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      COVID-19 as social disability: the opportunity of social empathy for empowerment

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          Abstract

          Summary box COVID-19 has conferred new experiential knowledge on society and a rare opportunity to better understand the social model of disability and to improve the lives of persons with disabilities. The COVID-19 experience may offer contextual knowledge of the prepandemic lives of persons with disabilities and foster greater social awareness, responsibility and opportunities for change towards a more inclusive society. Information, family and social relationships, health protection and healthcare, education, transport and employment should be accessible for all groups of the population. The means must be developed and deployed to ensure equity – the deployment of resources so that people with different types of needs have the same opportunities for living good lives in inclusive communities. We have learnt from COVID-19 that inclusive healthcare and universal access should be the new normal, that its provision as a social good is both unifying and empowering for society as a whole. Social empathy is ‘the ability to more deeply understand people by perceiving or experiencing their life situations and as a result gain insight into structural inequalities and disparities’.1 Social empathy comprises three elements: individual empathy, contextual understanding and social responsibility.1 COVID-19 has created a population-wide experience of exclusion that is only usually experienced by subgroups of the general population.2 Notably, persons with disability, in their everyday lives, commonly experience many of the phenomena that have only recently been experienced by members of the general population. Although about 1 billion people or approximately 15% of the world’s population, have some form of disability, ignorance and fear about disability and discrimination towards people with disability still persists.3 Public understanding of disability is shaped by a medical model of individual deficit, ignoring societal barriers that transpose the attribute of some type of psychological or bodily impairment into the social experience of disability.4 This is the core message of the social model of disability that recognises the role of the social environment in the experience of disability.4 While there are many personal and social aspect of disability that people without a disability may never experience, there is an opportunity for the population-wide experience of COVID-19 to change others’ perceptions of people with disability. The reported differential impact of COVID-19 on persons with disabilities highlights systemic barriers and their impact on those left behind by the social system.5 6 The conflating of disability with ‘comorbidity’ or ‘frailty’ is not due to any biological predilection for the virus but rather to implicit ableist assumptions that the ‘elderly’ or persons with pre-exiting ‘conditions’ are similar to people with disability. This also ignores the intersectionality of discrimination (gender, income, ethnicity and education) that compounds and heightens risk for persons with disability.4 6 The COVID-19 experience may offer contextual experience of the prepandemic lives of persons with disabilities and in doing so foster greater social responsibility and opportunities for change and a more inclusive society. In the following commentary, we highlight this by drawing parallels between articles of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD)7 about the COVID-19 experience and common experiences of people with disabilities. Confinement, isolation, lack of connection and interaction with immediate surroundings and family is an aspect of the COVID-19 experience and is highlighted in Article 19 (UNCRPD): ‘Living independently and being included in the community’.7 The COVID-19 experience has given some a sense of what it must be like to live in institutions and not being able to ‘get out’, or living in a house in the community but still feeling apart from the local community. Isolation and loneliness are a common experience for some people with disability.6 Feeling well informed—having access to good information—has, for some, been a struggle in COVID-19 times. UNCRPD Article 21 concerns ‘access to information’7; due to the COVID-19 pandemic, the general population have experienced the challenges of receiving information that is not always clear or understandable.5 6 This is similar to the everyday experience of some people with disabilities who have to contend with public health information that is rarely available in accessible formats (sign language, captioning, easy-to-read