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ILO Policy Brief on COVID-19
The coronavirus disease continues to spread across the world following a trajectory that is difficult to predict. The health, humanitarian and socio-economic policies adopted by countries will determine the speed and strength of the recovery.
Due to the time-sensitivity of the pandemic, current scholarship predominantly put the discussion of COVID-19 as a central subject in epidemiology. Much of the available research has focused on the development of vaccines, the availability of tests, as well as the technical guidelines for the public to take precautions like practicing social-distancing and wearing face masks (Burki, 2020; Worby and Colin J., 2020; Meredith, 2020; Chughtai et al., 2020). To enrich our current understanding of the pandemic, our project examines how the COVID-19 pandemic is affecting the entire globe, from the economic repercussions to adjustments in ways of living, working, and socializing. Through two case studies in Shanghai and New York State, in terms of their respective governmental and public responses to the pandemic, we hope our project can provide greater insight into how COVID-19 is impacting the world and our personal lives.
To quote Anne Burdick, “The phrase Digital Humanities thus describes not just a collective singular but also the humanities in the plural, able to address and engage disparate subject matters across media, language, location, and history. But, however heterogeneous, the Digital Humanities is unified by its emphasis on making, connecting, interpreting, and collaborating.” Through our comparative study, we hope to bring previously separated scholarships in China and the U.S. by including Mandarin-outlet popular and academic sources to study the effectiveness of the preventative measures. Both regions contracted a high number of cases, but had different results as Shanghai has few reported new cases from local transmission whereas New York is currently experiencing a second surge. By comparing Shanghai and New York, we revealed that the policies and practices behind Shanghai’s success in controlling COVID-19 depended on people’s compliance and collaboration. Based on the exploration of our data set, we conclude that the use of facemasks, the practice of traveler testing, as well as strict lockdown policies in severely affected areas (including delivery-only grocery options) are among the most effective measures in limiting the number of COVID-19 cases and deaths.
With this project, we hope to educate people on how easily viruses can be transmitted and infect an entire population and how social distancing and home isolation are key strategies in halting the spread of the virus. This education is made even more vital due to the widespread increases in mental illness, substance abuse, and economic hardships. While the cultural and political differences between Shanghai and New York prevent the adoption of the same safety practices, we believe that looking into how Shanghai has handled the COVID-19 pandemic may shed light on the most effective procedures that other countries should implement.
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There are hundreds of coronaviruses, most of which circulate in animals. Only seven of these viruses infect humans and four of them cause symptoms of the common cold. But, three times in the last 20 years, a coronavirus has jumped from animals to humans to cause severe disease.
SARS, a beta coronavirus emerged in 2002 and was controlled mainly by aggressive public health measures. There have been no new cases since 2004. MERS emerged in 2012, still exists in camels, and can infect people who have close contact with them.
COVID-19, a new and sometimes deadly respiratory illness that is believed to have originated in a live animal market in China, has spread rapidly throughout that country and the world.
The new coronavirus was first detected in Wuhan, China in December 2019. Tens of thousands of people were infected in China, with the virus spreading easily from person-to-person in many parts of that country.
The novel coronavirus infections were at first associated with travel from Wuhan, but the virus has now established itself in 177 countries and territories around the world in a rapidly expanding pandemic. Health officials in the United States and around the world are working to contain the spread of the virus through public health measures such as social distancing, contact tracing, testing, quarantines and travel restrictions. Scientists are working to find medications to treat the disease and to develop a vaccine.
The World Health Organization declared the novel coronavirus outbreak “a public health emergency of international concern” on January 30. On March 11, 2020 after sustained spread of the disease outside of China, the World Health Organization declared the COVID-19 epidemic a pandemic. Public health measures like ones implemented in China and now around the world, will hopefully blunt the spread of the virus while treatments and a vaccine are developed to stop it.
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- COVID-19: The Novel Coronavirus COVID-19: The Novel Coronavirus 1. A Novel Deadly Virus (course expires 9-15-20) 2. Spread, Case Fatality, and Symptoms 3. Treatment and Vaccines 4. Public Health Response 5. Protecting Healthcare Workers 6. Pandemic Preparedness 7. Conclusion 8. References / Quiz Login or Register (Course expires 9-15-20)
A Global Deal for Our Pandemic Age
Report of the G20 High Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response
105. COVID-19 was not a black swan event. It may also constitute a dress rehearsal for a far worse pandemic, which could come at any time.
106. We must prepare for a world where pandemics are more frequent and increasingly dangerous. Preventing them, and never again allowing the human costs and economic damage that we have seen in the current crisis, must be a central obligation of national and global governance.
107. We must prepare for a world where pandemics are more frequent and increasingly dangerous. Preventing them, and never again allowing the human costs and economic damage that we have seen in the current crisis, must be a central obligation of national and global governance.
108. We must prepare for a world where pandemics are more frequent and increasingly dangerous. Preventing them, and never again allowing the human costs and economic damage that we have seen in the current crisis, must be a central obligation of national and global governance.
109. We must prepare for a world where pandemics are more frequent and increasingly dangerous. Preventing them, and never again allowing the human costs and economic damage that we have seen in the current crisis, must be a central obligation of national and global governance.
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STUDENT ESSAY The Disproportional Impact of COVID-19 on African Americans
Volume 22/2, December 2020, pp 299-307
Maritza Vasquez Reyes
We all have been affected by the current COVID-19 pandemic. However, the impact of the pandemic and its consequences are felt differently depending on our status as individuals and as members of society. While some try to adapt to working online, homeschooling their children and ordering food via Instacart, others have no choice but to be exposed to the virus while keeping society functioning. Our different social identities and the social groups we belong to determine our inclusion within society and, by extension, our vulnerability to epidemics.
