Topic: COVID-19

Climate Change Places Vulnerable Populations in a Double Bind During Storm Seasons in COVID-19 Era

By Vivian V. Altiery De Jesús, MBE
Program Coordinator | Berman Institute
Doctor of Medicine 4th year -Student (MD) | UPR-SOM

The National Oceanic and Atmospheric Administration predicts an “extremely active” hurricane season for 2020. Climate change is responsible for increased hurricane strength and frequency in the Atlantic Ocean, with residents of islands like Puerto Rico and the Bahamas suffering devastation of environmental phenomena caused by industrialized countries’ carbon footprints. Previously, this has been framed as climate injustice .

Traditionally, people living in hurricane risk zones without the option to move in with family members or friends are relocated in shelters until the storms goes away and the country regains some stability during the storm aftermath.  However, the 2020 Storm Season is different. The COVID-19 pandemic imposes more risks to the population. And even prior to COVID-19, people in shelters had (and still have) communicable disease outbreak risks, as well as mental health and other health risks.

Climate changes and the COVID-19 pandemic have exacerbated vulnerabilities and placed disadvantage population in a dilemma. The first option is that people remain at their house located in the high-risk flood zone. This option may delay COVID-19 exposure; however, the household members could be at risk of drowning if the rescue team is not successful. On the other hand, if the rescue team is successful, the victims would be relocated to a shelter. Household members could be exposed to COVID-19 during the rescue attempt or at the storm shelter. The second option is choosing to relocate at the shelter before the storm arrives. In this scenario, household members are at risk of COVID-19 infection for longer time, but do not risk third parties involved in the disaster response.  Under a utilitarian perspective, the second option would be desirable since it minimizes the harms for household members and rescuers. However, there is an ethical responsibility at local and global levels owed to this vulnerable population.

In summary, vulnerable populations are in a double bind. The strategies for surviving hurricane seasons are high-risk for infectious outbreak. Climate change increases the likelihood of both devastating hurricanes and infectious disease outbreaks like COVID-19. Climate injustice are exacerbated for vulnerable and disadvantage populations that cannot safely weather from the storms.  What can we do to mitigate the harms imposed by climate change and the current pandemic?

At local level, efforts should be made to maintain social distancing among the people located in shelters. This could be through either by increasing locations or implementing features that facilitates social distancing (e.g. installing dividers).  Special locations should be considered for high risk COVID-19 patient such as elderly and immunocompromised population. Careful planning is needed, though, since complex cases will arise (i.e. an immunocompromised 10-year-old should not be separated from her non-immunocompromised mother). Nonetheless, minimizing the exposure of the high-risk COVID-19 population would be helpful.  Masks should be mandatory at the shelter. It is most likely that the quantity being sheltered exceeds the recommended quantity during gathering (e.g. no more than 10 people in a room). Therefore, interventions that slows COVID-19 spreads, such as wearing masks, should be implemented.  Hygiene efforts must be maximized; hand sanitizer, water and soap should be available. Countries at risks of Hurricanes should devised planning designs that encourage and promotes personal and overall hygiene at shelters without increasing the risks of COVID-19. The CDC offers guidelines for Public Disaster Shelters & COVID-19, providing insight to personal preparation and safety measures.  Lastly, local authorities should implement infectious surveillance for communicable disease, including COVID-19, in an attempt to mitigate outbreaks in the population.

At the global level, countries should collaborate in mitigating Category 5 Hurricanes formation. Warmer water in the tropics, means stronger atmospheric systems. Scientists had created models that shows the consequences if temperatures continue to increase. Unfortunately, even if all the Caribbean region eliminated completely their carbon footprint, it would not be enough to mitigate climate change. Regardless of the pandemic status, Category 5 Hurricanes, places vulnerable population in economic risk (e.g. losing their house), social risk (e.g. assessing education, employment after the event) , and health risks (e.g. mental health, diabetic complications).  Which again highlights climate injustice.