or braille documents). There have also been reports of some people being made to feel ‘different’ because of their COVID-19 status. Article 5 of the UNCRPD relates to ‘Equality and Non-Discrimination.’7 The onset of COVID-19 has shown that people might be discriminated against based on nationality, age or other attributes because of the perceived predilection for COVID-19.8 9 The advent of COVID-19, may have created anxiety about contamination, and fearful reactions to and stigmatisation of those who are believed to have come in contact with it.9 This may even extend to the development of prejudice towards whole groups—Asian people8—the vast majority of whom obviously have no association with COVID-19. The recent plan by the Chilean government to issue ‘release certificates’ to persons recovered from COVID-19 is another instance of use of illness as a divisive factor.10 This may be representative of the experience of legitimacy/illegitimacy experienced by some people with disability. Access to healthcare for persons with or without COVID-19 has become difficult and is related to the Article 25 of the UNCRPD that describes ‘right to health’.7 COVID-19 has led to prioritisation of people who receive healthcare services, with the concept of ‘worth’ attached to individuals, based on pre-existing health status, with cancelled, delayed or suspended services.6 11 12 These challenges typify the barriers to accessing healthcare experienced by persons with disabilities, due to limited accessible services, poor understanding of individual needs, and lack of appropriate equipment.13 Reduced opportunities for or access to education, work and employment are the focus of Articles 24 and 27, respectively.7 The COVID-19 experience offers insights into the experience of loss of meaning, loss of opportunity to participate, loss of income, living on benefits but not being able to contribute, loss of identity as an independent and valued asset of the community and perhaps an inability to work or study remotely due to lack of accessibility.5 However, we now have a greater understanding as a society that alternative work and/or education formats are possible and are effective, which may result in increased chances for persons with disabilities and equalise opportunity in the future. These few examples provide the general population an opportunity for social empathy and action to enhance social inclusion for people with disability. We offer the following recommendations to ensure that this moment of collective social insight is not squandered, repressed or simply forgotten as we rush back to ‘normal’: First, it obvious that being forced to stay indoors is not pleasant for anybody, nor is it socially acceptable for others to be lonely or isolated. It is important to promote varied mechanisms for interaction, inclusion and participation within and across our communities for persons with disabilities. Second, information should be accessible to all groups of the population, and alternative means of communication should be incorporated systematically to inform and enable all persons based on their own needs and abilities. Third, some population groups are more likely to experience discrimination and to be pushed into the corners of society. Social policies that promote equity—the distribution of resources so that people with different attributes have the same opportunities—in society will create a society for all. Fourth, we have learnt from COVID-19 that inclusive healthcare is desired by all, that it has the potential to weave us together and that no one should be denied access based on personal attributes. Universal healthcare should be the new normal not a privilege.14 Finally, we now understand the socioeconomic experiences of vulnerable groups in settings where social welfare is absent.12 15 Social protection and benefits are among the measures recommended by the International Labour Organization to fight COVID-19.16 As we come out of COVID-19, it is important to recognise the purpose and meaning of engaging in work, for all, across all abilities. Alternative means of working and studying should allow for greater accessibility for everyone. COVID-19 has conferred new experiential knowledge on all of us. We have a rare opportunity to understand and better the lives of persons with disabilities for whom some aspects of the COVID- 19 experience are enduring. This allows us greater understanding of the importance of implementing in full a social and human rights model of disability, as outlined in the UNCRPD. To not learn from history may well doom us to repeat it, but to not learn from our experience of the present, is to wilfully neglect the opportunities of the moment. As a society have we learnt that we are better than that?