COVID-19 is killing people on a large scale. As of October 10, 2020, more than 7.7 million people across every state in the United States and its four territories had tested positive for COVID-19. According to the New York Times database, at least 213,876 people with the virus have died in the United States.  However, these alarming numbers give us only half of the picture; a closer look at data by different social identities (such as class, gender, age, race, and medical history) shows that minorities have been disproportionally affected by the pandemic. These minorities in the United States are not having their right to health fulfilled.
According to the World Health Organization’s report Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health , “poor and unequal living conditions are the consequences of deeper structural conditions that together fashion the way societies are organized—poor social policies and programs, unfair economic arrangements, and bad politics.”  This toxic combination of factors as they play out during this time of crisis, and as early news on the effect of the COVID-19 pandemic pointed out, is disproportionately affecting African American communities in the United States. I recognize that the pandemic has had and is having devastating effects on other minorities as well, but space does not permit this essay to explore the impact on other minority groups.
Employing a human rights lens in this analysis helps us translate needs and social problems into rights, focusing our attention on the broader sociopolitical structural context as the cause of the social problems. Human rights highlight the inherent dignity and worth of all people, who are the primary rights-holders.  Governments (and other social actors, such as corporations) are the duty-bearers, and as such have the obligation to respect, protect, and fulfill human rights.  Human rights cannot be separated from the societal contexts in which they are recognized, claimed, enforced, and fulfilled. Specifically, social rights, which include the right to health, can become important tools for advancing people’s citizenship and enhancing their ability to participate as active members of society.  Such an understanding of social rights calls our attention to the concept of equality, which requires that we place a greater emphasis on “solidarity” and the “collective.”  Furthermore, in order to generate equality, solidarity, and social integration, the fulfillment of social rights is not optional.  In order to fulfill social integration, social policies need to reflect a commitment to respect and protect the most vulnerable individuals and to create the conditions for the fulfillment of economic and social rights for all.
Disproportional impact of COVID-19 on African Americans
As noted by Samuel Dickman et al.:
economic inequality in the US has been increasing for decades and is now among the highest in developed countries … As economic inequality in the US has deepened, so too has inequality in health. Both overall and government health spending are higher in the US than in other countries, yet inadequate insurance coverage, high-cost sharing by patients, and geographical barriers restrict access to care for many. 
For instance, according to the Kaiser Family Foundation, in 2018, 11.7% of African Americans in the United States had no health insurance, compared to 7.5% of whites. 
Prior to the Affordable Care Act—enacted into law in 2010—about 20% of African Americans were uninsured. This act helped lower the uninsured rate among nonelderly African Americans by more than one-third between 2013 and 2016, from 18.9% to 11.7%. However, even after the law’s passage, African Americans have higher uninsured rates than whites (7.5%) and Asian Americans (6.3%).  The uninsured are far more likely than the insured to forgo needed medical visits, tests, treatments, and medications because of cost.
As the COVID-19 virus made its way throughout the United States, testing kits were distributed equally among labs across the 50 states, without consideration of population density or actual needs for testing in those states. An opportunity to stop the spread of the virus during its early stages was missed, with serious consequences for many Americans. Although there is a dearth of race-disaggregated data on the number of people tested, the data that are available highlight African Americans’ overall lack of access to testing. For example, in Kansas, as of June 27, according to the COVID Racial Data Tracker, out of 94,780 tests, only 4,854 were from black Americans and 50,070 were from whites. However, blacks make up almost a third of the state’s COVID-19 deaths (59 of 208). And while in Illinois the total numbers of confirmed cases among blacks and whites were almost even, the test numbers show a different picture: 220,968 whites were tested, compared to only 78,650 blacks. 
Similarly, American Public Media reported on the COVID-19 mortality rate by race/ethnicity through July 21, 2020, including Washington, DC, and 45 states (see figure 1). These data, while showing an alarming death rate for all races, demonstrate how minorities are hit harder and how, among minority groups, the African American population in many states bears the brunt of the pandemic’s health impact.
Approximately 97.9 out of every 100,000 African Americans have died from COVID-19, a mortality rate that is a third higher than that for Latinos (64.7 per 100,000), and more than double than that for whites (46.6 per 100,000) and Asians (40.4 per 100,000). The overrepresentation of African Americans among confirmed COVID-19 cases and number of deaths underscores the fact that the coronavirus pandemic, far from being an equalizer, is amplifying or even worsening existing social inequalities tied to race, class, and access to the health care system.
Considering how African Americans and other minorities are overrepresented among those getting infected and dying from COVID-19, experts recommend that more testing be done in minority communities and that more medical services be provided.  Although the law requires insurers to cover testing for patients who go to their doctor’s office or who visit urgent care or emergency rooms, patients are fearful of ending up with a bill if their visit does not result in a COVID test. Furthermore, minority patients who lack insurance or are underinsured are less likely to be tested for COVID-19, even when experiencing alarming symptoms. These inequitable outcomes suggest the importance of increasing the number of testing centers and contact tracing in communities where African Americans and other minorities reside; providing testing beyond symptomatic individuals; ensuring that high-risk communities receive more health care workers; strengthening social provision programs to address the immediate needs of this population (such as food security, housing, and access to medicines); and providing financial protection for currently uninsured workers.
