsobebefit-



tingthehealthoftheirpatients.

Conclusion

Climatechangeisthemajorthreattohealth.Althoughsomehealth systems and professionals have acted on climatechange, many have not. There is a huge opportunity forhealthprofessionalstotakeandevenleadactionstomitigateclimatechange,andIurgethemtodoso.

References

1. WorldHealthOrganisation.WHOcallsforurgentactiontopro-tecthealthfromclimatechange.https://www.who.int/global-change/global-campaign/cop21/en/

2. Lancet. Health and climate change. https://www.thelancet.com/climate-and-health

3. LancetCommissiononClimateChange.Healthandclimatechange:policyresponsestoprotectpublichealth.Lancet2015:386:1861-914.https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60854-6/fulltext

4. IntergovernmentalPanelonClimateChange.GlobalWarm-ingof1.5ºC.NewYork:UnitedNationsFoundation,1918.https://www.ipcc.ch/sr15/

5. LancetCountdownonClimateChange.Trackingtheconnec-tionsbetweenpublichealthandclimatechange.https://www.lancetcountdown.org/

6. GreenFacts.Impactsofa4°Cglobalwarming.https://www.greenfacts.org/en/impacts-global-warming/l-2/index.htm

7. CarbonBrief.Analysis:CoronavirussettocauselargesteverannualfallinCO2emissions.9April2020.https://www.carbonbrief.org/analysis-coronavirus-set-to-cause-largest-ev-er-annual-fall-in-co2-emissions

8. MeyerA.ContractionandConvergence:theProportionate

ResponsetoClimateChange.http://www.gci.org.uk/images/Proportionate_Response.pdf

9. PencheonD.Moraloffset.BMJOpinion2010.https://blogs.bmj.com/bmj/2010/10/04/david-pencheon-moral-offset/

10. NHSEngland.ANetZeroNHS.2019.https://www.england.nhs.uk/greenernhs/a-net-zero-nhs/

11. NHSEnglandSustainableDevelopmentUnit.NaturalRe-sourceFootprint.Reducingtheuseofnaturalresourcesinhealthandsocialcare.2018.https://www.sduhealth.org.uk/policy-strategy/reporting/natural-resource-footprint-2018.aspx

12. TheGlobalClimateandHealthAlliance.http://climateand-healthalliance.org/

13. UKHealthAllianceonClimateChange.http://www.uk-healthalliance.org/

14. WorldMedicalAssociation.WMAresolutiononclimateemer-gency.Adoptedbythe70thWMAGeneralAssembly,Tbilisi,Georgia,October2019.https://www.wma.net/policies-post/wma-resolution-on-climate-emergency/

15. Liu,J.X.,Goryakin,Y.,Maeda,A.etal.GlobalHealthWorkforceLaborMarketProjectionsfor2030.HumResourHealth15,11(2017).https://doi.org/10.1186/s12960-017-0187-2

16. SmithR.Actionsthathealthprofessionalscantaketocountertheclimateemergencyandimprovetheirhealth.BMJOpinion2019:https://blogs.bmj.com/bmj/2019/11/08/actions-that-health-professionals-can-take-to-counter-the-climate-emer-gency-and-improve-their-health/

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HowtoBuildClimateResilientHealthSystems:Reinforce the Framework Instead of Reinventing the WheelSojung Yoon MBBSMScPublicHealthLondonSchoolofHygiene&TropicalMedicine,London,UKWONCAWorkingpartyontheEnvironmentSojung.Yoon1@student.lshtm.ac.uk

Article InformationEpub; 01.04.2020Final(v3) 01.06.2020

Cite as:YoonS.(2020)Howtobuildclimateresilienthealthsystems;Reinforcetheframeworkinsteadofre-inventingthewheel.SushrutaJHealthPolicy&Opinvol13(2)DOI:

Abstract

Climatechangewillhaveadverseeffectsonhealthatapopulationscale.Healthsystemsneedtobestrengthenedinorderto better address changing health needs and increaseddemand. Frameworks exist to guide the improvement of healthsystems,however,theydonotnecessarilyaddressadaptationstobemadeforclimatechange.ThisarticlereviewstheWHOOperationalFrameworkandidentifieswherethiscanbebuiltupontotacklechanginghealthneedsduetoclimatechange. Key words;Climatechange,healthsystems,resilience

Background

Climate change is acknowledged as the biggest publichealth threat of the century. The consequences of humanactions, notably the burning of fossil fuels, are affectingall countries in the world. According to the report of theIntergovernmentalPanelonClimateChange(IPCC),climatechange is expected to significantly increase health risks,especially in low-middle-income countries (LMICs).(1)Also,it will disproportionately affect vulnerable groups in eachcountry, such as the poor, children and the elderly, andpeoplewithpre-existingcomorbidities.

With a rising exposure to climate change and a limitedcapacitytoadapttoimpacts,healthsystemsoflow-middle-incomecountriesalreadyfacechallenges.Climatechangeisdifferentfromothertraditionalpublichealthissuesinthatithaseffectsoverextendedperiodsonaglobalscale,issubjectto multiple uncertainties, is strongly mediated by socialdeterminantsofhealth,andcausesdiverseand interactinghealth impacts.Therefore, it requires strengtheninghealthsystems in collaboration with different actors at variouslevels.Theconceptof‘resilience’hasbeenproposedtoequiphealth systems facingclimatechangeandotherchallengessuch as a pandemic, natural disaster, or conflict. Buildingresilient health systems is to raise the capacity of healthsystemstoabsorb,adapt,andtransformexposedtoashock,andstilltoprotectandimprovepopulationhealth.(2,3)

This editorial will review the current World HealthOrganization (WHO) framework gaps. Lessons fromadaptationresponsesaroundtheworldwillbeconsideredin order to suggest how to build climate resilient healthsystemsfromapeople-centredperspective.

WHO Operational framework and knowledge gaps

WHOhas identifiedsix“buildingblocks” inhealthsystemsthatarenecessarytosupportthedeliveryofUniversalHealth

Coverageandtoimprovehealth.Startingfromthisframeworkandconsideringacomprehensivehealthresponsetoclimatechange,WHOhasoutlinedtheoperationalframeworkwithtencomponents(Fig.1).

This framework suggests that climate resilience shouldbeincorporatedintoeverysectorofthehealthsystem,andasasystemicapproach,interconnectionsbetweenthevariouscomponents are emphasized to reinforce one another.All building blocks should become climate resilient, andthe health sector should extend its sphere of operationsbeyonditselftoothersectors(e.g.,water,energy,food,andagriculture).

Figure1.TencomponentscomprisingtheWHOoperationalframeworkforbuildingclimateresilienthealthsystems,andthemainconnectionstothebuildingblocksofhealthsystems Thisframeworkcanbeusefulinseveralways.Itpresentsasimplewaytodiscussthekeyfunctionsofhealthsystems.Itprovidesacommon languageandasharedunderstanding.As itreliesonalreadywell-knownsixbuildingblocks, it iseasytoadapttodifferentcontextsandensuringallessentialfunctionsofhealthsystemsarecovered.Nonetheless,manygapscouldemergefromaddressingtheadaptationofhealthsystems with this framework. These building blocks areconsideredasetofinputsthatcontributetothehealthsystem.Consequently, this framework neglects the links betweeninputs,outputs,andoutcomes.Howmuchcanbeexpectedand done from systemic changes? What is happening intheprocessbywhichinputsaretransformedintooutputs?Also, it is difficult to identify the interactionsbetween thebuildingblocksanddifferentactorsatvariouslevels.Areallbuildingblocksequally important, ifnot,whichonewouldbeprioritizedwhen there are trade-offs?Howcan climateresilience policies be aligned with a global governanceframeworkwiththepartnership?Howcandifferentactors,including local and community level, reinforce each other,

Policy



and collaborate against fragmentation? To address thesegaps,lessonsfromadaptationresponsesinreal-worldneedtobelearned,nottoreinventthenewwheel,buttoreinforcetheoldone.

A people centered perspective

Climate change includes the interrelationship betweendifferentaspects:humanbeingsandecosystems.Resilienceis not just about absorbing shocks from outside but alsoharnessing the changes in the existing systems. A peoplecentered perspective highlights the capacity of peopleimproving their livelihood in the face of environmentaldisturbances. This resilience is underpinned by humanagencyandempowermentbycenteringpeopleasthemainactorsinthepolicyandpractice.(4)Especiallybecausesocialandeconomicdeterminantsofhealthactivelymediate theeffectsofclimatechange,itisessentialtoputpeople’svaluesand needs in the center of health systems and to ensurepeople’sparticipationinthepolicyprocess.

Local knowledge

Despite growing knowledge, there is a lack of enoughunderstanding to address the links between climatechangeandhealth. It isnotonlyabout scientificevidence,but rather the capacity to combineand integratedifferenttypesofknowledgeandhowtopreparethisknowledgeforadaptation.

Evidence suggests that local and indigenous communitieshave been successfully adapting to climate change bydeveloping context-specific practices and building theresilience of their communities.(5, 6) Local knowledge isconsidered toprovide an effective strategy for adaptation.In African Sahel, local farmers have developed severaladaptationmeasures,includingtheearlywarningsystemforextremeweathereventswiththewealthoflocalknowledgeon predicting weather and climate. They also havesuccessfully achieved sustainable livelihoods by adapting

to variabilities in their farming and livestock keeping.(5)Climatechangeadaptionstrategiescanrecognizethevalueof indigenous knowledge systems developed in a specificcontext,alsobecauseofuncertaintiesinthecurrentscientificevidencebase.Consideringthatindigenouspeopleinmostpartsoftheworldcontributelittletoclimatechange,butareatmostriskofitsoutcomes,theirparticipationisessentialbased on the principle of justice. When their knowledgeandexperienceareincorporatedintoclimatechangehealthpractice,adaptionwillbemoreeffectiveandsustainable.

Community participation and delivery

Community participation in the process of developingadaptation strategies has been emphasized in manyliteratures.(7,8)Communityempowermentcanactivatelocalcapacitytoimproveresilienceandconsiderequityinhealthsystems.

Most studies suggest that sea-level rise will cause therelocationofresidentsatriskoffloods.(9)Incontrast,coastalcommunities in the Philippines preferred to stay andimplementadaptivemeasures themselves tominimize therisk of floods.(8) They adapted to flooding by constructingstilted houses and raising floors with coral stone. Peoplein Funafuti, Tuvalu, wished to remain as well because oftheircultureandidentity.(10)Bothcommunitiesconsideredmigration as the last option, opposite to the strategy byauthorities.Itimpliesthatbottom-upadaptationmeasurescan be completely different from top-down approaches.Community-based adaptation engages people to activelycope with the health impacts of climate change, leadingto the climate resilience of health systems. Furthermore,community participation is crucial for adaptation policiestogainpublic acceptance.Nevertheless,not all adaptationmeasuresbycommunitiesaresustainableinthelongterm.Asabove,inthePhilippines,manyislandersusedcoralstonetoraisetheirfloorsforadaptationtoflooding.Thismeasurecan temporarily reduce the impacts of climate change;however,itmightincreasethevulnerabilityofcommunitiesinthelongrun.

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Multicentered relationship

Addressing climate change and implementing adaptationresponsesinhealthsystemsrequiresengagementbetweenvarious levels and types of governance. Horizontal andverticalcollaborationcouldplayanimportantrole,andthesecollaborations require a synergistic relationship betweenstakeholders.Multilevel governance has been proposed as it enablescombiningdecisionsacrossdifferentlevelsandsectors,anddifferent institutional typesat thesamelevel.(11)It isbasedon participation and coordinationwith accountability andtransparencyacrossandwithinlevels.

Anincreasingnumberofcitiesandlocalgovernmentshavepledgedmitigationandadaptationinitiativesunderpinninghealth co-benefits. The Covenant of Mayors (CoM) is aninitiative in which local authorities voluntarily committo reduce CO2 emission. As of 2020, it involves 10,009signatoriescovering318millionpeople,mainly inEurope.The development of multilevel governance has facilitatedthe participation of small municipalities. Provinces andregionshavecommittedtoprovidingfinancialandtechnical

support to these municipalities. Results from monitoringinventoriesin2017showedachievementof23%reductioninCO2emissionscomparedto2005.(12)

Conclusion

Although climate change impacts through ecosystems,thinkingresilienceofhealthsystemsgoesbeyondthatandstayswiththepeopleinhabitingtheseecosystems.Apeoplecentered perspective can address the social determinantsof health andunderline the capacity of people to adapt tochanges. However, there is a lack of research on a peoplecenteredperspectiveonclimatechangeandadaptation.Thecritical lessonfromtheworld isworking ‘with’peopleandputtingtheirvaluesinthecenterofhealthsystems.

Resilience depends on social values regarding what weconsider important and howwe allocate resources.Whenthereare trade-offsandprioritiesamongsocial,economic,andenvironmentalobjectives,whodecides,basedonwhatkind of values? These questions should be discussedwiththe consensus of people, not be left to experts with theframework.

References 1. AnIPCCSpecialReportontheimpactsofglobalwarmingof

1.5°Cabovepre-industriallevelsandrelatedglobalgreen-housegasemissionpathways,inthecontextofstrengtheningtheglobalresponsetothethreatofclimatechange,sustain-abledevelopment,andeffortstoeradicatepoverty.Intergov-ernmentalPanelonClimateChange;2018.

2. BlanchetK,NamSL,RamalingamB,Pozo-MartinF.Govern-anceandCapacitytoManageResilienceofHealthSystems:TowardsaNewConceptualFramework.IntJHealthPolicyManag.2017;6(8):431-5.

3. Operationalframeworkforbuildingclimateresilienthealthsystems.Geneva,Switzerland:WorldHealthOrganization;2015.https://apps.who.int/iris/handle/10665/189951

4. TannerT,LewisD,WrathallD,BronenR,Cradock-HenryN,HuqS,etal.Livelihoodresilienceinthefaceofclimatechange.NatureClimateChange.2014;5(1):23-6.

5. NyongA,AdesinaF,OsmanElashaB.Thevalueofindigenousknowledgeinclimatechangemitigationandadaptationstrate-giesintheAfricanSahel.MitigationandAdaptationStrategiesforGlobalChange.2007;12(5):787-97.

6. MahooH,MbunguW,YonahI,RechaJ,RadenyM,KimeliP,etal.IntegratingIndigenousKnowledgewithScientificSeasonalForecastsforClimateRiskManagementinLushotoDistrictinTanzania.Copenhagen,Denmark:CGIARResearchProgramonClimateChange,AgricultureandFoodSecurity(CCAFS);2015.

ContractNo.:CCAFSWorkingPaperno.103.7. PearceT.Adaptationtoclimatechangeandfreshwater

resourcesinVusamavillage,VitiLevu,Fiji.Regionalenviron-mentalchange.2018.

8. LauriceJameroM,OnukiM,EstebanM,Billones-SensanoXK,TanN,NellasA,etal.Small-islandcommunitiesinthePhilippinespreferlocalmeasurestorelocationinresponsetosea-levelrise.NatureClimateChange.2017;7(8):581-6.

9. Ayeb-KarlssonS,vanderGeestK,AhmedI,HuqS,WarnerK.Apeople-centredperspectiveonclimatechange,environmentalstress,andlivelihoodresilienceinBangladesh.SustainSci.2016;11(4):679-94.

10. MortreuxC,BarnettJ.Climatechange,migrationandadap-tationinFunafuti,Tuvalu.GlobalEnvironmentalChange.2009;19(1):105-12.

11. Romero-LankaoP.ClimateChangeandCities:SecondAssess-mentReportoftheUrbanClimateChangeResearchNetwork.Cambridge,UnitedKingdomandNewYork,NY,USA;2018.

12. KonaA,BertoldiP,Monforti-FerrarioF,RivasS,DallemandJF.Covenantofmayorssignatoriesleadingthewaytowards1.5degreeglobalwarmingpathway.SustainableCitiesandSocie-ty.2018;41:568-75.

Summary Points

Climatechangeisasignificantthreatandrequirestheresilienceofhealthsystems.

Apeoplecenteredperspectivecanbeenablingtoaddressadaptationmeasuresbyputtingpeople’svalueandneedsinthecenterofhealthsystems.

Lessonsofrecognizingthelocalknowledge,enhancingcommunityparticipation,andmultilevelgovernancecanbelearnedfromtheworld.

Buildingclimateresilienthealthsystemsdependsonsocialvaluesandrequirestheconsensusofpeopleinthesociety.



ClimateChangeandNutritionNiamh Kelly ANutr, BSc Human Nutrition, PolicyResearchOfficerinSustainableFoodSystems,LondonSchoolofHygiene&TropicalDiseases,[email protected]

Abstract

Humanhealthandplanetaryhealthareintertwinedinmanyways,foodsystemsbeinganexample.Thisarticledescribesthecomplexmannerinwhichfoodsystemsimpactontheenvironmentandhowourdietarychoiceshaveconsequencesforclimatechange.Subsequentchangestoweatherpatternsandecosystemscanthendestabilisethesefoodsystemsimpactingonhumanhealth.Thisarticleexplainshowvariouscomponentsoffoodsystemsmustbeconsideredwhenattemptingtounderstand effects on climate change. It concludes by offering practical solutions on an individual and societal level tomitigatetheseeffects. Key words: Climatechange,nutrition,foodsystems,sustainability

Cite as: Kelly N.ClimateChangeandNutrition.Sushruta2020(Jul)13(2):pre-printv1ePub23.04.2020DOI:10.38192/13.2.8Climate change and Nutrition

TherecentCOVID-19pandemichasbroughtintofocusthelinkbetweenhumanhealthandplanetaryhealth.Thisis

somethingweneedtokeepinmindoncewemakeitthroughthis crisisandensure thatwemove forward inaway thatbenefitsbothhumanhealthandtheenvironment.Oneareathat needs particular attention is food; our food systemshaveatremendousimpactontheenvironment,accountingfor 20-30% of total global greenhouse gas emissions (1).Foodsystems includeeverything thathappens toour foodfrom farm to fork such as the agricultural practices used,processing, transport and food waste. However, thesedifferentaspectsofthefoodsystemdon’tcontributeequallytoclimatechange.About two thirdsofemissions linked toour foodare fromtheagriculturalsideof foodproduction,mainlyfromlivestockandchangesin landuseforfarming.Theremainingthirdisaccruedduringprocessing,packagingandtransport.

Livestock and Land use

Livestock alone produce approximately 15% of overallGHG emissions, mainly due to methane production fromcattle and sheep, but also includes contributions fromfeedproductionandchangesinlanduseforgrazing.Largeareas are deforested each year to convert the space intopastureforanimalstograze,orcropstobegrown.Forestsare considered “carbon sinks”whichmeans they are goodfor soaking up carbon from the atmosphere. Therefore,removing large amounts of forests reduces the amount ofcarbondioxidebeingabsorbed,butcanalsoleadtocarbondioxide actually being released into the atmospherewhenthetreesarecutdown.

Water use

Water used in agriculture is a combination of storedrainwater (called “green” water) and groundwater whichisfoundinthespacesbetweensoilandrocksunderground.We are increasingly reliant on groundwater in agriculture,

particularlyinIndiawhere90%ofgroundwaterisusedforagriculture.As temperaturesriseand incidenceofdroughtincreases in certain areas more water will be needed toproduce crops, particularly those such as almonds andavocadoswhicharegrownindry,hotareasandrequirealotofwater.

Transport

Half of the food consumed in the UK is imported, addingextraemissionstoourfoodsystem(2).AboutonethirdofUKfoodisimportedfromEuropeandtheother20%comesfromvarious regions including Africa, South America and Asia.Fruitandvegetablesarethemaintypesoffoodsimported,partlyduetothedemandforcertainfruitsandvegetablesallyearround,ratherthanwhentheyareinseason.However,thisisacomplexissueandtherearetimeswhentransportingfoods fromabroad in facthas loweremissionsthan locallyproduced foods. Forexample, growing tomatoes in theUKunderheatedconditionscanbemoreenergyintensivethanthosegrowninSpain(1).

Biodiversity

Biodiversity, or the variability of species in a region, is animportantpartofplanetaryhealthas each speciesplacearoleinsustainingecosystems.Oneofthemaindriversoflossofbiodiversityischangesinlanduse,suchasdeforestationand changes in land use for farming, which can destroyanimalhabitats.Aswellasthis,someagriculturalprocessesare putting some of our pollinators such as honeybees asrisk. In the United States a large portion of the honeybeepopulation are transported to California by beekeeperseachyeartopollinatealmondtrees.Itisriskybringingsucha largeproportionofonespeciestoone locationas if theycame incontactwithapathogen, there is thepotential forthebeepopulationtobedepleted(3).

How climate change can affect our food systems

Policy

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Therehasbeenanincreasingoccurrenceofextremeweatherevents like floods, forest firesanddrought inrecentyears,whichcanhavemajorimpactsonfoodproductionandsupply.However,theseeventsandthewarmingoftheplanetisnothappeningevenly.Low-andmiddle-incomecountries,whichholdmostoftheworld’spopulation,aremorevulnerabletoclimatechangethanhighincomecountriesandhavealreadybegun seeing some of its affects. Additionally, amodellingstudy carried out in 2016 by Springman and colleaguespredictsthatby2050therewillbea3.2%reductioninfoodavailability,whichconsistsmainlyofreductionsinfruitandvegetables,andtheseeffectswillpredominantlybeseeninAfrica,SoutheastAsiaandWesternPacificRegions(4).

Rising temperatures will increase the demand for waterfor use in agriculture, particularly in drought prone areas.Seasonalpatternshavebeguntoshiftslightlyandthisalongwith changes in rainfall and temperaturesmakes harvestsunpredictable and can lead to spoilageand food loss.Thisdysregulation can also negatively affect insect pollinatorswhichmaybegintomigratetootherareasthathaveamoresuitableclimate.

Itisdifficulttopredicteachwayclimatechangemayaffectour food supplies but there is some debate over whetherclimatechangemayimpactthenutritionqualityoffoods,orwhether some crop pests and diseasesmay becomemorevirulent (5). Due to our widespread use of monocropping,whereonlyonevariationofacropisgrown,achangeinthebehaviourofpestscouldleadtodevastatingimpactsonfoodproduction.

What can we do about it?

Whilethisallcansoundveryworrying,therearethingswecandotohelpreduceourimpact.Onalargescale,researchisbeingconductedontechnologythatcanbeusedtoreduceemissions linked with agriculture, such as using robotsinsteadofheavymachinery,improvedirrigation,andverticalfarmingwherefruitandvegetablearegrownonshelvesoneontopoftheother.Butwhatcanwedoourselvestoreducetheimpactofourdietonclimatechange?

Reducing waste

Onethirdof thefoodproducedworldwide iseither lostorwasted.Food isconsidered“lost”when it is removed fromthe food chainbefore it gets to the consumer, for examplefood lost through processing ultra-high processed foodsor being rejected by supermarkets because of size, shapeorcolour.Whereaswasterefers to the food that is thrownawayafterreachingtheconsumer.Astheglobalpopulationispredictedtoriseto9billionby2050,itiscrucialwestarttotacklethisissuebyreducingourfoodwaste;buyingonlywhatyouneedandfreezingfoodsyouwon’tusebeforetheygooff.

