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Health equity and COVID-19: global perspectives
letter
Author(s):
Efrat Shadmi
1
,
,
Yingyao Chen
2 ,
Inês Dourado
3 ,
Inbal Faran-Perach
1
,
4
,
5 ,
John Furler
6 ,
Peter Hangoma
7
,
8
,
9 ,
Piya Hanvoravongchai
10
,
11
,
12 ,
Claudia Obando
13 ,
Varduhi Petrosyan
14 ,
Krishna D. Rao
15 ,
Ana Lorena Ruano
16
,
17 ,
Leiyu Shi
18 ,
Luis Eugenio de Souza
3 ,
Sivan Spitzer-Shohat
19 ,
Elizabeth Sturgiss
20 ,
Rapeepong Suphanchaimat
21
,
22 ,
Manuela Villar Uribe
23 ,
Sara Willems
24
Publication date (Electronic):
26 June 2020
Publisher:
BioMed Central
Read this article at
There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.
Abstract
The COVID-19 is disproportionally affecting the poor, minorities and a broad range of vulnerable populations, due to its inequitable spread in areas of dense population and limited mitigation capacity due to high prevalence of chronic conditions or poor access to high quality public health and medical care. Moreover, the collateral effects of the pandemic due to the global economic downturn, and social isolation and movement restriction measures, are unequally affecting those in the lowest power strata of societies. To address the challenges to health equity and describe some of the approaches taken by governments and local organizations, we have compiled 13 country case studies from various regions around the world: China, Brazil, Thailand, Sub Saharan Africa, Nicaragua, Armenia, India, Guatemala, United States of America (USA), Israel, Australia, Colombia, and Belgium. This compilation is by no-means representative or all inclusive, and we encourage researchers to continue advancing global knowledge on COVID-19 health equity related issues, through rigorous research and generation of a strong evidence base of new empirical studies in this field.
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Most cited references25
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The COVID‐19 epidemic
The current outbreak of the novel coronavirus SARS‐CoV‐2 (coronavirus disease 2019; previously 2019‐nCoV), epi‐centred in Hubei Province of the People’s Republic of China, has spread to many other countries. On 30. January 2020, the WHO Emergency Committee declared a global health emergency based on growing case notification rates at Chinese and international locations. The case detection rate is changing daily and can be tracked in almost real time on the website provided by Johns Hopkins University 1 and other forums. As of midst of February 2020, China bears the large burden of morbidity and mortality, whereas the incidence in other Asian countries, in Europe and North America remains low so far. Coronaviruses are enveloped, positive single‐stranded large RNA viruses that infect humans, but also a wide range of animals. Coronaviruses were first described in 1966 by Tyrell and Bynoe, who cultivated the viruses from patients with common colds 2. Based on their morphology as spherical virions with a core shell and surface projections resembling a solar corona, they were termed coronaviruses (Latin: corona = crown). Four subfamilies, namely alpha‐, beta‐, gamma‐ and delta‐coronaviruses exist. While alpha‐ and beta‐coronaviruses apparently originate from mammals, in particular from bats, gamma‐ and delta‐viruses originate from pigs and birds. The genome size varies between 26 kb and 32 kb. Among the seven subtypes of coronaviruses that can infect humans, the beta‐coronaviruses may cause severe disease and fatalities, whereas alpha‐coronaviruses cause asymptomatic or mildly symptomatic infections. SARS‐CoV‐2 belongs to the B lineage of the beta‐coronaviruses and is closely related to the SARS‐CoV virus 3, 4. The major four structural genes encode the nucleocapsid protein (N), the spike protein (S), a small membrane protein (SM) and the membrane glycoprotein (M) with an additional membrane glycoprotein (HE) occurring in the HCoV‐OC43 and HKU1 beta‐coronaviruses 5. SARS‐CoV‐2 is 96% identical at the whole‐genome level to a bat coronavirus 4. SARS‐CoV‐2 apparently succeeded in making its transition from animals to humans on the Huanan seafood market in Wuhan, China. However, endeavours to identify potential intermediate hosts seem to have been neglected in Wuhan and the exact route of transmission urgently needs to be clarified. The initial clinical sign of the SARS‐CoV‐2‐related disease COVID‐19 which allowed case detection was pneumonia. More recent reports also describe gastrointestinal symptoms and asymptomatic infections, especially among young children 6. Observations so far suggest a mean incubation period of five days 7 and a median incubation period of 3 days (range: 0–24 days) 8. The proportion of individuals infected by SARS‐CoV‐2 who remain asymptomatic throughout the course of infection has not yet been definitely assessed. In symptomatic patients, the clinical manifestations