Social determinants of health and the pandemic’s impact on African Americans’ health outcomes
In international human rights law, the right to health is a claim to a set of social arrangements—norms, institutions, laws, and enabling environment—that can best secure the enjoyment of this right. The International Covenant on Economic, Social and Cultural Rights sets out the core provision relating to the right to health under international law (article 12).  The United Nations Committee on Economic, Social and Cultural Rights is the body responsible for interpreting the covenant.  In 2000, the committee adopted a general comment on the right to health recognizing that the right to health is closely related to and dependent on the realization of other human rights.  In addition, this general comment interprets the right to health as an inclusive right extending not only to timely and appropriate health care but also to the determinants of health.  I will reflect on four determinants of health—racism and discrimination, poverty, residential segregation, and underlying medical conditions—that have a significant impact on the health outcomes of African Americans.
Racism and discrimination
In spite of growing interest in understanding the association between the social determinants of health and health outcomes, for a long time many academics, policy makers, elected officials, and others were reluctant to identify racism as one of the root causes of racial health inequities.  To date, many of the studies conducted to investigate the effect of racism on health have focused mainly on interpersonal racial and ethnic discrimination, with comparatively less emphasis on investigating the health outcomes of structural racism.  The latter involves interconnected institutions whose linkages are historically rooted and culturally reinforced.  In the context of the COVID-19 pandemic, acts of discrimination are taking place in a variety of contexts (for example, social, political, and historical). In some ways, the pandemic has exposed existing racism and discrimination.
Poverty (low-wage jobs, insurance coverage, homelessness, and jails and prisons)
Data drawn from the 2018 Current Population Survey to assess the characteristics of low-income families by race and ethnicity shows that of the 7.5 million low-income families with children in the United States, 20.8% were black or African American (while their percentage of the population in 2018 was only 13.4%).  Low-income racial and ethnic minorities tend to live in densely populated areas and multigenerational households. These living conditions make it difficult for low-income families to take necessary precautions for their safety and the safety of their loved ones on a regular basis.  This fact becomes even more crucial during a pandemic.
Low-wage jobs: The types of work where people in some racial and ethnic groups are overrepresented can also contribute to their risk of getting sick with COVID-19. Nearly 40% of African American workers, more than seven million, are low-wage workers and have jobs that deny them even a single paid sick day. Workers without paid sick leave might be more likely to continue to work even when they are sick.  This can increase workers’ exposure to other workers who may be infected with the COVID-19 virus.
Similarly, the Centers for Disease Control has noted that many African Americans who hold low-wage but essential jobs (such as food service, public transit, and health care) are required to continue to interact with the public, despite outbreaks in their communities, which exposes them to higher risks of COVID-19 infection. According to the Centers for Disease Control, nearly a quarter of employed Hispanic and black or African American workers are employed in service industry jobs, compared to 16% of non-Hispanic whites. Blacks or African Americans make up 12% of all employed workers but account for 30% of licensed practical and licensed vocational nurses, who face significant exposure to the coronavirus. 
In 2018, 45% of low-wage workers relied on an employer for health insurance. This situation forces low-wage workers to continue to go to work even when they are not feeling well. Some employers allow their workers to be absent only when they test positive for COVID-19. Given the way the virus spreads, by the time a person knows they are infected, they have likely already infected many others in close contact with them both at home and at work. 
Homelessness : Staying home is not an option for the homeless. African Americans, despite making up just 13% of the US population, account for about 40% of the nation’s homeless population, according to the Annual Homeless Assessment Report to Congress.  Given that people experiencing homelessness often live in close quarters, have compromised immune systems, and are aging, they are exceptionally vulnerable to communicable diseases—including the coronavirus that causes COVID-19.
Jails and prisons : Nearly 2.2 million people are in US jails and prisons, the highest rate in the world. According to the US Bureau of Justice, in 2018, the imprisonment rate among black men was 5.8 times that of white men, while the imprisonment rate among black women was 1.8 times the rate among white women.  This overrepresentation of African Americans in US jails and prisons is another indicator of the social and economic inequality affecting this population.
According to the Committee on Economic, Social and Cultural Rights’ General Comment 14, “states are under the obligation to respect the right to health by, inter alia , refraining from denying or limiting equal access for all persons—including prisoners or detainees, minorities, asylum seekers and illegal immigrants—to preventive, curative, and palliative health services.”  Moreover, “states have an obligation to ensure medical care for prisoners at least equivalent to that available to the general population.”  However, there has been a very limited response to preventing transmission of the virus within detention facilities, which cannot achieve the physical distancing needed to effectively prevent the spread of COVID-19. 
Segregation affects people’s access to healthy foods and green space. It can also increase excess exposure to pollution and environmental hazards, which in turn increases the risk for diabetes and heart and kidney diseases.  African Americans living in impoverished, segregated neighborhoods may live farther away from grocery stores, hospitals, and other medical facilities.  These and other social and economic inequalities, more so than any genetic or biological predisposition, have also led to higher rates of African Americans contracting the coronavirus. To this effect, sociologist Robert Sampson states that the coronavirus is exposing class and race-based vulnerabilities. He refers to this factor as “toxic inequality,” especially the clustering of COVID-19 cases by community, and reminds us that African Americans, even if they are at the same level of income or poverty as white Americans or Latino Americans, are much more likely to live in neighborhoods that have concentrated poverty, polluted environments, lead exposure, higher rates of incarceration, and higher rates of violence. 
Many of these factors lead to long-term health consequences. The pandemic is concentrating in urban areas with high population density, which are, for the most part, neighborhoods where marginalized and minority individuals live. In times of COVID-19, these concentrations place a high burden on the residents and on already stressed hospitals in these regions. Strategies most recommended to control the spread of COVID-19—social distancing and frequent hand washing—are not always practical for those who are incarcerated or for the millions who live in highly dense communities with precarious or insecure housing, poor sanitation, and limited access to clean water.