Thereiscurrentlyresearchlookingintocirculareconomiesforfood,whichareclosedloopsystemsthataimtomaximiseresources and reduce as much unnecessary waste aspossible.Outsideofthis,somecompaniesaremakingprofitsfrom these “lost” foods and delivering surplus or rejectedfruitsandvegetablestohomesandoffices,ormakingsauces

orsmoothies fromit.Aswellasthis, thereareavarietyofappssuchasKarmaandTooGoodtoGo,lookingtoreducefoodwastefromrestaurants,wherethepubliccanpurchasefoodfromfoodoutletsatareducedpricetopreventitfrombeingthrownaway.AnotherexampleisOLIO,whichhelptoreducehouseholdwastebyallowingmembersofthepublictoadvertisefoodstheywillnotuseforsomeoneelsetopickupforfree.

Reduce meat consumption

Diets that are considered environmentally friendly arethosethataremoreplantbasedwithasmallerproportionofanimalproducts,particularlyvegetarianandvegandiets.Thesedietsalsotendtobehealthierthanthosewithhigherimpactsontheenvironmentastheyarehigherinfibreandlower in saturated fat. Therefore, adopting sustainableenvironmentallyfriendlydietsbeanextremelyusefulwayofpromotingbothpublichealthandplanetaryhealth.

A lot of the messages about dietary change for planetaryhealth focus on promoting veganism, removing all animalproducts from the diet. While it is entirely possible tomeet your nutritional requirements on a vegan diet withsupplementsof fortified foods, it is important tobeawareavegandiet isnotalwayssuitable foreveryone. Instead, itmightbemoreuseful for themajorityofpeople to reducetheirmeatconsumption,particularlyredmeat.AmodellingstudybyGreenandcolleaguespredictedthatapersoncouldreduce their Greenhouse Gas emissions by 40% if theyreducedtheirredmeatconsumptionbythreequarters(6).

Buy locally produced, seasonal foods

Buyinglocallyproducedfoodsthatareinseasonwillhelptoreducethetransportemissionsassociatedwithoutofseasonfoods andpotentially reducewater usage for crops grownindroughtpronecountries.However,thiswouldrequireustoeducateourselvesaboutwhatfruitandvegetablesareinseasonmonth tomonth. Avoiding plastic packagingwhenpossible,asmostpeopleareaware,canalsohelpreducetheenvironmentalimpactofyourdietandmanysupermarketshave begun trialling refill stations in their stores. Anotherconsiderationislimitingconsumptionofultrahighprocessedfoodswhichrequirealotofresourcesbutalsoleadstofoodloss.

Despite the challenges linked tomaking our food systemsmoresustainable,theseactionshavethepotentialtoimprovenotonlyplanetaryhealthbutourownhealthtoo.Smallandsustainablechangessuchasthosementionedabovecanhelptotransformourfoodsystemstoreducetheiroverallimpactontheenvironment,increasedemandformoresustainablyproduced foods and potentially safeguard against some oftheeffectsofclimatechangeonnutrition.

References

1. 1. Garnett T, Smith P, Nicholson W, Finch J. Foodsystems and greenhouse gas emissions (Foodsource:chapters).2016.

2. Office for National Statistics. Food Statistics in yourpocket2017-GlobalandUKsupply-GOV.UK[Internet].



FoodStatisticsPocketbook.2017 [cited2020Mar10].Available from: https://www.gov.uk/government/publications/food-statistics-pocketbook-2017/food-statistics-in-your-pocket-2017-global-and-uk-supply

3. CavigliI,DaughenbaughKF,MartinM,LerchM,BannerK,GarciaE, et al. Pathogenprevalenceandabundancein honey bee colonies involved in almond pollination.Apidologie.2016Mar1;47(2):251–66.

4. SpringmannM,Mason-D’CrozD,RobinsonS,GarnettT,GodfrayHCJ,GollinD,etal.Globalandregionalhealtheffectsoffuturefoodproductionunderclimatechange:A

modellingstudy.Lancet.2016May7;387(10031):1937–46.

5. SpecialReportonClimateChangeandLand—IPCCsite[Internet].[cited2020Mar21].Availablefrom:https://www.ipcc.ch/srccl/

6. Green R, Milner J, Dangour AD, Haines A, Chalabi Z,MarkandyaA,etal.Thepotentialtoreducegreenhousegas emissions in the UK through healthy and realisticdietary change. Clim Change. 2015 Jan 26;129(1–2):253–65.

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An Online Survey of HealthcareProfessionalsintheCOVID-19PandemicintheUK:Perceptions of Risk FactorsIndranil ChakravortyMBBSFRCP,Sunil Daga PhD,MRCP,MBBS,Subodh DaveMRCPsych,Subarna ChakravortyPhDMRCPCHFRCPath,Neeraj Bhala MDFRCP,Geeta Menon MSFRCOpth,Ramesh Mehta OBEMDFRCPCH, JS Bamrah MB,BS,FRCPsych,MHSMResearch&InnovationForum,BritishAssociationofPhysiciansofIndianOrigin,UKCorrespondenceto:[email protected]

KEYWORDS:COVID-19,Socialdistancing,BAME,PersonalProtectionEquipment,HealthCareworkers

Cite as:ChakravortyI,DagaS,DaveS,ChakravortyS,BhalaN,MenonG,MehtaR&BamrahJS.AnonlinesurveyofhealthcareprofessionalsintheCOVID-19PandemicintheUK.Sushruta2020(Jul)vol13(2):ePub25.04.2020(pre-printv1.2*)DOI:10.38192/13.2.9

Acknowledgement: The authors would like to thank all the respondents, BAPIO Think Tank, members of BAPIO and associates inpublicisingandsharingthissurvey.

ABSTRACT

To explore the emerging concerns of COVID-19 relatedissues amongst health care workers, members of a rangeof healthcare organisations, governmental agencies, andthemedia,anonlineself-administeredsurveyofhealthcareworkers was undertaken by the British Association ofPhysiciansofIndianOrigininApril2020.

ResultsThe respondents were predominantly hospital doctors(67%), aged between 40-60 years (72%) and from Black,Asian, andMinority Ethnicity (BAME) backgrounds in theUK(86%).Thirtypercentofrespondentshadoneormorehealthcomorbidities.Over78%reportedeither lackof,orinappropriatepersonalprotectiveequipment(PPE)fortheirroleand68%ofrespondents felt that theywereunable tocomplywith or that itwas impractical to adhere to socialdistancingatwork(includingcommuting).Atthetimeofthesurvey,18.5%ofrespondentsreportedhavingaconfirmedorsuspecteddiagnosisofCOVID-19.Inmultivariateanalysis,inability to self-isolate and having a BAME backgroundemergedasindependentrisk(OR1.45)forCOVID-19whenadjustedforconfoundingfactors.

Conclusions

These results add to the emerging concerns expressedinternationally on the observation that BAME ethnicityappears to have a higher risk of developing COVID-19.This is the first study that adjusted work-related factors(inability to maintain social distancing and inadequatePPE)andcomorbidities.Ourworksupportstheimperativefor designing and conducting urgent larger studies tounderstandthisriskandplanappropriatemitigationoftheriskstohealthcareworkers

*version1.2 includesadditionofself-isolationasariskforCOVID-19.SeeTable4.

INTRODUCTIONWearelivinginunprecedentedtimesandinthemidstofapandemicthathaschangedourworldinmanyways.Whilethe interdependency can cause rapid global spread of apandemic, it can also offer opportunities for equally rapidcollaborationsandexchangeofvital information.ThedatafromItaly,SpainandFrancehasledtoasignificantincreasein mortality figures, when compared with initial reportsfrom Wuhan, China. Equally concerning were the reportsemerging of healthcare workers succumbing to the virushaving contracted it whilst on duty [1]. This has led to anunderstandableconcernregardingtheeffectivenessofPPEprovided to HCWs. Another demographic trend observedin data emerging from intensive care units in the UK andUSAisahighernumberofBlack,AsianandMinorityEthnic(BAME)patientsdyingofCOVID-19[2-4].Thishighlightstheimportanceofstudyingthepotentialcausesleadingtothisoutcome,sothatfactorstomitigatethisriskcanbeinstitutedearlyinpreventivestrategiesandtreatmentoptions.

Early reports from the UK media of healthcare workerssuccumbing to this illness were almost exclusively fromBAME communities. Hence, increased demands to the UKgovernmenttoreportonethnicityofthosethatareaffectedanddying[5].Combiningthiswithotherearlyindicatorsthatobesity(intheUSA),increasedprevalenceofhypertension,cardiovascular and renal disease in theBAMEpopulationsin the west may be the underlying cause of the observedincreasedrisk[6].

The British Association of Physicians of Indian Origin(BAPIO) is anational, voluntary,membershiporganisationset up originally to represent and support the cause ofdoctors from the Indian subcontinent. In recent years,

Article



BAPIOhas expanded its remit toprovide the samedegreeofrepresentationtoallhealthcareprofessionalsinamulti-professionalenvironmentandhasworkedcloselywithothersimilarorganisations.BAPIO,throughitsvariousarms,hasextensive experience of working with national regulatorybodies, academic institutionsandroyal collegesacross thespectrum.BAPIOexecutivesetoutbroadtermsofreferenceforitsResearch&InnovationForum(BRIF),whichthroughactive engagement and serious debatewithmembers andcollaborators fromthescientificcommunity, embarkedondesigningspecificstudiestoanswerthequestions.

This survey was designed to explore the prevalence ofCOVID-19 among HCWs, their access to suitable PPE andtheir ability to maintain social distancing at work, whilecommuting to-and-from work and for self-isolating whennecessary.

Rationale:

The extent and impact of the COVID-19 pandemic isevolving with over 2.5 million people infected so far andover170,000deathsreportedworldwide[7]Observationsincaptivepopulationssuchascruise-liners[8][9][10].showsthatSARS-CoV-2 spreads rapidly and often through proximityto asymptomatic cases/carers. Therefore, public healthscientists across most affected countries worldwide haveidentified“socialdistancing”,‘’stayingathome’’andfrequenthandwashing as the strongly recommended measures tocontain the spreadof thedisease.HCWrepresent a groupthat have to do exactly the opposite by commuting (oftenusingpublic transport), caring forpatientswithprovenorsuspectedCOVID-19and interacting for severalhours at atimeincloseproximitywithcolleaguesamongwhomtherewillundoubtedlybeasymptomaticcarriersofthedisease.

Data from Italy shows about 20% frontline HCW becameinfectedandmanyhavelosttheirlives [1].Mediareportsinthe U.K. have highlighted the concerns of many frontlineHCW regardingwell documenteddeaths [5] [11] [12]. A recentsurvey by the British Medical Association highlightedconcerns amongst respondents of the perceived lack ofpersonalprotectiveequipment(PPE)forfrontlineHCW[13].ThereisconcernamongstHCWabouttheincreasedriskofacquiringSARS-CoV-2infectionwhileatwork.

Theemergingsignalofincreasedriskandpooreroutcomesrequires further exploration[3] [4] [6]. Current evidence froma scanof emergingdata and focus groups [2] suggests that age(over60years),comorbidities(suchascardiovascular,kidney disease and diabetes), male sex, and BAMEbackground may be risk factors for increased COVID-19associatedmortality. There is lack of data that establishesBAMEethnicityasanindependentriskfactoroverandabovemedical,demographicandsocial/culturalfactors.

Theaimofthissurveyistoexplorethepersonalexperiencesandperspectives fromHCWson the risk of COVID-19 andantecedent demographic, geographical and professionalfactorsinrelationtothisrisk.

METHODS

Participants:

The surveywasopen to allHCWs in theU.K. in electronicformatonly.Thequestionnairewassharedviasocialmedia(twitter,Facebook,WhatsAppandpersonalsocialnetwork)and emails were sent to all HCWs on the BAPIO contactdatabase. The survey introduction stated the purpose andintention to disseminate the results through publicationin SUSHRUTA Journal ofHealthPolicy&Opinions and theindividuals’responsesarecompletelyanonymous.Atotalof2003responseswerereceived.

Questionnaire:

The questionnaire was developed by the members of theBRIF,withfurtherdiscussionswithmembersoftheBAPIOThinkTankwhichhas65activemembers froma rangeofhealthcarespecialties,thusformingstakeholderinvolvementin designing the survey. The five key focus areas for datacollectionswere:1. Demographics including age, ethnicity and co-

morbidities2. COVID-19status–confirmed,suspectedornone3. Occupational factors – geographical distribution,

profession,workarea4. PreventiveMeasures-5. Personal protection equipment – availability and

appropriateness6. Socialdistancing-whileatworkandcommutingto-and-

fromwork7. Self-isolatingandpersonalsafety8. LikelihoodofCOVID19

Administration of the questionnaire:

The questionnaire was administered online using Googleformsandafullversionisavailableintheappendixtothispaper.Thequestionnairereceivedresponsesfrom14.04.20to21.04.2007:30HUKsummertime.Thequestionnairehas11questions,witharangeofoptionsfromasingleanswertomultipleoptionsdependingonthesubjectmatter.

Statistical Analysis

The rawdata (in .CSV format)was checked,missing itemsresolved and analysed independently by two primaryinvestigators.Theresultswerecheckedforconsistencyandinferencesdiscussedandagreedwithallauthors.Inadditionto descriptive statistics of the population of respondents,the survey results were analysed using non-parametrictests,univariateanalysisandregressionanalysis(Bivariatelogistical regression) using SPSS software v26 (IBM Inc,USA). The primary outcome measure was a self-reporteddiagnosis (confirmed by viral PCR swab testing) and / orclinical suspicionbasedonNHSguidance for self-isolationduetoclassicalsymptoms.

RESULTS

1. Demographics

Majorityofrespondentswereagedbetween40-60years

(Figure 1), hospital doctors (Figure 2), and from BAMEcommunities (Figure 3). Further distribution of individualethnic groups amongst the respondents is given in table1, showing amajority of SouthAsians.Therewas an evenrepresentationfromallpartsoftheU.K.(Figure4).Nearlya

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thirdofrespondentsreportedoneormorecomorbiditieswhichwererelevanttotheNHSvulnerabledisease-groupguidance(Figure5).

Figure1:Histogramshowingagerangeofrespondents

Figure2:Histogramshowingtheprofessionsoftherespondents



Figure3.Piechartshowingtheethnicityoftherespondents

Table1:Detaileddistributionofethnicityofrespondents

Figure4:Histogramshowingthegeographicaldistributionofrespondents

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Figure5:Piechartshowingthereportedcumulativeco-morbidities

2. COVID-19 status

Prevalence

Casedefinitionwasbasedon respondentswho reportedhavinga confirmed (Viral swabPCR)orself-isolatingwithCOVID-19 related symptoms (asperPHEdescription).Therewere79 (3.94%)confirmedand297(14.83%)suspectedCOVID-19cases,anoverallproportionof19%ofthesurveypopulation.Arangeofsourcesofpotentialexposureswerereported(SeeFigure6andFigure7).

Figure6:Histogramshowingclinicalworkareaforrespondents



Figure7:PiechartshowingCOVID-19statusforrespondents

3. Occupational Risks

Analysisoftherespondent’sprofessionalgroup,clinicalareaofworkorNHSregionwerenotfoundtobesignificantfactorsintheriskofhavingCOVID19.

4. Preventive Measures

Thesurveyresponseswereclassifiedtobe‘noissues’orappropriatePPEand‘issues’includinginappropriate,restricted/shortsupplyorbeingreprimanded.Usingthisclassification,wefoundthat78%ofrespondentsreportednothavingadequateorappropriatePPEfortheirroles.TheresponsestotheindividualansweroptionsaregiveninTable2.AccesstoPPEdidnotshowanysignificantcorrelationorlikelihoodtohavingadiagnosisofCOVID19inoursurvey.

Table2:PPEavailabilityandappropriateness

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Social Distancing

Table3:Socialdistancingcompliance

WeaskedrespondentsifthePPEsupplyandsocialdistancingwasadequateandappropriateandifnotthepossibleissues(seeTable3,Figure8andFigure9respectively).

Figure8:Piechartshowingrespondentsreportingappropriatevsnon-appropriate/restrictedPPEavailability

Figure9:PiechartshowingrespondentsabilitytocomplywithSocialDistancingguidance



Self-Isolating (Vulnerable Staff)

Rspondentswereaskedwhethertheywereabletoself-isolateduetoapersonalhealthreasonorlivingwithafamilymember.Figure10,givestheproportionsofrespondentswhoreported(1)beinginself-isolationduetoapersonalorfamilymemberbeingatrisk(7.5%),(2)workinginnon-patientfacingroles(5.6%),(3)notabletoself-isolatedespiteknownrisk(21.9%),(4)havebeenofferedtoself-isolatebutchosennotto(2.4%)and(5)notapplicable(63%).

Figure10:Showingrespondentsandtheirself-isolatingstatus(seetextforcategories1-5)

5. Multi-variant analysis of developing suspected or confirmed COVID19

Abinarylogisticregressionmodel(Loglikelihood1902.648a,Cox&SnellRSquare0.009)afteradjustingcomorbidities,PPEandsocialdistancingshowedthatBAMEethnicityandinabilitytoself-isolate(orchoosingnotto)wereindependentlyassociatedwithincreasedriskofCOVID-19(confirmedorsuspected)(SeeTable4).

Table4:Binarylogisticregressionanalysis

DISCUSSION

ThissurveywasthefirststeptowardsexploringthespectrumofCOVID19relatedproblemsreportedamongsthealthcareworkersintheUKandtohelpdecidethekeyscientificquestionstoaddressandtheareastoprioritiseforfutureresearch.Thisdataisexploratoryinnatureandalthoughthereareimportanttrendsemerging,thiswillneedtobetakeninthecontextofaself-administered,anonymised,onlinesurvey.

What do the results indicate?

Firstly,itanswersthefundamentalquestionthatbeinganHCWfromaBAMEcommunitymakesit1.5timesmorelikelythatonewillacquireCOVID-19.Theconfoundingfactorsofage,regionalspreadofriskandfacilities,co-existingco-morbidities,workinginhighrisksettingsarenotshowntobesignificantinexplainingthisrisk,atleastinanalysisoftheresultsofthis

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survey.BasedonarangeofrapidanalysisofemergingdatafromtheUSAandUK, it isclearthatthereappearstobeadifferentialspectrumofdiseaseinBAMEcommunities.

Whatisunclearatpresentarethereasonsthatmayexplainthisobservation.Thereisspeculationaboutseveralclinical,social,economic,culturalandevenreligiousfactorsthatmaycontributetoahigherriskscenario.UnlikethepopulationofWuhandistrictinChina,thepopulationamongsttheBAMEcommunities inUKandUSAremainshugelyheterogenous.IntheUK,HCWscomefromseveralethnicgroupsoriginatingatdifferentpoints intimefromcountriesacrosstheglobe.Every social, cultural, clinical, educational and religiousfactors are bound to bewidely variable. Howwould it bepossible then todefineandexplore factorscontributing totheobservedhighriskofCOVID-19insuchadiversegroup?Then hypothetically, it may also be possible that the richcommonalityofexperienceasaBAMEHCWinUKNHS,mayhave an over-riding contribution to the observed risk, fargreaterperhaps than the inherent factorsbasedonorigin.Thisinthecontextofthissurvey,isspeculationandwillneedto be explored through well-designed and funded studiesamongstHCWs.

ThesecondareaofanxietyandconcernisinrelationtoPPE.Our results indicate that a vast majority of respondents’report having inappropriate PPE for clinical risk, of PPEbeing inshortsupply,beingrestricted inbeingable tousePPEorbeingreprimandedforusingPPE.Thisisself-reportedandmaybesubjecttoadifferentinterpretationofthePHE,UKgovernmentandNHSguidanceon theappropriatenessof PPE for different clinical situations. Having said that,it is important to recognise the rising tide of professionalopinionsharedinprofessionalgroups,reinforcedbysurveysconductedbymedicalroyalcollegesandotherprofessionalassociations which indicate that there is substance inthis finding. Our data suggests an alarming majority ofrespondents report inadequate or inappropriate PPE. Thereport from a small proportion of respondents (n=64) ofbeingreprimandedisacauseforfurtherconcern.Giventhebackground of institutional racism, bullying, harassment,microaggressions and differential treatment of HCWsfrom certain minority and migrant groups, this finding isespeciallyveryworrying[14].

The third area of interest relates to the concept of socialdistancing guidance from the NHS and Public HealthEngland forall. It is true that inmostclinicalareas, teamshave towork inclosequarters toprovidecare topatients.While, inan intensivecareunitsetting, this isprovidedbyHCWswearingPPE throughout the entire shift, this is notpractical or possible in other less intense areas. There isthusadichotomy inhow individuals respond to the socialdistancing guidance. There is also a learned helplessnessamongst staff on the inevitability of asymptomatictransmission between staff working in close quarters. Infact,thehighprevalenceofCOVID-19amongststaffseeninoursurveyandreportedfromItaly,SpainandFrancetellsasimilarstory. It isunclearwhetherHCWsacquire infectionwhiletreating/caringforpatientsorwhileworking/restingincloseproximity tocolleaguesremains tobeestablished.Our survey is not designed or powered to answer this

question.However,ourregressionanalysisindicatesthatforthispopulation,itisunlikelythatPPEorinabilitytocomplywithsocialdistancingwouldhavecontributedtoincreasedriskofCOVID-19.Hence,moreresearchisneededtodecidewhatPPEisappropriateineachclinicalriskscenarios.

Finally,thequestionofself-isolationforHCWswithpersonalhealthrisk,livingwithavulnerablefamilymemberorhavingtoforegoself-isolationintheinterestofone’semploymentas well as for selfless service. Our results indicate thatover1/5HCWswereunabletoself-isolatedespitetherisk,henceexposingthemtoahigherriskofCOVID19.Inabilitytoself-isolateorchoosingnotto,appearstobeasignificantrisk factor forCOVID-19.Acceptingtheweaknessofaself-reportedquestionnaire,thisisaworryingtrendandperhapsrequires further exploration with occupational healthexpertsandhumanresourcesdepartments.

Thereareinevitablyseverallimitationstotheinterpretationandconclusionsonecandrawfromthisdata.Primarily,thereisapossibilityofaselectionbias.Byitsnatureofdistributioni.e via BAPIO members and their associates connectedthroughwidesocialnetworks,itisinevitablethatthemajorityof respondents would be from a BAME or predominantlySouthAsianorigin.TheproportionofrespondentsreportingontheirCOVID-19diagnosisorsuspecteddiagnosisisalsobasedontherecallbiasofrespondents.Thesurveydidnotuseregistrationnumberorinstitutionalemailforverificationintheinterestsofspeedandbreadthofdatacollection.Thisisinconsonancewithusualpracticeforonlineortelephonedistant surveys of professionals where self-reporting ofstatusisreliedon.Theresearchershavenoreasontobelievethat a respondent would have any reason to falsify theirrepresentations.Thesecondsafeguardwasthatthesurveywas sent via BAPIO membership database and encryptedsocialnetworkstoverifiedrecipients.Thedatadistributionamongstprofessionalgroups,regionalspread,agegroupandclinical sectorsbroadly represents theBAPIOmembershipandassociates.Hence,althoughnotarepresentationofthewholehealthcareworkforceintheUK,itdoesrepresenttheBAPIOmembershipfootprint. CONCLUSIONS

Asfarasweareaware,thisisthefirstsubstantialsurveyofBAMEhealthcareworkers,primarilydoctorsworkingacrossprimary and secondary care in the UK. It is evident fromthissamplethatadequateprotection,orratherlackofit,isamajorconcernamongstthem,andismoreprevalentthanhasbeenpreviouslyreported.ThesurveydemonstratesthatthereisahighriskofinfectionfromCOVID-19inhealthcaresettings,andyetourrespondentsputthemselvesinharm’swayfromasenseofduty.Asignificantnumber(15%)wereself-isolatingonsuspicionofhavingthevirus,addingtotheevidencethatthelackoftestingmighthavehamperedtheirreturn to work. Our respondents were unable to complywith social distancing at the workplace, but they did notappeartobeoverlyconcernedaboutthis.Finally,thissurveyadds significant weight to the argument that ethnicitymaybean independent risk factorand further research isneededurgentlytounderstandthisriskandpreventfurtherunnecessarydeaths fromunderstandingwhoisvulnerable



APPENDIX Survey questions

COVID19 5min Survey for Healthcare Professionals

BritishAssociationofPhysiciansof IndianOrigin is conducting anonline surveyof all healthcareworkers including itsmembers to estimate (a) the availability and appropriateness of personal protection equipment in different healthcaresettings,(b)staffwhoareoff-workandhavebeenoff-workduetosuspectedCOVID19,(c)availabilityofstafftesting(d)socialdistancingatworkandfinally(e)safetyofvulnerablestaffmembersduringredeployment.TheanonymiseddatawillbeanalysedandresultspublishedinSushruta.netandformpolicyforBAPIOExecutivecommitteeinrepresentingitsmembershipaswellashealthcareworkersfromappropriateBAMEbackgrounds.