Lastly, the pandemic is forcing restructuration in various social system such as education, health, traveling, and workforce. In a more dramatic light , it feels like we are “re-inventing civilization”. This is our chance to incorporate designs that mitigates climate change. It is hard to see any positivity in the COVID-19 pandemic, but if we were to choose one, we should take the opportunity to aim for a fair climate in our new post-COVID-19 society.

Planning How to Allocate and Distribute a COVID-19 Vaccine

Researchers from the Berman Institute of Bioethics have co-authored a new report providing an ethical framework for making decisions about allocation and distribution of a COVID-19 vaccine during the initial period when such a vaccine has first been authorized for use and is still in limited supply.

Released by the Center for Health Security at Johns Hopkins Bloomberg School of Public Health, the report, Interim Framework for COVID-19 Vaccine Allocation and Distribution in the United States, proposes specific tiers of high-priority candidates for receiving a first vaccine based on this framework, including recognizing the contributions of essential workers who have been overlooked in previous allocation schemes:

Tier 1 includes those:

  • Most essential in sustaining the ongoing COVID-19 response.
  • At greatest risk of severe illness and death, and their caregivers.
  • Most essential to maintaining core societal functions.

Tier 2 includes those:

  • Involved in broader health provision.
  • Facing greater barriers to access care if they become seriously ill.
  • Contributing to maintenance of core societal functions.
  • Whose living or working conditions give them elevated risk of infection, even if they have lesser or unknown risk of severe illness and death.

The framework is guided by the following ethical principles, which the report authors believe should guide COVID-19 vaccine allocation and help identify more specific policy goals and objectives around vaccine policies:

  • Promotion of the common good, by promoting public health while enabling social and economic activity.
  • The importance of treating individuals fairly and promoting social equity, for example by addressing racial and ethnic disparities in COVID-19 mortality, and by recognizing the contributions of essential workers who have been overlooked in previous allocation schemes. 
  • The promotion of legitimacy, trust and a sense of community ownership over vaccine policy, while respecting the diversity of values and beliefs in our pluralist society.

The Berman Institute’s Anne Barnhill, Carleigh Krubiner and Alan Regenberg are among the co-authors, as is former Hecht-Levi Fellow Justin Bernstein, and Ruth Faden contributed.

You can access the new report here.

The Public’s Role in COVID-19 Vaccination

Authors:
Schoch-Spana M, Brunson E, Long R, Ravi S, Ruth A, Trotochaud M on behalf of the Working Group on Readying Populations for COVID-19 Vaccine
Date posted:
July 09, 2020
Publication type:
Report
Publisher:
The Johns Hopkins Center for Health Security
See also: View PDF

Introduction

This report considers human factors in relation to future vaccines against the novel coronavirus (SARS-CoV-2), drawing on insights from design thinking and the social, behavioral, and communication sciences. It provides recommendations—directed to both US policymakers and practitioners, as well as nontraditional partners new to public health’s mission of vaccination—on how to advance public understanding of, access to, and acceptance of vaccines that protect against COVID-19.

Problem

The protracted COVID-19 pandemic has placed multiple stresses on the US public: the threat of illness and death, the isolating effects of physical distancing measures, and the uncertainties and hardships associated with disrupted economic activities. People’s resilience is being sorely tested. Operation Warp Speed (OWS) is taking extraordinary steps to develop SARS-CoV-2 vaccines as swiftly as possible and, along the way, to inspire hope that relief is coming. Despite vaccination’s promise of release, some Americans—including those most at risk of COVID-19 impacts—may miss out on, or opt out of, this life-preserving public health measure. Some may worry about whether SARS-CoV-2 vaccines are safe or if they work at all. Some may be mistrustful of vaccine manufacturers, the agencies that regulate the industry, and/or the public health authorities recommending the products. For others, the issue may be access: Will a COVID-19 vaccine be affordable, easy to get to without losing wages or taking public transportation and risking infection, and/or provided in a place that feels safe? Under these circumstances, what can be done to ensure that target populations benefit from SARS-CoV-2 vaccines? With the current lag time in vaccine availability, US vaccination planners and implementers can exercise foresight and take proactive steps now to overcome potential hurdles to vaccine uptake.