of the disease usually start after less than a week, consisting of fever, cough, nasal congestion, fatigue and other signs of upper respiratory tract infections. The infection can progress to severe disease with dyspnoea and severe chest symptoms corresponding to pneumonia in approximately 75% of patients, as seen by computed tomography on admission 8. Pneumonia mostly occurs in the second or third week of a symptomatic infection. Prominent signs of viral pneumonia include decreased oxygen saturation, blood gas deviations, changes visible through chest X‐rays and other imaging techniques, with ground glass abnormalities, patchy consolidation, alveolar exudates and interlobular involvement, eventually indicating deterioration. Lymphopenia appears to be common, and inflammatory markers (C‐reactive protein and proinflammatory cytokines) are elevated. Recent investigations of 425 confirmed cases demonstrate that the current epidemic may double in the number of affected individuals every seven days and that each patient spreads infection to 2.2 other individuals on average (R0) 6. Estimates from the SARS‐CoV outbreak in 2003 reported an R0 of 3 9. A recent data‐driven analysis from the early phase of the outbreak estimates a mean R0 range from 2.2 to 3.58 10. Dense communities are at particular risk and the most vulnerable region certainly is Africa, due to dense traffic between China and Africa. Very few African countries have sufficient and appropriate diagnostic capacities and obvious challenges exist to handle such outbreaks. Indeed, the virus might soon affect Africa. WHO has identified 13 top‐priority countries (Algeria, Angola, Cote d’Ivoire, the Democratic Republic of the Congo, Ethiopia, Ghana, Kenya, Mauritius, Nigeria, South Africa, Tanzania, Uganda, Zambia) which either maintain direct links to China or a high volume of travel to China. Recent studies indicate that patients ≥60 years of age are at higher risk than children who might be less likely to become infected or, if so, may show milder symptoms or even asymptomatic infection 7. As of 13. February 2020, the case fatality rate of COVID‐19 infections has been approximately 2.2% (1370/60363; 13. February 2020, 06:53 PM CET); it was 9.6% (774/8096) in the SARS‐CoV epidemic 11 and 34.4% (858/2494) in the MERS‐CoV outbreak since 2012 12. Like other viruses, SARS‐CoV‐2 infects lung alveolar epithelial cells using receptor‐mediated endocytosis via the angiotensin‐converting enzyme II (ACE2) as an entry receptor 4. Artificial intelligence predicts that drugs associated with AP2‐associated protein kinase 1 (AAK1) disrupting these proteins may inhibit viral entry into the target cells 13. Baricitinib, used in the treatment of rheumatoid arthritis, is an AAK1 and Janus kinase inhibitor and suggested for controlling viral replication 13. Moreover, one in vitro and a clinical study indicate that remdesivir, an adenosine analogue that acts as a viral protein inhibitor, has improved the condition in one patient 14, 15. Chloroquine, by increasing the endosomal pH required for virus‐cell fusion, has the potential of blocking viral infection 15 and was shown to affect activation of p38 mitogen‐activated protein kinase (MAPK), which is involved in replication of HCoV‐229E 16. A combination of the antiretroviral drugs lopinavir and ritonavir significantly improved the clinical condition of SARS‐CoV patients 17 and might be an option in COVID‐19 infections. Further possibilities include leronlimab, a humanised monoclonal antibody (CCR5 antagonist), and galidesivir, a nucleoside RNA polymerase inhibitor, both of which have shown survival benefits in several deadly virus infections and are being considered as potential treatment candidates 18. Repurposing these available drugs for immediate use in treatment in SARS‐CoV‐2 infections could improve the currently available clinical management. Clinical trials presently registered at ClinicalTrials.gov focus on the efficacy of remdesivir, immunoglobulins, arbidol hydrochloride combined with interferon atomisation, ASC09F+Oseltamivir, ritonavir plus oseltamivir, lopinavir plus ritonavir, mesenchymal stem cell treatment, darunavir plus cobicistat, hydroxychloroquine, methylprednisolone and washed microbiota transplantation 19. Given the fragile health systems in most sub‐Saharan African countries, new and re‐emerging disease outbreaks such as the current COVID‐19 epidemic can potentially paralyse health systems at the expense of primary healthcare requirements. The impact of the Ebola epidemic on the economy and healthcare structures is still felt five years later in those countries which were affected. Effective outbreak responses and preparedness during emergencies of such magnitude are challenging across African and other lower‐middle‐income countries. Such situations can partly only be mitigated by supporting existing regional and sub‐Saharan African health structures.