Your personal detailswill not be collected or stored. BAPIO takes personal data securitywith utmost seriousness andcomplieswithGDPRregulations.Foranyqueriespleaseemailadmin@bapio.co.uk

1. Please confirm your role in healthcare ?

Column 1

HospitalDoctorNurses/AdvancedCarePractitioners/Midwife/HCAs/PAsPrimaryCareGP/Nurses/DistrictNurses/AdministratorsAlliedhealthprofessional(Physio/Pharmacist/Speechtherapst/Scientist)Managers/Estates/Food/Portering/AdministrationintermediateCare/NursingHomes/CarersAnyotherrole?

2. Please confirm your healthcare sectorColumn 1

SecondaryortertiarycarefacilityPrimarycare(GPPractice)intermediate/Nursing/CareHomesAcademicinstitutionwithnodirectpatientcareRemoteworkingwithnocolleagueorpatientcare

3. Please confirm your geographical sector (NHSE/I mapped regions)

Column 2LondonEastofEnglandMidlandsNorthEast&YorkshireNorthWestSouthEastSouthWestScotlandWalesNorthernIrelandOutsidetheUK

4. Please confirm your circumstances in relation to COVID19

Column 1

AcutecareofCOVID19patientsinED/Inpatients/ICUInpatientsonnon-COVIDwardsPrimary/Intermediatecare/reviewofCOVID19patientsorsuspectedContactwithCOVID19patientsathome/carehomesPersonal/FamilycontactwithCOVID19

andwhoisn’t. REFERENCES

1. COVID-19: protecting health-care workers. Lancet 2020, Volume 395, ISSUE 10228, P922, March 21, 2020

2. ICNARC Case Mix Programme Database COVID19 Report; 17 April 2020

3. Is ethnicity linked to incidence or outcomes of covid-19? BMJ. 2020 Apr 20

4. The COVID-19 Pandemic: a Call to Action to Identify and Address Racial and Ethnic Disparities; J Racial Ethn Health Disparities. 2020 Apr 18

5. Exclusive: deaths of NHS staff from covid-19 analysed; HSJ 22 April 2020

6. Ethnicity and COVID-19: an urgent public health research priority; The Lancet April 21, 2020

7. https://www.who.int/docs/default-source/coronaviruse/situation-

reports/20200422-sitrep-93-covid-19.pdf?sfvrsn=35cf80d7_4].8. Initial Investigation of Transmission of COVID-19 Among Crew

Members During Quarantine of a Cruise Ship - Yokohama, Japan, February 2020. MMWR Morb Mortal Wkly Rep. 2020 Mar 20

9. Chronology of COVID-19 Cases on the Diamond Princess Cruise Ship and Ethical Considerations: A Report From Japan; Disaster Med Public Health Prep. 2020 Mar 24

10. COVID-19 outbreak on the Diamond Princess cruise ship: estimating the epidemic potential and effectiveness of public health countermeasures. J Travel Med. 2020 Feb 28.

11. https://news.sky.com/story/coronavirus-half-of-a-e-staff-at-one-hospital-in-wales-have-covid-19-reveals-medic-11972384

12. https://www.telegraph.co.uk/news/0/nhs-died-coronavirus-frontline-workers-victims/

13. https://www.bma.org.uk/news-and-opinion/bma-survey-finds-doctors-lives-still-at-risk-despite-government-pledges-on-ppe

14. https://www.england.nhs.uk/about/equality/equality-hub/equality-standard/workforce-race-equality-standard-2019-report/

25



Community/SocialcontactthroughdailyactivitiesNotapplicable

5. Your COVID19 status at any time

Column 1

ConfirmeddiagnosisofCOVID19fromswabtestSuspectedCOVID19/self-isolatingCOVID19familycontact-selfisolatingNosymptomsordiagnosisofCOVID19Inshielding/pro-activelyavoidingexposuretoCOVID19Notapplicable

6. Availability of appropriate Personal Protection for your role based on PHE guidance

Column 1

PPEhasalwaysbeenavailableandappropriatePPEhasbeenalwaysavailablebutnotalwaysappropriateformyrolePPEhasbeeninshortsupply/restrictedPPEhasbeeninappropriateformyroleNoPPEavailableformyrole(atanytimeduringthispan-demic)Ihavebeenrestricted/reprimandedfromwearingPPE

7. Social distancing (SD) at work (not including patient contact with PPE) or during commuting based on PHE guidance of 2m

Column 1IamabletocomplyfullywithSDguidanceIamnotabletocomplyfullywithSDguidanceIcannotfullycomplywithSDguidanceduringcommutingItisnotpracticaltoexpecttocomplywithSDatworkIamworkingawayfromdirectpatientcontactduetohealth/familyreason

8. Safety of vulnerable staff at heightened risk from exposure to COVID19 (see PHE/ NHS guidance on at risk groups)

Column 1

Iaminself-isolationduetomyhealth/familyriskIaminnon-patientfacingdutiesduetomyhealth/familyrisksIamnotabletoself-isolateoravoidCOVID19exposureinspiteofmypersonal/familyriskIhavebeenofferedbutchosennottoavoidCOVID19expo-sureriskNotapplicable

9. Your age group

Column 1

20-29years30-39years40-49years50-59years

60-69years70-79years>79years

10. Ethnicity appears to have a relationship to suscepti-bility and outcomes in COVID19 *Choose

Caucasian(British/IrishTraveller/AnyotherWhite)Black/African/Afro-Caribbean/African-AmericanSouthAsian-Indian/Pakistani/Bangladeshi/OtherArab/Middle-eastern/NorthAfricanChinese/SEAsianAnyotherethnicityMixedDonotwishtodeclare

11. Co-morbidities

Column 1

NochronicconditionsHypertensionDiabetesChronickidneydiseaseAsthma/COPD/ChroniclungdiseaseHeartdiseaseCerebrovasculardiseaseMentalHealthconditions(any)PregnancyNotwishingtodeclare



TheBushfiresDownunder-AMedicalEmergency,NowandLaterShailja Chaturvedi BSc,MBBS,FRANZCPConsultantPsychiatristSydneyNSWAustraliashail150@hotmail.com

Article InformationEpub: 01.042020Finalv2 01.06.2020

Cite as: ChaturvediS.(2020)TheBushfiresdownunder–Amedicalemergency,nowandlater.SushrutaJHealthPolicy&Opinvol13(2):v3DOI:10.38192/13.2.2

Abstract

AlthoughAustralia isaccustomedtobushfiresonaregularbasis theextremityof the latestepisodewasunprecedentedcausingworldwideconcern for thepeopleandecosystemsof thecountry.Thisarticledescribes thecausesofbushfiresalongsidetheenvironmentalimpacts.ItreflectsontheheroicmannerinwhichtheAustralianpeoplesralliedtogethertoovercometheiradversity,concludingonlessonstobelearnedforfuturegenerations.

Key words: Australia,burning,bushfires,airpollution

Introduction

An unprecedented catastrophe was created by theuncontrolled bushfires in Australia. Between September2019untilJanuary2020anestimated19millionhectaresoflandand6000buildingswereburnt,killingatleast40peopleand about 1.25 billion animals, driving some endangeredspecies topossibleextinction, includingAustralia's famousKoala bear, with the mammoth blaze destroying 30% oftheir habitat (1).Theestimatedcostofthe2019Bushfire islikelytoexceedthe$4billioncostofthe2009BlackSaturdayfire. State of emergency was declared in various parts ofthe countrywith the Australian government pledging $50millionsforfireaffectedwildlife.

Bushfires are a necessary part of the life cycle for severaltrees and plants such as Eucalyptus in Australia (2) (3).Loose flammable bark and combustible oil in their leavesmaypromote thespreadof fire.AlthoughbushfiresareanintegralpartoftheAustralianenvironment,thesefiresweremoreextremethaneverknownbefore.Thehorrificwildfireswereclearlyvisiblefromsatellitesimages,thesmokerisingat least17kmhighandmovingapproximately11,000kmacrosstheSouthPacificOcean. NASAestimatedemissionsof306milliontonesofcarbondioxide.Asaresult,insomeareas, air quality exceeded twenty times the hazardousrating. A possible cause for these devastating fires isclimatechangewhichmayhavebroughtforwardthestartof bushfire season and delayed its finish. The tragic lossof lives and properties and the destructive impact on theenvironment has raised serious concerns in every sectionof the community (4). Tourism sector revenues have fallenbymore than a billiondollars. The fireshaveunderminedAustralia'sreputationintheinternationalhighereducationmarkettothetuneof$38billion.

Health Effects

Themedical community has taken on its emergency carerole, but also worked to understand the far reachingconsequencesofthesefiresonhumanhealth.Theimmediatefocus on diseases resulting from contaminated water andfoodanddiseasesecondarytoextremeairpollutionbecamea public health priority. There was increased sedimentconcentrationindrinkingwaterintherunoffareaswithleadinexcessofcurrentdrinkingwaterguidelines.Thebushfiresfollowed by heavy rains havewashed ash alongside otherparticulatematterintoriversturningthewatersiltblackandkilling the fish.Althoughbushfire smokeaffectshealth, itsfullunprecedentedimpactbothintheshortandlongtermneeds further exploration(5). Therewas a 51% increase inambulancecallsforbreathingdifficultiesduetosmokeanda25%increase inexacerbationofasthmaandCOPDsinceNovember last year (6). Prolonged exposure to high levelsof toxic particles and carcinogens also raise the fear of aspike in lung cancer in thenextdecadeandbeyond.WHOestimated that ambient air pollution contributes to 4.2million premature deaths globally each year. In Australia,atmospheric PM (particulate matter) 2.5 contributed to2800prematuredeaths(2%ofalldeaths)in2016.Arecentstudy in China concluded that long term exposure to highconcentration of ultra-fine particle of PM 2.5(air qualitymeasure) found in bushfire smoke are linked to stroke inrelationtothedoseofexposure(7).

The Australian medical community and governmentagencies set up Breath Easy Clinics. More emergencyconsultations were created both in person and throughvideoconferencing inbushfireaffectedregionsworking incoordinationwith first responders such as police officers,firefighters,paramedicsandTheAustralianDefenceForce.

Article

27



Mentalhealthconditionslikedepression,anxietyandpost-traumatic stress disorder were acknowledged by fundingextrasessionsofmentalhealthconsultations.Theprofoundhealtheffectshighlightedtheneedforfutureplanning.Attheoutsetallocating$5millioninresearchgrantstoinvestigatethelongtermimpactonphysicalandmentalhealth.

An Australian study conducted during the 2009 BlackSaturday disaster, illustrated the physiological stressfirefighters experienced in hot, smoky and physicallydemandingconditionsunleashinganinflammatoryresponsethatputstheindividualsatriskofpoorhealthwithrepeatedexposure. It has been implicated as a predictor of arterialdisease andmyocardial infarction. The researchers foundtheir inflammatory changes consistent with 'overstrainedathletes'(8).

Theprojectedlifetimeadversitiesarelikelytoincludementalhealth issues, risky/high level alcohol consumption, non-communicablediseases,familyviolenceandenvironmentaldamage.Themainimpactseemstobedelayedwhenpeoplehave a chance to stop and reflect on their experiences (9).Aprospectivestudyof1526peoplewhosuffered losses in1983AshWednesdaybushfire found thatafter12months42%were defined as suffering from psychiatric illness orpsychiatric symptomsusingGeneralHealthQuestionnaire,about double the expected community prevalence.Fortunately, after 2 years half of these numbers showedhuman resilience and improved. Strong recommendationsweremadetointroducedisastermanagementinthemedicalcurriculumtopreparegenerationsofdoctorsforincreasedclimate events culminating in public health emergencies.The generosity of ordinary people was commendablediggingdeepintheirpocketsfromallwalksoflife.AustralianIndiansintheirusualspiritofselflessservicedonatednearlyhalfamilliondollarsinadditiontofrontlineservicessuchasfoodvans.ThereweremanyfundraisingeventsbringingsolidarityamongstallAustralians.Sydneyattracted70,000peopletosupporttheperformanceoflocalandinternationalstarsraisingwellover$50million.

The Future

Thisexperiencehasmostdefinitelyleftnoroomforcom-placency.TheeffectsofclimatechangespecifictoAustraliaarerecognisedandinclude:significantlinearassociationbetweenexposuretohightemperatureandgreatermortal-ityinlargecitiesofSydney,MelbourneandBrisbane.Esti-matedannualproductivitylossesfromheatstressof$616peremployedpersoninAustralia.2177reporteddeathsfromextremeweatherconditionsinthepast100years.Anobserved13.7%increaseindenguecarryingmosquitostotransmitdiseasetohumansinAustraliabetween1950and2016.

AustralianMedicalAssociationjoinedotherorganizationsaroundtheworldincludingBritishandAmericanMedicalAssociationsalongwithDoctorsfortheEnvironmentAus-tralia,inrecognizingclimatechangeasahealthemergency

(3).IthascalledonAustralianGovernment:

To adopt mitigation target within Australian carbon budget.To promote health benefits of addressing climate change.To develop national strategies for health and climate

change.To promote an active transition from fossil fuel to renew-able energy.To establish a National Sustainable Development Unit to decrease carbon emission in health care sector.

Lastmonth,theboardofapublichospitalinNewSouthWalesrejecteda$15milliondonationfromacoalminingventure,sayingtheproject’spotentiallynegativeeffectsonthelocalpopulation’shealthmadeitunethical.Theboard’sdecisionshouldbewidelyandloudlyapplaudedespeciallyatatimewhenAustraliaisgrapplingwithitsworst-ev-erbushfireseasonthathascomeatthehandsofclimatechange.MedicalJournalofAustraliahasrecentlystated:“Heatexposureismorelethalthananyothernaturaldisas-terinAustralia”(10).

Theaftermathofbushfireislikelytobeconsiderablewithlongstandingimpactsonthebuiltandnaturalenviron-ment.Rebuildinglifebothindividuallyandnationally,willbeamammothtask.Thereisaproudhistoryofhealthpro-fessionalsstandinguponissuesofimportance.Asbestos,smokingandclimatechangearesomeofthosewhichwillnowoccupythemindsofAustralianresearchersandpeoplearoundtheworld.TheFebruarymiraclerainof350mminsomepartsofAustraliahasfinallyhelpedtobringtheblazeundercontrol.Asalltheemergencywarningarebeingdowngradedpeoplearegraduallyreturninghomeforyetanotherphaseofgrief,siftingthroughtheirfiredamagedproperties.

Works Cited

1. Cabinet.,ABCNews.[internet]PrimeMinistertoTakeProposalforBushfireRoyalCommissiontoCabinet.[up-dated12/01/20Availablefromhttps://www.abc.net.au/news/2020-01-12/bushfire-royal-commission-propos-al-to-go-to-cabinet-morrison/11860954

2. Harris,Sarah,andChrisLucas.“UnderstandingtheVaria-bilityofAustralianFireWeatherbetween1973and2017.”PLoSONE,vol.14,no.9,PublicLibraryofScience,2019,p.e0222328,doi:10.1371/journal.pone.0222328.

3. Vardoulakis,Sotiris,etal.“BushfireSmoke:UrgentNeedforaNationalHealthProtectionStrategy.”TheMedicalJournalofAustralia,vol.212,no.8,Feb.2020,p.n/a-n/a,doi:10.5694/mja2.50511.

4. DiVirgilio,Giovanni,etal.“ClimateChangeIncreasesthePotentialforExtremeWildfires.”GeophysicalResearchLet-ters,vol.46,no.14,BlackwellPublishingLtd,July2019,pp.8517–26,doi:10.1029/2019GL083699.

5. Beggs,PaulJ.,etal.“The2019ReportoftheMJA–LancetCountdownonHealthandClimateChange:ATurbulentYearwithMixedProgress.”MedicalJournalofAustralia,vol.211,no.11,JohnWileyandSonsInc.,Dec.2019,pp.490-491.e21,doi:10.5694/mja2.50405.

6. Johnston,FayH.,etal.“AirPollutionEventsfromForestFiresandEmergencyDepartmentAttendancesinSydney,Australia1996-2007:ACase-CrossoverAnalysis.”Environ-mentalHealth:AGlobalAccessScienceSource,vol.13,no.1,BioMedCentralLtd.,10Dec.2014,p.105,doi:10.1186/1476-069X-13-105.

7. BorchersArriagada,Nicolas,etal.“AssociationbetweenFireSmokeFineParticulateMatterandAsthma-RelatedOut-comes:SystematicReviewandMeta-Analysis.”EnvironmentalResearch,vol.179,no.PtA,AcademicPressInc.,1Dec.2019,p.108777,doi:10.1016/j.envres.2019.108777.

8. Brook,RobertD.,etal.“ParticulateMatterAirPollutionandCardiovascularDisease:AnUpdatetotheScientificState-mentfromtheAmericanHeartAssociation.”Circulation,vol.121,no.21,1June2010,pp.2331–78,doi:10.1161/CIR.0b013e3181dbece1.



COVID-19andClimateChangeAahil DamaniMBBSStudent,GuysKings&StThomas’sMedicalSchool,London,UKMusicSocietyPresident19/[email protected]

AbstractClimatechangehasbeenafocalissueforcenturies,butevenmoresointhelastdecade,withmuchfocusinrecentmonthsontheVenetiannaturalhazardsandtheAustralianbushfires;visibleeventsthatwereclosetohome;intheWest.However,fastforwardafewmonths,wenowfindourselvesinanunimaginableandunprecedentedsituation;theCOVID-19pandemic,aPublicHealthEmergencyofInternationalConcern(PHEIC)aswellasaneconomiccrisis,andclimatechangecouldnotbemorerelevant.

Cite as: Damani,A.(2020)COVID-19andClimateChange.Sushruta13(2):pre-printv1;ePUB03.05.2020DOI:10.38192/13.2.10

Therehasbeenanexponentialriseinthenumberofcasesand deaths, loss of jobs, increase in debt, panic buying aswellasasenseoffearspreadingacrosstheglobe.However,manywill have seen or heard stories of fish appearing intheVenetianwaters (1), or the images of theChinese skiesappearing clear and blue for the first time in a while. Sohow does climate change fit into the picture? The roleclimate change plays in COVID-19 is important and littleattentionhasbeenpaidtothis.Whilstthenumberofstudiesare increasing exponentially, there is still a dearth of dataon the topic. In this article, I hope toexplore thedifferentrole climateplays in thispandemic. Iwill focuson3mainaspectsoftheinterrelationshipbetweenclimatechangeandinfectiousdiseases,withCOVID-19beingthecasestudy:

1. Effect of lockdown (secondary to the pandemic) onclimate change

2. Effect of lockdown (secondary to the pandemic) ondatacollectionofairpollution

3. EffectoftheSARS-CoV-2(virus)onindividuals fromareaswithhighairpollution

1: Effect of lockdown (secondary to the pandemic) on climate change:

Firstly, thepandemichastakentheworldbysuchastorm,that healthcare systems are fearing for their capacity.Lockdown (or quarantine) is one very effective way toslow the transmission of the disease by limiting physicalinteractionsbetweenoneandanother;flatteningthecurve.Ofcourse,thisresultsinlesstravelling,workingfromhomeandfewersocialinteractions,allofwhichonewouldassumeresult in less air pollution. But is that actually makinga difference to the climate? The peak of the pandemiccoincidedwiththeseasonalspringsmog,whichisthemostpollutedtimeofyearduetothewindsfromEuropeaswell

as fertilising plants and crops in the farmyard (2). In theSpringof2014,theseasonalsmogintheUKcausedaround600deaths(3).Althoughactivitiesthatcontributemassivelytoairpollutionhavecometoagrindinghalt,thishasbeencounteractedbyotheractivitiesthathavenotceaseddespitea lockdown: agriculture andwoodburning toheathomes.Thishascontributedtotheparticlepollutionnumbersstillbeingabovewhatisconsideredalowairpollutionbanding(scoreof<4onthe10-pointAirQualityIndexscale)(2).

InVenice,forexample,theclarityofthewaterisnotactuallydue to less air pollution but rather due to an “absence ofmotorised transport”, according to Davide Tagliapetra, anenvironmentalresearcher(4).Whichposesthequestion,withCOVID-19 silencing the tourism and hospitality industry,could the pandemic enable us to pay closer attention tothe inter-connectednessof tourismon climate change andmodifyourattitudestowardstourism?

2. Effect of lockdown (secondary to the pandemic) on data collection of air pollution

Infectious disease outbreaks pose another problem; dueto the rapid transmission, nature of the virus and theincubationperiodtheyoftenrequiresuspected individualsdisplaying signs and symptoms of the virus to self-isolateandstayathometopreventfurtherspread.Theimpactontheworkforcecanbesubstantialanddetrimental;TransportforLondon(TfL)reporteda thirdof theiremployeeswereoffworkdue to illnessor self-isolating(5) and theNationalHealthService(NHS)reportedafigureof25%(6).Whilsttheexposure to the virus in these professional organisationsvary, itwould not be unreasonable to assume that similartrends are being observed in other sectors as hinted bya report by the London Air Quality Network. A reducedworkforce;decreaseinsupplymeansthereisadiscrepancyinmeetingtheincreaseddemand.

Article

9. ResearchSchoolofPopulation,HealthHowtoprotectyourselfandothersfrombushfiresmoke[internet]AustralianNation-alUniversityResearch[updated15/01/20]Availablehttps://rsph.anu.edu.au/phxchange/communicating-science/how-protect-yourself-and-others-bushfire-smoke

10. Mackee,Nicole.SmokeHaze:"robustevidence"ofimpactneeded.Insightplus,MJA[Internet].24February2020,issue7,availablehttps://insightplus.mja.com.au/2020/7/smoke-haze-robust-evidence-of-impact-needed/

Continued from ........The Bushfires Downunder

29



Wehaveseenwithinthemedicalprofession;theshortageofnursesanddoctorsisnotonethatcanbesimplyaddressedin an acute emergency suchas this.The same canbe saidabouttheaircontrolemployees.Theserolesrequiretrainingandtasksinvolvetheutilisationofspecificinstrumentation(7)thatcertainindividualscanuse,makingthemdifficulttoreplacewiththeknock-oneffectisthatinvaluabledatathatmaybecompromised.Forthoseunaffectedandfittowork,unclearguidelinesissuedbythegovernmentmaketheadviceopenforinterpretation.Theconstantchangingofguidelinesreflectsthemagnitudeofunknownwithregardstothevirus.Whilstmuchattentionhasbeenpaidtothepathophysiologyof the virus, the difference in mortality between the twogenders and the efficacy of outbreak control measures, itis inevitable thatonce thepandemicpassesand thestormcalms down, scientists and environmentalists will aim todrawcomparisonsbetweenairpollutionlevelsandhospitaladmissions due to COVID-19 by region. Which makes itparamount that accurate data concerning air quality iscollectednow.

