Padmini Murthy, M.D., M.P.H., M.S., FRSPH, FAMWA, is Professor and Global Health Director at New York Medical College School of Health Sciences and Practice, Global Health Lead for American Medical Women’s Association and Chair of the International Health Section for the American Public Health Association.
March is Women in History Month. The terms “women have broken barriers” or “shattered the glass ceiling” often describe women achievers and pioneers in various disciplines. Some of these women have overcome gender discrimination, violence, or personal and professional inequalities, and have made noteworthy contributions in many disciplines including medicine and public health. In my roles as a physician, public health professional and educator, it is important to remember these points throughout the year—not just during the month of March.
Women Physicians in the United States
Early Pioneers
In 1849, Dr. Elizabeth Blackwellwas the first woman in the US to receive a medical degree. Her work as a visionary was instrumental in laying the foundation for integrating clinical medicine and public health.
Berta Van Hoosenwas an outspoken physician and the founding President of the American Medical Women’s Association, the vision and voice for women in medicine since its establishment in 1915. The organization has been working on projects locally and globally to improve the health of the communities by addressing the ongoing public health challenges.
Rebecca Lee Crumplershattered the glass ceiling in more ways than one as the first African woman to earn an M.D. degree and practice as a physician in the United States.
Mary Edwards Walkerwas a woman surgeon in the U.S. Army. She was a staunch feminist and had the unique distinction of being the only woman recipient of the Medal of Honor bestowed upon her for her service during the civil war.
Susan La Flesche Picottehas the unique distinction of being the first American Indian woman to receive her M.D. degree. She worked tirelessly to improve the public health of her community on the Indian reservation in Omaha.
Alice Hamiltonwas a pioneer in promoting workers’ industrial health and safety in the 1890s. She was appointed as the first woman to the faculty at Harvard University.
Present Day Pioneers
Antonia C. Novellowas the first woman to be appointed Surgeon General of the United States in 1990. She was a key player in launching the Healthy Children Ready to Learn Initiative, a Public Health Initiative. Her other initiatives focused on preventing childhood injuries and promoting childhood immunization.
Joycelyn Elderswas the first African American to serve as Surgeon General and was a strong proponent of universal health coverage.
Regina Benjaminwas the second African American Woman to serve as Surgeon General of the United States. She played a vital role in implementing the National Prevention Strategy in 2011, which focused on incorporating wellness and prevention to improve the health status of Americans nationally.
The role of women physicians worldwide has evolved from obscurity since medieval times to being recognized as leaders who have made a difference in promoting the health and well-being of their communities.
Interestingly Women’s History Month had its origins as a national celebration in 1981 when Congress passed Pub. L. 97-28 which authorized and requested the then US President Ronald Reagan to issue a proclamation designating the week of March 7, 1982, as “Women’s History Week.”
As we celebrate women’s history month, let us appreciate and acknowledge the women physician brigade in the United States who work tirelessly to promote public health locally, nationally and globally.
In October 1991, the First National People of Color Environmental Leadership Summit brought together close to 300 Black, Latino, American Indian, Pacific Islander, Asian American, and other activists of color to elevate the environmental justice movement, which aims to address the inequitable distribution of environmental risks among vulnerable populations. The movement was founded by people of color with an explicit emphasis on securing “political, economic and cultural liberation that has been denied for over 500 years of colonization and oppression.”
The summit was a defining moment in the environmental justice movement’s history. There, leaders outlined the movement’s mission and, in doing so, established a clear connection between environmental justice and public health, highlighting inequities in environmental factors that affect health—such as access to clean air, land, food, and water; the right to a safe and healthy work environment; protection from toxic/hazardous waste; and more.
From the summit emerged a defining document: the 17 Principles of Environmental Justice. These principles outlined the movement’s demands and emphasized its intersection with the environmental drivers of health.
Thirty years after the 1991 summit, the principles that emerged are as important today as they were when published, as environmental injustice remains a core cause of health inequities that disproportionately affect communities of color and low-income communities. As an initial example, tree coverage—which reduces air pollutants and improves health in multiple other ways—has been found to vary by neighborhood population demographics, with greater coverage and health benefits in Whiter, wealthier neighborhoods. Furthermore, today communities of color and low-income communities are disproportionately exposed to the increasing harmful health effects of climate change, which poses a greater threat to communities without the infrastructure and resources to protect themselves from and rebuild after harmful weather events.
The geographic distribution of federal and state infrastructure projects is also an issue of environmental justice. A report on environmental racism from 1987, four years before the summit, found that race was “the most significant among variables tested in association with the location of commercial hazardous waste facilities” nationally; at the time, “three out of every five Black and Hispanic Americans lived in communities with uncontrolled toxic waste sites.” As Ramon Jacobs-Shaw discussed in a Forefront article, the Dakota Access Pipeline placement less than a mile north of the Standing Rock Sioux Reservation is a modern-day example of environmental racism: “when marginalized racial and ethnic minority communities are disproportionately burdened by environmental hazards (such as oil pipelines) compared to more privileged groups.”
Environmental justice has become more visible in recent years, but much remains to be done. To more effectively address the historical and contemporary environmental inequities that cause health inequities, policy makers should revisit the mission and key goals of the environmental justice movement, as captured in the Principles of Environmental Justice, and apply this seminal framework to environmental policy making. Taking a cue from and building on community-led initiatives, policy interventions should target the connection between health inequities and environmental injustice in accordance with the needs and perspectives of the communities they impact. Focusing on this intersection provides an opportunity for more impactful, far-reaching change than would be possible by addressing health and environmental problems separately.
In this article, I will outline how the Principles of Environmental Justice can inform policy and support community empowerment work by focusing specifically on two frameworks present in the Principles of Environmental Justice: participatory and distributive justice.
Where To Target Interventions
To advance health equity, environmental interventions must be rooted in environmental justice. While there are several levels at which environmental injustice needs to be addressed, I propose a focus on the points at which disparities in distribution of environmental benefits or burdens translate into disparities in health.