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COVID-19 exacerbating inequalities in the US
Aaron Van Dorn, Rebecca E Cooney, Miriam Sabin (2020)
COVID-19 does not affect everyone equally. In the US, it is exposing inequities in the health system. Aaron van Dorn, Rebecca E Cooney, and Miriam L Sabin report from New York. In the US, New York City has so far borne the brunt of the coronavirus disease 2019 (COVID-19) pandemic, with the highest reported number of cases and the highest death toll in the country. The first COVID-19 case in the city was reported on March 1, but community transmission was firmly established on March 7. As of April 14, New York State has tested nearly half a million people, among whom 195 031 have tested positive. In New York City alone, 106 763 people have tested positive and 7349 have died. “New York is the canary in the coal mine. What happens to New York is going to wind up happening to California, and Washington State and Illinois. It's just a matter of time”, said New York Governor Andrew Cuomo, while asking for greater federal assistance. The response within New York City, known for its historically strong public health responses, has been to ramp up for the surge, but also to tailor the approach to address some of the most basic touchpoints that could worsen health outcomes, including providing three meals a day to all New York residents in need. Oxiris Barbot, commissioner of the New York City Department of Health and Mental Hygiene stated, “Our primary focus at this moment has to be on keeping our city's communities safe. This means supporting the public hospitals with supplies; connecting underserved people to free access to care; and delivering health guidance through the trusted voices of community organizations. The COVID-19 pandemic will come to an end eventually, but what is needed afterward is a renewed focus to ensure that health is not a byproduct of privilege. Public health has a fundamental role to play in shaping our future to be more just and equitable.” Confirming existing disparities, within New York City and other urban centres, African American and other communities of colour have been especially affected by the COVID-10 pandemic. Across the country, deaths due to COVID-19 are disproportionately high among African Americans compared with the population overall. In Milwaukee, WI, three quarters of all COVID-19 related deaths are African American, and in St Louis, MO, all but three people who have died as a result of COVID-19 were African American. According to Sharrelle Barber of Drexel University Dornsife School of Public Health (Philadelphia, PA, USA), the pre-existing racial and health inequalities already present in US society are being exacerbated by the pandemic. “Black communities, Latino communities, immigrant communities, Native American communities—we're going to bear the disproportionate brunt of the reckless actions of a government that did not take the proper precautions to mitigate the spread of this disease”, Barber said. “And that's going to be overlaid on top of the existing racial inequalities.” Part of the disproportionate impact of the COVID-19 pandemic on communities of colour has been structural factors that prevent those communities from practicing social distancing. Minority populations in the US disproportionally make up “essential workers” such as retail grocery workers, public transit employees, and health-care workers and custodial staff. “These front-line workers, disproportionately black and brown, then are typically a part of residentially segregated communities”, said Barber. “They don't have that privilege of quote unquote ‘staying at home’, connecting those individuals to the communities they are likely to be a part of because of this legacy of residential segregation, or structural racism in our major cities and most cities in the United States.” The negative consequences of health disparities for people who live in rural areas in the US were already a problem before the pandemic. Underserved African Americans face higher HIV incidence and greater maternal and infant mortality rates. Undocumented Latino communities working in rural industries such as farming, poultry, and meat production often have no health insurance. Poor white communities have been badly hit by the opioid crisis and across rural areas, especially in the southern states, high rates of non-communicable diseases are driven by conditions such as obesity. With higher COVID-19 mortality among those with underlying health conditions, these areas could be hit hard. © 2020 Spencer Platt/Getty Images 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. 