Cross-Cutting Recommendation: Put People at the Center of a Revolutionary SARS-CoV-2 Vaccine Enterprise

US research requires reconfiguring to value the contributions of both bioscience and social and behavioral science to inform SARS-CoV-2 vaccine development. If embedded within the COVID-19 response, rapid social, behavioral, and communication science can deliver timely data and empirically based advice to support vaccine delivery strategies and uptake. In the SARS-CoV-2 vaccine enterprise, communities can be active research partners, rather than passive study subjects. Finally, human-centered design principles (aka “design thinking”) can help improve the planning and implementation of the COVID-19 vaccination program.

  • Joined by private foundations, OWS should commit a portion of its budget and work through the National Institutes of Health (NIH), the National Science Foundation (NSF), and the Centers for Disease Control and Prevention (CDC) to support rapid response research into the social, behavioral, and communication issues related to COVID-19 vaccination.
  • NIH should adapt the Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) model to include social/behavioral research on COVID-19 vaccination. Minority serving institutions are well-placed for partnering with communities in which hyper-localized understanding of vaccine access and acceptance issues is very much needed.
  • State and local health officials, along with university researchers from the social, behavioral, and communication sciences, should partner with grassroots groups in projects to understand how their communities are thinking about, and wanting to learn more about, SARS-CoV-2 vaccines.

Johns Hopkins Launches K-12 School Reopening Policy Tracker

A multidisciplinary team of Johns Hopkins University researchers today launched a new website that provides a range of tools dedicated to assessing and guiding K-12 school reopening plans across the United States, including a School Reopening Policy Tracker that provides real-time analysis of the latest guidance documents from every state.

According to researchers from the JHU eSchool+ Initiative, 46 State Boards of Education and 13 national policy organizations have thus far issued policy guidance about reopening K-12 schools. Equity issues are at the crux of a safe return for low-income children and children of color, and yet, one-third of reopening plans do not mention equity considerations for disadvantaged students at all, and most others mention them with little detail.

“As the United States continues to think about reopening, schools are at the forefront of every conversation. For parents to resume full-time work, schools will need to reopen, but only in a way that makes every effort to protect the safety and health of students, teachers and staff,” said Annette Campbell Anderson, deputy director of the JHU Center for Safe and Healthy Schools and an assistant professor at the School of Education. “Schools will also need to find new ways to make up for losses in learning, health, and support systems that occurred as a result of the closure. These discussions are happening right now, and our tracker analyzes how states’ proposed recovery plans support students, teachers, and parents.”

The Tracker and additional resources created by JHU’s eSchool+ Initiative are available here, and include:

“What children lose by not being in school is enormous; school attendance is a life-defining experience that is critical for educational, social and emotional development. School-age children, who very rarely die or become seriously ill from COVID-19, are being denied the benefits of attending school to protect the rest of us, particularly those at greatest risk of contracting the virus,” said Ruth Faden, founder of the Johns Hopkins Berman Institute of Bioethics.

“The biggest ethical challenge for decision makers is determining how to balance the interests of children and the interests of the rest of society. Factored into this moral calculus is the additional argument that school reopening is integral to economic reopening; parents need the full-day child care schools provide in order to return to their stores, offices and factories. This big-picture trade-off decision does not, however, exhaust what is ethically at stake. Many difficult ethical decisions about exactly how schools should reopen need to be resolved.”

A collaboration between JHU’s Consortium for School-Based Health Solutions, the Berman Institute, the Rales Center for the Integration of Health and Education, and schools of Education, Medicine, and Public Health, the eSchool+ Initiative is a cross-disciplinary effort to provide actionable real-world information and guidance that has characterized the University’s response to the COVID-19 pandemic.