Many are familiar with the river analogy about the social determinants of health, in which people suffering from poor health are triaged out of a river because something upstream is making them sick. This ominous upstream infector represents the social determinants of health, while the people pulling patients out of the river represent the modern medical system.
I offer a different analogy for the relationship between environmental and health injustice: a tree with roots, a trunk with branches, and fruit growing at the tips.
In this analogy, the roots represent the underlying causes of environmental injustice, namely racism and income inequality. These are the unseen drivers that allow exploitation of powerless people and natural resources, and they are the foundation on which the tree grows. The trunk and branches of the tree represent where power and wealth are stored and distributed. The trunk signifies where decisions about resource distribution are made, and the branches illustrate communities that need resources to thrive. Finally, the fruit on the tree represents the outcome of the resource distribution across branches. Some branches will produce bunches of plump fruit; others will produce fewer, smaller fruits; and some will produce no fruit. Some branches will be so weak that they cannot survive the next harsh winter, while others will grow stronger every year.
Environmental injustice transforms into health injustice at the point when power and wealth can be wielded to improve or protect the environment—in the trunk—but are instead routed away from struggling populations—weak branches—to those that are already thriving—strong branches already bearing fruit. Those weak branches then grow weaker still.
To address the intersection of environmental and health justice located in the tree trunk, the decision-making power lodged there needs to be shared with the communities who will be affected by the outcomes of those decisions. Thus, interventions targeted at this section must be rooted in participatory justice. To address the intersection of environmental justice and health justice located in the branches, the effects of decisions made in the trunk need to be distributed equitably—this doesn’t mean that every branch receives the same resources every year, but that every branch receives what it needs to thrive and produce fruit equally to the other branches. Interventions targeted at this section of the tree must be rooted in distributive justice.
Rooting Interventions In Justice
As framed by the Principles of Environmental Justice, advancing environmental equity through interventions rooted in participatory and distributive justice will improve public health.
Participatory Justice
Participatory justice is about fair participation in decisions that could create problems or solutions for people. This means reallocating decision making, typically held by people who historically hold power in society, to the people affected by the decisions, typically the people disproportionally without power in society. Participatory justice is a central part of the environmental justice movement, as outlined by several of the Principles of Environmental Justice:
Environmental Justice demands the right to participate as equal partners at every level of decision making, including needs assessment, planning, implementation, enforcement, and evaluation.
Environmental Justice affirms the fundamental right to political, economic, cultural, and environmental self-determination of all peoples.
Environmental Justice must recognize a special legal and natural relationship of Native Peoples to the US government through treaties, agreements, compacts, and covenants affirming sovereignty and self-determination.
To ensure participatory justice in the decision-making and policy-making processes that impact communities’ physical and social environments, representatives from these groups need to be more than “at the table”; they need to be the actual decision makers. This starts with representatives from affected groups increasing their understanding of the policies about and outcomes of unequal distribution of resources and projects that can harm the environment and increase health risks among communities. Achieving participatory justice must include empowering community leaders to become knowledgeable about the environmental justice issues in their localities and the solutions that could work for their communities.
Efforts to bolster participatory justice are underway in many communities through self-empowerment initiatives. For instance, the Deep South Center for Environmental Justice is a resource for environmental justice research, education, and health and safety training for environmental careers with a goal of developing “leaders in communities of color along the Mississippi River Chemical Corridor and the broader Gulf Coast Region that are disproportionately harmed by pollution and vulnerable to climate change.” The Center offers workshops about how to monitor neighborhood environmental hazards, understand the risks of toxic exposures, know the duties of governmental agencies, develop strategic advocacy for policies and decisions that prevent and remedy unsafe environmental conditions, and more.
Furthermore, Greenaction for Health and Environmental Justice is a grassroots health and environmental justice organization that partners with low-income and working-class, urban, rural, and indigenous communities. They provide trainings for youth and communities at large on how to understand environmental review processes, best practices in community organizing, how to reduce health risks, and more. They also help communities document the health and environmental impacts of harmful projects as well as document the living stories of communities “to ensure that community voices are at the forefront of their struggle and to ensure communities remain in control of their narratives.”
Organizations such as the Deep South Center for Environmental Justice and Greenaction for Health and Environmental Justice are helping complete a vital part of the participatory justice puzzle by empowering citizens to become experts and advocates about the environmental injustices in their communities. However, if these community leaders and representatives do not hold any political power, they cannot participate in the policy making that impacts their communities. To achieve participatory justice, policy-making power must be redistributed from current policy makers to these local leaders from communities most affected by environmental injustice.
Within current power structures, this means electing environmental justice leaders who can accurately represent and act on input from their constituents. Organizations such as WE ACT for Environmental Justice, the League of Conservation Voters, and the Sunrise Movement provide leadership development opportunities for individuals as well as build support for political candidates that uphold environmental justice values at the local, state, and federal level. In a political system such as that of the US—in which financial support and endorsements from large, nationally known organizations are nearly essential for electoral victory—organizations such as these are a vital steppingstone on the path to redistributing decision-making power to environmental justice leaders.
Distributive Justice
Distributive justice is about more than fair participation in decision making—it is about the outcome of those decisions. Distributive justice concerns how burdens and benefits should be distributed. According to the 2007 text Environmental Justice and Environmentalism, while “many aspects of the environment cannot physically be transferred from one community to another,” distributive justice in terms of environmental justice is about “the distribution of benefits and costs of environmental resources.”
Distributive justice is reflected in several of the Principles of Environmental Justice and is integral to the environmental justice movement:
Environmental Justice mandates the right to ethical, balanced, and responsible uses of land and renewable resources in the interest of a sustainable planet for humans and other living things.
Environmental Justice affirms the need for urban and rural ecological policies to clean up and rebuild our cities and rural areas in balance with nature, honoring the cultural integrity of all our communities, and [provide] fair access for all to the full range of resources.