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          Public responses to the novel 2019 coronavirus (2019‐nCoV) in Japan: Mental health consequences and target populations

          In December 2019, cases of life‐threatening pneumonia were reported in Wuhan, China. A novel coronavirus (2019‐nCoV) was identified as the source of infection. The number of reported cases has rapidly increased in Wuhan as well as other Chinese cities. The virus has also been identified in other parts of the world. On 30 January 2020, the World Health Organization (WHO) declared this disease a ‘public health emergency of international concern.’ As of 3 February 2020, the Chinese government had reported 17 205 confirmed cases in Mainland China, and the WHO had reported 146 confirmed cases in 23 countries outside China.1 The virus has not been contained within Wuhan, and other major cities in China are likely to experience localized outbreaks. Foreign cities with close transport links to China could also become outbreak epicenters without careful public health interventions.2 In Japan, economic impacts and social disruptions have been reported. Several Japanese individuals who were on Japanese‐government‐chartered airplanes from Wuhan to Japan were reported as coronavirus‐positive. Also, human‐to‐human transmission was confirmed in Nara Prefecture on 28 January 2020. Since then, the public has shown anxiety‐related behaviors and there has been a significant shortage of masks and antiseptics in drug stores.3 The economic impact has been substantial. Stock prices have dropped in China and Japan, and other parts of the world are also showing some synchronous decline. As of 3 February 2020, no one had died directly from coronavirus infection in Japan. Tragically, however, a 37‐year‐old government worker who had been in charge of isolated returnees died from apparent suicide.4 This is not the first time that the Japanese people have experienced imperceptible‐agent emergencies – often dubbed as ‘CBRNE’ (i.e., chemical, biological, radiological, nuclear, and high‐yield explosives). Japan has endured two atomic bombings in 1945, the sarin gas attacks in 1995, the H1N1 influenza pandemic in 2009, and the Fukushima nuclear accident in 2011: all of which carried fear and risk associated with unseen agents. All of these events provoked social disruption.5, 6 Overwhelming and sensational news headlines and images added anxiety and fear to these situations and fostered rumors and hyped information as individuals filled in the absence of information with rumors. The affected people were subject to societal rejection, discrimination, and stigmatization. Fukushima survivors tend to attribute physical changes to the event (regardless of actual exposure) and have decreased perceived health, which is associated with decreased life expectancy.7, 8 Fear of the unknown raises anxiety levels in healthy individuals as well as those with preexisting mental health conditions. For example, studies of the 2001 anthrax letter attacks in the USA showed long‐term mental health adversities as well as lowered health perception of the infected employees and responders.9 Public fear manifests as discrimination, stigmatization, and scapegoating of specific populations, authorities, and scientists.10 As we write this letter, the coronavirus emergency is rapidly evolving. Nonetheless, we can more or less predict expected mental/physical health consequences and the most vulnerable populations. First, peoples' emotional responses will likely include extreme fear and uncertainty. Moreover, negative societal behaviors will be often driven by fear and distorted perceptions of risk. These experiences might evolve to include a broad range of public mental health concerns, including distress reactions (insomnia, anger, extreme fear of illness even in those not exposed), health risk behaviors (increased use of alcohol and tobacco, social isolation), mental health disorders (post‐traumatic stress disorder, anxiety disorders, depression, somatization), and lowered perceived health. It is essential for mental health professionals to provide necessary support to those exposed and to those who deliver care. Second, particular effort must be directed to vulnerable populations, which include: (i) the infected and ill patients, their families, and colleagues; (ii) Chinese individuals and communities; (iii) individuals with pre‐existing mental/physical conditions; and, last but not least, (iv) health‐care and aid workers, especially nurses and physicians working directly with ill or quarantined persons. If nothing else, the death of the government quarantine worker must remind us to recognize the extent of psychological stress associated with imperceptible agent emergencies and to give paramount weight to the integrity and rights of vulnerable populations. Disclosure statement The authors declare no conflicts of interest. Supporting information File S1 Online health information sources for the novel coronavirus (2019‐nCoV). Click here for additional data file.
