Pandemic 101: do no harm

Hippocrates refusing the gifts of Artaxerxes after he appealed for his help to cure an epidemic that was ravaging the Persian troops. (Credit: Wellcome Images)

“As to diseases, make a habit of two things—to help, or at least to do no harm."

Do no harm is popularly understood to be a tenet of clinical medicine, a soundbite from the Hippocratic Oath.  Hippocrates’s most famous dictum refers specifically to disease outbreaks, and actually comes from the first book of his Treatise on Epidemics. A longer translation helps:

“The physician must be able to tell the antecedents, know the present, and foretell the future — must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm.”

Twenty-five centuries later, the Covid-19 pandemic puts Hippocrates’s advice in context, and the enormous harm caused by an internationally careless response makes his caution brutally clear.

Across the globe, one billion children are suffering extreme anxiety, enduring physical and mental trauma, and facing uncertain futures. Covid is amplifying  and accelerating pre-existing pandemics of youth mental ill-health, gender-based violence, and child labour.

Without a vaccine or an effective testing strategy to identify contagious people in real time, shutdowns are the only option to suppress Covid, prevent hundreds of millions of infections, and save millions of lives, at the cost of economic prosperity, social devastation, political participation, mental health, and backsliding on development targets.

While it's easy to blame the Covid crisis for the setback to the Sustainable Development Goals (SDGs), a deeper understanding yields the opposite, more constructive approach.

A year ago, the global governance agenda comprised 17 independent SDGs and Climate Change was the defining issue. Within months, the laser-focus on a single shared health agenda -- controlling Covid -- clarified that the foundational importance of global health   -- the third SDG -- is central to achieving the other 16.  Not just the SDGs, of course -- without health, we can't get anything done, whether travel, work, socializing or sport.

The three most important determinants of health are education, income and employment. Although education is traditionally ranked third behind income and employment, in a pandemic with 500M jobs lost already, and little social protection, education becomes the most important determinant of all. Education is essential for the destruction of the cycle of poverty, inequities in health and our best chance of social and economic recovery, as well as achieving the 2030 agenda.

Unfortunately, international carelessness has cost us education and compromised us all.  When the pandemic was declared in March, the indiscriminate shutdowns included schools, which are hotspots for influenza.

But Covid isn't the flu,  schools are not hotspots and children are not super-spreaders.  But the lack of political leadership willing to recognise these facts, coupled with panic and the domino effect, meant every single country except Sweden closed its schools. By April, 188 countries had closed schools nationwide, affecting 1.5 billion children— 90 per cent of all students.  As of 30 October,  nearly 600 million students  remain affected, more than half of these are girls.

This crisis is all the more tragic because it is man-made.  Pandemic influenza targets infants, young children and teenagers, but Covid rarely causes illness in children, and deaths are extremely rare. Children, the least infected, are the worst affected. This is the pandemic's paradox -- that the smallest victims become the biggest casualties.

Moreover, the social and economic fall-out will persist long after Covid-19 ceases being a threat.

Well beyond traditional education, schools enhance children’s physical, social and mental health, promote their emotional and intellectual development, and provide essential services. Worldwide, schools are health hubs – providing checks for vision, hearing, scoliosis –  rubella vaccine and HPV vaccines. Across Africa, primary schools are the platform for delivery of primary health care, such as mass drug administrations, vaccinations, and nutritional support. For example, in 2019, some 900 million children were treated for Neglected Tropical Diseases.

The tight links between education and health are reflected in the recent coupling of the World Health Organisation (WHO) and UNICEF.

While the tech industry has made a land-grab for education, Covid has made clear that online instruction is no substitute for teachers and classroom learning. Online learning amplifies educational gaps that already leave children from disadvantaged communities behind. Moreover, in the absence of schools, 490 million students have had no access to education at all.  Girls and other minority groups have been further marginalised.

The unequal impact on girls endangers our future workforce -- and health. 2020 is WHO's Year of the Nurse and Midwife -- a timely (and prescient) acknowledgement that women are critical to healthcare. Globally, 70 per cent of the health care workforce are women. In OECD countries, 50 per cent of doctors and just over 90 per cent of the long-term care workforce are women.

To compound the problem, shutting down schools is much easier than re-opening them. Schools aren't places of transmission, and children aren't vectors. In Sweden, the only country that never closed down childcare and schools through from K1 age 15, without any mandated masks, desk or play distancing, or class size cuts not a single child died due to Covid --despite high levels of community transmission. Studies in Australia, Ireland, UK, Singapore and Japan show teachers rarely transmit to each other, let alone to children.16  In Sweden an analysis showed that while taxi drivers were at five times greater risk of contracting severe Covid-19, teachers were not.

But the misinformation, and mistrust of authorities, politicization of the issue and evidence-free policy exemplified in the US  mean that facts are not enough. Reopening schools will require trust and social traction. This is critical not just for school return, but vaccine uptake-- because vaccines don't work, vaccinations do.

How do we generate that trust?

To create safe classrooms that don't need teachers to teach through masks and six feet away from students, we may need clever ventilation overnight ultraviolet disinfection.

But we also need policy that prioritises school re-openings ahead of pubs, and which recognises teachers, school staff, bus drivers as essential workers and prioritised for vaccines. We need all stakeholders around the table - ministers of education, parents, intergovernmental agencies, school principals, teachers unions and transport workers.

Rapid tests can build confidence but are still time consuming and too expensive for long-term.  More importantly, they may not work for children themselves. Outdoor masking of students and cancelling of ball play and team sports, even though outdoors transmission is negligible. Schools have become already become places of restriction, uncertainty, and limitation.

Beyond school lunches and latrines, sports may be the ultimate 'pull factor'. Particularly for girls. So we need the help of sporting industry, beginning with the International Olympics Committee and FIFA.  In the US the winning combination of Title 9 (discrimination on the basis of gender) and soccer enabled girls to graduate and go all the way to the Olympics and the World Cup.

Most of all we need to hear from the kids themselves-- needlessly forced to suspend or forgo traditional education, friendships, sports to protect their communities without any say in the matter, despite their right to education and their right to be heard.

Playing Covid by the influenza playbook didn’t alter community transmission spread. Instead, it created a man-made education crisis.

This is a critical moment for children. Across the globe, anxiety and depression rates have doubled. Eating disorders are growing.  Kids are angry, anxious, traumatised,  abused, scared, and losing hope.

Children are not only our common futures, but also our collective responsibility. Education makes the difference between shorter, darker, unhealthier lives and brighter, hopeful futures.  Beyond education, schools provide protection, physical and mental health, and are the key to jobs, food security, gender equity, livelihoods, gender equity, equity and improved economic opportunity, environmental responsibility, and social justice.  How many SDGs is that?

Worldwide, kids need to go back to school. That they never should have left is an important public-health lesson to learn.

Annie Sparrow is a pediatric intensivist and public health specialist. She is an associate professor at Mount Sinai, a practising aid worker in Congo and Syria, advisor to the Director-General WHO and an advocate for marginalised and vulnerable children everywhere.


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