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The current issue and full text archive of this journal is available on Emerald Insight at:
https://www.emerald.com/insight/2059-4631.htm
Through the lens of COVID-19 Through
COVID-19
Fiona MacVane Phipps
Independent Researcher, Istanbul, Turkey
Abstract 271
Purpose – The purpose of the IJHG Review is to enable readers to gain a quick overview of articles contained
in an individual issue.
Design/methodology/approach – All current articles are read by the Review Editor who then prepares the Received 25 June 2020
Review. Revised 29 June 2020
Accepted 29 June 2020
Findings – Common themes are identified and key concepts are extracted from each article.
Practical implications – The Review enables readers to prioritize articles of the greatest interest to them.
Originality/value – The originality value of the IJHG Review is that no other Emerald Journal offers a Review
section of this kind.
Keywords Medical education, Primary care, Nursing, Surveillance or screening, Clinical leadership culture
Paper type General review
Introduction
As this issue goes to press, the world is still in the epicenter of the COVID-19 pandemic. Some
nations, having taken swift action, such as New Zealand, have been able to move forward into
a “new normal.” Others such as India and Taiwan may be experiencing the viral “second
wave” while yet others such as the United Kingdom and United States are easing quarantine
measures while still experiencing high rates of infection. This pandemic is something new,
with early vaccines just starting trials amid poor understanding of what levels of immunity
are afforded by having survived the virus. Two of the seven articles in this issue of IJHG
report on some aspect of the pandemic; therefore, it seemed appropriate to review all of this
issue’s articles using a critical lens to examine what they reveal about how health care and
health governance must change to manage the global COVID-19 pandemic. John Dunne, the
17th-century English poet, famously declared: “No man is an island.” Currently, we can state
that “No nation is an island,” even when it is. The measures taken, or not taken in one country
in the battle against this new coronavirus, have the capacity to affect individuals and nations
far beyond any national borders.
The first article reviewed is about Internet health literacy in Jakarta (Sumaedi and
Sumardjo, 2020). This is relevant in light of the current COVID-19 pandemic as social
distancing, restricted access to GPs, clinics and other healthcare facilities have increased the
global public’s use of the Internet to gain information, purchase necessities and stay in touch
with family and friends.
Online health literacy in Jakarta
Indonesia is the fourth most populous country in the world with over 273m citizens, just over
half of whom live on the island of Java. As of June 24, 2020, the number of cases of COVID-19
were 49,000 with 2,573 deaths (Jakarta Post 24.06.2020). Indonesia has implemented a
vigorous testing program and introduced mandatory social distancing and other protective
measures such as business, school and mosque closures. The government is beginning to
ease some restrictions, although popular tourist destinations such as Bali remain closed. The
capital and largest city in Indonesia is Jakarta, with a population of approximately 10m.
International Journal of Health
Jakarta, in common with other high-density urban areas, has a high prevalence of Governance
noncommunicable disease (NCD) such as cancer, obesity, diabetes, hypertension, kidney Vol. 25 No. 3, 2020
pp. 271-278
disease and cardiac disease. The Ministry of Health attributes this to the influence of creeping © Emerald Publishing Limited
2059-4631
Westernization in terms of adoption of high-fat/high-sugar diets combined with a reduction in DOI 10.1108/IJHG-06-2020-0067IJHG exercise as more and more people are employed in sedentary occupations and use public or
25,3 private transport for their home to work commutes. Chronic ill-health increases vulnerability
to COVID-19 infection and may result in long-term comorbidities such as reduced lung
function, changes in glucose metabolism and cardiac function, psychological effects and
chronic fatigue (Cox, 2020; Du, 2020).
Jakarta residents needed health education before the onset of the COVID-19 pandemic and
now it is even more important when online health resources are ideally placed to provide
272 information during times of quarantine or reduced access to health services. Using the
Internet to access health advice has many advantages. Indonesia has one of the world’s
largest mobile Internet use rates; in Jakarta, 80% of the population uses mobile Internet
technology, which indicates web literacy, ideal for transmission of current health information
and advice. The use of Internet technology for health information is most effective when
based on health literacy, social influence and the perception of the Internet as a valuable
source of health information.
A recent (pre-COVID-19) survey in Jakarta attempted to determine the reasons for use or
rejection of online technology as a source of health information. Residents over the age of 17 in
subdistricts of five Jakarta municipalities were invited to participate; a sample of 369 people
responded by taking the survey. However, the sample was self-selecting and the majority of
respondents were housewives between the ages of 31 and 40 with a high school education.