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            The COVID-19 response must be disability inclusive

            There are more than 1 billion people living with disabilities (PLWD) worldwide. The coronavirus disease 2019 (COVID-19) pandemic is likely to disproportionately affect these individuals, putting them at risk of increased morbidity and mortality, underscoring the urgent need to improve provision of health care for this group and maintain the global health commitment to achieving Universal Health Coverage (UHC). 1 PLWD, including physical, mental, intellectual, or sensory disabilities, are less likely to access health services, and more likely to experience greater health needs, worse outcomes, and discriminatory laws and stigma. 2 COVID-19 threatens to exacerbate these disparities, particularly in low-income and middle-income countries, where 80% of PLWD reside, and capacity to respond to COVID-19 is limited.3, 4 Preparedness and response planning must be inclusive of and accessible to PLWD, recognising and addressing three key barriers. First, PLWD might have inequities in access to public health messaging. All communication should be disseminated in plain language and across accessible formats, through mass and digital media channels. Additionally, strategies for vital in-person communication must be safe and accessible, such as sign language interpreters and wearing of transparent masks by health-care providers to allow lip reading. Second, measures such as physical distancing or self-isolation might disrupt service provision for PLWD, who often rely on assistance for delivery of food, medication, and personal care. Mitigation strategies should not lead to the segregation or institutionalisation of these individuals. Instead, protective measures should be prioritised for these communities, so care workers and family members can continue to safely support PLWD, who should also be enabled to meet their daily living, health care, and transport needs, and maintain their employment and educational commitments. Third, PLWD might be at increased risk of severe acute respiratory syndrome coronavirus 2 infection or severe disease because of existing comorbidities, and might face additional barriers to health care during the pandemic. 2 Health-care staff should be provided with rapid awareness training on the rights and diverse needs of this group to maintain their dignity, safeguard against discrimination, and prevent inequities in care provision. COVID-19 mitigation strategies must be inclusive of PLWD to ensure they maintain respect for “dignity, human rights and fundamental freedoms,” 5 and avoid widening existing disparities. This necessitates accelerating efforts to include these groups in preparedness and response planning, and requires diligence, creativity, and innovative thinking, to preserve our commitment to UHC, and ensure people living with disabilities are not forgotten.
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              COVID-19: maintaining essential rehabilitation services across the care continuum

              Summary box Rehabilitation services are essential: They need to continue during a pandemic and after as they are an essential component of high-value care offered for individuals across the lifespan to optimise physical and cognitive functioning to reduce disability. Rehabilitation care is affected: Globally, the response to COVID-19 is shifting rehabilitation services provided in all settings, introducing new burden on patients, families and healthcare workers. Measurement needed: A core set of measures needs to be adopted to monitor the health and functional outcomes for COVID-19 and other patients at risk for functional decline and to assess the quality, availability and accessibility of services today and as our nations recover. Telerehabilitation is necessary: Remote delivery of care and the necessary rapid scale-up of telehealth could be optimised if financial, infrastructure, resource, training and cybersecurity barriers were addressed. Collaboration can support needs in the home: Novel partnerships that include the rehabilitation community could enhance communication and delivery of safe and effective home-based rehabilitative strategies to mitigate the consequences of COVID-19 and reduced service capacity. Direct care providers need personal protective equipment: Rehabilitation providers in all settings should be ensured personal protective equipment and training to use it effectively. Introduction COVID-19 is overwhelming healthcare services and healthcare workers globally. The response, appropriately, is on the ability to care for people who become critically ill, protect their carers and keep people physically distanced. However, this response has shifted what is considered and how to provide essential healthcare services. Rehabilitation services, which optimise physical and cognitive functioning to reduce disability, are a core component of high-value care.1 The decisions to shift, transform, delay or discontinue rehabilitation care are complex. These decisions have societal implications for today and the future. This commentary describes