“Schools are a nexus of health and well-being for children, particularly in less resourced communities where the burdens of the pandemic are being borne disproportionately,” said Dr. Megan Collins, an assistant professor of ophthalmology at the Wilmer Eye Institute and Berman Institute, and co-director of the Hopkins Consortium for School-Based Health Solutions. “While schools will be monitoring the COVID-19 ‘learning slide,’ what is missing is an eye on equity for disadvantaged groups. Even as education and public health leaders advocate for making classroom-based education a priority for those children most at risk for missing school, there is no clear guidance from school districts about how structural justice problems should be addressed. By creating the eSchool+ Initiative, we hope to contribute to ongoing discussions about narrowing health and academic equity gaps for disadvantaged students.”

Expecting the Unexpected: Guidelines for Medical Education Disaster Preparedness

By Vivian Altiery De Jesus, MBE, and Marielle Gross, MD

Health crises inevitably force us to struggle between maximizing scarce resources, safety, and patient care, typically at the expense of longer-term priorities such as medical education. While crises are characterized by unpredictability and range in form from pandemics to natural disasters, we can expect for these events to periodically occur. Making the most of medical education in these settings requires a thoughtful strategy.

 Crises Offer Unique Opportunities for Education

In 2017, Hurricane María devastated Puerto Rico while I was a third-year medical student. First, we were pulled from clinical rotations for three weeks. On our return, however, the crisis had drastically changed our healthcare system. There were unprecedented challenges for scarce resource allocation—we rationed everything from power plugs to ICU beds. As students, we found ourselves performing tasks well outside of our usual scope: both above and below our paygrade. For example, we sorted supplies and transported patients, but we also coordinated care and were charged with communicating bad news to patients’ and their families.

Despite these moments of heightened responsibility, the feeling of our education being sidelined after years of training and hard work, was a frustrating and difficult to process emotion. Where we were involved, it was often for duties that we would ordinarily have classified as “scut “ (i.e. delivering a blood test to the pathology department). While these were essential for patient care, and it was nice to be “useful,” these tasks had become verboten for millennial medical students. The unexpected nature of the changes, the lack of expectations and unknowns regarding how long they would last characterized the challenge.

Through all of this, I started to recognize positives: unique opportunities to build my character and fine tune my skills as a future practitioner. Our cases were unusual and complex. When we had the privilege of responsibility well beyond third year, such as being trusted to present and discuss a patient case with the radiology department, we felt the value of being essential care providers at a time when we would have ordinarily been merely observing.

I was proactive and embraced these positives, helping me get thorough the crisis with medical education intact. Indeed, the experience led me to pursue additional training in bioethics prior to proceeding with my clinical training. However, it would have been beneficial to have a framework or guidelines for what was expected of me and what I should expect from my medical education amidst a crisis.

History Repeats Itself

Three years later, I am a bioethics master’s student, embedded in an academic medical setting when COVID-19 struck.  The emotions, concerns and frustration shared among my peers and fellow medical students are very similar to the ones I felt during Maria. As before, there were mixed reactions, from feeling helpless to being entitled as a “paying customer” to proactive reactions1-4.

Again, the lack of a framework or guidelines for how to adjust medical education during a health crisis has imposed an additional challenge as public health needs yet again trumped medical education. Seeing this medical education crisis reoccur, I want to advocate for need a coherent strategy for how to make the most of the opportunity to strengthen the development of future physicians whose medical training coincides with a health crisis.

Medical Education should be Prepared for Health Crises

Preparedness is key for successful navigation during crises, however flexibility is key since each crisis is unique. However, most crises have a degree of predictability in what to expect regarding their impact on medical education and how to effectively respond. Having general guidelines and flexible protocols, rather than relying on ad hoc improvisation, would create structure for students where they need it most. This would support allow a better integration of medical education across the crisis and beyond, and may inspire students to take the positive side of training amid a crisis5.