Environmental Justice calls for universal protection from nuclear testing, extraction, production and disposal of toxic/hazardous wastes and poisons, and nuclear testing that threaten the fundamental right to clean air, land, water, and food.
When it comes to environmental resources, both burdens and benefits are at play. Environmental injustice is often caused by the inequitable distribution of a burden that makes an environment less healthy without any extra benefits or resources to compensate for it. One example of this is the unequal distribution of polluted air. A 2013 study in North Carolina found lower socioeconomic status, higher deprivation, and higher share of minority population were consistently associated with higher levels of annual average air pollution. Air pollution has been associated with increases in mortality and hospital admissions due to respiratory and cardiovascular disease.
Rooting environmental burdens and benefit allocation in distributive justice would ensure communities with disproportionally unhealthy environments do not face continuous risks, while those communities that have been exempted or shielded themselves from environmental harm, as well as done harm unto other communities, receive their proportionate share of environmental burdens. Anchoring environmental policy in distributive justice would equitably allocate resources to help communities invest in building and sustaining healthy environments.
In practice, this might look like measuring the distribution of environmental benefits and burdens, as well as their impacts on health, and making decisions that allocate these positive and negative outcomes justly. In other words, all branches of the tree are deserving of resources, and in some instances, certain branches should receive more than others to compensate for generations of inequitable distribution. This redistribution is not easy for many reasons, including that Whiter, wealthier communities are historically resistant to hosting environmental burdens and have the power and resources to protect themselves, shunting these burdens—such as the placement of hazardous waste facilities—to the communities without the economic and political power to resist them.
Using environmental impact statements and health impact assessments is a great place to start measuring the distribution of environmental benefits and burdens, but making sure to track outcomes against the initial estimates is vital—and is part of the participatory justice work outlined in the previous section. Also, enforcing regulations around who drafts environmental impact statements is important for their integrity; this was a central problem in the determination of the placement of the Dakota Access Pipeline.
Prioritizing those facing the greatest disadvantage when distributing environmental costs and benefits supports communities facing poor health outcomes connected to their environments. As outlined in the Principles, balance of environmental resources and thus balance of their subsequent health effects is a central part of the environmental justice movement.
There are efforts around the US to integrate environmental justice priorities into new projects and policies through acts of distributive justice. For example, St. Paul, Minnesota’s Climate Action and Resilience Plan includes explicit equity components to ensure disadvantaged neighborhoods are not left behind in the city’s adaptations and preparedness for the effects of climate change. For instance, to reduce emissions from the transportation sector, the plan describes transportation equity efforts to specifically support communities of color and low-income communities.
Furthermore, policy makers can ensure that parks in communities of color and low-income communities are preserved through green space protection laws. Parks are associated with several positive health outcomes and protection against the effects of climate change. In 2017, US Representative Nanette Barragán (D-CA) introduced to the House the Outdoor Recreation Legacy Partnership Grant Program Act, which would, in Barragán’s words, “protect a National Park Service program that promotes the development of greenspaces and recreation facilities in underserved parts of cities.” Passing laws such as this one aid in equitably distributing greenspace, a beneficial environmental resource.
Moving Forward
Now, targeting interventions at the trunk and branches does not address the roots of the tree—racism and income inequality. This target level instead focuses on the effects of racism and income inequality, rather than addressing the underlying causes themselves.
Many critique this approach on the grounds that equity cannot be reached by operating within systems built on an inequitable foundation. That can hold true, while at the same time we can desire to improve lives and advance equity within current systems, while they unfortunately still exist, to prevent sickness and death from occurring today. Interventions are needed at all levels of the tree—we must uproot structural inequities while still treating those living with the health outcomes caused by them.
Looking back at the Principles of Environmental Justice can inform future interventions aimed at the intersection between environment and health, where changes to environmental policies, and those who get to make them, could improve health outcomes. Using the Principles to frame these reforms would improve environments and subsequently advance health equity and justice.
WASHINGTON (AP) — Nearly half of the 500 million free COVID-19 tests the Biden administration recently made available to the public still have not been claimed as virus cases plummet and people feel less urgency to test.
Wild demand swings have been a subplot in the pandemic, from vaccines to hand sanitizer, along with tests. On the first day of the White House test giveaway in January, COVIDtests.gov received over 45 million orders. Now officials say fewer than 100,000 orders a day are coming in for the packages of four free rapid tests per household, delivered by the U.S. Postal Service.
Still, the White House sees the program as a step toward a deeper, yet more elastic, testing infrastructure that will accommodate demand surges and remain on standby when cases wane. “We totally intend to sustain this market,” Dr. Tom Inglesby, testing adviser to the COVID-19 response team, told The Associated Press. “We know the market is volatile and will come up and down with surges in variants.”
Testing will become more important with mask requirements now easing, say some independent experts. “If infection control is still our priority, testing is central,” said Dr. Leana Wen, a former Baltimore health commissioner and commentator on the pandemic. “Four tests per household for one family will only last you one time. There should be enough tests for families to test twice a week.”
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Inglesby maintains that the pieces are falling into place to accommodate that.
Private insurers are now required to cover eight free rapid tests per person, per month. Medicare coverage will start in the spring. The administration has also been making free at-home tests available through libraries, clinics and other community venues. Capacity for the more accurate PCR tests performed by labs has been built up. The White House recently put out a request to industry for ideas on how to sustain and expand domestic testing for the rest of this year.
Wen says people still need a guide for when to test and how often. “Right now it is still unclear,” she said.
President Joe Biden’s pivot to testing came under duress as the omicron variant gained force just before Christmas. Tests were frustratingly hard to come by, and expensive. The White House is sensitive to criticism that help may have come too late.
“There is no question some people found out they were positive from taking one of these tests and were able to keep other people from getting infected,” said Tim Manning, supply coordinator for the COVID-19 response team.