14 US states (mostly in the south and the Plains) have refused to accept the Affordable Care Act Medicaid expansion, leaving millions of the poorest and sickest Americans without access to health care, with the added effect of leaving many regional and local hospitals across the US closed or in danger of closing because of the high cost of medical care and a high proportion of rural uninsured and underinsured people. People with COVID-19 in those states will have poor access to the kind of emergency and intensive care they will need. Native American populations also have disproportionately higher levels of underlying conditions, such as heart disease and diabetes, that would make them particularly at risk of complications from COVID-19. Health care for Native American communities has a unique place in the US. As part of treaty obligations owed by the US government to tribal groups, the Indian Health Service (IHS) provides direct point of care health care for the 2·6 million Native Americans living on tribal reservations. According to the IHS, there are currently 985 confirmed cases of COVID-19 on tribal reservations, and 536 cases in the Navajo Nation alone (the largest reservation). However, the IHS's ability to respond to the crisis might be limited: according to according to Kevin Allis, Chief Executive Officer of the National Congress of American Indians, the largest Native American advocacy organisation, the IHS has only 1257 hospital beds and 36 intensive care units, and many people covered by the IHS are hours away from the nearest IHS facility. The IHS also does not cover care from external providers. Although there is a provision of the CARES Act stimulus bill that is intended to cover those costs, it is unclear how effective it would be if someone covered by the IHS is transferred to a non-IHS facility. © 2020 Reuters/Kevin Lamarque 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. The CARES Act also included US$8 billion to supplement the health and economies of Native Americans and Alaska Natives. Even that number was an increase from what President Donald Trump's administration originally wanted. “We knew the White House wanted to give us nothing”, Allis said. “And senate Republicans were okay with a billion and it fine-tuned its way to $8 billion.” But the deep history of injustice by the US government towards these people means that the US response will be looked on with suspicion. At the national level, the response has varied widely by state, with many states that voted for Trump in 2016—notably Florida, Texas, and Georgia—responding to the emerging pandemic later and with more lax measures. Florida Governor Ron DeSantis, a Republican Trump ally, was slow to implement social-distancing measures and close non-essential businesses, and Georgia Governor Brian Kemp ordered beaches closed by local authorities to be reopened on April 3. However, the trend has not been universal: in Ohio, Republican Governor Mike DeWine was swift in issuing orders to shut non-essential businesses and in responding to the crisis. The federal response has also been overtly political. States with governors that Trump sees as political allies (such as Florida), have received the full measure of requested personal protective equipment from the federal stockpile, while states with governors whom Trump identifies as political enemies (such as New York's Cuomo, Oregon's Jay Inslee, and Michigan's Gretchen Whitmer, all Democrats) have received only a fraction of their requests. Trump has also publicly attacked the responses of those governors on Twitter and during his daily briefings. In distributing funds made available by the CARES Act, Trump also appears to be playing favourites: New York received only a fraction of the $30 billion hospital relief funds from the bill ($12 000 per patient), while other states much more lightly affected received more ($300 000 per patient in Montana and Nebraska, and more than $470 000 per patient in West Virginia, all states that voted for Trump in 2016). Although the numbers of reported cases seem to be levelling off in New York City and other urban areas, perhaps evidence that social-distancing measures are beginning to have an effect, emerging morbidity and mortality data have already clearly demonstrated what many have feared: a pandemic in which the brunt of the effects fall on already vulnerable US populations, and in which the deeply rooted social, racial, and economic health disparities in the country have been laid bare.