Underlying health conditions
African Americans have historically been disproportionately diagnosed with chronic diseases such as asthma, hypertension and diabetes—underlying conditions that may make COVID-19 more lethal. Perhaps there has never been a pandemic that has brought these disparities so vividly into focus.
Doctor Anthony Fauci, an immunologist who has been the director of the National Institute of Allergy and Infectious Diseases since 1984, has noted that “it is not that [African Americans] are getting infected more often. It’s that when they do get infected, their underlying medical conditions … wind them up in the ICU and ultimately give them a higher death rate.” 
One of the highest risk factors for COVID-19-related death among African Americans is hypertension. A recent study by Khansa Ahmad et al. analyzed the correlation between poverty and cardiovascular diseases, an indicator of why so many black lives are lost in the current health crisis. The authors note that the American health care system has not yet been able to address the higher propensity of lower socioeconomic classes to suffer from cardiovascular disease.  Besides having higher prevalence of chronic conditions compared to whites, African Americans experience higher death rates. These trends existed prior to COVID-19, but this pandemic has made them more visible and worrisome.
Addressing the impact of COVID-19 on African Americans: A human rights-based approach
The racially disparate death rate and socioeconomic impact of the COVID-19 pandemic and the discriminatory enforcement of pandemic-related restrictions stand in stark contrast to the United States’ commitment to eliminate all forms of racial discrimination. In 1965, the United States signed the International Convention on the Elimination of All Forms of Racial Discrimination, which it ratified in 1994. Article 2 of the convention contains fundamental obligations of state parties, which are further elaborated in articles 5, 6, and 7.  Article 2 of the convention stipulates that “each State Party shall take effective measures to review governmental, national and local policies, and to amend, rescind or nullify any laws and regulations which have the effect of creating or perpetuating racial discrimination wherever it exists” and that “each State Party shall prohibit and bring to an end, by all appropriate means, including legislation as required by circumstances, racial discrimination by any persons, group or organization.” 
Perhaps this crisis will not only greatly affect the health of our most vulnerable community members but also focus public attention on their rights and safety—or lack thereof. Disparate COVID-19 mortality rates among the African American population reflect longstanding inequalities rooted in systemic and pervasive problems in the United States (for example, racism and the inadequacy of the country’s health care system). As noted by Audrey Chapman, “the purpose of a human right is to frame public policies and private behaviors so as to protect and promote the human dignity and welfare of all members and groups within society, particularly those who are vulnerable and poor, and to effectively implement them.”  A deeper awareness of inequity and the role of social determinants demonstrates the importance of using right to health paradigms in response to the pandemic.
The Committee on Economic, Social and Cultural Rights has proposed some guidelines regarding states’ obligation to fulfill economic and social rights: availability, accessibility, acceptability, and quality. These four interrelated elements are essential to the right to health. They serve as a framework to evaluate states’ performance in relation to their obligation to fulfill these rights. In the context of this pandemic, it is worthwhile to raise the following questions: What can governments and nonstate actors do to avoid further marginalizing or stigmatizing this and other vulnerable populations? How can health justice and human rights-based approaches ground an effective response to the pandemic now and build a better world afterward? What can be done to ensure that responses to COVID-19 are respectful of the rights of African Americans? These questions demand targeted responses not just in treatment but also in prevention. The following are just some initial reflections:
First, we need to keep in mind that treating people with respect and human dignity is a fundamental obligation, and the first step in a health crisis. This includes the recognition of the inherent dignity of people, the right to self-determination, and equality for all individuals. A commitment to cure and prevent COVID-19 infections must be accompanied by a renewed commitment to restore justice and equity.
Second, we need to strike a balance between mitigation strategies and the protection of civil liberties, without destroying the economy and material supports of society, especially as they relate to minorities and vulnerable populations. As stated in the Siracusa Principles, “[state restrictions] are only justified when they support a legitimate aim and are: provided for by law, strictly necessary, proportionate, of limited duration, and subject to review against abusive applications.”  Therefore, decisions about individual and collective isolation and quarantine must follow standards of fair and equal treatment and avoid stigma and discrimination against individuals or groups. Vulnerable populations require direct consideration with regard to the development of policies that can also protect and secure their inalienable rights.
Third, long-term solutions require properly identifying and addressing the underlying obstacles to the fulfillment of the right to health, particularly as they affect the most vulnerable. For example, we need to design policies aimed at providing universal health coverage, paid family leave, and sick leave. We need to reduce food insecurity, provide housing, and ensure that our actions protect the climate. Moreover, we need to strengthen mental health and substance abuse services, since this pandemic is affecting people’s mental health and exacerbating ongoing issues with mental health and chemical dependency. As noted earlier, violations of the human rights principles of equality and nondiscrimination were already present in US society prior to the pandemic. However, the pandemic has caused “an unprecedented combination of adversities which presents a serious threat to the mental health of entire populations, and especially to groups in vulnerable situations.”  As Dainius Pūras has noted, “the best way to promote good mental health is to invest in protective environments in all settings.”  These actions should take place as we engage in thoughtful conversations that allow us to assess the situation, to plan and implement necessary interventions, and to evaluate their effectiveness.
Finally, it is important that we collect meaningful, systematic, and disaggregated data by race, age, gender, and class. Such data are useful not only for promoting public trust but for understanding the full impact of this pandemic and how different systems of inequality intersect, affecting the lived experiences of minority groups and beyond. It is also important that such data be made widely available, so as to enhance public awareness of the problem and inform interventions and public policies.