Around mid-December, with omicron projections grimmer by the day, White House officials began discussing how to make free tests available for anyone who wanted one. But if the government started siphoning up tests on the market, that would just make the shortage worse.
“A critical thing to us was that anything we did had to be done in a way did not create a shortage at retail to the general public,” Manning said.
The White House enlisted the Pentagon and parts of the Health and Human Services Department that had worked on the Trump administration’s vaccine development effort to distribute vaccines. Logistics experts scoured the globe for available tests. The Postal Service was designated to take the orders and deliver them.
That part proved to be a good call, said Hana Schank, an expert on government technology projects with the New America think-tank. The Postal Service already had a database of every address in the land, and the means to deliver.
“At the federal level the only people who have a database connected to a fulfillment engine would be the Post Office,” she said.
The project took less than a month to get ready, Manning said. “We said this is not online retail,” he said. “This is emergency response, so we have go to as fast as possible.”
To make sure it wasn’t just the tech savvy who would end up getting free tests, the administration targeted a share of deliveries to people in low-income areas. The White House worked with service organizations to get the word out.
“We prioritized the processing of orders to the highest social vulnerability zip codes in the country,” testing adviser Inglesby said.
One of the service groups was the National Association of Community Health Workers, whose members help people navigate the health care system. Executive director Denise Smith said the group was able to use its website to link more than 630,000 people to COVIDtests.gov.
Overall about 20% to 25% of the tests have gone to people in distressed areas, officials said.
Now that demand is way down, it’s unclear what will happen to the White House giveaway program. Allowing repeat orders is one possibility.
Smith says groups like hers should get any surplus. “We know where the people are,” she said.
Although the program is still in its infancy, analyst Lindsey Dawson of the Kaiser Family Foundation believes its legacy may lie in familiarizing more people with testing. “It may get someone comfortable with utilizing the tests, thinking about how they might use testing in their lives,” she said.
Savita Sharaf, a retiree from the Maryland suburbs outside the nation’s capital, said she ordered her free tests around the middle of January and got them in early February. She’s tried to conserve them, for added peace of mind. In the stores, she couldn’t find tests for less than $25.
“I’m so relieved because I can immediately test myself,” Sharaf said. “If we had a high vaccination rate, it would be a little easier to say let up on this program. But I feel we have to watch for the next month or two, to see what happens.”
Copyright 2022 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.
HONG KONG — For two years, Hong Kong had largely avoided a major coronavirus outbreak with tight border controls and strict social distancing measures. Then Omicron triggered an explosion of infections, exposing the city’s failure to prepare its older — and most at risk — residents for the worst.
In a matter of weeks, the outbreak quickly overwhelmed Hong Kong’s world-class medical system. Ambulances arrived at emergency units in droves. Hospitals ran out of beds in isolation wards. Patients waited in gurneys on sidewalks and in parking lots, given emergency blankets for warmth during the coldest and wettest time of the year.
Hong Kong’s early success in keeping the pandemic at bay was the starting point of a complacency that has now had deadly consequences. Officials have moved too slowly to prepare for a broader outbreak, and did too little to address misinformation around vaccines, social workers and experts say. For many of the city’s one million residents who are 70 or older, the risk of getting sick had long seemed so low that they avoided getting inoculated.
Before the current outbreak, less than half of people in that age group were vaccinated. Among residents of care homes, the rate was even lower, at just 20 percent, according to the Hong Kong Council of Social Service. Now they are bearing the brunt of the city’s worst outbreak. More than 200 people have died this month from Covid, many of whom were over 70 and unvaccinated.
The hesitancy over vaccines has been attributed to misinformation about the vaccines’ potential side effects and efficacy, as well as a high level of public distrust of the government. But even as Hong Kong recorded more deaths in just over two weeks than it did in the last two years, some residents remained reluctant to get inoculated.
“I worry that the side effects of vaccination will kill me,” said Lam Suk-haa, an 80-year-old resident who stopped to talk on her way to a restaurant in the working-class neighborhood of North Pointon Wednesday. “For sure, I don’t dare get the shot.”
Ms. Lam said she was skeptical of Western medicine in general. She also said she had heard from a television news report that people like her who have high blood pressure, cholesterol and blood sugar levels could be at risk of severe side effects from vaccination. (The Centers for Disease Control and Prevention, in fact, recommends that older people with medical conditions get vaccinated to reduce the risk of severe illness.)
Health officials in recent days have repeatedly urged older people to get vaccinated and areworking to ramp up the inoculation of residents at care homes. The government also imposed rules requiring proof of vaccination to enter restaurants, malls and supermarkets. These measures have helped: Now, three-quarters of people in their 70s, and nearly half of those age 80 or older, have received at least one shot.
The vaccine entry requirement was what ultimately persuaded Ella Chan, 73, to get her first shot this week. She said she had initially hesitated because she had a cold, and then continued to put it off because of reports she had read that made her concerned.
“I didn’t want to get vaccinated then because I had read the newspapers and I had many worries, and I kept pushing it back and back, until now,” Ms. Chan said as she left a government building in North Point where she got her vaccination.
Such worries point to the misinformation about vaccines that has spread rapidly in Hong Kong, where residents can choose between the vaccine developed by Pfizer and BioNTech or the one developed by Sinovac, a private Chinese company.
Infrequent reports of deaths following inoculations turned into rumors about the dangers of vaccines that circulated widely on WhatsApp groups and social media, even though officials have not attributed any of the fatalities to either vaccine.
Terry Lum, a professor of social work at the University of Hong Kong, said that the government had been slow to correct misconceptions about the efficacy of the vaccines and their side effects. He said many older residents believed that the Sinovac vaccine was not effective and that the BioNTech vaccine caused many severe side effects.
“When that misinformation is circulating and no one comes out to clarify the information, and we have such low cases, the people wonder, ‘Why would I take the risk?’” Mr. Lum said. Some residents in the semiautonomous Chinese city were also suspicious of the government’s promotion of Chinese-made vaccines. “People felt there was a political reason for the government to push Sinovac,” he said.