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COVID-19: a potential public health problem for homeless populations
Jack Tsai, Michal Wilson (2020)
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is infecting people throughout the world. It is probable that coronavirus disease (COVID-19) will be transmitted to people experiencing homelessness, which will become a major problem in particular in North America where there are sizable populations of people experiencing homelessness in nearly every metropolitan city in the USA and Canada. In the USA, more than 500 000 people were reported to be experiencing homelessness on any given night over the past decade (2007–19). 1 The State of Homelessness in Canada 2016 report 2 estimated 35 000 people are experiencing homelessness on any given night in Canada. People experiencing homelessness live in environments that are conducive to a disease epidemic. Many people experiencing homelessness live in congregate living settings—be it formal (ie, shelters or halfway houses) or informal (ie, encampments or abandoned buildings)—and might not have regular access to basic hygiene supplies or showering facilities, all of which could facilitate virus transmission. People experiencing homelessness are a vulnerable group, and their potential exposure to COVID-19 might negatively affect their ability to be housed, and their mental and physical health. People experiencing homelessness aged younger than 65 years have all-cause mortality that is 5–10 times higher than that of the general population. 3 COVID-19 infection might further increase this mortality disparity. Many people experiencing homelessness have chronic mental and physical conditions, 4 engage in high rates of substance abuse (including sharing of needles), 5 and have often less access to health care, 6 all of which could lead to potential problems with screening, quarantining, and treating people who might have COVID-19. Such problems have occurred as recently as last year, when outbreaks of typhus, hepatitis A, tuberculosis, trench fever, and Shigella bacteria were reported among people experiencing homelessness in US cities with large homeless populations. 7 There are some additional issues, which are unique to people experiencing homelessness, to consider with regards to COVID-19. Homeless populations might be more transient and geographically mobile than individuals in the general population, 8 making it difficult to track and prevent transmission and to treat those who need care. COVID-19 was recently found to be transmittable via the oral–faecal route. 9 Some major US cities with large homeless populations, like San Francisco, have experienced issues with public defecation, which might pose an additional transmission risk for people experiencing homelessness and other individuals. Together, the multitude of potential vulnerabilities and risks for people experiencing homelessness in becoming infected, needing care, and transmitting COVID-19 cannot be ignored and must be planned for. Some lessons can be learned from the response to severe acute respiratory syndrome among homeless service providers nearly two decades ago. 10 Testing kits and training on how to recognise COVID-19 should be widely disseminated to homeless service providers and deployed in shelters, encampments, and street outreach. Alternative spaces might be needed to quarantine and treat people experiencing homelessness. If cities impose a lockdown to prevent COVID-19 transmission, there are few emergency preparedness plans to transport and provide shelter for the large number of people experiencing homelessness. In lockdowns, public spaces are closed, movement outside homes are restricted, and major roads of transport might be closed, all of which might negatively affect people experiencing homelessness. It is unclear how and where unsheltered people experiencing homelessness will be moved to if quarantines and lockdowns are implemented. In such a scenario, closures of shelters and other high-density communal settings (eg, drop-in centres and soup kitchens) are possible, which could increase the number of unsheltered people experiencing homelessness and reduce their access to needed services. Lockdowns and disease containment procedures might also be deleterious to the mental health of people experiencing homelessness, many of whom have fears around involuntary hospitalisation and incarceration. 11 In response to COVID-19, the State of Washington has declared a state of emergency, allowing cities to take extraordinary measures, which has included King County moving people infected with COVID-19 to housing units that were originally intended to provide housing for people experiencing homelessness. 12 As other cities follow suit, these actions might further displace people experiencing homelessness and put them at greater risk of COVID-19. Another complicating matter is that in December, 2019, the US Supreme Court declined to review the case of Martin v City of Boise, upholding a ruling that cities cannot arrest or punish people for sleeping on public property unless cities have provided adequate and accessible indoor accommodations. This legal precedent prevents the criminalisation of homelessness, but it is unclear if and how it will be applied during COVID-19 outbreaks. Cities with large homeless populations might face unique challenges while trying to contain COVID-19 and addressing homelessness, with the potential for both issues to exacerbate one another.