In 1966, Dr. Martin Luther King Jr. said, “Of all forms of inequality, injustice in health is the most shocking and inhuman.”  More than 54 years later, African Americans still suffer from injustices that are at the basis of income and health disparities. We know from previous experiences that epidemics place increased demands on scarce resources and enormous stress on social and economic systems.
A deeper understanding of the social determinants of health in the context of the current crisis, and of the role that these factors play in mediating the impact of the COVID-19 pandemic on African Americans’ health outcomes, increases our awareness of the indivisibility of all human rights and the collective dimension of the right to health. We need a more explicit equity agenda that encompasses both formal and substantive equality.  Besides nondiscrimination and equality, participation and accountability are equally crucial.
Unfortunately, as suggested by the limited available data, African American communities and other minorities in the United States are bearing the brunt of the current pandemic. The COVID-19 crisis has served to unmask higher vulnerabilities and exposure among people of color. A thorough reflection on how to close this gap needs to start immediately. Given that the COVID-19 pandemic is more than just a health crisis—it is disrupting and affecting every aspect of life (including family life, education, finances, and agricultural production)—it requires a multisectoral approach. We need to build stronger partnerships among the health care sector and other social and economic sectors. Working collaboratively to address the many interconnected issues that have emerged or become visible during this pandemic—particularly as they affect marginalized and vulnerable populations—offers a more effective strategy.
Moreover, as Delan Devakumar et al. have noted:
the strength of a healthcare system is inseparable from broader social systems that surround it. Health protection relies not only on a well-functioning health system with universal coverage, which the US could highly benefit from, but also on social inclusion, justice, and solidarity. In the absence of these factors, inequalities are magnified and scapegoating persists, with discrimination remaining long after. 
This current public health crisis demonstrates that we are all interconnected and that our well-being is contingent on that of others. A renewed and healthy society is possible only if governments and public authorities commit to reducing vulnerability and the impact of ill-health by taking steps to respect, protect, and fulfill the right to health.  It requires that government and nongovernment actors establish policies and programs that promote the right to health in practice.  It calls for a shared commitment to justice and equality for all.
Maritza Vasquez Reyes, MA, LCSW, CCM, is a PhD student and Research and Teaching Assistant at the UConn School of Social Work, University of Connecticut, Hartford, USA.
Please address correspondence to the author. Email: [email protected].
Competing interests: None declared.
Copyright © 2020 Vasquez Reyes. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.
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- v.12(5); 2020 May
COVID-19 Pandemic: Knowledge and Perceptions of the Public and Healthcare Professionals
Priyanka a parikh.
1 Department of Pediatrics, Pramukhswami Medical College, Karamsad, IND
Binoy V Shah
Ajay g phatak.
2 Central Research Services, Bhaikaka University, Karamsad, IND
Amruta C Vadnerkar
3 Department of Public Health, Child Health Foundation, Gandhidham, IND
4 Department of Public Health, International Pediatric Association, Gandhidham, IND
5 Department of Pediatrics, Deep Children Hospital, Gandhidham, IND
Somashekhar M Nimbalkar
Background and objective
The recent pandemic due to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a major concern for the people and governments across the world due to its impact on individuals as well as on public health. The infectiousness and the quick spread across the world make it an important event in everyone’s life, often evoking fear. Our study aims at assessing the overall knowledge and perceptions, and identifying the trusted sources of information for both the general public and healthcare personnel.
Materials and methods
This is a questionnaire-based survey taken by a total of 1,246 respondents, out of which 744 belonged to the healthcare personnel and 502 were laypersons/general public. There were two different questionnaires for both groups. The questions were framed using information from the World Health Organization (WHO), UpToDate, Indian Council of Medical Research (ICMR), Center for Disease Control (CDC), National Institute of Health (NIH), and New England Journal of Medicine (NEJM) website resources. The questions assessed awareness, attitude, and possible practices towards ensuring safety for themselves as well as breaking the chain of transmission. A convenient sampling method was used for data collection. Descriptive statistics [mean(SD), frequency(%)] were used to portray the characteristics of the participants as well as their awareness, sources of information, attitudes, and practices related to SARS-CoV-2.
The majority (94.3%) of the respondents were Indians. About 80% of the healthcare professionals and 82% of the general public were worried about being infected. Various websites such as ICMR, WHO, CDC, etc., were a major source of information for the healthcare professional while the general public relied on television. Almost 98% of healthcare professionals and 97% of the general public, respectively, identified ‘Difficulty in breathing” as the main symptom. More than 90% of the respondents in both groups knew and practiced different precautionary measures. A minority of the respondents (28.9% of healthcare professionals and 26.5% of the general public) knew that there was no known cure yet. Almost all respondents from both the groups agreed on seeking medical help if breathing difficulty is involved and self-quarantine if required.
Most healthcare professionals and the general public that we surveyed were well informed about SARS-CoV-2 and have been taking adequate measures in preventing the spread of the same. There is a high trust of the public in the government. There are common trusted sources of information and these need to be optimally utilized to spread accurate information.
In December 2019, the 2019 novel coronavirus disease (COVID-19) caused by novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in China, followed by a rapid spread all over the world. On March 11, 2020, the World Health Organization (WHO) raised its pandemic alert. As of April 11, 2020, COVID-19 had caused over 95,269 deaths in 189 countries and overseas territories or communities [ 1 ].