adjustments to the continuum of rehabilitation services across 12 low-income, middle-income and high-income countries in the context of national COVID-19 preparedness responses (table 1) and provides recommendations for decision makers on the provision and payment of these essential services. Table 1 Continuum of rehabilitation services across 12 low-income, middle-income and high-income countries in the context of national COVID-19 preparedness recommendations Country National government mandated COVID-19 response Rehabilitation services during COVID-19*(inpatient, redeployment/bed shift, outpatient/home and telehealth) Stay-at-home order 2020 National response Guidance for ‘non-essential’ healthcare services Argentina 20 March National lockdown:essential trips for cleaning supplies, medicines and food. Outpatient suspended. Inpatient rehabilitation still offered in reduced capacity.Other inpatient bed types converted to increase acute hospital bed capacity.Patients are not attending day rehabilitation programmes despite programmes being open.All outpatients clinics in all public and private hospitals closed.Physicians and therapists cannot get reimbursed for video telehealth visits (neither video nor telephone). Belgium 17 March  Containment and mitigation: school and retail closures, ban on all gatherings, movement only for essential needs and ban on non-essential international travel. Non-essential services suspended. Inpatient rehabilitation operational but discharging more quickly to prevent spread; all activities in patients’ room.Rehabilitation personnel but not beds have shifted to support acute care.All outpatient rehabilitation services discontinued.Government-approved renumeration for telerehabilitation for all provider types (expanded for COVID-19). Brazil By state  Containment and mitigation: national guidance defined essential services and recommendations for social distancing and foreign entry restricted. Non-essential services suspended. Reduced operations for inpatient rehabilitation.Shift in rehabilitation personnel and outpatient services, encouraged to use telemedicine.Federal Council of Medicine acknowledges use of telemedicine for teleorientation (distance guidance, training and patient referral), telemonitoring under medical supervision or guidance and teleinterconsultation (between physicians for diagnostic or therapeutic assistance). China 23 January Lockdowns across country: suspension of travel, banned public gatherings, early detection and isolation, mobility restrictions and quarantine for returning migrant workers. Non-essential services suspended. Inpatient rehabilitation for all non-urgent patients suspended.Shift in rehabilitation hospital beds or rehabilitation personnel to help with COVID-19 response.Outpatient rehabilitation suspended.All home care discontinued.Teleconsultation/virtual rehabilitation provided mostly free of charge. Germany 22 March  Containment and mitigation: travel restrictions, school closure, closing non-essential businesses and banned public gatherings. All elective surgeries and non-essential services postponed. Acute hospitals continued early acute rehabilitation.Rehabilitation hospitals discontinued care for chronic, non-acute problems; acute patients (eg, surgery and stroke) stay as long as needed.Some rehabilitation hospitals could be designated as overflow hospitals. Rehabilitatation personnel supporting acute hospitals.Outpatient rehabilitation is reduced but available for high need patients/essential care.Telerehabilitation for physicians and health professionals in the acute COVID-19 phase possible and reimbursed. Guyana 16 March Encouraging social distancing and hygienic practices.Established health emergency operations centre.Curfew and stay-at-home policy implemented and all non-essential business ordered closed. All elective surgeries and non-essential services postponed. Inpatient rehabilitation continued in acute hospitals.Outpatient rehabilitation therapists reassigned to acute hospitals.All community-based rehabilitation suspended in hinterland regions.Phased approach to cancelling/closing all outpatient rehabilitation services; patients receive self-led home-based programme.Telerehabilitation via telephone, Zoom, WhatsApp and emailing exercise programs. Also using MedBridge. India 24 March National lockdown: exceptions medical and pharma services, groceries, banks, telecom, gas stations as essential services, school closures and restriction of international and most domestic travel. Non-essential elective surgeries postponed Hospitals discharging stable patients at earliest possible.Inpatient rehabilitation continued for patients who cannot return or travel home.Rehabilitation personnel considered part of human resource mobilisation for training and possible role assignments.Outpatient and home-based rehabilitation suspended.Telerehabilitation via phone, Whatsapp and Zoom carried out by certain tertiary care and independent rehabilitation clinics especially for the neurologically ill patients. Singapore 7 April National lockdown: temp. screening, hospital and home quarantines, extensive tracing, social distancing, bans on large gatherings, schools