3. Effect of the SARS-CoV-2 (virus) on individuals from areas with high air pollution

Thecorrelationbetweenmajorcitieswithhighairpollutiondays and the number of COVID-19 cases would be aninteresting one to study. Whilst confounding factors andother determinants play a role,with an upper respiratorydisease such as Covid-19, the quality of air in the area inwhichsomeonelivesisboundtohaveanimpactonthepre-dispositiontotheseverityofthedisease.Wehavebeentoldrepeatedly,particularlyintheinitialstagesoftheoutbreakwhere there were uncertainties about the condition, thatthe majority of those dying have pre-existing conditions.Although the virus affects individuals of all ages, genders,ethnicities and does not discriminate, we do know thatmany of the pre-existing conditions such as asthma areexacerbated by air pollution (3, 8-11). Of course, correlationdoesnotmeancausationandfactorssuchassocioeconomicfactors and dense population play a part. Areas such asLondonmaketransmissionofthevirusbothwithinthecityandhouseholdsmorelikely.Butwiththesituationunfoldingsorapidlyandfastturnover-times,studiesarealreadyunderaway with Harvard university suggesting that areas withhigherfine-particlepollutionlevelsalsosawmortalityratesincrease by approximately 15% (12). However, the study isstillinitsinfancyandhasnotyetbeenpeer-reviewed.

To conclude, all aspects of the biopsychosocial model arecoveredbytheCovid-19outbreak.Thebiologicaleffectsofthevirusareevidentwithshortnessofbreath,coughingandclassicsignsofinfectionapparentformanyofthoseaffected.The social effects are also taking a toll onus; humans aresocial beings and the lockdown has proven to be difficulttobecomeaccustomedto,withwhatwas initially3weeksandstill inplacefortheforeseeablefuture.Nodoubt,boththe biosocial factors impact the psychological emotions ofanxiety,lonelinessandhelplessness.(13).Similarly,wecande-construct the 3 components of the biopsychosocialmodelandapplyittoclimatechange:

- Biological:lessairpollutionisbenefittingourhealth⇨ thosewithpre-existingrespiratoryconditionssuchasasthma- Social:Workingfromhomeresultsinlesscommuting

⇨ lesspollution- Psychological: The “one form of exercise a day”adviceisbeingtakenupbymanyandhasallowedustoreallyappreciatenatureandoursurroundingsmore, initspurestandmosttranquilform.Thisformofoutdoorexercisealsoactsasanoutletforstress.

However,astragictimesoftencallforsolidaritysuchastheinceptionoftheNHSin1948followingtheWorldWars,couldwecomeoutofthepandemicstrongerthaneverbeforeandrenewourcommitmenttoclimatechangeandairpollution?Could this be the catalyst and driver inmaking the 1-daytraffic stop possible and help reduce the seasonal springsmog?Couldthiseliminateunnecessarytravel,encouragingworkingfromhome?Couldthisreduceunnecessaryflightsacrosstheglobethatemitmoreenergythananythingelse?WithcitiessuchasMilanalreadypledgingtoreducevehicleuseinthepost-lockdownera(14),letushopethatothercitieswillfollowinitsfootsteps.Onlytimecantell.

References

1. Withouttourism,Veniceisintheclear[Internet].Sustainability-times.com.2020[cited2May2020].Availablefrom:https://www.sustainability-times.com/clean-cities/without-tourism-venice-is-in-the-clear/

2. FullerG.Lockdowneasesseasonalsmog–butlessthanexpected[Internet]. theGuardian. 2020 [cited1May2020].Availablefrom: https://www.theguardian.com/environment/2020/apr/02/lockdown-eases-seasonal-smog-pollution

3. Macintyre H, Heaviside C, Neal L, Agnew P, Thornes J,Vardoulakis S. Mortality and emergency hospitalizationsassociated with atmospheric particulate matter episodesacross the UK in spring 2014. Environment International.2016;97:108-116.

4. Brunton J. 'Nature is taking back Venice': wildlife returnsto tourist-free city [Internet]. the Guardian. 2020 [cited 1May 2020]. Available from: https://www.theguardian.com/environment/2020/mar/20/nature-is-taking-back-venice-wildlife-returns-to-tourist-free-city#maincontent

5. KhanS.Coronavirus(COVID-19)newsfeed[Internet].London.gov.uk.2020[cited1May2020].Availablefrom:https://www.london.gov.uk/updates/news-feed

6. AndrewGoddard,PresidentoftheRoyalCollegeofPhysicians.2020.

7. FullerG.COVID-19:Airpollutionduringlockdown[Internet].Kcl.ac.uk. 2020 [cited 1May 2020]. Available from: https://www.kcl.ac.uk/covid-19-air-pollution-during-lockdown

8. Carrington D. Preliminary study links air pollution tocoronavirusdeathsinEngland[Internet].theGuardian.2020[cited1May2020].Availablefrom:https://www.theguardian.com/environment/2020/apr/21/preliminary-study-links-air-pollution-to-coronavirus-deaths-in-england

9. Carrington D. Air pollution linked to far higher Covid-19deathrates,study finds[Internet]. theGuardian.2020[cited1 May 2020]. Available from: https://www.theguardian.com/environment/2020/apr/07/air-pollution-linked-to-far-higher-covid-19-death-rates-study-finds

10. WaltonH.Higherairpollutiondaystriggercardiacarrestsandhospitalisations[Internet].Kcl.ac.uk.2019[cited1May2020].Available from: https://www.kcl.ac.uk/news/higher-air-pollution-days-trigger-cardiac-arrests-and-hospitalisations

11. KhadkaN.Airpollution linked to raisedCovid-19deathrisk[Internet].BBCNews.2020[cited1May2020].Availablefrom:https://www.bbc.co.uk/news/health-52351290

12. WuX,NetheryR,Dominici F. A national study on long-termexposuretoairpollutionandCOVID-19mortalityintheUnitedStates [Internet]. Projects.iq.harvard.edu. 2020 [cited 1May2020].Available from:https://projects.iq.harvard.edu/covid-pm

13. Duffy B. Life under lockdown: coronavirus in the UK | ThePolicyInstitute[Internet].Kcl.ac.uk.2020[cited1May2020].Available from: https://www.kcl.ac.uk/news/life-under-lockdown-coronavirus-in-the-uk

14. Laker L. Milan announces ambitious scheme to reduce car



Introduction

The Covid-19 pandemic has changed the way we think,behave, andact. It is characterisedbyuncertainty, change,complexity,andambiguity.Lockdownandsocialdistancingto minimise the spread of SARS-CoV-2 and to keep staffand patients safe have necessitated significant and rapidchangesatpolicy,regulatory,andpracticelevel.Oneofthosechangesrelates to remoteconsultationand telemedicine1,2. Withinthespaceofafewweeks,mostofusnowhavehadtheexperienceofusingsomeformofremoteconsultation(RC).

The NHS Context

The NHS long-term plan commits that by 2024 everypatientinEnglandshouldbeabletoaccessdigitalservicesat least at theprimarycare level termedas 'DigitalFirst'3.Attheprimarycarelevel,thecurrentNHSguidanceadoptsthe "triage first"model using a telephone discussion. Theavailabilityofvideoconsultation(VC)enhancesthequality

ofinformationandtriage,leadingtobetterdecision-making.At the secondary and tertiary care facilities we continueto have traditional face-to-face outpatient clinics for newassessmentsandreviews.ItisimportanttonotethattheNHSandthewiderhealthcareservices have already been using telemedicine includingremote consultation4;theonlychangenowisthescaleandthe speed of adaptation and implementation. It has beenwidely observed that the NHS has demonstrated a highlyflexibleandresponsiveapproachtodealwiththepandemic.

Regulation

It is important to be fully up to date with the currentGeneralMedicalCouncil(GMC)regulationfortheuseofRC.TheGMChas setout10keyhigh-levelprinciples forgoodpractice inremoteconsultationsandprescribing thathavebeen supportedby13other regulatorybodies inEngland,Scotland,Wales,andNorthernIreland5.Theseprinciplesarenotnewguidance,rathertheexistingstandardsadaptedto

Article Remote Consultations – The New Norm? Abrar Hussain1, Samir Shah 2, Subodh Dave 3, Roshelle Ramkisson 4 & Mir Furruq Ali Quadri 5

1. Berkshire Healthcare NHS Foundation Trust2. Priory Hospital, Altrincham3. Royal College of Psychiatrists, UK4. Pennine Care NHS Foundation Trust 5. East and North Hertfordshire NHS Trust

Correspondence: [email protected]

Keywords:remoteconsultations,videoconsultations,NHSLongtermplan,triagefirst

Abstract:

COVID-19 pandemic has presented with unique challenges and opportunities for healthcare services globally. Remoteconsultationhasplayed an integral part to allow thehealthcare systems to function and at the same time to adhere totherestrictions topreventspreadofSARS-CoV-2.Regulators,organisations,cliniciansandpatientshavealladaptedandadjustedtothewidespreaduseofremoteconsultationsacrossspecialtiesandhealthcaresettings.Inthisarticle,wediscusstheadvantagesandlimitationsofremoteconsultationintheNHSanditsconsiderationinday-to-dayclinicalpractice.

Cite as: Hussain, A., Shah, S., Dave, S., Ramkisson, R., Quadri, M.F.A. (2020) Remote consultations- the new norm. Sushruta Journal of Health Policy & Opinion 13(2) epub 26.05.2020 (pre-print v1) DOI: 10.38192/13.2.11

use after lockdown [Internet]. the Guardian. 2020 [cited 1May 2020]. Available from: https://www.theguardian.com/world/2020/apr/21/milan-seeks-to-prevent-post-crisis-return-of-traffic-pollution

Additional Resources• Chow D. Coronavirus lockdown provides vivid picture of

how environment recovers without people [Internet]. NBCNews. 2020 [cited 1 May 2020]. Available from: https://www.nbcnews.com/science/environment/coronavirus-shutdowns-have-unintended-climate-benefits-n1161921

• Cui Y, Zhang Z, Froines J, Zhao J, Wang H, Yu S et al. Airpollutionandcase fatalityofSARS in thePeople'sRepublicofChina:anecologicstudy.EnvironmentalHealth.2003;2(1).

• Friedman L. New Research Links Air Pollution to Higher

CoronavirusDeathRates[Internet].Nytimes.com.2020

• [cited 1 May 2020]. Available from: https://www.nytimes.com/2020/04/07/climate/air-pollution-coronavirus-covid.html?auth=login-email&login=email

• Taylor M. Toxic air over London falls by 50% at busiesttraffic spots [Internet]. the Guardian. 2020 [cited 1 May2020]. Available from: https://www.theguardian.com/environment/2020/apr/23/toxic-air-over-london-falls-by-50-at-busiest-traffic-spots?CMP=share_btn_tw

• WynsA.ClimateChangeand InfectiousDiseases [Internet].ScientificAmericanBlogNetwork.2020[cited1May2020].Available from: https://blogs.scientificamerican.com/observations/climate-change-and-infectious-diseases/q

............Continued from: COVID-19 and Climate Change

31



thecurrentpandemicsituation.

The GMC emphasises in its guidance that in the currentsituationattimesdoctorsmayneedtoapplytheirprofessionaljudgmenttousetheresourcesavailableforconsultation5,6,7.TheRoyal Colleges, BritishMedical Association, and otherrelevantorganisationhaveprovidedguidanceandupdatesonRC.WewouldadvisefamiliarisingyourselfwiththemostrecentguidancefromyourrespectiveCollegeandregulatorybody.

It is vital to also consider the medicolegal implications,inherent risks, and limitations of virtual consultation8.Familiarising oneself with the available guidance andupdatesfrommedicalindemnityorganisationisessentialforsafeanddefensiblepractice.

The NHS Information Governance team's advice is that itisacceptable touseSkype,WhatsApp,Facetime,andothercommercially available products as a short-term measureduringapandemic9.Wewouldadvisethatwhereverpossible,cliniciansshouldconsiderusingNHSapprovedplatformforRC.

Technology and Platforms

The ideal technology for remote consultations is anNHS approved General Data Protection Regulations(GDPR) compliant tool, thathasboth the audio andvisualcomponents. The question one should askwhen choosinga fully compliant platform is how urgent and importanttheconsultation iskeeping inmindconsiderationsaroundsafety,confidentiality,anddataprotection.

There aremultiple platforms available bothpaid and free.Itwill alsodependonyourorganisation thatmayhaveanapprovedspecifiedconsultationplatform.Forahigh-qualityexperience of remote consultation, the clinician requirescorrect equipment with good webcam, audio, and videosystem. Internet connectivity for both the patient and theclinicianisvitalforeffectiveconsultation.

Preparation

IfoneisnotusedtoRC,itcanbealearningcurveandrequiresaperiodofadaptation.Allowingustobecuriousandexploreopportunitiesandexperimentingwithnewwaysofworkingisimportant.Thereisevidencethatoncecliniciansgetusedto using certain platforms, the RC becomes less stressful,moreefficient,directed,andfocused4,10.Itissometimeshelpfultocreateatemplatethatmayallowfor triageofpatientswhocanbesafelyseenbyRC. Itmaybe helpful to send focussed questionnaires or informationsheets to thepatientwhocould return it via secureemail.Suchdirectedandfocussedconsultationcanaddsignificantvalue and save time. Some platforms have the facility formultipleparticipants to join the consultations forexampleanotherhealthcareprofessionalthatisinvolvedinthecareoraninterpreter.

Developingflowchartsbasedonevidenceandforthemostcommonscenarioscancomehandyat timeswhena lotofclinical decision-makingwill be based on observation and

reports.Knowingwhentoavoidremoteconsultationsisalsoimportantandhavingalistofscenariosandcriteriatoguideyoumaybeimportant11.

Examination

In some specialities, RC can feel inadequate, as it is notpossibletoexamineapatient.Giventheextraordinarytimeswiththepandemic,somecreativeandoutoftheboxthinkingis needed12. Patients can be advised tomonitor their vitalparameters by the use of mobile applications or medicaldevicessuchasbloodpressuremachinesandglucoseteststhat are widely available for home use. For instance, in avirtual ADHD clinic, patientsmonitor their heart rate andbloodpressureandsendinformationthroughtheapplicationto inform their clinician. The patient receives some brieftrainingonhowtomonitortheirvitalsigns.Insomecases,followingaremoteconsultation,thepatientmayneedtobeseenfacetofaceforthesafedeliveryofcare.Thelikelihoodofsuchanoutcomeshouldbediscussedinadvancewiththepatient.

Table 1: DocumentationConsent whether it is written, implied, or verbal. Location of both clinician and patientTechnology/platform used along with limitations discussed Clarifying reasons for remote consultation Discussing circumstances to use face to face consultation Crisis or medical emergency management plan Clinic letter to the referrer, other providers and patient

Patient Perspective

Itisimportanttoensurethatpatientsandtheircarersarecomfortablewithremoteconsultationandallowthemtimetogetusedtoitespeciallyifitistheirfirstexperience.FeedbacksuggeststhatpatientsandcarersaregenerallyacceptingofRC,canmanagetechnicalproblems,understandlimitations,andaregenerallygrateful for thevirtualclinical inputandintervention. The other observation is that patients arehonestandable toexpress theemotionsbetteras there isstillsomedistancebetweentheclinicianandpatient.Thisisparticularlyimportantinmentalhealthconditions4,12,13.RCwillrequirespecialconsiderationandmoreskillespeciallywhenfacedwithchallengingcommunicationforinstanceincaseswherebadnewshastobedelivered10.Therapeutic Relationship

At the core of every good clinical interaction is a robusttherapeuticrelationship,onethatseekstoelicitinformationandallowsfordifficultdiscussionstotakeplace.Cliniciansconsider the therapeutic alliance as the most importantfactor for a successful outcome14.Asoundclinician-patientrelationship also helps to improve engagement in thetreatmentplanand reduces the riskofmiscommunicationandcomplaints.

RC can make it challenging to establish a meaningfultherapeutic relationship and clinicians may need to workharder. The rapid rollout of remote consultation duringthe COVID-19 pandemic has given clinicians little time to



translate their therapeutic skills from their consultationrooms to their computer screens. However, clinicians aregenerally used to working in constantly evolving clinicalenvironmentsandmostwouldhavetheflexibilitytoadapttothisnewworld.

Evidence suggests that the key principles of therapeuticinterpersonal relationships include therapeutic listening,responding to patient emotions and unmet needs, andpatient-centeredness15.Usingtechnologycanbeachallengeto developing rapport. Every interaction has the potentialtoelicitacountertransferencereactionintheclinicianandcarehas tobe takenthat this isappropriatelymanagedsothatitdoesnotdisrupttreatment16.

Patientswhoareused toeverydayvideoconferencingandother technological advances will find the transition toremote consultations easy. However, clinical consultationsare different from peermeetings and theymight find theclinicianon a screenquitedistant andharder to relate to.Any barriers in language and culture canmagnify this forthepatientandmaketheprocessdissatisfying.Worsestill,difficult transference feelingsand lackofconfidencemightimpactontheirabilitytotaketheclinicaladviceonboard.

Trainee Perspective

ThewideuseofRCcanhavehugebenefits for trainees. Inproviding follow up care, virtual Respiratory clinics canbe set up to follow up COVID-19 positive patients afterdischarge.Traineeswithminimalconsultantsupervisioncanmanagethissafely.Thisofferscontinuityofcareforpatientsand improves their level of satisfaction. It also helps thehospital-based staff to focusonpatients admitted anduseresourcesmoreappropriatelyincludingPersonalProtectionEquipment.Inageographicallywidespreaddeanery,traineeswho are located in other locations can also be recruited,therebymakingbetteruseofthemanpoweravailable.

Admission to hospital with COVID-19 is a traumaticexperience for patients and they prefer being able tospeaktotheirteamfromtheirhomesaftertheyhavebeendischarged.Inadditiontoreducingfurtherexposure,RCsareprovingusefulinallayinganxietyinpatientsandimprovingthedoctor-patientrelationship.

Wehaveobservedapositivetransformationintheinpatientreferral process as well with the system becoming moreefficient. The use of e-mails to send information andinvitationssecurelyincombinationwithRCsworkswell.

Additionally, ‘COVID-19 Webinars’ have been organisedby different departments (Respiratory, Cardiology,Gastroenterology, Renal, etc.) bringing together a richtraining experience and specialist focus on the latestinformation about COVID-19 including clinical updates,treatment protocols and the evidence basewhich appearsto be growing steadily. This enhanced learning experiencefortraineescanbesafelyaccessedfromthecomfortofourhomes.

The provision of mentoring for new trainees by seniortrainees is an additional feature and this can again be

safely delivered by remote technology.Overall, the traineeexperienceofRCispositiveandhasopenednewchannelsofeducationandcontinuingpatientcare.

Advantages

ThebiggestadvantageofRCistheeaseofaccesstotreatment.Patients donot have to rely on transport or support fromothers to attend appointments. Once they get used to theformat and process, they can manage the appointmentswithhighdegreeof autonomy.Reduced relianceon familyand friends can mean that they take more charge andresponsibility fortheircare; thiscan improveconcordanceandhealthoutcomes.

Patients can see their clinician from the comfort of their homes. Those who don’t drive will not be disadvantaged.Theyhavegreaterflexibilityintermsofappointmenttimes,as transit times will no longer need to be considered. RCalso allowmulti-disciplinary approach and it becomes loteasier to involve several specialists who may be locatedgeographically distant from one another to convene andprovide their clinical expertise to enhance the treatmentplan11,12,13.

Therearefinancialincentivesintermsofnothavingtobeartravel and parking costs and not having to take time offwork. Patientswill also benefit from the time saved. Theywould not have to wait unnecessarily in case clinics runover and will save time by avoiding travelling especiallyto regional centres and places with poor transport links.In the current COVID-19 situation, RC is the near-perfectsolution to maintaining social distancing and minimisingvirus transmission. RC contributes to reducing the carbonfootprint and can help in creating sustainable healthcaremodelsthatareenvironmentallyfriendlyandgreener17.

LimitationsThere are complex reasons that can make RC difficult tointegrateandsustainwithinahealthcaresystemincludingcost, logistics, and adverse impacts on professionals18.Cliniciansandpatientsneedgoodanduninterruptedaccessto the internet andpower sourcealongwith adevice thatsupports the consultation software. They might needspecialistsupporttotroubleshoottechnicaldifficulties.

TheGMCrecognisesthattherecouldbepotentialsafetyrisksand recommends considering if face-to-face appointmentis needed on a case-by-case basis6. Defence unions alsoadvise about being aware of inherent risks with remoteconsultations19.

It is not possible to perform a clinical examination apartfrom observation and inspection. Although mobileapplications can assist in the recording andmonitoring ofvital parameters like pulse rate and blood pressure,moredetailed and complex examination remains out of bounds.Itcanalsobedifficulttogetafullandaccuratepictureofapatient’smental state.However, inseveralareasofclinicalpractice e.g. dermatology, dentistry, and physiotherapy tonameafew,cliniciansareadaptingandabletousetechnologyto complete a full consultation. There are also issueswithpatientconsentandautonomy.Patientsmay find itharder

33



to decline appointments and may be coerced into seeingtheclinicianbyfamily.Itcanalsobedifficulttofullyensureconfidentialityasunbeknowntothepatient,familymemberorfriendmightbeinthevicinity.Thiscanbechallengingforclinicianinassessingriskandpotentialsafeguardingissues.Patients with learning, speech, visual, and hearingimpairmentsmayrequireadditionaladjustmentsandsupportwiththeseconsultations.Forcertainvulnerableindividuals

whoaresociallyisolated,face-to-faceappointmentsprovidesomeopportunitytoleavetheirhomesandmeetwithothers.There isarisk thisgroupwhoareoftenmarginalisedmaybecomefurtherwithdrawnandlonely.

Clinicians need to be aware that patients may record theconsultation. This is not necessarily a disadvantage whenclinicianisawareandgroundrulesconsidered.

Table 2 Important considerations for RCs

Dos Don’tsObtainvalidconsent AssumeconsentandconfidentialityEnsureconfidentiality Be late Explainlimitationsofconsultation BeambiguouswiththemanagementplanCheckcommunicationneeds,useverbalandnon-verbalcues AssumenooneisrecordingHaveatemplatetointroducethesession Usenon-approvedplatformsorappsEnsuregood,clearandaccuratedocumentation ContinuetheRCifyouhaveanyconcernsaboutpatientidentityor

confidentialityRemainuptodatewithcurrentregulationandorganisationalpolicy

RelysolelyonasingleplatformforRC,havetelephoneoptionasabackup

Ensuremedicalindemnitycover UseRCwherephysicalexaminationisessentialHaveanalternativeiftechnicalproblems RecordwithoutpriorconsentReviewthecaseloadtoconsiderwhereRCispossibleMaintainProfessionalism-dresscodeandbackground

Conclusion

We have made significant progress and strides in theuptake and use of technology in all aspects of our livesfrom consumerism to banking and beyond. In healthcare,despitethelimitationsandbarriersthatovertimethroughresearch, professional experience, and patient feedbackhavebeenrefinedand improved, theuseofRCs inclinicalpracticewillremain.Forhealthcareprofessionalsacrossalllevelsofserviceincludingprimary,secondary,andtertiarycare,therecentCovidoutbreakhasaccelerateditsuptake.The regulatory, indemnity, and health care organisationshavesupportedtheswifttransitiontousingRCstofacilitatesocial distancingwhilst continuing toprovidehealth care.The experiencesduring this timewill add to streamliningtheuseofRCsinthelong-termincludingadvancesinhybridmodels, risk stratification, contingency planning, andgovernancestructures.