In a connected world, fake news and rumor-mongering are common due to a surge in the use of the internet and social media. A confused comprehension in an emerging communicable disease of which even the experts have inadequate knowledge can lead to fear and chaos, even excessive panic, which has the probability to aggravate the disease epidemic [ 2 ]. During the SARS epidemic from 2002 to 2004, there were misconceptions and hence excessive panic in the general public concerning SARS. This led them to be resistant to comply with suggested preventive measures such as avoiding public transportation, going to a hospital when sick, etc. This contributed to the rapid spread of SARS and resulted in a more serious epidemic situation [ 3 ]. A similar experience occurred during the Ebola outbreak in 2009 in Africa. These experiences underscore the vital role of engaging with the general public and healthcare professionals and the importance of monitoring their perception of disease epidemic control, which may affect the compliance of community to the precautionary strategies. Understanding related factors affecting and influencing people to undertake precautionary behavior may also help decision-makers take appropriate measures to promote individual or community health. Hence, it is crucial to understand people’s risk perception and identify their trusted sources of information to effectively communicate and frame key messages in response to the emerging disease [ 4 ].
Since it is the novel coronavirus, its epidemiological features are not well known and new studies and publications will take anywhere from a month to a year making it important to know and understand the level of knowledge and preparedness of the healthcare personnel in terms of the managing the virus affected patients. Today healthcare professionals managing COVID-19 across the world are in an unprecedented situation, having to make tough decisions and working under extreme pressures. Decisions include equitable distribution of scant resources among the needy patients, balancing their own physical and mental healthcare needs along with those of the patients, aligning their desire and duty to patients with those to family and friends, and providing care for all unwell patients with constrained or inadequate resources. This may cause some to experience moral distress or mental health problems [ 5 ].
Effective communication is a priority in WHO’s COVID-19 roadmap; accurate and salient messages will enhance trust and enable the public to make informed choices based on recommendations [ 6 ].
As the outbreak intensified, social media has taken on new and increased importance with the large-scale implementation of social distancing, quarantine measures, and lockdown of complete cities. Social media platforms have become a way to enable homebound people to survive isolation and seek help, co-ordinate donations, entertain, and socialize with each other.
Social media platforms arguably support the conditions necessary for attitude change by exposing individuals to correct, accurate, health-promoting messages from healthcare professionals
In order to investigate community responses to SARS-CoV-2, we conducted this online survey among the general public and healthcare professionals to identify awareness of SARS-CoV-2 (perceived burden and risk), trusted sources of information, awareness of preventative measures and support for governmental policies and trust in authority to handle SARS-CoV-2 outbreak and put forward policy recommendations in case of similar future conditions.
We performed a cross-sectional survey of a convenient sample of respondents. The ethical approval for the study was taken from the Institutional Ethics Committee - 2, HM Patel Centre for Medical Care and Education, Karamsad via letter IEC/ HMPCMCE/ 2019 / Ex. 07/ dated March 23, 2020. All participants were above 18 years of age conveniently selected from the public at large by reaching out to the general public and healthcare professionals by the authors. The participants were largely from India. The consent of the participants was taken at the beginning of the survey. Two different self-administered questionnaires were used. The one for non-medical personnel (general public) is shown in Table Table1, 1 , while the one for medical and paramedical personnel is shown in Table Table2 2 .
WHO, World Health Organization
The questions were framed using information from the WHO, UpToDate, Indian Council of Medical Research (ICMR), Center for Disease Control (CDC), National Institute of Health (NIH), and New England Journal of Medicine (NEJM) website resources as updated till March 19, 2020. They were validated consensually by experts from the Department of Pediatrics, Pulmonary Medicine, Public Health, and General Internal Medicine. The COVID-19 questions for healthcare professionals, i.e., medical and paramedical personnel were applicable to consultants, residents, interns, medical students, physiotherapists, physiotherapy students, nurses, nursing students, dentists, etc. The questionnaire was administered in English with the help of Google forms, which is a cloud-based data management tool used for designing and developing web-based questionnaires and available free. A link to the online surveys was sent out to them via e-mails and different social media platforms, namely WhatsApp, Facebook, LinkedIn, and Instagram messages, hence without any geographical barrier. The data collection was started on the March 23, 2020 and was continued up till March 27, 2020 midnight. The dates are important as on 22 March there was a self-imposed Janata Curfew in response to Prime Minister of India’s call while from the midnight of March 24, 2020, there was a nationwide lockdown across India. The data was automatically collected in the form of a google sheet and the collected data was being exported automatically to google sheets (similar to Microsoft Excel).
Descriptive statistics [mean (SD), frequency (%)] were used to portray the characteristics of the participants as well as their awareness, sources of information, attitudes, and practices related to SARS-CoV-2. Due to large sample sizes in the healthcare professional group as well as the general public group, exploratory visual comparisons were presented without typical statistical tests of significance.
A total of 744 health and allied professionals and 502 persons from people at large consented and completed the survey. A majority (94.3%) of the participants were Indian residents with insignificant responses from outside India. It is presumed that the majority of the respondents are of Indian residents but the possibility of a handful of them being non-Indians cannot be ruled out because we did not collect demographic data. A comparison of awareness about SARS-CoV-2 between the general public and healthcare professionals is shown in Table Table3 3 .
The gender distribution was equal in the healthcare professionals group, whereas it was more male-dominated in the general public group (49.7% vs 56.4% males). The respondents were younger in the healthcare professionals group as compared to the general public group [mean (SD) age: 29.55 (12.53) vs 32.16 (13.32) years].
The majority of the participants from the healthcare professionals group [594 (80%)] and the general public group [410 (82%)] were worried about getting SARS-CoV-2 infection. Those who were not worried expressed justified reasons (mainly precautions) for their attitude. Online resources, television, peer group discussions, and scientific literature constituted the main sources of information in the healthcare professionals group, whereas television, social networking sites, and newspapers/magazines constituted the main sources of information in the general population group. Participants in both groups reported WHO and official Indian Government websites (ICMR, Ministry of Health and Family Welfare (MOHFW)) as the most trusted online resources.