Why this part of the population was so highly represented is unknown but a presumption
could be made that having responsibility for family health may be seen as part of the
housewife’s role. The authors state that their sample was purposive but do not explain in
what way it was purposive. A more effective purposive sampling technique may have been to
specifically invite people of different ages, genders and academic standing to take the survey,
thus ensuring a more balanced response. This would facilitate useful health governance
information about how specific segments of the population such as young people or retired
people use online health sites to learn about healthy behaviors, including diet and exercise. It
will be interesting to see if online health education becomes a part of the “new normal” once
the current pandemic is deemed to be under control.
Proactive strategic planning for patient-centered care
If nothing else, the current COVID-19 pandemic has highlighted the importance of strategic
planning and effective collaboration. The next article reviewed discusses these two essential
attributes of good medical care within the context of medical education (Aultman et al., 2020).
Strategic planning in health and academic settings helps to create commitment to shared
values, builds camaraderie and trust and informs a better understanding of work being done
by different groups such as staff, faculty and management. The shared value set built in this
way can help to combat the consumerism that is a pervasive and debilitating influence in
medicine and education at present.
In order to implement effective strategic planning, the authors state that there are four
impediments that must be overcome. These are: 1) an unpredictable external environment; 2)
a rapidly changing internal environment; 3) skepticism among faculty; 4) the culture of
medicine. Numbers 3 and 4 may well be two sides of the same coin. Faculty who embrace a
traditional medical-centric view of health care may be skeptical about changes that are
designed to foster an interprofessional culture with greater collaboration and blurring of role
boundaries. Proactive planning for such sweeping changes must include the needs of
patients/consumers who currently expect that they will be active participants in decisions
made about their own health care. Physicians trained in the classic “doctor knows best”
school of medicine can sometimes find it difficult to relinquish traditional medical authority
(Brownlee and Colucci, 2012).This paper describes strategic planning undertaken by the department of family and Through
community medicine in an unnamed medical university with three colleges (medicine, COVID-19
pharmacy, graduate education), all having a genuine commitment to interprofessional
learning; the university is known for this approach. The college of medicine is a merger of
three departments: family medicine, behavioral sciences and community health sciences and
has now been rebranded as the Department of Family and Community Medicine. The new
department has 26 faculty members and six staff members who represent ten different
disciplines. They have embraced strategic planning as a way to adapt to new challenges in 273
the current rapidly changing medical marketplace.
The authors suggest that students and patients both deserve recognition as consumers
and consumer values should have precedence over provider convenience. However, one could
argue that this viewpoint indicates that this institution views both healthcare and education
as commercial entities; it would seem that transformation of this mindset to embrace a service
mentality would be more congruent with the type of collaboration that the institution is
attempting to achieve.
In order to facilitate a smooth transition to new ways of studying and working in medicine
and related fields, a strategic planning framework was developed that included development
and implementation phases, documentation of milestones, feedback and progress markers.
This was done with a philosophy of inclusivity to build relationships and to serve
underrepresented populations in community and state.
World cafe and Delphi methods were used to identify activities that could stimulate
student interest in family medicine, with a resulting increase in family medicine students
from 8 to 12% of the medical student population. A focus on primary care research helped
to attract more students to primary care as a specialty. Research topics were all related to
conditions and situations that primary care physicians could expect to encounter such as
infant mortality, opioid addiction, respecting role of caregiver and the social determinants
of health.
One of the outcomes of this new collaborative approach to medical and other health
professional education was the establishment of a Student Run Free Clinic (SRFC) one Saturday
per month where medical and pharmacy students treated patients, with oversight from qualified
doctors and pharmacists. In total, 70% of patients attending this clinic are uninsured, the rest
underinsured. Before the current COVID-19 pandemic, the SRFC clinic hours had increased to
four Saturdays every month because of increased demand. The clinic is a focus of
interprofessional care where students learn clinical skills along with management, strategic
planning, grant procurement and outpatient office management.
Grant funding has been sought to enable clinic hours to increase to three days per week
(Saturday and two others), and there were plans to add a telemedicine curriculum and
incorporation of physician assistant students from a neighboring college. The two key
pathways for students are: urban and rural medicine; both focus on care for underserved
patients. Telemedicine would be particularly useful at the present time when social
distancing, self-isolating and quarantine are all in place. It will be interesting to see how this is
developed as it could provide a good model during future pandemics. The relationship
between COVID-19 and the transformation of telemedicine from a fringe to a mainstream
activity has recently been discussed in the medical literature (Mann et al., 2020).
In 2019, an accelerated program was developed for students who have already made a
firm choice to work in family medicine on entering medical school. Students following the
accelerated curriculum graduate in three years (instead of four). In addition, a social justice
pathway is being developed for students who want to work specifically with people in
socially and economically disadvantaged communities. This program will introduce students
to contemporary social justice including racial issues and help them to develop critical
thinking and compassion. These new methods of strategic planning, collaboration andIJHG shared responsibility for and with patients should help to prepare students for the way they
25,3 will need to work in the altered healthcare environment post COVID-19.