closed and travel restricted. Non-essential appointments, including elective procedures and outpatient rehabilitation, deferred. Inpatient rehabilitation continued but location shifted outside of acute hospitals into stand-alone rehabilitation (community) hospitals. Focus on intensive care, cardiopulmonary and severe, new onset disability.A significant proportion of outpatient providers shifted to inpatient.Limited outpatient rehabilitation personnel focused on postacute and shifted to small teams for physical distancing.All group and community-based rehabilitation activities suspended including day rehabilitation and senior activity centres.Home rehabilitation requests subject to review by health authorities, restricted to patients with significant new-disability and limited caregiver support.In-hospital rehabilitation consults and multidisciplinary team meetings through teleconference.Providers trained to deliver teleconsultations with national regulatory guidance for quality and cybersecurity. Spain 14 March National lockdown: exceptions medical and pharmacy services, groceries and banks. School closures and restriction of international travel. Non-essential services suspended, non-urgent surgeries postponed and outpatient clinics closed. Inpatient rehabilitation offered in reduced capacity.Rehabilitation beds shifted to extend capacity of acute care.Outpatient rehabilitation programmes suspended. All outpatient clinics in all public and private hospitals closed.The majority of home-based rehabilitation (but not completely) suspended.Physicians and therapists cannot get reimbursed specifically for telehealth visits (neither video nor telephone as of 23 April). In some contexts (eg, Catalonia) the Board of Physical Therapists organised a task force of volunteer physical therapists who can deliver some telephone-based rehabilitation. (Provision of healthcare is regulated and reimbursed regionally.) Tanzania Local only  Containment and mitigation: public gatherings ban, 30-day closure of schools, universities, training institutions, health screening at points of entry, 14-day quarantine for travellers from high-risk countries.  Local KCMC. Example: care for older adults suspended unless an emergency, outpatient block appointments, reduced elective surgeries and prioritised emergency surgeries. Inpatient rehabilitation offered but length of stay and visitors reduced to prevent hospital acquired infection (affecting amount of time therapists have to evaluate and treat patients+train family for home-based rehabilitation).Shift in rehabilitation personnel with those age >55 years exempt from patient contact.Outpatient rehabilitation appointments scheduled in blocks to avoid overcrowding and congestion especially in waiting areas.Telehealth not a standard of practice for rehabilitation (and not covered by insurance); patients discharged early and appointments delayed/cancelled have limited access to care. USA By state or city Stay at home orders, school closures, bans of mass gatherings and non-essential business closures. Recommendations to postpone all elective surgeries and non-urgent procedures and visits. Fewer rehabilitation beds; beds converted for acute care.Shift in rehabilitation personnel to acute inpatient and telemedicine follow-up.Outpatient rehabilitation available only for high need patients following. CDC recommendations for essential care.Rehabilitation teleconsultations. Slow scale to virtual visits. Physicians reimbursed. Therapists reimbursed by some private insurers but not reimbursed by government insurance until 30 April. UK 23 March National lockdown: only leave home for food, health reasons, work and other travel restrictions.Social distancing and personal hygiene guidelines. Non-urgent surgeries postponed. Hospital inpatients medically fit discharged early; inpatient rehabilitation offered in reduced capacity.Shift in rehabilitation hospital beds to maximise inpatient capacity; shift in rehabilitation personnel to provide greater acute hospital and community service support.Outpatient rehabilitation at reduced capacity.Telephone and digital/video-based consultation. *Authors provided reports of rehabilitation practice in the absence of national policies. CDC, Centers for Disease Control and Prevention; KCMC, Kilimanjaro Christian Medical Center. Changes to rehabilitation care across settings Rehabilitation addresses health and functioning for individuals across the lifespan. The immediacy of care needs varies by condition.2 Services are provided in every setting—acute hospitals, rehabilitation hospitals, outpatient clinics, in the community and in people’s homes—and resources vary by region. Guidance for the delivery of rehabilitation during COVID-19 is available for physiotherapy but not yet all rehabilitation professions.3 Several regions reported fewer non-urgent rehabilitation patient admissions in order to expand acute care bed capacity. Lengths of inpatient stays for patients who receive rehabilitation are now shorter in several countries including Belgium, India, Tanzania and the UK. Shorter inpatient stays reduce the time available to assess and treat patients and train