Most of the healthcare professionals reported that they had accessed videos by WHO/other sources [514 (69%)], read scientific articles [407 (54.7%)], and attended online lectures [242 (32.5%)] related to SARS-CoV-2.
Most healthcare professionals [727(98%)] as well as the general public [486(97%)] identified “difficulty in breathing” as the main symptom of SARS-CoV-2 infection along with cough and fever. Respondents from both the groups were aware of precautionary measures such as hand washing/sanitizer, wearing masks, social distancing, covering mouth while sneezing, and self-quarantine. Majority of the participants (62.7% in the general public and 71.8% in healthcare professionals) were aware of the infection period and the asymptomatic period (91% in the general public and 94.3% in healthcare professionals), but there appeared to be some confusion regarding curative treatment and vaccine availability in both the groups. Most participants rightly endorsed medical masks for healthcare workers, symptomatic patients, and persons who are coughing/sneezing. However, an appreciable proportion of healthcare professionals [303(40.7%)], as well as respondents from the general public [253(50.4%)], wrongly endorsed medical masks for healthy persons to protect themselves.
Most healthcare professionals [648(87.1%)] expressed their trust in the ICMR task force on SARS-CoV-2. Similar feelings were echoed by the general public [426(85%)] in trusting the current government.
Half of the general public respondents showed eagerness for the SARS-CoV-2 test without difficulty in breathing. A similar trend was observed among health professionals. Almost all respondents from the general public (98%) and the healthcare professionals (100%) endorsed seeking medical help if the breathing difficulty was involved.
Slightly more healthcare professionals reported regular influenza vaccination as compared to the general public [175(23.5%) vs 76(15.1%)]. Almost all the respondents agreed for self-isolation if needed. The majority of the respondents reported that they were washing the hands more frequently and knew the correct way of handwashing.
We present here a study of the awareness of SARS-CoV-2 among healthcare professionals and the general public with a comparison of many features among them. It is heartening to note that the knowledge with respect to SARS-CoV-2 is relatively high among the respondents.
There are, however, various limitations of the study and these are inherent due to the circumstances in which this survey was done. The study was begun on March 23, 2020, one day after Janata Curfew in India as requested by the Prime Minister and one day before the lockdown on March 24, 2020 [ 7 ]. The survey was filled during the days of the lockdown when the respondents had a lot of time on their hands and were probably active on social media as well as watching the television news. Hence, it is quite relevant that many individuals have their information from these two sources, making it important to ensure that accurate information through verified channels and healthcare professionals are presented and broadcasted to the people. This also points towards the importance of the right people being active on social media so that they can communicate the scientifically validated information to the masses.
The curfew and the lockdown ensured that the seriousness of the disease was impressed upon by the highest offices in the country, which is reflected in people taking good precautionary measures to protect themselves from the disease as well as break the chain of transmission. The cases in India have hence not risen to a very high number as rapidly as expected/projected, which also probably indicates that the message was well conveyed and well perceived. As this is a survey that was filled remotely, we need to be cautious in drawing strong conclusions.
Another limitation of the study is that the questionnaire was in the form of google forms and the language of conduct was English. This implies that the people who did not have access to the internet and were not literate were unable to be a part of this survey. But as the source of information for all the general public remains similar (television is ubiquitous in India), we can infer that they would have a similar response. We base this inference as the main sources of information of the public at large were newspapers, television, and WhatsApp despite having access to websites and other online sources. In villages, often the literate readout regional newspapers and news received on mobiles to the rest of the family/friends to ensure dissemination of information.
It is now known that the basic reproductive number (R0) of coronavirus is more in healthcare professionals as compared to the lay public and hence the relative indifference or "no worries" approach of healthcare professionals towards getting infected by SARS-CoV-2 is a concern. In the scenario where adequate personal protective equipment (PPE) may not be available to the healthcare facilities in India due to increased global demand, it is important that healthcare workers know their risk for being infected. In a recent study in Mumbai, 79% of the healthcare professionals were aware of the various PPE required with only 54.5% of them being aware of isolation procedures needed for SARS-CoV-2 infected patients [ 8 ]. The numbers for paramedical staff were also lower. India imports raw materials for PPE production from China and South Korea. Due to the shortage of materials and low rate of supply, the availability has taken a massive hit resulting in an acute shortage in the market. It is highly likely that many healthcare professionals will not use appropriate PPE, will get infected, and further spread infections to patients [ 9 - 11 ]. The Bhilwara cohort in Rajasthan is an example of how a healthcare professional needs to protect against infection since he/she is likely to transmit it to others [ 12 ]. Another example in Mumbai is Saifee hospital, which was shut down due to an infected healthcare professional who continued to work and passed on the infection to many during the asymptomatic phase. The SARS-CoV-2 disease presents a unique organism that can be spread for at least five days before developing symptoms and up to 37 days after presentation [ 13 , 14 ]. Given its high infectivity, it is a recipe for disaster if healthcare personnel gets it. We have not collected demographic information from the participants and hence it is possible that many of them work in situations where they may not anticipate getting infected. The previous few months have shown how surgeons, orthopedicians, dentists, etc., who typically do not deal with infectious diseases are getting infected by coronavirus [ 15 , 16 ]. In this scenario, it is worrying that only 80% of healthcare professionals were worried while the public was slightly more worried (82%).