The situation in Hong Kong is striking especially when compared to Singapore, an island of about five millionpeople where 95 percent of people 70 and older are vaccinated. Ho Ching, the wife of Prime Minister Lee Hsien Loong of Singapore, took to Facebook to urge Hong Kong’s older people to “put aside their distrust or mistrust of government, their memories of their flight from China, or any other reason for distrust of authorities.”
To some degree, the government’s cautious approach to vaccinations early on may have fed concerns about the risks. In March of last year, for instance, officials noted that the Sinovac vaccine should not be given to people with “uncontrolled severe chronic diseases,” and urged residents who weren’t sure about their medical conditions to consult their doctors before getting vaccinated.
“The fear around vaccination took hold and it was reinforced by the health care system,” said Karen Grépin, an associate professor at Hong Kong University who specializes in economics and health systems. “We created this idea that people needed to become healthy candidates in order to get vaccinated.”
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A new C.D.C. framework. The Centers for Disease Control and Prevention released new guidelines that will help counties determine when and where people should wear masks, practice social distancing and avoid crowded indoor spaces.
Now, officials are scrambling to get more older residents protected, but that addresses only one problem. Nursing home operators and social workers say the government’s lack of preparedness for the explosion in cases has created unnecessary chaos. When public hospitals ran out of beds, care homes didn’t have the staff or equipment to care for those who fell sick, nor the space to isolate them from the rest of the residents.
Nursing homes in Hong Kong have been closed to visitors since last fall. Still, cases have appeared in many homes in recent weeks, industry officials say. At meetings of representatives of some 300 homes this week, more than 70 percent said they had recorded Covid cases in residents or staff members, said Joe Chan, secretary of the Elderly Services Association of Hong Kong, an industry group.
“For us, the situation right now is really not healthy,” said Mr. Chan, who is also the managing director of the Granyet Elderly Care Group, which runs six homes with 640 beds. “There are no quarantine centers for our staff or close contacts with cases. All of them are stuck in elderly homes, which is not a good environment.”
The Hong Kong government has yet to issue official guidelines to nursing homes on how to handle an outbreak, said Chua Hoi-wai, the chief executive of the Hong Kong Council of Social Service. Despite having had two years to prepare for such an event, the rapid spread caught many by surprise.
“No one had ever expected we would have so many confirmed cases in so few weeks,” Mr. Chua said. Some care facilities, he said, are looking at waits of as long as a month for public health workers to visit and administer shots.
The spiraling outbreak might not sway the attitudes of Hong Kong residents like Ms. Lam, the 80-year-old who has yet to get the jab, unless the government makes inoculations mandatory.
“I won’t get vaccinated as long as I have a choice,” Ms. Lam said. “Let young people get the shot.”
Public health professionals ensure we have our daily necessities. If they didn’t have our backs, there simply wouldn’t be healthy food to eat, clean water to drink or non-hazardous air to inhale. These experts might excel at ensuring the provision of necessities, but they are just as excellent at taking on curveballs as well — think auto safety, vaccine development and distribution, the prevention of new infectious diseases, maternal and child health, obesity, and health care reform. Their insights are crucial to managing and providing solutions to such challenges.
Many of today’s key figures in this dynamic field got their start at the George Washington University (GW) Milken Institute School of Public Health. At this institution ranked 12th nationally (US News and World Report’s List Of Best Public Health Graduate Programmes), students explore the field’s history and carve its future — a fact evident through the cutting-edge research conducted in the institution’s state-of-the-art facilities.
From Washington D.C., the school studies AIDS, antibiotic resistance, the health of women and girls, natural disasters, health inequities, malaria vaccines, global nutrition, air pollution, climate change, and obesity. To encourage more to join the fight, it recruits top investigators, researchers, policy experts and educators.
Together and individually, they deliver comprehensive lessons in specialized areas. The Milken Institute School of Public Health has room for every world-bettering aspiration, offering Master of Public Health (MPH) degrees in Biostatistics; Community Oriented Primary Care; Environmental Health Science Policy, Epidemiology; Global Environmental Health; Global Health Epidemiology and Disease Control; Global Health Policy; Global Health Programme Design Monitoring and Evaluation; Health Policy; Health Promotion; Humanitarian Health; Maternal and Child Health; Physical Activity in Public Health; Public Health Communication and Marketing; as well as Public Health Nutrition.
It also offers Master of Science programmes (in Epidemiology, Health and Biomedical Data Science, Public Health Microbiology and Emerging Infectious Diseases, and Strength and Conditioning), alongside a Master of Health Administration programme, and a suite of joint or dual degree programmes.
Programmes by the Milken Institute School of Public Health uniquely position graduates for careers that require both breadth and depth of public health knowledge. Source: The George Washington University
Each 45-credit programme requires two years of study and is topical in its own unique way. For example, the MPH Biostatistics teaches students to apply statistical methods to the biological, biomedical, and health services sciences. Its curriculum is constantly revamped in line with global developments (25 courses have been added in the past two years).
“The curriculum is modern and pertinent to our world,” says Professor of Biostatistics, Heather Hoffman. “While students learn the foundation, cutting edge researchers serve as their mentors — each leverages their research and passion to educate.”
The MPH Global Environmental Health is just as dynamic, preparing students to work in resource-poor settings and apply analytic skills to prevent or reduce health problems associated with environmental hazards.
“Environmental risk factors should not be a fringe issue, rather environmental health needs to be central to the global public health agenda,” adds Susan Anenberg, director of the GW Climate and Health Institute.
“The GW Climate and Health Institute is a differentiating factor of this programme. It allows students to network with leaders in Environmental Health and helps them gain exposure to programming, events, and discussions. Most importantly, it teaches them to seek new solutions to global health and equity challenges associated with climate change.”
Despite each programme’s varying goals, they are all filled with experiential learning opportunities. For instance, all students at the Milken Institute School of Public Health take on a Practicum (internship or applied practice experience) during their programme to apply newfound knowledge.