For example, protocols could outline the different roles and duties of medical students during crises (i.e. understanding the logistic of being temporarily sidelined, what to expect and what is expected from them). These guidelines and protocols should be revised periodically with inputs from all training levels and sensitivity to individual circumstances. Medical students in the current crisis have been instrumental in providing insight and feedback for the advancement and implementation of tele-education technology.

Unfortunately, pandemics and natural disasters will continue to occur in the future. Just as we prepare our healthcare systems to handle and respond to these future events, so too must we prepare our medical educators and programs, particularly given their aligned long-term missions. A crisis like COVID-19 is an opportunity to learn from the experience and challenges of medical education amid a health crisis to optimize preparedness of this critical component of the healthcare system for the future.

Takeaways:

  1. Health crises sporadically take over healthcare systems with significant consequences for medical education.
  2. During a health crisis, medical students and their education are side-lined from clinical settings, compromising medical education and creating moral distress among students, but also creating a unique learning opportunities.
  3. Preparing for the unexpected via pre-set but flexible protocols for medical education during a health crisis may ease distress and support students to make the most of the crisis learning moment5.

References

  1. D. Cara. How Medical Student May Help Fight COVID-19. Gizmodo, March 18,2020, https://gizmodo.com/how-medical-students-may-help-fight-covid-19-1842385023
  2. Dev. Medical students feel sidelined in fight against COVID-19: ‘We want to help’ Crosscut, March 31, 2020, https://crosscut.com/2020/03/medical-students-feel-sidelined-fight-against-covid-19-we-want-help
  3. Krieger and A. Goodnough. Medical Students, Sidelined for now, Find New Ways to Fight Coronavirus. The New York Times, March 23, 2020 https://www.nytimes.com/2020/03/23/health/medical-students-coronavirus.html
  4. Rose. Medical Student Education in the Time of COVID-19. Journal of the American Medical Association. Published online March 31, 2020. Doi:10.1001/jama.2020.5227. [Accessed 8 April 2020].
  5. Blake A. ‘The Future Is Today’: Medical Students In the COVID-19 Pandemic. Health Affairs Blog, March 31, 2020 https://www.healthaffairs.org/do/10.1377/hblog20200326.510173/full/

A Physician’s Open Letter to Hospital Visitors

Dear Visitors: ­­­­

We love you, but for now we have to show it from a distance.

“Physical distancing,” staying away from each other and avoiding groups of people, is absolutely necessary to help fight COVID-19. This is most important in our hospitals, where the risk of catching and spreading the virus is highest. Patients still need to come to the hospital for care, but for now they can’t bring anyone with them. This can go two ways—it can make us more distant, or it can make us closer than ever.

Having a loved one in the hospital is never easy, and we know this policy makes it harder. It hurts when you can’t be there for loved ones when they need it most—even though we know it’s best for patients, healthcare providers and our community. We believe this pain of separation is proof that we need each other. Our shared discomfort with rules that keep people apart can also be the glue that helps us stick together.

The fight against COVID-19 is changing the world as we know it, and we expect even more changes in coming days, weeks and months. We’re all doing our best to cope, but many of us are feeling scared and alone. It’s natural to be mad and blame others, and to want to take as much as we can for ourselves. Yet, there has never been a time in history when the common ground that connects all people has been easier to see.

COVID-19 is a deadly virus that threatens everyone—all ages, colors and genders. Just as it affects all of us, we all have the power to help defeat it.

We’re in this together. We care deeply for our patients, and we love those who want to be here with us to support them. For now, we ask that you kindly show your love by going home!

Sincerely,
Dr. Marielle Gross

Marielle S. Gross completed her residency in Gynecology & Obstetrics at Johns Hopkins University School of Medicine in 2018. She is a Hecht-Levi Fellow at the Berman Institute of Bioethics. This summer, she will join the faculty at the University of Pittsburgh’s School of Medicine.