The difference in the source of information for healthcare professionals and the general public is stark when we compare information garnered through social media. Social media at 78.3% is the second-highest source for the general public, while the healthcare professionals give it a measly 1%. Since social media is prone to fake news, it is heartening that healthcare professionals are not learning from it. However, the reliance of the general public on social media indicates that healthcare professionals, professional organizations, and government officers need to invest a significant proportion of their time and resources to be active on social media to disseminate correct news. The shots heard round the world rapid-response network is an example that needs to be followed [ 17 ]. In another example, we have Dr. Roberto Burioni who has successfully given accurate data on social media. If more healthcare professionals were to enrich social media, it would be a useful platform for the public [ 18 , 19 ]. While many government officials are active on Twitter in India, the platform that is commonly used in India is WhatsApp, Telegram, Instagram, and TikTok and these are dynamic and keep changing. WhatsApp in the middle of this pandemic reduced the forwarding to just one person for a message that had been forwarded five times from the previous number of forwarding to five people (which was unlimited initially) [ 20 ]. It indicates the importance of this platform across the world for the spreading of messages. The healthcare professionals rated scientific journals at just about 40.9%. It may be due to the low availability of high-quality evidence or poor access that many healthcare professionals in India have to scientific journals, which are mostly published out of developed countries [ 21 ]. In a pandemic situation, this disparity in access can be catastrophic and hence most journals have provided open access to all coronavirus-related publications. Healthcare professionals accessed websites such as WHO, Medscape, MOHFW, CDC, Worldometers, covid19.com , ICMR, UpToDate, and PubMed, for reliable information, which is an indicator of their faith in health organizations across the world. Interestingly though at a low 29.3%, much of the general public accessed similar websites such as WHO, MOHFW, CDC, and ICMR. At the time that the survey was administered, online webinars via zoom or other applications were just beginning in India to educate clinicians searching for answers. This is not reflected in our current study due to many of the responses being filled before the same or the respondents not being part of these audiences. The study authors have attended many of these meetings conducted by the Indian Academy of Pediatrics, etc., and this information is made available via email or WhatsApp messages. In a changing world, both healthcare professionals and the general public need to have reliable and accurate sources of information.
The severity of illness was well identified by all who were surveyed as being difficulty in breathing. Another heartening aspect was that precautionary measures were well known to both the groups of participants with appropriate hand washing techniques, avoidance of public gatherings, and covering of the mouth while coughing and sneezing as the top three precautionary measures. During the first week of March in India, all the telephone and cellular caller tunes were changed to advisories of how to prevent coronavirus disease and when to seek medical help, which included the above messages apart from appeals on television, etc [ 22 ].
There was less knowledge related to treatment and vaccine among both healthcare professionals and the general public, which was a disappointing finding for healthcare professionals as they were expected to be aware of this. The same could be said of the knowledge of the infectivity period and duration of being asymptomatic after infection. There was a good knowledge of the usage of masks among the general public and healthcare professionals except for the usage of medical masks for healthy people to protect themselves. The ICMR and other bodies have issued guidelines on the usage of masks and this seems to have been disseminated widely [ 23 ]. There was also a low insistence on the need for testing those without respiratory difficulty. In a scenario where testing resources are limited, this is an appropriate response but since it is possible to have the infection without respiratory difficulty, especially early on, this disinterest in getting tested, especially in healthcare personnel is worrisome when there is enough evidence of spread from asymptomatic and mildly symptomatic persons. It is also likely that this response may be due to the fact during the time that this questionnaire was administered, the total cases rose from 400+ to about 800+ and the testing strategy of ICMR was limited to those with contact or travel to SARS-CoV-2-affected areas [ 24 ].
Since writing this manuscript, except for a single source event of a religious gathering in Delhi, which caused the doubling of cases to increase from about seven days to 4.1 days, it is reasonable to conclude that adequate knowledge exists among the general public. We can only hope that this would be enough to ensure that lockdown to reduce transmission and flatten the curve will be successful [ 25 - 28 ].
The COVID-19 pandemic has affected the world in various ways. The deficiency of information, the need for accurate information, and the rapidity of its dissemination are important, as this pandemic requires the cooperation of entire populations. The rapid survey that we conducted had a good response and we show that healthcare professionals and the general public were quite well informed about the coronavirus. They are aware of the measures needed to be taken to reduce the spread of the disease. The knowledge present allows the authors to speculate that the lockdown in India would be effective. The public receives a large amount of information from social media such as WhatsApp and the medical fraternity and government need to develop strategies to ensure that accurate information needs to spread in these fora. The public awareness is quite high and it is important that the knowledge of communication channels be known and be kept at the topmost priority throughout the pandemic.
We are thankful to Dr. Mili Shah for language check of our manuscript.
The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.
The authors have declared that no competing interests exist.
Consent was obtained by all participants in this study. INSTITUTIONAL ETHICS COMMITTEE ‐ 2 H M PATEL CENTRE FOR MEDICAL CARE AND EDUCATION, KARAMSAD [ECR/1123/Inst/GJ/2018] issued approval IEC/ HMPCMCE/ 2019 / Ex. 07/. The following is part of the text of the approval letter indicating approval for the study. "Your research proposal ‘Response of the public and health care providers to a pandemic of a new virus’ was submitted for review and approval by committee members under Exempt Review. As it involves collection of data using anonymous online questionnaire with maintenance of privacy and confidentiality, it qualified for an Exempt from Full Committee Review. The matter was reviewed by Committee Members and decided to review it under ‘Exempt from full committee’ review. After review and subsequent clarification by you, the project is approved by IEC in its present form. As the online form has information and consent section, which needs to be read and accepted by the respondents before answering the study questions, committee waivers the need for any other consent for data collection."
Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.
Conclusion and mission on COVID-19
Sergey Lavrov Photo: Courtesy of the Ministry of Foreign Affairs of Russia