Just before graduating and joining an illustrious list of 290,000 living alumni, students close their GW chapter with a Culminating Experience, which entails conducting research with a professor, writing a paper or strategizing a presentation. This requirement was set in place to ensure every budding public health professional leaves with something stellar to show for themselves. “It can even lead to job opportunities,” says Professor Hoffman.
Thankfully, there are plenty of those in Washington D.C. — where the Milken Institute School of Public Health is one of a kind. In fact, students have completed practicum and internships in various settings, federal agencies (like the US Agency for International Development, the US Environmental Protection Agency, the National Institutes of Health, not for profits (like MITRE Corporation, Helping Children Worldwide), and healthcare or public health groups (like Mercy Medical Center Cambodia, the Council of State and Territorial Epidemiologists). The opportunities are endless and GW’s Career Service team works with students to find the best match.
Opportunities aside, Ka Sin Cassie Ng, a second year Environmental Health Science and Policy student, loves living in DC! It is a city of culture, museums, home to the capital of the United States, and great public transportation. “I also enjoy D.C. because there are plenty of green parks and designated paths for me to ride my bike on,” she says. “Furthermore, D.C. is a smaller city, but it’s fun to navigate and gives students a nice balance of city life and nature.”
Little wonder why most of the Milken Institute School of Public Health classes are scheduled in the late afternoon and evening. This allows its 800 residential graduate students to take advantage of all that DC has to offer! With museums, historical landmarks, parks, cuisines, and shop-a-holic havens galore, there’s no better place to find the sweet spot between the rigours of a quality Master of Public Health and the dynamism of a vibrant student experience. Click here to learn more about the Milken Institute School of Public Health.
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19 February 2022 – The COVID-19 pandemic has accentuated the importance of health research in finding solutions to health challenges. To address the most urgent health priorities using evidence-based solutions, the Ministry of Health and Human Services (FMOH) of Federal Government of Somalia and National Institute of Health (NIH), with support from the World Health Organization (WHO) and other partners, convened the first ever health research conference in Garowe, Puntland, from 30 January to 1 February 2022.
Some of the brightest Somali minds came together at the event ─ 200 national and international researchers ─ to present 51 unpublished research abstracts, showcasing new evidence and best practices around public health actions in Somalia which were neither researched before in the country by anyone nor had any evidence been generated before on these priority public health issues. Overall, Somali authors submitted 91 abstracts; the rest were either published already or did not meet the expected criteria.
Dignitaries who participated in the conference included HE Dr Fawziya Abikar Nur, Federal Minister of Health and Human Services; HE Dr Jama Farah Hassan, Minister of Health, Puntland; HE Per Lindgarde, Ambassador of Sweden to Somalia; Dr Mamunur Rahman Malik, WHO Representative to Somalia and Head of Mission. Representatives from the Swedish International Development Cooperation Agency (SIDA), the Public Health Agency of Sweden (PHAS) and African Field Epidemiology Network (AFENET), and colleagues from the University of Umea and the Gothenburg University in Sweden also participated.
Professor Khalif Bile, Chair of the NIH Board of Directors and the Scientific Committee for the NIH Research Conference, spearheaded the event, taking it from an idea to reality. Under the leadership of Dr Abdifatah Diriye Ahmed, NIH Executive Director, the NIH Public Health Specialist and research focal person, Dr Mukhtar Bulale, organized the conference, bringing together all relevant stakeholders.
Institutions supporting the NIH
WHO extended financial support to the conference, through the Alliance for Health Policy and System Research (AHPSR), which aims to build health systems research capacity for low and middle-income countries and use new knowledge and evidence from public health research to set policies that support system building. The AHPSR promotes the generation and use of health policy and systems research to improve health systems in low- and middle-income countries, such as Somalia, while developing the research capacity of institutions, systems and individuals.
Other partners of WHO supporting this first ever research conference include the PHAS, which provided financial support to the conference, and collaborates with the NIH, in addition to AFENET and SIDA, which offer regular technical support to the NIH’s activities.
Members of academia from 32 public, private and international universities attended the conference, and supported the NIH team at various stages of planning and implementation.
Young, budding Somali researchers light glimmer of hope
Participants at the conference included scientific and technical committees, organizers, presenters, stakeholders, panellists and partners. The scientific committee for the event assessed abstracts, mentored some of the authors whose abstracts needed further refining, and developed guidelines and checklists for peer reviewing the studies.
Of the 51 researchers, seven were female. Additionally, 10 trainees from the first ever Frontline-Field Epidemiology Training Program (FETP-Frontline) conducted in Somalia in 2021, with support from WHO, the PHAS, AFENET and the United States Centers for Disease Control and Prevention (US CDC), offered support to conduct the research conference.
Sadia Hussein, one of the two trainees from the first FETP cohort who presented an abstract, and a WHO Public Health Specialist, explained that she got the idea for her study while she was working in Deynile, Banadir, as part of the FETP field work. She added she enjoyed participating in the conference as it was a forum where researchers and experts came together with policy-makers to display their research skills, while highlighting gaps in the health system, and linking research to the bigger picture in health.
Researchers presented on an extensive range of topics
Researchers presented their findings on six themes that had been selected after taking into consideration the Essential Package of Health Services (Somalia EPHS 2020), Universal Health Coverage (UHC) and Sustainable Development Goals (SDGs). Researchers presented 10 abstracts under the theme of health systems; 15 as part of reproductive, maternal, newborn, child and adolescent health; 18 under communicable diseases; 8 as part of noncommunicable diseases. Panelists delivered 12 informative presentations related to the themes of health research production and dissemination; and research training and capacity building, linking research to action.