Followingthepandemic,itisenvisagedthattheconvenience,cost-effectiveness,andbenefitsinavarietyofscenariosandsituations will lead to the use of RCs being embedded inpathwaysofcare.Medicalschoolsanduniversitiesmayhavetolooktopreparefuturegenerationstoembedthiswayofworking.

References

1. NHSEnglandandNHSImprovementClinicalguideforthe2. managementofremoteconsultationsandremoteworkingin

secondary careduring the coronaviruspandemic27March

2020 Version 1 https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0044-Specialty-Guide-Virtual-Working-and-Coronavirus-27-March-20.pdf

3. NHS England and NHS Improvement Advice on how toestablish a remote ‘total triage’ model in general practiceusing online consultations April 2020 Version 2 https://www.england.nhs.uk/coronavirus/wpcontent/uploads/sites/52/2020/03/C0098-Total-triage-blueprint-April-2020-v2.pdf

4. England NH, Improvement NH. The NHS long term plan:Chapter 5Digitally-enabled carewill gomainstream acrosstheNHS.2019.

5. WorldHealthOrganization.WHOguideline:recommendationsondigitalinterventionsforhealthsystemstrengthening:websupplement2:summaryoffindingsandGRADEtables.WorldHealthOrganization;2019.

6. https://www.gmc-uk.org/ethical-guidance/learning-materials/remote-prescribing-high-level-principles

7. https://www.gmc-uk.org/ethical-guidance/ethical-hub/remote-consultations

8. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice

9. The MDU. Conducting remote consultation. 2020 https://www.themdu.com/guidance-and-advice/guides/conduct-ing-remote-consultations

10. NHSX COVID-19 information governance advice for staffworking in health and care organisations. 2020. https://www.nhsx.nhs.uk/covid-19-response/data-and-informa-tion-governance/information-governance/covid-19-infor-mation-governance-advice-health-and-care-professionals/

11. WalkerRC,TongA,HowardK,PalmerSC.Patientexpectationsandexperiencesof remotemonitoring forchronicdiseases:Systematicreviewandthematicsynthesisofqualitativestud-ies. International journal of medical informatics. 2019 Apr1;124:78-85.

12. AthertonH,BrantH,ZieblandS,BikkerA,CampbellJ,GibsonA,McKinstryB,PorquedduT,SalisburyC.Alternativestothe



face-to-face consultation in general practice: focused ethno-graphiccasestudy.BrJGenPract.2018Apr1;68(669):e293-300.

13. Donaghy E, Atherton H, Hammersley V, McNeilly H, BikkerA, Robbins L, Campbell J, McKinstry B. Acceptability, bene-fits,andchallengesofvideoconsulting:aqualitativestudyinprimary care. British Journal of General Practice. 2019 Sep1;69(686):e586-94.

14. DonaghyE,HammersleyV,AthertonH,BikkerA,McneillyH,CampbellJ,McKinstryB.Feasibility,acceptability,andcontentofvideoconsultinginprimarycare.BritishJournalofGeneralPractice.2019Jun1;69(suppl1):bjgp19X702941.

15. StamoulosC,TrepanierL,BourkasS,BradleyS,StelmaszczykK, SchwartzmanD,DrapeauM.Psychologists’perceptionsoftheimportanceofcommonfactors inpsychotherapyforsuc-cessfultreatmentoutcomes.JournalofPsychotherapyIntegra-tion.2016Sep;26(3):300.

16. KornhaberR,WalshK,DuffJ,WalkerK.Enhancingadultthera-peuticinterpersonalrelationshipsintheacutehealthcareset-ting:Anintegrativereview.Journalofmultidisciplinaryhealth-care.2016;9:537.

17. Linn-Walton R, Pardasani M. Dislikable clients or counter-transference:Aclinician'sperspective.TheClinicalSupervisor.2014May15;33(1):100-21.

18. HolmnerÅ,EbiKL,LazuardiL,NilssonM.Carbonfootprintoftelemedicine solutions-unexplored opportunity for reducingcarbonemissionsinthehealthsector.PLoSOne.2014;9(9).

19. GreenhalghT,VijayaraghavanS,Wherton J,ShawS,ByrneE,Campbell-RichardsD,BhattacharyaS,HansonP,RamoutarS,Gutteridge C, Hodkinson I. Virtual online consultations: ad-

vantagesand limitations(VOCAL)study.BMJopen.2016Jan1;6(1):e009388

20. MDDUS.Resourcelibrary:riskalerts,Inherentrisksinremoteconsulting. 2018. https://www.mddus.com/resources/re-source-library/risk-alerts/2018/may/inherent-risks-in-re-mote-consulting

Conflictofinterest:NoconflictofinterestdeclaredbytheauthorsAuthor’sContributions

Continued from...... Remote Consultations – The New Norm?

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MeltingIceandMalaria– The Tip of the Climate Change Iceberg?Catherine Dominic QueenMary’sUniversityofLondon,UK

[email protected]

Article InformationEpub 01.04.2020Latestversion 01.06.2020

Cite as: Dominic,C.(2020)Meltingiceandmalaria-Thetipoftheclimatechangeiceberg.SushrutaJHealthPolicy&Opin13(2)DOI:10.38192/13.2.5

Editorial Review:Thisisanambitiousarticlethatgivesathoroughoverviewofthekeywaysinwhichclimatechangewillaffectglobalhealth.Itprovidesausefulgroundinginthetopicofclimatechangeandhealthforthosenewtothesubject.Theauthorprovidesgoodevidencedbasedexamplesoffuturehealthscenariosinawarmingplanet.Thestyleissuccinctandreadablewithcomplexideasexplainedwithoutjargon.RamyaRavindrane(GuestEditor)

Keywords: Malaria,climatechange,icebergs

Introduction

A line from theWHO report on climate change struckmeparticularly – ‘Roman aristocrats retreated to hill resortseachsummertoavoidmalaria’.1HopingtopursueacareerinTropicalMedicineandGlobalHealth,theclimatecrisisisoneofmyprimaryconcernsforthefutureofglobalhealth–willtherecomeatimewhenwespendoursummerholidayshidinginthePenninesfrominfectionsatgroundlevel?BeingamedicalstudentinLondonduringtheclimatestrikesitwasinspiringtoseepeopleprotestgovernmentinactionaroundpreventingclimatechange-itiscertainthatclimatechangeishavingameasurable impactonglobalhealthandthat itis time that we encourage awareness and act against it. IwaspersonallyinspiredwhenadoctorinanMDTmeetingmade everyone pause to discuss climate change activism.By mentioning the effect of climate change on infectiontransmissionandvectors,naturaldisasters,mentalhealth,foodsecurity,productivity,andairpollution/allergiesIwillstrive to explore the impact of climate change on globalpopulationhealth.

Natural disasters and Mental Health

Itisreportedthatthenumberofweather-relateddisastershastripledsincethe1960sandhadadisastrousimpactonpopulationsofdevelopingcountries.Risingsealevelsdestroyand displace populations and have a concrete impact onpeople’sphysicalhealth(e.g.fromtrauma,disease,droughtor famine) and the burden of mental health due to theirdisplacement. 1Floodsnotonlycontaminatedrinkingwaterandincreasewaterbornediseasesbutcausedirectphysicalimpactonglobalhealthsuchasdrowningsanddamage tohealthcare provision systems. Following natural disasters,there is an increase inmental illness such as the levels ofanxietyandPTSDshownfollowingHurricaneKatrina.2 There

is a direct correlation between heat and exacerbation ofexistingmentalhealthconditions-UniversityofMaryland’sHowardCentreforInvestigativeJournalismfoundemergencycallsrelatingtopsychiatricconditionsincreasedabout40%inBaltimore in summer2018when temperatureswereatarecordhigh.3 The mental health consequences of climate change range from anxiety and depression to suicidality.4 Health risks continue to occur after an extreme eventsuchasinvolvementincleanuporasaresultofdamagetoproperty,lossofinfrastructure,socioeconomicimpactsandthedegradationofthesurroundingenvironment. 4

Food and Productivity

Climatechangeisthreateningourfoodsecurity–aswellasan increase in bacterial foodpoisoning cases due to rapidproliferation of bacteria in warmer climates, higher seatemperatures will lead to higher mercury concentrationsinfishandcontaminantsfromrunoffwillenterthesoilwegrowourplantsin.5Theyieldofmanyofourfarmedcropsis predicted to decline because of the combined effects ofchangesinrainfallwithincreasedcompetitionfromweeds.2 Thenutritionalvalueoffoodmaydeclineduetodecreasednitrogenandthereforeproteinconcentrationinmanyplantsduetoelevatedlevelsofcarbondioxideintheair. 2Increaseduseofherbicidesandrisingfoodpricesthreatenthestabilityofhealthonaglobalscalewithregardstothenutritionofthepopulationandapotentialfurtherincreaseinmalnutritionindevelopingcountries.

Air pollution and allergen prevalence

Australia is burning! The headlines from the last monthemphasise the recent and recurrent increase in wildfires,which are expected to increase in number and severitytherefore contributing to climate change via smoke and

Article



otherairpollutants.5Increasedairtemperatureandcarbondioxidelevelsincreasethesuspensionofairborneallergenstriggeringasthmaexacerbationsglobally.Thereisanincreaseinparticulatematterresultingfromourburningoffossilfuelsthatisincreasingourriskoflungcancer,chronicobstructivepulmonary disease and death as a population. 5 Groundlevel ozone is increasing and is associated particularlywith decreased lung function – this is caused by increasedtemperatureandmethaneemissionsparticularly.2Increasedconcentrations of carbon dioxide in the atmosphere cancauseanincreaseingrasspollenwhichtriggersallergiesinaround20%ofpeople–anENTspecialistcommentedthatthe overlap of seasonal allergens is increasing due to thechangesinatmosphereandclimate.3

The effect of climate change on vectors and infection transmission

Malaria is a public health concern and proven to be oneof the most sensitive diseases to climate change – usingmodelling,theWHOshowedthatatemperatureincreaseof2-3degreesCelsiuswouldincreasethenumberofpeopleatriskofmalariabyaround3-5%orseveralhundredmillionforcontext. 1 Climate changewill affect infection transmissionpatterns and have catastrophic impact in already under-developed economies by decimating the workforce andcausing unnecessary death – malaria, though treatable, isoftenunrecognisedor the countries affected simplydonothavetheresourcesto-andthereforehasamuchlargerimpactinSub-SaharanAfricathanifitweretobecomeaprobleminamoredevelopedcountry.

The changes in climactic conditions will affect water andvector-borne diseases especially by lengthening the timesof year during which disease is able to spread and whenthe vectors or organisms are plentiful and prevalent, andexpandingthegeographicalareasaffectedsuchasforexamplea prediction of the area of China wherein schistosomiasisoccursincreasing.6Mosquitovectorsofmalariaanddengueare sensitive to changes in climate and it is predicted thattheirprevalencewillcontinueto increasewith increases inheat and fluctuations in seasons 1– the ‘vectorial capacity’,or ability to infect people, of the dengue virus reached arecord high in 2016. 3 Climate changes increases the riskof water-borne illnesses with the increasing temperaturecausingalteredandincreasedprecipitation,risingsealevels,morefrequentstormsandsubsequentrunoff.Thisincreasesexposure to waterborne pathogens such as Giardia andincreases theprevalence of diarrhoeal diseasewhichhas ahugetollonthepopulationbothintermsoflostproductivityandunnecessarysuffering.2 Afurtherproblemisthemeltingpermafrost uncovering potentially long dormant strains offorexampleanthrax,whichcouldcauseepidemicsofsuchascalethatwecannothandle.

How to increase community participation in efforts to lower climate change?

The principal of tackling climate change, like many otherpublichealthconcerns,isprimarilytoeducatethepublicandnotthroughtheapocalypticandalarmistnarrativesometimesusedunsuccessfullyinthepress.Wemustconvincethepublicthat, though a serious issue which is having catastrophicimpact, thereisstillsomuchtheycandowithintheirdailylivestohelptackleclimatechange-talkingaboutsolutions,

andpreparednessinsteadoftalkingaboutdisaster–howcanweprotectoursocietyfromimpendingdoom?Publichealthstrategiesmustbedevelopedathighleveltomakeiteasierforpeopletotakepositiveandconsistentactionintheirdailylives – a simple examplewould be, ifmeat consumption ishaving anegative impact on climate changebut vegetablesareexpensive,tocreatemeans-testedgovernmentsubsidiesto alleviate this cost. Further to this, it is necessary todevelopaclearstrategyonclimatechangeasanationwiththe implementation of community and school programmesaround education and promoting awareness and actionaround climate change – this is somethingNGOs currentlyfocuson,buttheschemesmustbenationalisedtohaveatrueeffect.Asscientistsitisourdutytoengagewithcommunitiesandtacklemisconceptionssurroundingclimatechange.

Conclusion – WHO and who?

The keymessage in all of the areas that climate change isaffecting,isthatitiseverybodyontheplanet’sproblem–itisaffectingeachoneofusandthereforeitiseachindividual’sresponsibility. Currently resource poor countries are theones ravaged by natural disasters andwe are far removedfrom their tragedy – but that should notmean thatwe byany means ignore their plight. Vulnerable groups are the‘who’thattheWHO(worldhealthorganisation)isconcernedamount – those of low income, certain races, immigrantgroups, indigenous peoples, children and elderly, pregnantwomen, vulnerable occupational groups, disabled peopleand thosewithpre-existingorchronicconditions.AsGretaThunbergrecentlysaid‘IwantyoutofeelthefearIfeeleveryday.AndthenIwantyoutoact.Iwantyoutoactasyouwouldinacrisis.Iwantyoutoactasifourhouseisonfire.’whichisfittinglytrue–theplanet,allofourhome, isonfirebothliterallyandmetaphorically, and this ishaving catastrophicimplications for the health of our global population. Thereis definitely a shift is social attitudes, such as the conceptof ‘flight shaming’which isencouragingpeople tocut theiremissionsbyflyingless,towardsacommunitywhereweareeachabletomakeanindividualandacommunitydifference.

References

1. Who.int. (2019). [online]Availableat:https://www.who.int/globalchange/climate/en/chapter6.pdf [Accessed 24 Sep.2019].

2. Cdc.gov. (2019). Climate change and Public Health - HealthEffects - Mental Health and Stress-Related Disorders | CDC.[online]Availableat:https://www.cdc.gov/climateandhealth/effects/mental_health_disorders.htm[Accessed24Sep.2019].

3. Holden, E. (2019). Climate Change Is Having WidespreadHealth Impacts. [online] Scientific American. Available at:https://www.scientificamerican.com/article/climate-change-is-having-widespread-health-impacts/ [Accessed 24 Sep.2019].

4. Health2016.globalchange.gov.(2019).TheImpactsofClimateChange on Human Health in the United States: A ScientificAssessment. [online] Available at: https://health2016.globalchange.gov/[Accessed24Sep.2019].

5. 19january2017snapshot.epa.gov. (2019). Climate Impactson Human Health | Climate Change Impacts | US EPA.[online] Available at: https://19january2017snapshot.epa.gov/climate-impacts/climate-impacts-human-health_.html[Accessed24Sep.2019].

6. Zhou,X.,Yang,K.,Yang,G.,Wu,X.,Kristensen,T.,Bergquist,R.and Utzinger, J. (2009). Potential impact of, and adaptationto, climatechange influenceonschistosomiasis transmissioninChina–a)experiencesfromChina.IOPConferenceSeries:EarthandEnvironmentalScience,6(14),p.142002. T

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Estimatedtocauseaquarterofamillionadditionaldeaths1peryearbetween2030and2050, climate change is an

imminent threat. A phenomenon growing with vehementstride, it continues tomenace thevery facetsof lifewe,ashumanity,takeprideinestablishing:environment,economyandhealth.Inthisessaywewillexplorethefurore,climatechangeexhibitsonthehealthofpopulations,analysingthesuccessofoperationstomitigateitstyrannyontheplanet.After all, there is no sense in adversity if not to cultivateinnovation.

To begin with the undisputable, baselinetemperaturesarerising.Whatisalreadyanageingpopulationinmany developed countries is further threatened by thegrowingincidenceofheatwaves,whichcontributedirectlyto deaths from cardiovascular and respiratory disease.For instance, the European heat wave in the summer of2003 recorded more than 70,000 excess deaths1. Hightemperatures also raise ground-level ozone (a majorcomponent of smog) and particulate matter air pollution,exacerbating further cardiovascular and respiratorydisease. Furthermore, extreme heat increases the levelsof pollen and other aeroallergens, triggering increasedhospital admissions for asthma. Whilst not part of theglobalclimatechangeassociatedwiththetroposphere,theexampleofstratosphericozonedepletionacceleratedbythewidespreaduseofchlorofluorocarbon(CFC)sinaerosolsandrefrigerantsinthepast,illustratesexactlythereciprocationof damaging behaviour between industry and the planet.Thereciprocationitselfbeingthatthestrippingawayoftheozone barrier increases ultraviolet (UV) exposure on theEarth’ssurface,anoccurrence that increases the incidenceofskincancer.

Itisalsoimpossibletoignorethemoredrasticmeansbywhichclimatechangeattacksthehealthofpopulations:natural disasters. Whether it’s hurricane Sandy directlyclaiming the livesofover125victims2 in theUnitedStatesof America, or the devastating secondary implications ofcycloneAilaintriggeringawidespreaddiarrhoeaoutbreakinfectingover7,000peopleinBangladesh3,climatechangehasoftenpublicisedthemagnitudeofitspoweronaglobalscale.Itisimportantnotonlytoconsidertheimmediacyofthedamageexhibited,butalso its long-standingeffectsondevelopingnations,forwhomhealthcareinfrastructurecanbeseverelyundermined.Onthetopicofweather,increasinglyvariablerainfallpatternscandiminishfreshwatersupplies.Thelackofsafewaterthen

goesontocompromisehygiene,increasingtheriskofwater-bornediseases. Recognisedby theUnitedNationsGeneralAssembly4asabasichumanright,acompromisedaccesstocleandrinkingwatermustbeseverelycondemned.Ifsuchanadversityinitselfcannotsuccessfullyconveytheimportanceof assigning climate change its due alarm, then we mustintrospectively question what further manifestations weneedtowitnessinordertobelieveitsmenace.

The eradication of once inescapable epidemicshasbecomesynonymouswithdevelopment,a landmarkofevolution almost. Yet, climate change has tapped into thisverydomainandisslowly,butsurely,reintroducingshadowsbelievedtohavebeensquelched in thepast.This iswhereweaddresstheseverityofvector-bornediseases,forwhichclimate change advantageously lengthens transmissionseasonsandwidensgeographicrange.Alreadykillingover400,000peopleper year1 (andmainly childrenunder age5 in certain African countries), Anopheles-driven malariaposesanundeniablethreatthatcan’taffordtobeacceleratedbythenefariousinfluenceofclimatechange.ItiswithsimilarreasoningthatIemphasisethepotentialofthephenomenonto increase our exposure to the Aedesmosquito vector ofdengue.Outbreaksofthesetropicaldiseasesmayinundatehealthcare infrastructure in low-income countries (LICs),dampening the burdens to communities for whom healthsetbackscantranslateintoacycleofeconomicpoverty.

Onthetopicofglobaldamagedistribution,itisimperativetoacknowledgethelargertollofclimatechangeonLICs.Severeweathereventsandchangingrainfalltrendsareprojectedtocausedeclinesincropyields,threateningfoodproductionforagrowingglobalpopulation.Theextenttowhichrisingfoodpriceswillwidenglobaleconomicinequalityisunknown,butwhat iscertain is thecompromiseon foodsecurityand, inthecaseofelevatedatmosphericCO2levelsdecreasingplantnitrogen-andthereforeprotein-concentration,thenutrientcontentofcrops.Asfarasmalnutritionisconcerned,Imustreferbacktotheprinciplesofbasichumanrights,andwherethatisthreatened,seriousreflectionandmitigationshouldfollow.

The detriment of climate change on global healthisnot limitedtoitsphysicalmanifestations,butalsointheareaofmentalhealth.DescribedbytheAmericanPsychiatricAssociationas“achronicfearofenvironmentaldoom,”5eco-anxietyisanemerging,yetpertinent,issue.Accordingtoa2018national survey, almost 70%of people in theUS are

EssayClimate Change & HealthShreya GopisriStudent(17years),KingEdwardVICamphillSchoolforGirls,Birmingham,[email protected]

Article InformationSubmitted29Jun2020Pre-print1Jul2020



worriedaboutclimatechange,with51%feelinghelpless5.Ranging from post-traumatic stress disorder (PTSD)incurredfromhurricaneKatrina, toamoreominoussenseofgrowingdisquietudeinthefaceofdamagetocommunitygroups,alossoffood,andreducedmedicalsupplysecurity,it is clear climate change challenges mental health from both more,andless,obviousangles.Inadigitalworlddominatedbyconstantmediacoverage,peopleareoftenoverwhelmedbythejuxtapositionoftheirdesireto‘savetheplanet’,withtheir supposed lack of control of the problem. After all,instinctistopreservewhatwecanforfuturegenerations.

Nowforthetoneshiftwehaveallbeenwaitingfor:theissueofclimatechangeisnotasovercastasithasbeeninthepast.Infact,thequestionisnolongersolelywhatwehavedonetopropagateit,butratherwhatwehavedone,andcanfurtherdo, tomitigate it.As Imentionedbefore, adversitybreedsinnovation,andwhilethiscanbeseenonaglobalscaleinthedevelopmentofCarbonCaptureandStorageschemesfor instance, local efforts are equally laudable. In theUK,WokingBoroughCouncil employs its ownutility company(‘Thamesway’),whichprovidessustainableenergyfromsolarfarms.Theirendeavour tomake theirresidents’daily livesmoreenergyefficienthasreducedlocalenergyconsumptionby52%,andCO2emissionsby82%,since19906.Anothersmall-scale approach with a large-scale effect is London’sBedZED6(BeddingtonZeroEnergyDevelopment)initiative,whichhascreatedaregionofhomesthatuse80%lessenergyforheating.Aheroicinitiativeinitself,theUKGovernment’s‘GreenDeal’scheme6contributesupto£1,250towardsthecost of installing two energy saving home improvements,like loft insulation. The complaint, therefore, should notbethatthenecessary innovationdoesnotexist,butratherthatitdoesn’talwaysreceivethelevelofsupportneededtomakethedifferenceitstrivestoestablish.Itcomesdowntoconsumerstopavethepathforsuchprogress.

I, for one, believe strongly that education is theengine of revolution. What can be engrained into theyoungestofmindswillsoontranslateintoafuturegenerationmoresecureinitsendeavours. Asapersonalexample,myseven-year-old brother rose to the challenge of this year’sBritish ScienceWeek by presenting a project on the issueof global climate change! The simple advice he shared on“switchingoffthelightwhenleavingtheroom”and“turningoffthetapwhenbrushingyourteeth”resonatedwithme.Infact, these simple solutions prove to be themost effectivewhen undertaken collaboratively as a global population.Astudy7haspublishedthatasinglelight leftonovernightover a year accounts for asmuch greenhouse gas as a cardrive fromCambridge to Paris. Kuznets Curve6 shows theproportionality between rising economic development(wherebasicprioritiesoffood,waterandshelterhavebeenachieved)andaffluence,educationandanincreasingconcernfortheenvironment.Thisreaffirmsthesignificanceofakeystakeholder,oftenoverlookedintheircapabilityofbridgingthegapbetweenenvironmentalindifferenceandagenuinechance of change: the consumer. Schools canplay amajorroleinchangingperceptionsandbehavioursbyencouragingrecycling,reducingfoodmilesand‘WalktoSchool’schemes.As reasonable as it is toblame industryandmultinationalcorporations(MNC)sfortheirincredulouscarbonfootprints,

considerableresponsibilityalsolieswitheachandeveryoneofusinourplaceasconsumers.Whenitcomestoreducingcarbonfootprints,thepowerlies,quiteliterally,inourownfeet,inthatthepathsweindividuallyandcollectivelychoosetotakewillcontributetoincreasingglobalsustainability.