Noise pollution and hearing health
The third paper focusing on public health exposes the dangers of noisy environments, not
related to occupational hazards (Shroff and Jung, 2020). This review first appeared in the
274 Review section of IJHG 25.2 and therefore cannot be related to COVID-19 except to say that
we have all become used to a much quieter world during the period of lockdown. Many people
would like to see the COVID-19 reduction in noise pollution become a more permanent part of
life, but without the restrictions imposed by the virus.
Occupational noise hazards are regulated with the onus on the employer to protect
employees’ hearing. Therefore, the real culprits of noise-induced hearing loss (NIHL) currently
are those associated with nonregulated noise. This may be traffic or noisy environments such
as trains, subways or social gatherings. Hearing loss can also occur through a single incident of
very loud noise such as exposure to an explosion, gunfire or fireworks (NIH, 2019). However,
one of the most insidious causes of NIHL comes from personal music devices played at high
volume. As high decibel sound is transmitted directly into the inner ear via headphones or ear
buds, the effects can be much greater than the listener recognizes. As hearing deteriorates, the
typical listener response is to increase the volume, thereby exacerbating a problem, which may
not even be acknowledged. However, NIHL is an easily prevented problem that has serious
psychological and occupational repercussions and which needs more research to determine the
extent of problem. The authors recommend more coordinated campaigns to raise awareness
and alter social and cultural association of loud noise with pleasurable activities.
The association of noise with pleasure apparently has a physiological basis as sounds
over 90 decibels stimulate pleasure sensations in the inner ear, while at the same time
destroying hair cells in the cochlea, which are essential for the transmission of sound.
Therefore, while social and cultural associations are important, humans seem predisposed to
enjoy noise. More research into this phenomenon would be interesting, especially as
campaigns to reduce hearing loss often focus on promoting appreciation of quiet sounds.
While deafness may seem trivial compared to the current COVID-19 pandemic that leads
to high mortality rates, for the person experiencing NIHL, it is a life-changing disability.
Deafness may reduce life opportunities and occupational choices in the young. It also
contributes to social isolation and a reduction in self-confidence. Clearly NIHL is a problem
that needs to be taken seriously both in this country and globally, to prevent large-scale
hearing loss in segments of the population who would not naturally experience this.
Advanced clinical practice roles in England
This study examined the ACP roles in primary care in England and how these roles meet the
workforce capability framework requirements set out by Health Education England (HEE)
(Thompson et al., 2020). This discussion of ACP roles in England was written before the
COVID-19 pandemic so does not bring pandemic-related care into the discussion. However,
many health professionals have been working outside of their standard roles in order to meet
the needs of hospitals in caring for COVID-19 patients (American College of Surgeons, 2020;
RCN, 2020).
A clear understanding of the ACP role will help ACPs and nurses working in less specialist
roles to understand their responsibilities and accountability during extraordinary times such
as the current pandemic.
Confusion exists about what defines the ACP role. Standardization of the role definition
and the educational and practice requirements for ACPs could help to eliminate this. At
present there are people working in what should be ACP roles who are not working to therole’s potential and other people that self-identify as ACPs but are not working at ACP level. Through
The ACP role was developed to meet the challenges of increasing demands on the primary COVID-19
care system and a corresponding shortage in key primary care staff, particularly GPs.
The ACP role developed from the nurse practitioner role introduced in the 1980s. ACPs
can reduce pressure on primary care services by replacing GPs at some consultations. Some
studies have shown that ACPs perform just as well as GPs in terms of outcomes but at a
reduced cost. That, of course, raises questions about how ACPs should be paid as it might be
defined as unfair for both professional groups to employ ACPs as a substitute for doctors but 275
at a reduced salary. This discussion is not covered in the current paper but as nurses and
other health professionals increasingly take on roles once the sole province of physicians,
such questions cannot be ignored.
In 2017, HEE published a framework for ACPs that can be applied across all professions.
This framework identifies experience, autonomy and complex decision-making as the key
identifiers of ACP. The framework also identifies a master’s degree or equivalent as the
appropriate educational preparation for this role and states that an ACP should demonstrate
skills in leadership, management, education and research together with a high level of specific
competence. A large problem in ensuring competency and consistency across all ACP roles is
that it is not a qualification that is validated by the NMC and to date the NMC has not shown
an interest in making it a recordable qualification. Whether the COVID-19 pandemic and the
associated requirement for nursing staff with higher-level skills will change the NMC stance
on registration remains to be seen.
Social cohesion lessons from COVID-19
Although politicians are fond of the expression “We are all in this together” when discussing
the current COVID-19 pandemic, this assertion is blatantly false. The pandemic damages the
poor and marginalized portions of society more swiftly and produces more social, economic
and educational damage than it does to the socioeconomically privileged portions of society.