Presenters stimulated thought-provoking discussions between the sessions, including around strengthening pharmacovigilance and drug regulation; increasing and motivating human resources for health; occupational safety of health workers with the introduction of new diagnostics, improving access to health care for women; and providing compassionate care while maintaining dignity and the privacy of female patients. They discussed how to reduce and eliminate the harmful practice of female genital mutilation (FGM); and recruit assistant community-based midwives to improve maternal health care in rural areas. The only experimental study that was presented focused on ‘Effects of the Coenzyme Q10 on the Peripheral Nerve Injury: An Electrophysiological Study’, presented by a university professor.
Furthermore, participants debated over how to address the high burden of multi-drug resistant tuberculosis in Somalia, and the need to deploy community health workers to enhance early detection of the disease, in order to reach the SDGs’ target of ending tuberculosis epidemics by 2030. These rich discussions aim to spur changes in policies and programming eventually.
Introduction of the first Somali Health Action Journal
As another significant milestone, the NIH Board of Directors launched the Somali Health Action Journal (SHAJ) at the conference. This is the first Somali health journal that will receive articles, facilitate their review by peers, motivate Somalis to conduct further research, write and publish new articles, and take up opportunities to disseminate and use research for policy-making and the design of useful programmes.
The editors of the journal committed to supporting young Somali researchers by mentoring them where possible. The journal aims to inspire the young and future generations of Somali health professionals to study different topics that will lead to innovations in health in the country.
Research must address country’s problems
HE Dr Fawziya Abikar Nur, Minister of Health and Human Services for Somalia, praised the NIH, its board of directors, and scientific committees for motivating several young Somalis to present their findings on crucial health topics.
“Iencourage you to document these national efforts ─ both what works and what does not work and why ─ but, above all, provide us solutions that can address the challenges we face,” she said, while thanking the partners who made the event a resounding success.
While lauding the Government of Somalia for its exemplary role in organizing a milestone event of this kind, and commending international researchers for visiting Puntland for the historical gathering and partners such as the PHAS for their support, Dr Mamunur Rahman Malik inspired young and experienced Somali researchers by announcing that WHO will work with the NIH to introduce state-of-the-art libraries in all ministry of health buildings of Somalia. He also added the WHO would award the young researchers nominated by the NIH for the best research presented in future conferences.
Dr Malik reminded the audience that in 1990, it was noted that only 10% of global health research was allocated for addressing 90% of global health problems. A commission set up to address this problem warned that if this disparity was not changed, the world would experience a large burden of infectious diseases, increasing rates of tuberculosis, malaria, and epidemics of noncommunicable diseases including heart diseases. As predicted, Dr Malik explained, the world is now seeing a high burden of these diseases, including infectious and noncommunicable diseases.
“I encourage you to come up with a national health research agenda and improve collaboration between the public and private sector, especially universities,” said Dr Mamunur Malik. “Also, research needs to contribute to improving national health. For example, diarrhoea and malaria contribute to a high burden of diseases but people do not have access to health services. Research should help address issues like this, and how to improve access in fragile settings like in Somalia, address health inequities, and increase access to drugs so people lead healthier lives.”
Putting Somalia on the global research map
On behalf of the NIH team, Dr Mukhtar Bulale explained that the sessions were successful and led to rich discussions with questions being answered, which was a flagship symbol illustrating useful nationally owned health research.
“Even though we started small, this conference has put Somalia on the global research map. Seeing young researchers put their best foot forward has given us immense hope that Somalia’s health research development is undergoing a recovery phase. We saw at the conference a unity of purpose, solidarity and eagerness for research partnerships and solutions to challenges. I urge stakeholders to ensure we do not miss the opportunity to support these young, dynamic researchers,” Dr Bulale said.
At the end of the conference, the Federal Ministry of Health, NIH, and stakeholders advocated for sustained investment in health research to further promote the Essential Package of Health Services 2020, which would benefit the Somali population. They also resolved to promote health system research, linking it to public policy formulation, while ensuring it focuses on addressing existing barriers to health service delivery. This implies the development of a national research agenda to invest — attention, resources and skills — in research that will result in improved health outcomes for the populations, and thematic areas where more evidence is required to inform policies and strategies. Together, they also committed to foster cooperation between the public and private sector in health system research, and to promote the development of innovative technologies and approaches. The partners resolved to strengthen the links between evidence generation and health care provision, while calling on all national and international stakeholders to develop the capacity of learning institutions and to facilitate high-quality research in the country.
Note to editors
The World Health Organization (WHO) country office for Somalia, the Government of Sweden and the Public Health Agency of Sweden (PHAS) are providing support to Somalia’s Federal Ministry of Health and Human Services (FMOH) to support the establishment and strengthening the capacity of the National Institute of Health (NIH) of Somalia. Please below articles for additional information on this exemplary collaboration.
The COVID-19 pandemic has had a catastrophic impact on the health care system in the United States and globally. In the US alone, over 20 percent of all health care workers have left the profession since the start of the pandemic.
As across the US, the pandemic has hit Baltimore, Maryland with repeated devastating surges. Nearly 1 million people in Maryland have officially been infected with COVID-19 since the start of the pandemic, and 13,720 have died.
A nurse looking out a hospital window (Credit: pexels.com/EVG Photos)
In January, COVID-19 infections and hospitalizations reached all-time highs throughout Maryland due to the spread of the highly contagious Omicron variant, with a peak of 3,462 people hospitalized on January 11. As with many other Democratic Party-led states, Maryland is prematurely lifting its mask mandate just as cases are once again starting to rise.
The World Socialist Web Site conducted the following interview with a public health professional who works at a hospital in Baltimore and requested anonymity. They describe the horrific conditions in their hospital during the recent surge of the Omicron variant.
Evan Blake (EB): Can you describe your role at the hospital where you work and speak about the situation there, specifically the issue of redeployment?
Health Professional (HP): I am a public health professional and administer externally funded programs, including FEMA funding for COVID relief, our mobile vaccination unit, and our hospital based vaccine clinics, as well as being involved in data analysis and surge response.
I’m at a hospital system in the Baltimore region, and “redeployment” of staff within hospitals is happening at my system as well as multiple others in this region and the DC/Capital region. I don’t think that a lot of people outside the health care system know that this is even happening, let alone what it means.