Toconclude,thegrowingthreatofclimatechangeon the health of populations cannot be underestimated,but the most important message from this essay is thatthere is still hope.Continued support of ‘green’ initiatives,a more conscientious profile as a consumer and a widerappreciation of our contribution to the global carbonfootprint can significantly protect future generations fromthe impending damage climate change inflicts. Whilst wecan’tallbea ‘GretaThunberg,’wecanat leastexerciseourresponsibilityformaintainingasustainable lifestyle.Whenitcomestoclimatechange,thesmallestinitiativescanmakethebiggestdifference.So,inthefaceofthisadversity,letuscollaborateasaglobalcommunityofresponsibleconsumersandsupportinnovationwiththestrongestofladders:effort.

References1. WHO (2018). Climate change and health. [online]. Available

at: https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health#:~:text=Climate%20change%20affects%20the%20social,malaria%2C%20diarrhoea%20and%20heat%20stress.[Accessed:30June2020]

2. DoSomething.org(2014). 11 facts about Hurricane Sandy.[online]. Available at: https://www.dosomething.org/us/facts/11-facts-about-hurricane-sandy [Accessed: 30 June2020]

3. Wikipedia(2020).CycloneAila.[online].Availableat:https://en.wikipedia.org/wiki/Cyclone_Aila#Impact [Accessed: 30June2020]

4. UNDESA(2010).International Decade for Action ‘Water forLife’ 2005-2015. [online]. Available at: https://www.un.org/waterforlifedecade/human_right_to_water.shtml [Accessed:30June2020]

5. Medical News Today(2020). Climate change and health:Impacts and risks. [online]. Available at: https://www.medicalnewstoday.com/artic les/327354#overview[Accessed:30June2020]

6. David Holmes, Rebecca Priest, Andy Slater, Kate Stockings,Rebecca Tudor. (2019). GCSE 9-1 geography EDEXCEL BRevisionGuide.UnitedKingdom:OxfordUniversityPress.

7. THE CAMBRIDGE green CHALLENGE (2018). EnvironmentandEnergy.[online].Availableat:https://www.environment.admin.cam.ac.uk/facts-figures[Accessed:30June2020]

Conflict of Interest none declared

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ClimateChangeandChildhoodGuddi Singh BA, MB BChir, MPH, MRCPCH, EADTM&HPaediatric RegistrarGuy's & St.Thomas' NHS Foundation Trust, UK@DrGuddiSingh [email protected]

Key words: Climatechange,childhood,

Cite as: SinghG.Climatechangeandchildhood.Sushruta2020(Jul)vol13;issue2:ePubhttp://www.sushruta.netVersion2-received09.04.20

WhenIwasachild,IwasaproudmemberoftheWorldWildlife Fund for Nature. I would pore over my

issuedgreenwalletandthegleamingsilver-goldcoinswithendangered species imprinted where the Queen’s headshouldbe.Savingtheworldwasanoblegoal,andasayoungperson,Iwasearnestaboutit.

Today,asapracticingpaediatrician,Iseeitlessasaquaintinterestthanamatteroflifeanddeath.InthetwoandahalfdecadessinceIfirstworriedaboutdeforestationandspeciesextinction, my worst fears have come true. Humanity haswipedout60%ofanimalpopulationssince1970anduptohalfofallmaturetropicalforestssince19501.Atthisrate,extraordinary creatures like tigers and rhinoswill inhabitonly our myths. The generation before mine ignored theunfolding crisis, and focused instead on economic growthat all costs: churningoutmountains of needless stuff, andthrowing that stuff away,burningever-more fossil fuels intheprocess.Mygenerationcouldhavechangedthings,butwewere lulled intocomplacency,as fashionbecamefaster,productsmoredispensableandfar-flungcountrieseasiertoflyto.

Weknewaboutthedangersofclimatechangeasearlyasthe1950s, and yet did nothing to reduce emissions. Industryknew,ourgovernmentsknew, theenvironmentalistsknew- everyoneknew.Andwe all still know.Weknow that thecomingtransformationsofourplanetmaywellunderminethe very possibility of civilisation. And we know that thecomingchangeswillbeworse forourchildren,andworseyet still for their children, whose lives – our actions havedemonstrated – mean nothing to us. We have failed toappreciate the danger, andwe have failed to act.We havefailed to put aside our own interests for thosewho comeafterus.

As a paediatrician, the real tragedy is in prognosticatingthehealthofchildreninthewarmingyearstocome.AstheWHO-Unicef-Lancetcommission2asks,isthere“Afuturefortheworld’schildren?”Whatkindsofliveswilltheyekeouton aplanet scorchedand scarred?Areweexpecting themtoplay ingardensturnedtodeserts?Toclimbthecharredremainsof trees?Toeat fromtinswhereweusedtopluckfreshfruit?Insteadofacarefree,creativeexistence,theywillmigratelongdistancesinsearchofasafehome.Butsafetywillbehard to find.Aclimate-changedworld isaconflict-

riddenonewithmassdisplacementtriggeredbyrisingsealevelsanddesertification,puttingpressureonthefewplacesstillhospitabletolife.In2016thenumberofmalnourishedpeopleintheworldreachedover2billion.3 If the near future promises population increase, food shortage and nutrientcollapsewhatnumberwillthisriseto?

As temperatures rise, malaria, dengue and Lyme diseasewill spread. In overcrowded conditions, diseases onceconsideredvanquished-suchasTBandcholera-willreturnemboldened. Much of the progress that medical sciencehas made on these fronts could be wiped out in a singlegeneration.

This isnothyperbole; in awicked twist of injustice, thoselivinginthenationsthathavecontributedleasttothiscrisis–Bangladesh,Ethiopiaandthesmallislandnations-areatthisverymomentfacingsituationsjustlikethosedescribed.Howlongbeforetheentireworld’schildrensufferthesamefate?

The dangers to the wellbeing of our children are soconsiderableitmakesmequestionwhetherIoughttobringchildrenofmyownintosuchaworld. If Idid,onethingiscertain: Iwould be enraged. Iwould not leave the streetsor thedoorsofpoliticiansuntilsomeonecouldgivemeananswerforwhywehavebeensohorriblybetrayed.

TheExtinctionRebellionandtheschoolclimatestrikeshavebroughtthiscrisistointernationalattention.Andyetstates’responsetoprotestorshasbeentoarrestthem. Howdareweimprisonthosewhostandforthefutureofourchildren?Politicians criticise climate protests for ‘significantlydisrupting the lives of others’. But it’s only disruption ifyou’redistractedbysomethingelse:mindlessconsumptionorendlessprofit.Theseprotestsandclimatestrikesarenotdisruption-theyarevital.

Wehavecostourchildrentheearth.Itisdifficulttolookatthisfactandnotflinch.Butdoingsoilluminates.Thedangerposedtoourchildrenbrings intoreliefadimensionof thecrisisthathasbeenlargelyabsent–themoraldimension.In“LaudatoSi”,theencyclicalontheenvironmentandhumanecology,PopeFrancisquotesSt.Bartholomew:“tocommitacrimeagainstthenaturalworldisacrimeagainstourselves,and a sin against God”. 4 He urges that environmentalproblems require us to look not just for technological

Opinion



solutionsbut for a change at the veryheart of humanity -otherwisewearedealingmerelywithsymptoms.

IamnotaCatholic,butthisisalanguageIcanunderstand.As a doctor, there is no greater threat to the health ofmypatientsthantheviabilityofourheartbreakinglybeautiful,fragile, planet Earth. All paediatricians – and arguably alldoctors-shouldbeclimateactivists.Weshouldbestandingside-bysidewiththeExtinctionRebellionandwithstrikingchildren.

CouldIhavedonemoretohelpsavetheplanetasachild?Probably, as Greta Thunberg is demonstrating. 5 Can I do more to help save it now? Absolutely. And I urge mycolleaguestojoinme.Itiseasytocomplainthattheproblemistoovastandeachofusistoosmall.Buteveninthefaceofoverwhelmingodds,actionisstillpossible.

Formymedicalcolleagues,thereismuchwecando.First,wemustjoincallsonourgovernmentstotellthetruthaboutclimate change, declare an ecological and climate changeemergency and make serious moves to radically reduceemissions. Second, we must lobby to ‘green’ our medicalinstitutions: to divest from fossil fuels and go plastic-freeimmediately. Finally - and most essential– we must backa vision for the world that puts planetary health at thecentre.Wemustpushforaneconomicmodelthatdoesnotprivilegeprofitandgrowthforthefew,butthatencouragesabundanceforthemany.SuchmodelsarebeingdevelopedasIwrite.6Modelsthatmight,justmight,secureaworldforourchildrentoinherit.

Everything is changing about the natural world, andeverythingmustchangeaboutthewayweconductourlives.Theweightofscienceandmoralityinsistsweact,andthatweactnow.

References1. Barrett, M., Belward, A., Bladen, S., Breeze, T., Burgess, N.,

Butchart,S.,...&deCarlo,G.(2018).Livingplanetreport2018:Aiminghigher.

2. Clark,H., Coll-Seck,A.M.,Banerjee,A., Peterson, S.,Dalglish,S.L.,Ameratunga,S., ...&Claeson,M.(2020).Afuturefortheworld's children? A WHO–UNICEF–Lancet Commission. TheLancet,395(10224),605-658.

3. WorldHealthOrganization.(2018).Thestateoffoodsecurityandnutritionintheworld2018:buildingclimateresilienceforfoodsecurityandnutrition.Food&AgricultureOrganisation.

4. Francis,P.(2016).LaudatoSi':OnCareForOurCommonHome.PerspectivesonScienceandChristianFaith,68(4),266-268.

5. Thunberg,G.(2019).Nooneistoosmalltomakeadifference.Penguin.

6. VandenBergh, J.C.,&Kallis,G.(2012).Growth,a-growthordegrowth to stay within planetary boundaries?. Journal ofEconomicIssues,46(4),909-920.

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AirPollution:ATaleofTwoCitiesRamyadevi Ravindrane MBBS,iBsc

Abstract:

Thisarticledescribesthebattlewithairpollutionintwolargecities,LondonandDelhi.Airpollutionisamajorcauseofmorbidityandmortalityacrosstheglobe,particularlyaffectingthoseinlarge,urbanenvironments.Actionhasbeentaketoreducepollutionlevelsandsomeimprovementhavebeenseen,butnottoasignificantenoughdegree.Weashealthcareprofessionalshavearesponsibilitytoadvocateforgreaterchangetobemade.

Key words: Airpollution,NewDelhi,London,morbidity

Cite as:RavindraneR.AirPollution:ATaleofTwoCities.Sushruta2020(Jul)vol13(2);epub1.4.20DOI:10.38192/13.2.4

Air pollution and Health

Having lived in London for the last ten years with manysummersspentinbustlingIndiancities,IoftenworryhowmuchpollutionIhavebeenexposedto.It’snotuncommononmywalk home from the underground station to smellthe pungent fumes from car exhausts. Likewise, I recallcountless times lookingup at anurban skyline in India toseegreysmokewaftthroughtheair.Newspapersoftenlikenliving in a large city to smokingover ahundred cigarettesayear(1).However,theseseeminglysensationalistheadlineshold truth. Chronic exposure to ambient air pollution hasdevastatingeffectsonhealthandthoselivinginlarge,urbanareasareoftenthemostexposed.

Air pollution is the amalgamation of harmful chemicals intheairduetonaturalorhumancauses.Outdoororambientair pollutants include carbon monoxide, nitrogen oxides,sulphur dioxide and particulate matter (small particlesproducedinpartbyburningfossilfuels)whichareemittedfromvehicleexhaust,fumesfromindustry,heatandpowergenerationandagriculture.Anotherchemical,groundlevelozone, is a key element of smog,which is producedwhenchemicalssuchasthosefoundinvehicleexhaustfumesreactinsunlight.

Breathinginthesepollutantsonadailybasishasdisastrousconsequencesonourhealth.91%oftheworld’spopulationliveinareaswheretheairqualityisbelowthestandardsetbyWHO.Ambientairpollution lead tosignificant levelsofmorbidity and mortality through cardiovascular disease,respiratory disease and cancer. WHO figures show that29% of all deaths and disease from lunch cancer and 4.2Millionprematuredeaths in2016wereduetooutdoorairpollution(2).Chronicexposuretoparticulatematterleadstocardiovascularandrespiratorydisease,nitrogendioxidecancauseairwayinflammationandozonecanleadtoworseningofasthmaandstuntedgrowthinchildren(3).

Notonlyisambientairpollutiondirectlydamagingtohealth,but it also acts as amechanismof climate change. Carbondioxide, though not directly damaging to health, is themajorby-product of burning fossil fuels and is apowerfulgreenhousegas,trappingheatintheatmosphere.Particulatematterworsens this problem by settling on surfaces such

as ice caps and snow reducing their reflective propertiescausinglesslighttobereflectedfromtheearth’ssurfaceandincreasingsurfacetemperatures.

London

Londonisacitywithalonghistoryofairpollution.1952wastheyearoftheGreatSmog,aweeklongepisodeofextremeairpollutioninwhichtheairwasthickwithapollutedfog.Itcontributedtothedeathofatleast4,000people.Asaresult,theCleanAirActsof1956and1968werecreated.Theseactsbanned emissions of black smoke from urban residentialareasandfactorieswhichwereforcedtoswitchtosmokelessfuels (4).Theactwassuccessfulinreducingvisiblepollutionduetoparticulatematter. However,despitetheclearingofthe skies, air quality in London is still of serious concernwith current pollution levels exceeding limit values set bytheEuropeanUnion(4).

The latest report by the London Air Quality Network for2018 showed that large reductions in carbon monoxidehavebeen seenover the last twenty years. Therehas alsobeenadecreaseinnitrogendioxidelevelsbetween2017to2018 andparticulatematter 10 and2.5.Nonetheless, it isimportanttobearinmindothernitrogendioxidelevelsarestill exceeding set limits causing themajority of the9,400prematuredeathsperyear linked toambient airpollutioninLondon(5)(6).WithonethirdofLondon’sschoolsbeingincloseproximitytoroadswithillegallyhighlevelsofnitrogendioxideweneedcontinuedvigilanceagainstthisthreat(3).

Steps are being taken to tackle this problem through theLondon Local Air Quality Action Plan. This initiative givesresponsibilities to each London borough to monitor andputinplaceschemestoreduceairpollution.Thekeyareasbeing addressed are transport and green infrastructure.Encouraging active travel is one component, specificallycreating cycle super highways and more pedestrianizedareassuchastheVanGoghWalkinLambeth.Thecongestioncharge zone is being used to create an ultralow emissionzoneasofApril2019.Thismeansthatanyvehiclesenteringthe congestion charge zone will also need to meet aminimumexhaustemissionstandardorpayanextracharge.Possiblymostsignificantly therewillbeaUKwidebanonnewpetrolanddieselcarsasof2035.Greeninfrastructure

Opinion



refers to green spacesdesigned topromotehealthy living,mitigate flooding, improve water and air quality, cool theurban environment and promote ecological resilience. Byincreasing thenumbersofandaccess togreenspaces it ishoped air qualitywill improve through reduced industrialandtransportrelatedemissionsandreduceddispersionofpollutants(3)(7).

Delhi

EverydayinDelhiapproximatelyeightypeopledieduetoairpollutionrelatedillness(8).In2016DelhiexperiencedoneofitsworstepisodesofDiwalismog. Pollution levelswere someof thehighestDelhi hadseenoverthepreceding17yearswithPM2.5fourteentimesthe allowed standard. According to the Centre for Scienceand Environment pollution levels were higher than thoserecordedintheGreatSmogofLondon1952(9).‘Diwalismog’isthepeakofextremeairpollution,largelyduetoparticulatematter,thatoccursasaresultofthecombustionoffireworksincelebrationof theHindufestival.Thesmogof2016wasparticularlyextremedue toamixtureof fireworks,vehicleexhaust fumes, fumes from burning garbage and burningof paddy residues in neighbouring states coupled with alackofwind.Thisleftparticulatematterstagnantintheairanda smog that lasted tendays(10).Emergencyactionwasrequired,schoolswereshutdown,theBadarpurpowerplantwasclosedandconstructionwashaltedfortendays.

The incident in 2016 lead to long term steps being takento address the air pollution crisis affectingDelhi. Areas ofpriorityincludedreductioninemissionsfromdieselfuelledvehicles,wasteburning,constructionandpowerplants.TheDelhiCleanairactionplanlaidoutkeyactionneededinordertotacklethisworseningissue(9).Specificmeasuresincludedlawsagainstvisiblypollutingvehicles,morepedestrianizedzonesand improvedpublic transportsystems (11).Badapurcoalfiredpowerplantwaspermanentlyshutdownin2018(12).Pollutingindustriesweretargeted,withindustrialunitsnotcompliantwithenvironmentalandwastemanagementpoliciesshutdownandsanctionsplacedonindustriesusingpoorqualityfuelsuchasfurnaceoilwhichemitsextremelyhighlevelsofsulphurwhenburned.Wastemanagementwasakeyissuewithgreatervigilanceoveralreadybannedopenburningofwasteandcropburning.Legalframeworkswereputinplacetoensureproperrecyclingofconstructionwaste.Banning of diesel generator sets and limitations onuse ofbrickkilnwhicharefiredbycoalwasalsorecommended(9).

Someimprovementwasseenwithdecreasingaveragelevelsofparticulatematterandsulphurdioxidefrom2016to2017.Resultsof theAirQuality Index (AQI) showed thenumberofdayswithverypoororsevereairqualityhaddecreasedandsatisfactorydaysnearlydoublingfrom2016to2017(13).However,despitethisarepeatepisodeofseveresmogwasseenin2019.APublichealthemergencywasdeclared.TheAQI inNewDelhiwasun-recordable indicating levelsover999(normalairqualitybetween0-50).OnNovember3PM2.5 levelswere 23 times higher than theWHO air qualityguidelines(14).

Next Steps

The effect of air pollution on health is well established.Thousands of people around theworld, particularly thoseinmajorcities,aresuffering illhealthandearlydeathdueto unnaccepatble levels of exposure. Governements areattempting to take action, but change is not occuring fastenough. As a society we need to realise that a paradigmshiftisrequired.Thisisnotacrisistobeavertedforfuturegenerations, this is a crisis we are living through now.On an indiviudal level better choices to reduce fossil fuelcombustion such as active travel are required. However,thereisalimittowhatonepersoncando.Weashealthcareprofessionals have a responsbility to advocate for ourpatientsnotjustintheclinicalsetting,butalsointhewidercommunityonpublichealthmatterssuchasthis.Wemustput pressure on our governemtns to rapdidly divest fromfossil fuels, increase legislation on air pollution levels andinvest inrenewable fuelsources. Ifwedonotwewillonlycontinue to seepatients suffering frompreventable illnessonamassscale.Changecanhappen,aswehaveseenwithsuccessful initiatives to reduce pollution to date, but wecannotbecomplacent.

References

1. Wharton, Jane. Metro.co.uk. [internet] [updated5/12/2019 cited 29/03/2020. Available: https://metro.co.uk/2019/12/05/breathing-air-london-like-smoking-160-cigarettes-11276899/.

2. World Health Organization, who.int, [internet], [updated2//5/2018, cited 29/3/2020] Available: https://www.who.int/news-room/fact-sheets/detail/ambient-(outdoor)-air-quality-and-health.

3. London Councils, londoncouncil.gov.uk, [internet], [updated1/2020, cited 29/3/2020] Available: https://www.londoncouncils.gov.uk/sites/default/files/Policy%20themes/Environment/Demystifying%20air%20pollution%20in%20London%20FINAL%20FULL%20REPORT_IM_0.pdf#page=15

4. MetOffice,metoffice.gov.uk, [internet], [updated20/4/2015,cited 29/03/2020]Available: https://www.metoffice.gov.uk/weather/learn-about/weather/case-studies/great-smog.

5. Mittal, Louise. Baker, Timothy. LondonAirQuality SummaryReport 2018. [internet]. King’s College London. [updated10/2020,cited29/3/2020].Available:http://www.londonair.org.uk/london/reports/2018_LAQN_report.pdf.

6. Walton,Heather.Dajnak,David.Beevers,Sean.Williams,Martin.Watkiss,Paul.Hunt,Alistair.London.gov.uk.[internet].King’sCollege London. [updated 14/07/2016, cited 29/03/2020].Available: https://www.london.gov.uk/sites/default/files/hiainlondon_kingsreport_14072015_final.pdf.

7. GreaterLondonAuthority.London.gov.uk.[internet].[updated4/2020., cited29/03/2020].Available: https://www.london.gov.uk/sites/default/files/green_infrastruture_air_pollution_may_19.pdf.

8. India environmental portal. Indiaenvironmentalportal.org.uk. [internet]. [cited 29/03/2020] Available: http://www.indiaenvironmentportal.org.in/content/439810/increasing-deaths-due-to-air-pollution-in-delhi-and-mumbai/

9. Sunita Narain, Anumita Roychowdhury. Towards a CleanAir Action Plan, Lessons fromDelhi. Centre For Science andEnvironment.NewDelhi.CentreForScienceandEnvironment.[updated2016,cited29/03/2020].

10. Najar, Nida. Barry, Ellen. Nytimes.com. [internet]. New YorkTimes. [updated 25/1/2016, cited 29/03/2020]. Available:https://www.nytimes.com/2016/11/25/world/asia/india-delhi-fireworks-air-pollution.html

11. Ministry of Environment. Indiaenvironmentalportal.org.[internet]. Centre for Science and Environment. [updated08/10/2018, cited 29/03/2020]. Available: http://www.indiaenvironmentportal.org.in/files/file/Comprehensive%20

Action%20Plan.pdf.