Therefore, if societies can include as many of their citizens in their strategies to combat the
coronavirus pandemic, then they will be much more successful at “flattening the curve” and
ultimately eradicating the virus.
In their discussion on social cohesion and COVID-19, Mendoza and Dayrit (2020) state that
the two main aspects of social cohesion that are required in an effective response during a
global pandemic are first, international collaboration to share data and scientific knowledge,
and second, national cohesion. That is, individual nations need to ensure that they have a
viable strategy; at the same time all government agencies, educational establishments,
businesses and individuals must work together to protect against widespread transmission
of the virus. At the time this article was being prepared for publication (late June 2020), it was
quite evident, by looking at national infection and death figures from the start of the
pandemic to the present, which nations did indeed implement effective strategies at the
right time.
There are two aspects of national governance that together provide the most effective
blockade against out-of-control viral distribution patterns. These are a publicly funded
national health service where all citizens have the same rights to access health care regardless
of economic or employment status and a comprehensive social protection system that ensures
no one goes hungry or is homeless.
The weakest link in an international drive to eradicate the COVID-19 virus is the country
(or countries) without comprehensive national health and social care systems as this can
result in pools of infection remaining, particularly among the poorest members of society.
Finally, in modeling national and international solutions, it is important to remember that
even epidemiologists tend to make predictions based on “normal” systems. Currently, withIJHG the world still partially in “lockdown,” the old normal no longer exists. Modeling predictions
25,3 on viral spread or human responses need to take social and economic changes brought about
by the pandemic into consideration. It is only with new commitment to national coherence
and international cooperation that COVID-19 can be defeated.
Treatment costs of HIV in Turkey
276 The next review article examines the cost of HIV treatment in Turkey (Balci et al., 2020).
While this article was submitted prior to the COVID-19 pandemic, it is important to note that
healthcare costs for HIV patients may go up during a pandemic because a compromised
immune status makes people living with HIV more vulnerable to diseases such as flu or
coronavirus. Even while remaining well, increased social costs may be incurred due to the
need for more rigorous forms of social isolation, which may prevent people from working or
performing normal self-care activities such as shopping for groceries or collecting
prescriptions from a pharmacy.
Direct costs of HIV/AIDS treatment in Turkey remain unreported.
Costs of drug treatment represent the most significant costs as medical care and hospital
costs are relatively low in Turkey. Anti-retroviral drugs have revolutionized HIV/AIDS care,
allowing people to live relatively normal lives within normal lifespans. This, however, does
mean much longer treatment times and higher costs as people living with HIV will require
lifetime support with ART drugs.
The first AIDS case in Turkey was reported in 1985. By 2017, there had been 17,800
cases of AIDS. ART is offered free of charge to patients with HIV as part of the national
insurance system.
Cost analysis for treatment used data collected from different sources including hospital
databases. Only the head of the research team had information that could lead to
identification of study participants. To retain anonymity, a unique number was assigned to
each participant that allowed tracking across different treatment venues.
Analysis of data indicated that the average treatment cost for patients with HIV in Turkey
in 2017 was $4381.93. In total, 90% of this cost was for medication. Laboratory costs were the
second highest expense at 6.44% of the total followed by clinic examination and consultation
costs at 1.82% of total costs. The cost was highest for the group of patients with CD4þT cell
values ofJapan’s COVID-19 deaths, which are low in comparison to other countries despite Japan Through
having a highly concentrated population and a very large number of elderly citizens (Covid- COVID-19
19 Tracker, 2020; Malicdem D, 2020).
This paper discusses ethical issues highlighted by the current pandemic from the Iranian
perspective. The authors point out that in a global crisis such as the COVID-19 pandemic,
international cooperation is essential and this should transcend politics or ideology. Instead,
global cohesion is required based on scientific, medical and humanitarian principles. This is
illustrated by a quotation from the classic Persian poet, Saadi “Human beings are members of 277
a whole, in creation one essence and soul, if one member is afflicted with pain, other members
uneasy will remain.”
Conclusion
The seven articles reviewed in this issue of IJHG 25.3 report on various issues relating to
health governance. The countries from which the contributions come have varied healthcare
systems and differing needs. However, by examining all of these issues through the lens of
COVID-19, similarities emerge. It is to be hoped that all of us involved in health governance,
whether from clinical, educational, managerial or journalistic perspectives, will take forward
the messages of collaboration, shared scientific knowledge and compassion for those
suffering from the physical, psychological, emotional or social symptoms associated with the
COVID-19 pandemic.
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Corresponding author
Fiona MacVane Phipps can be contacted at: fiona@macvane.com
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