Author and article information
Contributors
Efrat Shadmi:
ORCID: http://orcid.org/0000-0001-9752-5724
eshadmi@univ.haifa.ac.il
Journal
Journal ID (nlm-ta): Int J Equity Health
Journal ID (iso-abbrev): Int J Equity Health
Title:
International Journal for Equity in Health
Publisher:
BioMed Central
(London
)
ISSN
(Electronic):
1475-9276
Publication date
(Electronic):
26
June
2020
Publication date PMC-release: 26
June
2020
Publication date Collection: 2020
Volume: 19
Electronic Location Identifier: 104
Affiliations
[1
]GRID grid.18098.38, ISNI 0000 0004 1937 0562, The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences,
, University of Haifa, ; 31905 Mount Carmel, Israel
[2
]GRID grid.8547.e, ISNI 0000 0001 0125 2443, School of Public Health, , Fudan University, ; Shanghai, PR China
[3
]GRID grid.8399.b, ISNI 0000 0004 0372 8259, Health Collective Institute, , Federal University of Bahia, ; Salvador, Brazil
[4
]GRID grid.414840.d, ISNI 0000 0004 1937 052X, The mobile clinic for minimizing prostitution damages, , Ministry of Health, ; Haifa, Israel
[6
]GRID grid.1008.9, ISNI 0000 0001 2179 088X, Department of General Practice, Faculty of Medicine, Dentistry and Health Science,
, The University of Melbourne, ; Melbourne, Australia
[7
]GRID grid.12984.36, ISNI 0000 0000 8914 5257, Department of Health Policy and Management, School of Public Health, , University of Zambia, ; Lusaka, Zambia
[9
]GRID grid.7914.b, ISNI 0000 0004 1936 7443, Bergen Centre for Ethics in Priority Setting (BCEP), , University of Bergen, ; Bergen, Norway
[10
]GRID grid.7922.e, ISNI 0000 0001 0244 7875, Faculty of Medicine, , Chulalongkorn University, ; Bangkok, Thailand
[13
]GRID grid.12650.30, ISNI 0000 0001 1034 3451, Department of Clinical, , Umeå University, ; Umeå, Sweden
[14
]GRID grid.78780.30, ISNI 0000 0004 0613 1044, Gerald and Patricia Turpanjian School of Public Health, , American University of Armenia, ; Yerevan, Armenia
[15
]GRID grid.21107.35, ISNI 0000 0001 2171 9311, Department of International Health, , Johns Hopkins University, ; Baltimore, USA
[16
]GRID grid.507190.a, Center for the Study of Equity and Governance in Health Systems, CEGSS, ; Guatemala City, Guatemala
[17
]GRID grid.7914.b, ISNI 0000 0004 1936 7443, Center for International Health, , University of Bergen, ; Bergen, Norway
[18
]GRID grid.21107.35, ISNI 0000 0001 2171 9311, Health Policy and Management, Bloomberg School of Public Health, , Johns Hopkins University, ; Baltimore, USA
[19
]GRID grid.22098.31, ISNI 0000 0004 1937 0503, The Azrieli Faculty of Medicine, , Bar-Ilan University, ; Zefat, Israel
[20
]GRID grid.1002.3, ISNI 0000 0004 1936 7857, Department of General Practice, , Monash University, ; Melbourne, Australia
[21
]GRID grid.415836.d, ISNI 0000 0004 0576 2573, International Health Policy Program, Ministry of Public Health, ; Nonthaburi, Thailand
[22
]GRID grid.415836.d, ISNI 0000 0004 0576 2573, Division of Epidemiology, Department of Disease Control, , Ministry of Public Health, ; Bangkok, Thailand
Author information
Efrat Shadmi
http://orcid.org/0000-0001-9752-5724
Article
Publisher ID: 1218DOI: 10.1186/s12939-020-01218-z
PMC ID: 7316580
PubMed ID: 32586388
SO-VID: 4960a25f-7893-4c2a-ba76-38077aa15856
Copyright © © The Author(s) 2020
License:
Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
History
Date
received
: 29
May
2020
Date
accepted
: 10
June
2020
Categories
Subject:
Commentary
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ScienceOpen disciplines: Health & Social care