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12. Goswami,Sweta.Hindustantimes.com.[internet].HindustanTimes.[updated5/10/2018,cited29/03.2020].Available:https://www.hindustantimes.com/delhi-news/badarpur-thermal-plant-delhi-s-biggest-power-generator-to-shut-down-from-october-15/story-6r1DhoDjb7G0yr48iv8IqI.html

13. CentralPollutionControlBoard.AnnualReport2017-18.[in-ternet].MinistryofEnvironment,ForestandClimateChange.[updated2018,cited29/03/2020].Available:https://cpcb.

nic.in/openpdffile.php?id=UmVwb3J0RmlsZXMvOTIyXzE1N-jQwMzg5OTFfbWVkaWFwaG90bzE0Mjg2LnBkZg==

14. Mansoor,Sanya.AirPollutionTurnedIndia'sCapitalIntoa'ClimateEmergency.'It'sPartofaGlobalTrendKilling7MillionPrematurelyEachYear.[internet]Time.[updated6/11/2019,cited29/03/2020].Available:https://time.com/5718012/new-delhi-pollution-2019/

GoingVirtual– ‘No going back in the cave….’Reflections of a NHS Trust ChairJagtar Singh OBE, MSc, BA Hons, MIFireCoventry & Warwickshire Partnership [email protected]

Cite as:SinghJ.Goingvirtual-‘Nogoingbackinthecave…’.ReflectionsofanNHSChair.Sushruta2020(Jul)vol13(2)DOI:10.38192/13.2.7pre-printePub21.04.2020(awaitingpeerreview)

Editorial Review: 23.04.2020AbhayChopada([email protected])

Thisisareflectivepaperwhichsummarizesthecurrentdisruptionintraditionalworkingenvironmentwithgoodinsightintotherapidintegrationofalternativestotraditionalmeetings.Ienjoyedtheclearandinsightfulcommentary.Thesuggestionsareverypracticalanddoableforadaptationbytheaudience.Thepapercouldhavebeenbolsteredwithsomebackgroundanalysisofsimilartransformationsinotherindustriesinnon-pandemicsituationstoassessthesustainabilitybeyondthecurrentphase.Iwouldalsorecommendinclusionofinnovativethinkingandtechnologyinnovationsinthisareatohavebeenassessed.Onbalance,IamhappythistimelypublicationforSushrutaaudienceandwouldencourageafollowuppublication3monthsdownthelwithwideranalysisofdigitalengagementpracticesacrossaspectrumofindustries.

The impact of the Covid-19 crisis and how Trust Boards have adopted technology to face the challenges of how they continue to function effectively.

....Continued form .......Climate Change and Childhood...

Opinion

....Continued on page 44



Hindsight is a wonderful thing, so I won’t apologise forusing it. Many organisations will have dusted down theiremergency plans from previous health crises as an initialdefencetothechallengesthatCOVID-19brought.Howevernot many would or could have anticipated the challengesthat the lockdownwouldpresent, inparticular the lackoffamiliaritywith digital technology. In this article I discusshowtheabilitytocopewiththesechallengesallowsTruststonavigate theirway throughanunprecedentedcrisisbutalsopresentsadisruptiveopportunitytochangethewayweworkforever.

Wehaveall facedemergenciesandsituations that testourleadership and our systems in the past but nothing likeCOVID-19.Thenational lockdownwasanabrupthardcut-off of how Iworkedandhowmynatural stylebestworksface to facewithpeople.Withindays I found thatmost ofmy meetings had to be conducted virtually. Technologyapps thatmany took forgrantedbecameanessentialnewlanguagewithintheNHS.AtapaceIhaveneverwitnessedinmytimeintheFireServiceortheNHS,adoptionofnewskillsbecamecompulsoryandhavingtoadaptrapidlytonewwaysofworking became a survive or die situation. The board’sresponsibilityofdutyofcarehasneverbeforebeentestedinthewayCovid-19haschallenged.TheneedtoreacheverysinglememberoftheTrustwithclarity,toprovideassuranceand build confidence, and to ensure their wellbeing andabilitytodotheirjob,wasnevermoreimportant.

This is the first of a series of articles that will track myjourney during the period of lockdown and beyond. Thisarticle provides a personal insight into my experience ofgoing virtual and what this means for future working, aswell as some tips on how to cope and help youmake thetransition.My storydemonstrateshowquickly individualsneed to switch to new ways of working due to externalpressures,inthiscaseCOVID19.Myexperienceoverthelastfewweeksshowshowvirtualmeetingscanbechallengingand rewarding inequalmeasure.However thisnewworldorderisnowafundamentalwayofhowwegetthingsdone–andisheretostay.

WhenweareoverCOVID19itismybeliefthatwewillnotbeabletogobacktotheoldwaysofworking.Asonememberofmystaffsaidtome‘wecannotgobackintothecave.’Virtualmeetingswill increasinglycomplement the traditional faceto face roundtablemeetings and sowemust embrace theopportunities that this sadly tragic situation offers. It willbeevenmoretragicifintheendNHSTrustsrevertbacktohow theyworkedpreCovid-19. I hopenever againwill aGPmake youwait 7 days for an appointment. During thecurrentlockdown,everyoneIhavespokentohashadacallbackfromaGPinhoursnotdays.Whatagreatimprovementandtransformation.

SoherearemypersonalinsightsintomyjourneyoverthelastfewweeksofhowImanagedtoadaptandcope.Theyinclude,afterafewfalsestarts,thethingsIhavedonetoimprovemyand others’ experiences and to helpmakemeetingsmoreeffective,inclusiveandefficient.Iamsuremanyofyouareonasimilarorthesamejourneyofdiscoveryandchange.WhatIhavesuggestedbelow is thereforenotdefinitive. In fact Iwouldwelcomeyoutoshareyourexperiencessopleasefeel

free to send themme at [email protected] and I willupdatethisarticleandshareourcollectivethinking.

1. Personalised checklist. Thiswillhelpyouavoidsomeofthebasicpitfallsofvirtualmeetings.Ihavehighlightedmy starter-for-ten below – please help me make thisricherbysharingyourcopingmechanisms.

2. Formality and purpose. I have found that it worksbetterifeachmeetinghassomeelementofformalityandstructure through agendas, objectives and decisions/outcomes. You may be at home, but remember youare in a workplace meeting. Dress comfortably butappropriately and try not to offer any distractionsthroughyoursurroundings/background.

3. Prepare then test, test and test. I cannot stress this pointenough.Beingtotallyreliantontechnologythereare several things that must be considered beforeembarkingonyourfirstandsubsequentvirtualmeetingsuntiltheybecomesecondnature.Eventhenmakingthebasic checks will help ensure a smooth, efficient andeffectivemeeting.

4. Be clear and take the lead if you are chairing or facilitating. Notallappsarethesame.Thewayinwhichinvitationsandjoininginstructionsarecommunicatedisdifferentineachcase.Breakinglanguagedownandusing‘Noddy’ joining instructions and navigation guidance,whilst seemingly patronising, does work. Speak topeopleinadvancetoinstilandensureconfidence.

5. Listen and be heard.Bodylanguageandotherphysicalsignsyoucanpickupinafacetofacemeetingwillnotbeevidentinthesameway.Thereforetheneedandabilityto listenmore intentlyandcommunicatingclearlyandconcisely is imperative. Remember, if you are usingvideo,yourfacialgestureswillbeprevalentmorethannormal.

My top tips for effective, inclusive and efficient virtual meetings with multiple attendees:

►BeforetheDay.

• Makesureeveryonehas thesameappand link forthemeetinganditworksontheirdevice

• Provide sufficient help and support to ensure thetechnologyworksforyourattendees

• Check the link and the technology works on yourdevice

• Givepeopleclearandsimpleinstructionsonhowtojointhemeeting

• Encourage participants to join the meeting a fewminutesbeforethescheduledstart

►OntheDay.

• Ifyouarethechairorfacilitatorjoinearlyandhaveourphonecloseby

• Maketimeforintroductions(unlessit’sabroadcastcommunicationsexercise)

• Clarifytheagendaandpurposeforthemeeting• Outline the key protocols of making comments or

askingquestions• Considerappointinga facilitator tokeepaneyeon

chatboxconversationsandmanageQ&As

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►Goodpractice

• Be an active listener and show verbal empathythroughout the meeting

• Askparticipants tomute theirmicrophoneswhennottalking

• Don’tbetemptedtofillthegapsofsilence• Encourage participants to give physical signs of

acknowledgement(egthumbsup)• Use the chat box facility to seek agreement/

confirmationand/ortoraisequestions• Give everyone attending the opportunity to

contributeandinput• Ensure you have practiced good governance and

received good assurance on the key issues andobjectives

• For longer meetings ensure you schedule breakpoints

• Attheendofthemeetingsummarisethekeypoints,decisionsandactions

• Afterthemeetingprovideasummaryrecordofthemeetingtoallattendees

►Trytoavoid

• Don’tbetootaskoragendaled–allowthemeetingtoflowandpeopleopportunitytospeak

• Don’trunmeetingsformorethanonehourwithoutschedulingabreak

• Long ‘speeches’ from participants or the sameparticipantsdominatingagendaitems

• Keeppresentationsshortanddigestible• Distractionsinthebackground

Finally,onapersonalnote,Ihavehadtomakethenecessaryadjustments that theCovid-19challengehas createdand Inowfeelhealthierforhavingtotravelless.Asanation,weare lighteron theenvironmentwith less fuelconsumptionandalivetothemanybenefitsofadifferentwayofworking.Wenowhave the opportunity to embrace the change thatnecessity has forced upon us, but is also bringing about arealisationthatwecanbefarmoreefficient.OnlytimewilltellbutIgenuinelyfeelourdecisionmakingprocessisalsobeginningtobecomeevenbetterandfaster.

Idonotbelievethatweshould,orthatourstaffwillallowus,togobacktotheoldwaysofworking,orasonememberofstaffsaid,‘go back into that cave’.

Embrace the change and don’t return to the cave!



ClimateChangePolicy:From Negligence to Implementing a Carbon Tax Jay Anil Patel1,2,Olivia June Bloodworth1,Vishal Ashokkumar Unadkat1,3,Seetal Assi1,4,Ashni Asit Badiani5 1. SchoolofMedicine,UniversityofSouthampton,Southampton,UK2. LondonSchoolofHygieneandTropicalMedicine,London,UK3. ImperialCollegeLondon,London,UK4. KingsCollegeLondon,London,UK5. SchoolofMedicine,UniversityofLiverpool,Liverpool,UKCorrespondenceto:[email protected] Summary WiththeUKleavingtheEUin2020,itspoliciestocombatclimatechangecurrentlyremainundecided.Onepolicydiscussedinthisreportisacarbontax.Thisreportfindsthatimplementationofacarbontaxwillrequireafavourablepoliticalclimate,publicattentionandanappropriatecost,withastartingpriceof£40pertonneofCO2emitted,graduallyrisingto£100-125/tCO2(1).Also,tobepoliticallyacceptable,theremustalsobe‘revenuerecycling’,withsomeoftheproceedsofthecarbontaxbeingredirectedtopublicservices(2,3). Key words: Climatechange,carbontax,revenuerecycling Cite as: PatelJA,BloodworthOJ,UnadkatVA,AssiS,BadianiAA.ClimateChangePolicy:FromNegligencetoImplementingaCarbonTax.Sushruta2020(Jul)vol13;issue2;ePub06.04.2020https://www.sushruta.net

Introduction Since the industrial revolution, humankind has madeunprecedenteddevelopment,withhealth,technologiesandeconomies improving. The lives of people have improvedimmeasurably.Yet,wehaveexploitedtheenvironmenttoabreakingpoint,andurgentactionisrequiredtocombattheworseningsituation.WiththeUnitedKingdom(UK)leavingtheEuropeanUnion(EU),onesuchpolicybeingdiscussedisimplementationofacarbontax.Thisreportwilladdresstheevidenceonclimatechange;whyitdidnotreachthepolicyagenda earlier; and the implementation of a carbon taxpolicytocombatthedeleteriouseffectsofclimatechange. History Currently, theUKuses theEU’s EmissionsTrading System(ETS) system which is a ‘cap and trade’ system, wherecompanies receive or buy emission allowances, which aretradable (4).Allofone’semissionsmustbecoveredby thisallowanceandexceedingthemincursheavyfines(4).TheUKhasalsomaintainedacarbonpricefloorsince2013,whichproducerswererequiredtopayiftheEUETScarbonpricefellbelowthisthreshold(5).However,withBrexit,theUKmayneedtorevisititscarbonemissionsstrategybecausetheETSmaynolongerbeapplicable. The Evidence Base The scientific consensus is that climate change is real andman-made,witharound97%ofscientistsholdingthisview.

Data on the impact of climate change is provided by theIntergovernmental Panel onClimateChange (IPCC),whichconsistsofworkinggroupsI,IIandIIwhoassessthephysical scientific basis for climate change, the impact of climatechangetonaturalsystemsandhowtomitigatetheeffectsofclimatechangerespectively.Thefindingsoftheirmostrecentreport,the5thAssessmentReport,arereportedbelow(6):

• Averageglobaltemperatureshaverisenandhumansare“extremelylikely”tohavecausedthisrise.

• Greenhouse gas emissions (nitrous oxide, carbondioxide and methane) have risen since preindustrialtimes,withthemajoritybeingduetohumans.

• Global sea levels have risen and polar ice sheets havemelted.

• Therehaveandwillbegreaterrisksofextremeweathereventsduetoglobalwarming.

• Risingtemperaturesandextremeweathercanandhavecausedcropfailures.

• Rising temperatures will further threaten endangeredspeciesandecosystems.

Policymakers aim to prevent global temperatures fromrisingbymore than2°Ccompared topreindustrial figuresbecause above this temperature, scientists feel that therewillbeirreparabledamagetotheplanet(7). Failure to Make the Policy Agenda

1. McDonalds meets Misinformation – the role of democracy, capitalism and profit maximisation

Review

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According to Forbes, six oil companies are in thelargest 25 companies in the world (8). Clearly, theyhave large financial interests in the climate changeagendaconsideringthat the fossil fuel industry isalarge driver of anthropogenic (man-made) climatechange. These companies worry that tougherenvironmentalregulationwouldaffecttheirbottomline. In response, they have lobbied governments,paying US Congressional climate change deniersUS$1.87millionbetween2007and2015. Similartothetobaccoindustry,oilandgasproducershave attempted to sow seeds of doubt about thedeleteriouseffectsoftheiractivitiesupontheplanetthroughthefundingofresearchandmisinformation.ExxonMobilfunded39studieswhich“misrepresentedthescienceofclimatechange”in2005(9)andfundedthe production of Sceptics’ Handbook, a pamphletdenyingman-madeclimatechange,whichalteredtheevidencebaseandmadesomepeoplescepticalaboutclimatechange.ItalsoshiftedtheOvertonWindow,whichdefinesthespectrumofacceptabilityofpublicpolicies,awayfromclimatechangeaction,allowinglooser environmental regulations to continue;therefore, oil and gas companies could continue tooperate freely andmaximise their profits.Also, theeconomic capital of energy giants allows them tothreaten tomove their operations overseas if their demandsareunmetandhasallowedthemtospend$1billionsincetheParisAgreementonlobbying(10).

2. The media and its framing of climate change:

Yet,theframingofclimatechangehasbeencriticaltotheinactionregardingit (11).Firstly, ithasbecomeapartisanissue,preventingaction.Thelefthaslargelywanted to tackle climate change,whereas the righthas either displayed ignorance or an unwillingnessto tackle climate change. In the UK, the partisandivide has impeded political progress,with Laboursupporters 56% more likely to be extremely orvery worried about climate change compared toConservative voters (12). To this end, the role ofthemedia,whoareable to shape the thoughtsandpreferences of the public to dictate the politicalagenda,hasbeencriticalinframingclimatechangeasapartisanissue(11).Overall,thispoliticalpolarisationofclimatechangehaspreventedactiontomitigateoradapttoitseffects.

3. The People:

Despite scientific consensus over anthropogenicclimatechange,therearescepticsanddeniers.According to Schwartz (13), climate change scepticsand deniers display “wilful ignorance” of modernscientificevidence.Theyoftendislike theeconomicand political implications of climate change, hencetheychoosetonotbelieveinit(14).Forthesepeople,tacklingclimatechangedoesnotwarrantthepolitico-economictradeoff.

The Policy Agenda Shaping the Policy Agenda

Firstly, for climate change action to be taken, itmust beon the policy agenda. Kingdon states that implementationof policies requires actionwithinwindowsof opportunity,whichrequire(15):

• focusing events which attract public attentiontowardstheissue.

• afavourablepoliticalclimate.• asolutiontotheproblem.

Producing a Favourable Political Climate The first challengemust be to convince the population ofthe deleterious effects of climate change and that actionmustbeundertaken.Yet,consideringthevestedinterestsofcorporationsandtheapathyofsomeindividualstowardsthesubject,theremaybesomepeoplewhowillbeunchangingintheirbeliefs.However,46%ofEuropeansdidnotfeelthat“climatechangeisaveryseriousproblem”–ifsomeofthesepeopleareopentochangingtheiropinion,itwilladdfurtherweighttothemassesofpeopledemandingfurtheraction(16).Therefore,thosewhounderstandtheimportanceofclimatechange must undertake concerted action to highlight theissuetopolicymakers. Ultimately,politiciansareresponsivetovoters,hencegreaterpublic support for an issuewill encouragepolitical action.However,thepoliticalclimatemustalsobeappropriateforaction. Considering UK PrimeMinister Johnson’s previousstatements labelling Extinction Rebellion climate changeactivists as “uncooperative crusties” and his previouslyscepticalviewsoveranthropogenicclimatechange,thismayprovedifficult. Also, the power of focusing events must be harnessed -includingsudden,adverseweatherevents-whicharemorelikely due to climate change, and the publicity gained byactivistsincludingGretaThunbergandExtinctionRebellion(6,7,15,17). APotentialSolution–ACarbonTax Havingplacedclimatechangeactionhighuponthepoliticalagenda, a solution is required. One such response is acarbon tax, which taxes greenhouse gases emitted. It canbe applied tomanufacturing, power plants, transport andthe household energy industries. Burning fossil fuels is anegativeexternality,withthesocietalcostsofenvironmentaldamage outweighing the price paid by consumers andproducers. Therefore, there is often overconsumption ofthese resources above what is societally optimal, hencea carbon tax should reduce theamountof greenhousegasemittedbyraisingtheircosts. The UK government had previously suggested a price ofGB£16per tonneofCO2produced if therehadbeenano-dealBrexit (18).However, this figure appears to be too low–Burke,Byrnes andFankhauser suggest that to allow theUKtoreachitsnet-zeroemissionstargetby2050,acarbontaxwouldneedtocostaround£40/tCO2inmostsectorsandriseto£100-125/tCO2by2050(1).Itmayreducegreenhousegas emissions through several mechanisms, such as by:encouragingtheenergyindustrytoswitchtocleanerformsofenergy,withsimilarmeasuresreducingUKcoalusageby



91%since1990(19);reducingtheamountofenergyusedbyindustries;andpromotingefficientenergyusage. Political Implications of a Carbon Tax Practically, a carbon tax would be relatively simple toimplement in the UK, with fuel-use currently beingmonitoredandreportedintheEUETSsystem(5,20).However,implementing new taxes remains politically challenging,with the Gilets Jaunes movement arising in opposition tofuel price increases and Australia having repealed theircarbon tax (2,5).Despitethis,acarbontaxwouldgenerate£20billioninannualrevenueforthegovernment(1).Ifrecycledappropriately,theserevenueswouldincreasethewillingnessof thepublic toaccept thisnew tax,withSwedishcitizensmorelikelytoacceptacarbontaxifaccompaniedbyincometax cuts (2,3). Practical Implementation of a Carbon Tax

Tobe effective at reaching anet-zero emissions targetby2050,acarbontaxmustbesetataround£40/tCO2inmostsectorsandriseto£100-125/tCO2by2050(1).

• To be politically acceptable, the carbon tax mustincrease gradually over time, allowing people andcompaniestoaltertheirenergyusagepatterns,suchasbyswitchingtogreenerenergysourcesorincreasingtheirenergyefficiency(21).

• Tobepoliticallyacceptable,acarbontaxmustrecyclerevenuebackintotheeconomy(2,3,5).Itisalsoessentialthat policymakers explain how these resources arebeingusedtoensurepublicacceptabilityofthecarbontax – for example, these resources could be used toreduce income taxes, provide a carbon dividend orsubsidisegreentechnologies(21).

Drawbacks of a Carbon Tax However, some people argue that implementation of acarbontaxwillleadtonegativeeconomicandenvironmentalconsequences,withfirmsmovingabroadtonationswithlessstrictenvironmentalregulations(20,22).However,theseeffectsarelikelytobemodest,withthemajorityofgreenhousegasemissions in developed countries produced by nontradedsectors, including electricity, transport and construction,whichcannotbeoutsourcedoverseastonationswithlooserenvironmentalregulations(20,22). Also,acarbontaxmayberegressive,harmingthepoorestinsociety,whospendagreaterproportionoftheirincomeonenergyandfuel(21).Appropriaterecyclingofrevenuetothepoorestinsocietymayovercomethischallenge(21). References 1. BurkeJ,ByrnesR,FankhauserS,BeaumanC,BellamyO,Bowen

A,etal.Howtopricecarbontoreachnet-zeroemissionsintheUK[Internet].2019[cited2020Mar4].Availablefrom:

www.cccep.ac.uk2. Beiser-McGrathLF,BernauerT.Couldrevenuerecyclingmake

effectivecarbontaxationpoliticallyfeasible?SciAdv.2019Sep18;5(9).

3. JagersSC,MartinssonJ,MattiS.Theimpactofcompensatorymeasures on public support for carbon taxation: an

experimental study in Sweden. Clim Policy [Internet]. 2019[cited2020Mar4];Availablefrom:https://www.tandfonline.com/action/journalInformation?journalCode=tcpo20

4. EUEmissionsTradingSystem(EUETS)[Internet].2015.[cited2020 Mar 4]. Available from: https://ec.europa.eu/clima/policies/ets_en

5. Geroe S. Addressing Climate Change Through a Low-Cost,High-ImpactCarbonTax.JEnvironDev.2019;28(1):3–27.

6. PachauriRK,AllenMR,AlE.ClimateChange2014SynthesisReport[Internet].RajendraK.Pachauri(Chair),MylesR.Allen(UnitedKingdom),VicenteR.Barros(Argentina),JohnBroome(United Kingdom), Wolfgang Cramer (Germany/France),Renate Christ (Austria/WMO), John A. Church (Australia),LeonClarke(USA),QinDahe(China),PurJ-PvanY(Belgium),Technical, editors. 2014 [cited 2019 Dec 4]. Available from:http://www.ipcc.ch.

7. Theimpactsofclimatechangeat1.5C,2Candbeyond[Internet].CarbonBrief.2018[cited2020Mar3].Availablefrom:https://interactive.carbonbrief.org/impacts-climate-change-one-pointfive-degrees-two-degrees/?utm_source=web&utm_campaign=Redirect

8. Forbes Magazine. The World’s Largest Public Companies[Internet]. Global 2000. 2019 [cited 2019 Dec 4]. Availablefrom:https://www.forbes.com/global2000/list/#tab:overall

9. Royal Society. Letter from the Royal Society to ExxonMobil.2006.

10. InfluenceMap. Big Oil’s Real Agenda on Climate Change[Internet]. 2019 [cited2019Dec4].Available from:https://influencemap.org/report/How-Big-Oil-Continues-to-Oppose-the-ParisAgreement-38212275958aa21196dae3b76220bddc

11. SteculaDA,Merkley E. Framing Climate Change: Economics,Ideology, and Uncertainty in AmericanNewsMedia ContentFrom1988to2014.FrontCommun.2019Feb26;4.