family. Any need for continued home-based care has implications for caregivers particularly while social distancing. In addition to shorter lengths of inpatient stays, all 12 countries report outpatient and home-based rehabilitation care suspended or operating at reduced service capacity. These inevitable decisions for protection of both healthcare workers and the general public may result in increases in disability and morbidity from a lack of necessary rehabilitation care to those with continued care needs. Patients at home with limited ability to move independently or facilitate their own self-care activities, and patients with prolonged hospitalisation for COVID-19 who have returned home, are at high risk of several adverse health effects. Skin breakdown, muscle weakness, joint stiffness, reduced range of motion, changes to bowel and bladder functioning, venous stasis, oedema, decreased rate of metabolism and respiratory movement, lowered mood and depression are measurable in the first week of limited mobility. It is critical that public health communication continue to address the significance of daily activity and movement while uniquely considering limitations of individuals with significant physical or cognitive disability. Guidance needs to also ensure the safety of caregivers involved and be provided for households without available caregivers. Protecting providers of direct care While there is concern for people with unmet rehabilitation needs, it is important to protect all direct care providers, paid and unpaid, during a pandemic response. Many components of rehabilitation care require patient contact, for example, treating patients weaning from mechanical ventilation, developing patients’ balance techniques after stroke and fitting a new limb after amputation. Furthermore, rehabilitation personnel from Guyana to Singapore are being redeployed to meet needs in care settings different than their usual work environment. In Spain, health workers represent 15% of all COVID cases and, in response, the country has mobilised retirees, medical residents or other health personnel. In Singapore, private sector and retired rehabilitation staff may join frontline healthcare. In planning for adequate personal protective equipment and training for its use, governments need to include all direct care providers in their calculations to adequately protect people in homes and community-based settings when direct-patient contact is still necessary. Telerehabilitation Telephone consultation for care is an option in some regions but is dependent predominantly on the availability of personnel. Use of video visits and other forms of virtual care, although preferred for rehabilitation over telephone consultation alone, requires widespread and stable internet connectivity, availability of technology for both the rehabilitation provider and the patient, ‘tech literacy’ or the ability to use a device, the availability of ‘tech support’ to troubleshoot or first get connected and payment for provider time. Although rehabilitation in some countries such as Guyana, Germany and the UK is a component of universal healthcare coverage (UHC), governments and health insurers of other non-UHC countries need to pay therapists, in addition to physicians, to equitably provide care via telehealth. Use of telehealth under usual circumstances in all forms—text, telephone and video—requires planning, training and iterative improvement. It is imperative that experienced telehealth providers share protocols and become champions to support their peers with rapid scale-up in this challenging environment. Publications are emerging, and some professional societies are sharing guides for remote consultations.4 5 China and the USA have live webcast sessions with national experts to train rehabilitation providers and online communities to empower caregivers. Creative solutions to use free and commercially available communication tools like WeChat and WhatsApp are being used in Brazil, China and Guyana. These approaches are limited in Tanzania and likely other low-income countries due to costs for data plans and limited in-home internet access. With the majority of rehabilitation care provided remotely during a pandemic response, telehealth strategies need the infrastructure and to be resourced and financed appropriately. Measuring the impact of COVID-19 Enhanced measurement and monitoring are desperately needed at the individual, health system and national levels. With the release of the WHO Rehabilitation Guide for Action only this past year,6 few countries had fully completed a systematic assessment of the rehabilitation situation and developed a strategic plan to adequately meet rehabilitative needs prior to this pandemic or to activate during pandemics. Yet, today, we need alignment on a measurement strategy. Longitudinal assessments of health and functional outcomes are needed to monitor individual and population health and support clinical decision making for allocation of scarce resources in all settings. The global significance of measurement on practice and policy was evident in the release of COVID-19 outcomes assessments of intensive care unit