12. SocialResearchN.BritishSocialAttitudes35:ClimateChange.13. Schwartz SA. The Denier Movements Critique Evolution,

Climate Change, and Nonlocal Consciousness. Explore[Internet]. 2010 [cited 2019 Dec 4];6(3):135–42. Availablefrom:http://dx.doi.org/10.1016/j.explore.2010.03.005

14. Krugman P. Betraying the Planet - The New York Times.New York Times [Internet]. 2009 [cited 2019 Dec 4];Available from: https://www.nytimes.com/2009/06/29/opinion/29krugman.html?_r=1

15. KingdonJ.Agendas,alternativesandpublicpolicies.2010.16. Stokes B, Wike R, Carle J. Global Concern about Climate

Change,BroadSupportforLimitingEmissions-PewResearchCenter [Internet]. Pew Research Center. 2015 [cited 2020Mar 2]. Available from: https://www.pewresearch.org/global/2015/11/05/global-concern-aboutclimate-change-broad-support-for-limiting-emissions/

17. Belam M. Greta Thunberg: teenager on a global mission to‘make a difference’ . The Guardian [Internet]. 2019 [cited2020Apr8];Available from:https://www.theguardian.com/environment/2019/sep/26/greta-thunberg-teenager-on-aglobal-mission-to-make-a-difference

18. BurkeJ,ByrnesR.WhattheUKcanlearnfromcarbonpricingschemes around the world [Internet]. Carbon Brief. 2019[cited2020Mar4].Availablefrom:https://www.carbonbrief.org/guest-post-what-the-uk-can-learn-from-carbon-pricing-schemesaround-the-world

19. Department for Business Energy and Industrial Strategy,National Statistics. 2018 UK Greenhouse Gas Emissions,Provisional Figures [Internet]. 2019 [cited 2020 Mar 4].Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data /file/790626/2018-provisional-emissions-statistics-report.pdf

20. Aldy JE, Stavins RN. The Promise and Problems of PricingCarbon.JEnvironDev[Internet].2012Jun18[cited2020Mar3];21(2):152–80. Available from: http://journals.sagepub.com/doi/10.1177/1070496512442508

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21. BurkeJ,ByrnesR,FankhauserS.PolicybriefGloballessonsfortheUKincarbontaxes.2019.

22. Aldy JE, PizerWA. The Competitiveness Impacts of ClimateChange Mitigation Policies. Harvard Proj Clim Agreements

[Internet]. 2015 Jan 26 [cited 2020Mar 3]; Available from:ttps://www.belfercenter.org/sites/default/files/legacy/files/dp73_aldy-pizer.pdf

Continued from ......Climate Change Policy.......

The Coronavirus CollectiveAStudent’sPerspectiveDijay Dave

Asa5thYearMedicalStudent, I found myself in astrange positionwhen lockdown began. Iwas not a FinalYear,sowasnotjoiningmypeersingraduatingearly.Butatthesametime,Ifeltthathadenoughclinicalexperiencetobeanassetonthewards,ratherthanaliability(mypreviousexperienceasaHealthcareAssistantaside).

My universitywas quick to respond to the crisis andsuspendedourclinicalplacements.Avolunteeringschemewassetupinthefollowingweeks,asaresultofthestrongdesireofthemedicalstudentstohelp.IhavetoadmitthatIdidnotsignupimmediately;questionsstillswirledinmymindifIwouldactuallybeuseful,andevenatthatearlypointitwasbecomingapparentthatBAMEindividualshadaworseprognosis.Ihavetwoparentstolookafter,eachwithseveralco-morbidities,whoIfeltneededypresenceforboththeirphysicalandpsychologicalhealth.Nevertheless,whilstathomeIfellapulltothewards,whetheritwasanaltruisticdesireorbasescientificcuriosityIamstillunsure.

Themedia’scatastrophisingmachinedidnothelp.AfterreceivingaletterfrommyGPdesignatingmyparentsas“Shielded”withprovisionsofmedicationandgroceriestothem,Isigneduptovolunteer.MyyoungerbrotherreturnedfromUniversity and took onmy responsibilities as youngcarer.Toprepareforbeingbackonthewards,IcompletedaCOVIDe-learningpackagecoveringthebasicsofDonningandDoffing aswell the basics ofNon-InvasiveVentilation(NIV),andIsatinonthevirtualroundtableofdiscussionswithdoctorswhohadpriorexperienceofworkinginsuchclimates.

TheoneImostrememberwasbyImperialcollegealumnus,MrDavidNottof“WarDoctor”fame,whospokeon the importance of senior doctors demonstrating calmleadership.Ididn’tunderstanditthen,butaftertwomonths,Iunderstanditnow,givenhowmuchmymoodreflectedthatofthejuniordoctorsandconsultantsunderwhomIworkedonagivenday.

Goodleadershipwasn’tlimitedtotheseniorclinicians,the kind F1s and nurses took me under their wing anddemonstratedpatiencewhichwasinstrumentalin

mefeeling part of the team. Their stress became mystress, whilst their good humour allowed me to expressmine.Theyencouragedmetoreflectonmyexperienceanddidn’tjudgemykeenspirit.

COVID has been a learning experience for me as amedical student: it has cemented my desire to pursue acareer inmedicine, remindedmeof the importanceofmyrelationshipsbothathomeandatworkandshownmeupclose the importance of good clinical leadership throughunchartedwaters.

BetterNewWorldNitin Shrotri

MankindhashadamassiveshockFromtheCovid,thathastalkedthetalkIthaslaidus,completelyflatandlow

Morethanever,intheyearswe’veknownYetmankindwithin,it’sownbrightsparkItrealisesitserrors,asitsitsinthedarkAndslowlybutsurelyitbeginstohopeAbetternewworld,insteadofsit’nmopeAsfamilies,huddledtogetherathomeSomeofusarealoneandlonesome

Love’scomebacktous,indifficultdaysForwhowehaven’thad,foryearsacrazeOutofthehouse,afewluckyonesroamO’ervalesengreen,ast’world’sa-stormByhaplesspolice,getcaughtintheparkOrgetaspottosurvive,inNoah’sarkAswewatch,PlanetEarthtakingbackWhatithadlostunderourhumanattackWerealisethatperhapsandverymuchMankindmuststopbehavingassuchGoogleandApplecreatingnewappsGatesandMicrosoftfillinginthegapsAssocialdistancingbecomesthenormHumanstostayawayasperappinformLivingwithotherinhappiness,harmony

Withothercreatures,lovelybugs&bunnyCountriestoomustimmediatelystop

Treatingpoorbadly,sohealfromd’shockTheonlyoneway,someofuswillmakeitBykeepingfromother‘aneacheveryBritButmoresoalsobyrespectingourplanetUnlesswewanttobecalled,aCovidiot!



HiddenTalentsJeet Thacker

For several decades, people have made myriad ofpredictionsofwhat lifewouldbe like in2020,butnoonecould have predicted what’s happening now. Nature hastakenitstollonus.Ontheflipside,naturehasbestoweduswithspectacular

unseenviewsofHimalayas,seenforthefirsttimeindecadesfrom rooftops of houses.Aswell as purified andpollutionfree riversandapeacefulenvironment free fromthedailytrafficnoises.Aroundtheworld,nationsstandunitedandarehelpfulto

eachotherinthispandemic–atrulycommendablefeat.Asthey say “in the timeof test, family is thebest”; lockdownhasclearlyunitedpeoplewiththeirfamily,andIfeelhappyaboutthis.Peoplearespendingmoretimetogetherathomeandonlinewithotherfamilymembers.Moreover, people have now become more aware about

theirhealth.Iutilizedthistimetodovariousonlinecertificatecourses on COVID and other self development activitiesto enhancemy clinical skills and knowledge. I even did adiploma. I attendedmanywebinars and talks of theRoyalCollegeSocieties,whichweretrulyhelpful.Outsideofwork,I have used this opportunity to unlockmy hidden talentsincalligraphyandphotography.Iliketoplaykeyboardandthesetimeshaveinspiredmetocomposenewtunes.Ibelieve this lockdownhasmadememorespiritualand

religious, too.We do prayer sessions two times a day andseekblessingsoftheAlmightyforourwellbeingandpeaceof mind and soul. This situation has reminded me of thestrengthintheprayersanddeepenedmyfaith.I thinkour situationwillmakegovernmentsallover the

worldrecognizetheimportanceofhealthcareworkers,andalsoawakenthemtoinvestmoreinhealthsectors.Furthermore, the necessity of quick action on the

development of health science and researchwill certainlyarise.Itrulybelievethispandemicshouldbeaneyeopenertoall

aboutourplanet’ssustainabilityandhowoneshouldrespectnatureaswell.DrJeetThackerisadoctorfromBhuj,Gujarat.Hereceived

hisMBBSdegreefromPDUGovMedCollege,Rajkotin2019.Followingthis,hehasdoneclinicalattachmentsatGuysandStThomas’sHospitalLondon,NorwichHospital&QEHBBirmingham.Heaspiring

tobecomeaspecialistwhileworkingintheNHSandservehumanity.

Behind the MaskRishika Sinha

AsaGP,endofLifevisitshavebeenthemostdifficult.Iwouldlike to see my patients with sympathy and compassion.However,withamask,visorandglovesalongwithanapronandheadcoverdonnedon,howamIsupposedtobeempathic?

Iwouldnotwanttoseemyowndoctorlikethis,wouldI?Iamusedtosittingnexttopatientsandholdingtheirhands.Now,therelativesonlytalktomeoverthephone.

They ask me: “If the diagnosis is COVID pneumonia,thenwhy I can’t give someoxygen?Whyaren’t theygivenantibiotics?Whydidthehospitalnotkeepthem?”

“Ifitwasn’tforCOVIDmymothershouldhavebeenabletoliveabitlonger.”“Whydidthehospitalleavemyanorexicmy daughter in the ward? Doctor, can you answer thesequestions?”

Everyday,IgothroughthisupheavalandturmoilwhichIfeelhasmadeusallhelpless.Iwasnotpreparedforthis.

Intheevenings,whenIamreadytogohome,mychestfeelssoheavy.However,ifIgohomewithsuchaheavyheartIcan’tlookaftermyfamily.

OnceIamoutofBillinghamandontheA19,Icryloudlyand literally howl to let off the built-up emotions. But, bythetimeIreachhomeIfeelreadytofaceabeautifuleveningwithmychildrenandhusband.

Dr Rishika Sinha has been a GP Partner at KingswayMedical Centre, Billingham since 2006, and a GP Trainersince2008.ShecametotheUKin2001,havingreceivedherMBBSfromPatnaMedicalCollegeinIndia.

She is the Clinical Lead for Primary Care at her localClinicalCareGroup.SheismarriedtoaGPandhastwolovelychildren.

AStudentoftheMindShantosh KumarThe Covid-19 Pandemic has been truly an unprecedentedand“unreal”experiencesofar.Ontheonehandthenewnessoftheexperienceandtheintrigueofbeinga“scientist”,andon the other, the challenge of coping with ever changinghuge amounts of data and “conflicting evidence base” andapplying it forourpatientsphysicalandmentalwellbeing.Thisisdifficult.

Overall so far, it has been rewarding coming homeknowingthatmypatientsarewell,andmyfamilyissmilingwithrelief.

Mydaughterhasbeenextremelyproudofme.Preventionis always the mantra I was indoctrinated with when Igrew up studying medicine in India. My background andtraining have helped me stay calm and focused. Whilst I

The Coronavirus Collective

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The Coronavirus CollectivehavenotcontractedCovid-19(tothebestofmyknowledge), I know of friends who have, andthosewhohavesufferedfatalconsequencesfromtheir encounters in clinical practice. This wassurrealandsomethingthatIwillfinddifficulttogetover.

Iaminastateofinternalpanic,butoutwardcalmness when I look at my family. I want toprotect themandbe there for them,but Iwentthroughagrippingfewweeks(thisislessernow)

ofthinkingthatitmaybethelasttimeImayseethem.

The BAME part, has been less of a directexperience changer for me. It has for mycolleaguesandIcanseewhy.TheplacewhereIworkhasbeenextremelyresponsive,supportiveand understanding of these challenges andproactively made provisions to help me andpeoplelikemefromBAMEbackgrounds.Forthat

Iamgrateful.Life came into sharp perspective. Priorities

clearly changed. So many things I took forgrantedIdidlessso. Icreatedanemailaccountformylittleoneandhavestartedwritingtoher,memories that she can hold onto if somethinghappens.

Doingtherightthing,therightway,supportingothers, being kind, being humanehave all beenthefocusofmyactionsandwork,evermorethanitwasbefore.

Atthispoint,tocontemplateafutureisdifficultandIamfocusingononedayatatime,toavoidhugepanicsettingin.IammindfulofmyparentsandIfindmyselfbeingmorestoicasIrealizetheenormity of the situation and the helplessnessfacingusall.Iamgrateful,tobealive,tobethereformyfamilyandforwhatIcanonlydescribeasahumblingexperience.

Asastudentofthemind,Ihavenoticedhowthe truenatureofpeople comes to the fore, forgoodandforworse.Iwishallreadingthissafety,health and an experience that has hopefullystrengthened us, our families and as a BAPIOgroup. Santosh Kumar is a consultant ForensicPsychiatristinNorthEastEngland.Hewastrainedby some truly eminent teachers, and amazingparents, in India and in the UK. He remains akeen student of themind and a follower of thepassionateworkofBAPIOhereandinIndia.

WhenaPandemicStrikesSarthak Bahl

IwasinSpainenjoyingmyannualleavewhenwefirstheardaboutCOVID-19makingdeepimpactonItaly.ItalyhadgoneintolockdownandsoonSpainwastodeclareaNationalEmergency.Our first impressionwas thatwewould still be able to gohome

peacefullyonourarrangedflightwhichwastwodayslater.Inthenextfewdays,wenotedwhatanimpactof

CoronavirusPandemiccanbe.Allthestreetswereempty,restaurantsweregettingclosedandwhenwereachedairportforourflights,airportlookeddeserted.Wesawfirst-handexperiencewhatlifeamidstapandemiccan

befortourists.Wewereabletotakeaflighthome,butIsoonrealizedlifewasabouttochange.Reachingbackhome,nextfewdays,Ibegan

experiencingsymptomsofCOVID-19andstartedtoself-isolateasperNationalGuidance.Self-isolatingwasdifficultaswewererunningoutoffoodsoonand

nodeliveryslotswereavailable.I feel really sadwhenI thinkabout vulnerable groupsand

howtheirexperiencemighthavebeenamidst thiscrisiswhen theyhadtodependonothersforfooddelivery.Afterrecoveringfromsymptoms,Iwasabletojointhehospitalagain.Wewereputonemergencyrotaof12hrshifts inorder tomake

sure service didn’t suffer as a result of medical staff callinginsick.MyrotationintoGeriatricMedicinewassooncancelledaswasforothertraineesthroughouttheU.K.toavoiddisruptiontoservicebyrotationoftrainees.In the first fewdays, thewardsoonfilledwithCovid-19patients

andusasdoctorswereleftamazedbychangeinPPEguidanceeveryotherdaybythePublicHealthEngland.SeeingstoriesofdoctorsdyinginthelineofdutyduetolackofPPEwasdistressing,aswerestories of BAME communities being more affected due to various

factors.Butamidstthisgloom,thereweresomepositives.Whetherit

wasvariousNGOscomingtogethertohelphealthcareworkersbysupplyingPPE,ormedicalstudentscomingtogethertoofferchildcareforseniormedicalstaffmembers;Itwasamazingtoseetheroleofcommunitiesinmakingsurethathealthcarestaffneverfeltalone.Personally,Ibenefitedalotfromthesupportofmyfriends

duringthiscrisis.Beingawayfromfamilyishardforeveryone,butifwecometogetherashealthcareworkers,wecanmakethistimeeasier.Duringthistimeinlock-down,Ihavelearnthowtocookandhave

startedcyclingbackagain.IhavemadesurethatIusemytimeoffworktohelp inthetrialofCOVID-19vaccinebyvolunteeringtohelpatLSTM,Liverpool.Iamnotsureifthispandemicisover,butIamsurethatthiscrisis

hasbroughtallhealthcareworkersandcommunitiestogetherwithasenseoftogetherness.Born in SriGanganagar,Rajasthan, India,SarthakBahl completed

hisMBBSin2017fromAmritsar.Heiscurrentlyworkingasajuniorl inLiverpool.He is also involvedwithBMAMerseyDCas a rep toconsultants’committee.



PerspectiveAxelle Schneider

AsaFrenchperson,myexperiencemightbealittledifferentthanyours,butI’lltrymybesttotellyouhowIfelt.Lifeinlockdownwasn’tthatbadforme,Iwasinthecountrysideatmyboyfriend’sparentsplace.Wewere7inthehousebutit’squitebig,sowehadenoughspace.

My father in law is adoctor (equivalent of aGP in theUK)sohewasonthefrontline.Inmyopinionitwasquitereassuring, because it helped us to stay updated on thesituation and also stay calm and positive. My mom alsoworksinhealthcareandshehasbeenabitstressedandveryexhaustedbyallofit.

Lockdownhasallowedmetohavesometimeformyself,thinking about what kind of life I really want and moreimportantlywhatamIabletodoinordertobeself-sufficientinthefuture.

Ihadenoughtimetoreadalot,learnhowtoplaychess,learn some gardening stuff and look for universities toachieve my diploma. I’ve also cooked a lot and starteddifferentsportsprogramswhichhelpedmeloose10kgs.

One thing thatwasn’t easywas that Ididn’tplanat allat firsttobeinthisplacewhenlockdownwasannounced.MaybeIwouldhave feltmorecomfortablewithmyfamilyoratmyownplace.IwouldhavelovedspendingthistimewithmybrotherandsisterthatIdon’treallygettoseemuch.

I’mawarethatmysituationisfarfromdifficult,andthatforsomepeople, ithasbeena livinghelleversince itwasannounced.That’swhyI’mtryingmybesttobegratefulforthewayitturnedoutformeandthinkingaboutwhatIcouldchangeinmydailylifenowthatlockdownisover,inordertoactforadifferentfuture.

The OneWhoMust NotbeNamedAnonymousCorona. The New Corona. The virus.Allthesepseudonymsarenowpartofthevarietyoflanguagethatonemayhearoutsidethepuborwhilesocialdistancingona(crowded)beach,soakinguptheunusuallywarmsun.Inmyworkplace,Isimplyrefertoitusingthe'onewhomustnotbenamed'–inspiredbyJKRowling'sLordVoldemort.

I say, 'you don't wish to take away something (virus)thatyoudidnotcomeinwith.Thisplusanodoftheheadandanunderstanding smile, is all it takes toget thisvitalacknowledgmentacross.

Ihaveseenthisintheeyesofpeople,whoaresobreathlessorshackledtotheiroxygendeliverydevicesthatspeechisnotpossible.Asimpleliftingtheeyebrowsasasking,'haveIgothedreadedvirus'andasilentnod,'yesyouhave'.Thentheeyesareaverted,theinevitabilityofthesentencesinksindeepandnofurtherwordsareexchanged.

Wearearacethat isusedtothe ideaof the inevitable,thefatethatisnotinourhands,theacceptancethatonehasdonethebestonecan,therestisnotworththinkingabout.

Something strange Ihavenoticed is that like inhorrorfilms, the nights are the most difficult to live through. Inthedaytime,anyamountofdreadfulnewsfromtheblaring'newsbriefings'canbetolerated,butatnight,oneiswokendrenchedinsweat(cold)andsittingupinalonelybed,onecanonlycheckthatoneisbreathing,checkthetemperatureof thebrowwitha tremblinghand, thankone' luckystarsand lieback thinkingofhow theworldmight look fromaproneposition.

Medical knowledge is a dangerous thing. Yes, you say,if applied wrongly or without care, there can be dangersahead.Iamsuremanyintheprofessionwillagreethatthesameknowledgecanbeequallydangerouswhenthetablesareturned,andonefacesthesameprospects.

Iknowofcolleagueswhohavescouredtheliterature,readevery scrap of publishedmaterial to glean the knowledgethatwouldhelpmakesenseoftheunknowndanger.Ihavedonethesame.Ihavereadmorepapersinthelast3monthsthaneverdid,evenwhenIwrotemy80kwordthesis.

Lifeissacred.Alotisridingonourshoulders.Whileweoffercomforttothoseinourcareandhelpthemtomakessense of the injustice of health and disease. We are notimmunetotheseworries.Ihavelearnttoacknowledgemyfears and anxieties. To share openly, and therein findmysolace.

Youshouldtryit.

The Coronavirus Collective

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The Physician - Part I Contributors

Akash Srinivasan; ImperialCollegeMedicalSchoolAnanthakrishnan Raghuraman; CheltenhemGeneralHospitalDane Howard; Pharmacydepartment,StJames’sUniversityHospital,LeedsTeachingHospitalNHSTrust;Elaine Jackson; ChiRunningPractitioner(www.chirunning.uk)Indranil Chakravorty; StGeorgesUniversityHospitalNHSTrust,BAPIOInstituteforHealthResearchJS Bamrah CBE; BAPIOInstituteforHealthResearchKassiani Iliadou; AcuteMedicine,StGeorge’sUniversityHospitalsFoundationTrustKirit Mistry; SouthAsianHealthActionCharityKoottalai Srinivasan;KeeleUniversityMedicalSchool,PrincessRoyalHospitalPakinee Pooprasert; StGeorge’sUniversityHospitalMana Rahimzadeh; StGeorge’sUniversityHospitalMaria Memtsa; UniversityCollegeofLondonNeeraj Bhala; QueenElizabethHospitalUniversityHospitalBirminghamNHSFoundationTrustPakinee Pooprasert; MaritimeHospital,KentRamesh Mehta OBE; BrithishAssociationofPhysiciansofIndianOriginRehan Khan; RoyalLondonHospitalSahana Rao;OxfordUniversityHospitalsNHSTrustSarah Siddiqui;HealthEducationEnglandSubarna Chakravorty;KingsCollegeHospitalSubodh Dave; RoyalDerbyHospitalNottinghamUniversitySunil Daga; StJames’sUniversityHospital,LeedsTeachingHospitalNHSTrustRakesh Patel; NottinghamMedicalSchool,UniversityofNottinghamTriya Chakravorty; SchoolofClinicalMedicine,Queen’sCollege,UniversityofOxfordVeena Daga; LeedsGeneralInfirmary,LeedsTeachingHospitalNHSTrustVipin Zamvar;RoyalInfirmaryofEdinburgh



The Physician - Part I Contributors

Akash Srinivasan; ImperialCollegeMedicalSchoolAnanthakrishnan Raghuraman; CheltenhemGeneralHospitalDane Howard; Pharmacydepartment,StJames’sUniversityHospital,LeedsTeachingHospitalNHSTrust;Elaine Jackson; ChiRunningPractitioner(www.chirunning.uk)Indranil Chakravorty; StGeorgesUniversityHospitalNHSTrust,BAPIOInstituteforHealthResearchJS Bamrah CBE; BAPIOInstituteforHealthResearchKassiani Iliadou; AcuteMedicine,StGeorge’sUniversityHospitalsFoundationTrustKirit Mistry; SouthAsianHealthActionCharityKoottalai Srinivasan;KeeleUniversityMedicalSchool,PrincessRoyalHospitalPakinee Pooprasert; StGeorge’sUniversityHospitalMana Rahimzadeh; StGeorge’sUniversityHospitalMaria Memtsa; UniversityCollegeofLondonNeeraj Bhala; QueenElizabethHospitalUniversityHospitalBirminghamNHSFoundationTrustPakinee Pooprasert; MaritimeHospital,KentRamesh Mehta OBE; BrithishAssociationofPhysiciansofIndianOriginRehan Khan; RoyalLondonHospitalSahana Rao;OxfordUniversityHospitalsNHSTrustSarah Siddiqui;HealthEducationEnglandSubarna Chakravorty;KingsCollegeHospitalSubodh Dave; RoyalDerbyHospitalNottinghamUniversitySunil Daga; StJames’sUniversityHospital,LeedsTeachingHospitalNHSTrustRakesh Patel; NottinghamMedicalSchool,UniversityofNottinghamTriya Chakravorty; SchoolofClinicalMedicine,Queen’sCollege,UniversityofOxfordVeena Daga; LeedsGeneralInfirmary,LeedsTeachingHospitalNHSTrustVipin Zamvar;RoyalInfirmaryofEdinburgh

The Physician

Volume: 6 Issue: 1 MAY 2020

climate & health

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