patients7; similar data are needed on the functional recovery of patients with COVID-19. Service-level records need to be monitored to ensure adequate quality and equity with constrained resources. In the longer term, greater attention to national census and cohort surveys will be needed to detect changes in population health that can inform policy decisions on rehabilitation service needs and geographic disparities. The rehabilitation community needs to unite to consider a core set of measures to monitor recovery of patients with COVID-19, health of persons with disability and chronic conditions, and the quality, availability and accessibility of services today and as our nations recover. Recommendations Rehabilitation care is at a unique turning point. In 2017, the WHO had already noted ‘substantial and ever-increasing unmet need for rehabilitation services worldwide’.8 Today, we are faced with a new population of patients at risk of functional decline in addition to the disability pandemic already present among one billion people globally. We are providing care in new ways and standards of care are changing. The following recommendations are provided to mitigate the consequences of COVID-19’s impact on rehabilitation care and support continued health with reduced risk of disability. Governments need to include rehabilitation and other direct care providers in home-based and community-based settings in their plans for personal protective equipment acquisition and training. Global collaboration across rehabilitation professionals needs to accelerate the sharing of resources, instructional tools, education and training packets for how patients and families can continue rehabilitation at home during a pandemic response. Public health messaging on mental and physical health while social distancing needs to expand with input from rehabilitation professionals to provide guidance for persons living with physical and cognitive limitations, with and without caregivers. Public–private partnerships are needed to better support rapid scale of telehealth today and in the future to ensure effective use, financing, cybersecurity, access and increased reliability of broadband networks to reach people in low-resourced areas. The rehabilitation community needs to unite on measurement of care and outcomes because the evidence established in real world practice today could transform care and lives tomorrow. Conclusions The WHO called on nations to ensure continuity of essential services in parallel to scaling public health preparedness and response measures.9 Our shared experience is that national agencies did not issue specific guidance for the provision of rehabilitation. Considerations for service delivery balanced risk of transmission with both the availability of resources to provide care and the patient’s acuity, level of urgency and potential for harm if services were postponed or altered. Rehabilitation service providers mobilised quickly to provide the best, safest care possible to those in greatest need; decisions were in many cases made locally. Looking beyond the pandemic, rehabilitation needs to remain at the forefront of discussions for UHC; barriers to infrastructure, implementation and financing care via telehealth and alternative approaches need to be eliminated. Strong leadership for inclusion of rehabilitation in public health and healthcare policymaking is acutely needed to ensure high-value care and reduce the global burden of disease.
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                Author and article information

                Journal
                BMJ Glob Health
                BMJ Glob Health
                bmjgh
                bmjgh
                BMJ Global Health
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2059-7908
                2020
                23 August 2020
                : 5
                : 8
                : e003039
                Affiliations
                [1 ]departmentAssisting Living & Learning (ALL) Institute, Department of Psychology , Maynooth University , Maynooth, Ireland
                [2 ]departmentInteraction Centre and Global Disability Innovation Hub , University College London , London, United Kingdom
                [3 ]World Federation of the DeafBlind (WFDB) , Oslo, Norway
                [4 ]departmentOlomouc University Social Health Institute (OUSHI) , Palacký University , Olomouc, Czech Republic
                Author notes
                [Correspondence to ] Dr Ikenna D Ebuenyi; ikenna.ebuenyi@ 123456mu.ie
                Author information
                http://orcid.org/0000-0002-3329-6296
                http://orcid.org/0000-0003-2541-5723
                http://orcid.org/0000-0001-6672-9206
                Article
                bmjgh-2020-003039
                10.1136/bmjgh-2020-003039
                7445099
                32830130
                af4f181b-09f9-4573-bca9-cf41165e71c9
                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

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                : 10 July 2020
                : 23 July 2020
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