No one without relevant certifications is caring for patients; however, hundreds of staff have been pulled from other job functions (finance, IT, philanthropy, etc.) to work directly in support roles. That would include covering for EVS (cleaning patient rooms and facilities), bringing meals and trays back and forth, transporting patients, assisting the registrar, working at the vaccine clinics, etc.
This is not without risk—being in the facility itself and being in patient rooms is obviously a risk, but we also run the risks of very aggrieved patients, families and community members.
We have had MULTIPLE bomb threats, armed individuals trying to break in, armed individuals ACTUALLY breaking in, stalking, tires slashed in our parking lots, people attempting to drive into or through the outdoor vaccine sites, people coughing or spitting on us. The nurses and social workers have taken the brunt of this. For example, I know at least one palliative care social worker that quit after she was attacked by a family member as they weren’t allowed to see their family member who was dying from COVID.
Nurses so far have not been allowed to unionize within this state that I know of (some of our support staff are unionized under SEIU), and many are out sick or outright quitting due to the conditions and the emotional and physical stress.
With regard to direct patient care, all direct patient care is still done by doctors, nurses, NPs, techs, respiratory therapists, etc., but it is harder and harder to find qualified people to fill these jobs. Many hospitals are paying out the nose for travel nurses to fill positions but refuse to pay their own staff nurses more.
We have been pulling nursing students out of school early and pulling doctors and nurses out of retirement. Many nurses have had to redeploy to ICU units or the ED [Emergency Department], for example many labor and delivery nurses were redeployed to an area ED because so many pregnant individuals with COVID were coming in.
Concurrently, I could not tell you a single member of any executive staff in this entire state (or outside of it, to be honest) that has publicly taken any kind of pay cut. Throughout the entire pandemic, myself and other hospital staff, including nurses, have not gotten any hazard pay. At one point we got a small (~$250) bonus for the holidays. Many of us were furloughed and some positions have been eliminated; I do think this has been worse for other systems but could not tell you for sure.
It is unconscionable to me that people making well into the six figures would not redistribute at least some of that salary to individuals doing dangerous direct patient care during a deadly pandemic, but I can’t even find anyone suggesting this step. Directors were also given a larger (but still small) raise than other levels of staff; to me this seemed like it should be the other way around.
The terrible conditions at my hospital are compounded by the feeling that I am living in two different worlds, or a sort of separate reality within and without the hospital.
When I enter our main hospital entrance, I immediately see a large portrait of a colleague who passed away from COVID, along with handwritten remembrances of him and other colleagues. We are wearing masks and face shields for hours at a time still, and many of our colleagues (a higher number than ever before) are out sick, but we are being asked to return faster than ever before as well, sometimes when we still have symptoms.
The emotional toll of caring for patients or populations who are suffering greatly and not necessarily being able to help them, and now it’s kids as well, is causing so many of us, me included, to suffer from anxiety, depression, insomnia, panic attacks, etc.
But then when I go outside the hospital, it seems like no one even cares. I go to the grocery store and many individuals are not even wearing masks at all. People are blithely traveling internationally or to and from areas of high incidence, people are at gyms without masks, people are going to concerts and parties inside with huge groups, people are eating and drinking inside. It is incredibly disheartening.
So many of us are burning out or suffering, and executive leadership has seemed to do very little to directly confront this. Sometimes staff will get a nice email thanking us or a small gift or a free meal, but I could not tell you a substantive gesture that has been made by executive leadership that would create real change and demonstrate an understanding of what staff, particularly patient care staff, is going through.
EB: The conditions you’ve described are absolutely horrific, the opposite of what it should be like in a health care facility. Was “redeployment” happening during previous surges, or is the Omicron surge the first time it’s happened for your hospital? Can you also tell me a bit more about what your experience has been like during the pandemic more broadly? Has the Omicron surge been significantly worse than previous surges or comparable?
HP: Redeployment was happening during previous surges but not nearly to the degree or scale of what happened during Omicron.
My experience during the pandemic has honestly been awful. I am actually looking to move out of health care at this point, and I have been working in the health care field in Baltimore for almost 15 years, specifically for six years with my current organization. I have never felt this burnt out or disconnected from why I originally wanted to work in the field.
Working at a hospital, particularly in public health, in Baltimore has never been “easy,” per se, but I have never once experienced the level of public vitriol and targeted harassment that I have experienced almost daily during the pandemic.
In addition to the bomb threats, armed robberies and vandalism, we have experienced people threatening us at vaccine clinics, people screaming at me or coughing in my face if I wear anything with the logo of the hospital or anything like that in the grocery store.
I know it’s been awful for the nurses, but also for other individuals. In particular, I have a coworker who is a palliative care social worker. We were unable to let many families physically be in the room with their dying loved ones, and outside of the many threats and abuse from family members, the emotional burden of that is awful.
I will say that many local small businesses, particularly restaurants, have been supportive and amazing. Many restaurants are STILL donating food to frontline workers. And many coworkers stepped up to help and support one another (ironically, we have a peer support group for emotional distress that we can’t start yet … because of COVID).
I do think the Omicron surge has been harder emotionally because many people in the “outside world,” including sometimes our own family members or friends, and politicians, seem to be operating as if the pandemic is over. So there’s the emotional burden of that on top of everything else.
EB: The points you raised on hospital executives not taking pay cuts, while nurses struggle to get by, are important. The annual Oxfam report was released in January and found that while the incomes of the bottom 99 percent of global society have fallen since the start of the pandemic, the top 10 wealthiest men in the world saw their wealth double, while a new billionaire has been created every 26 hours since the pandemic began. Can you comment on this broader growth of social inequality during the pandemic? How could this money have been put to use to end the pandemic, such as through fully-paid lockdowns?
HP: I suppose I shouldn’t be surprised by it, but it was incredible to me that a paid lockdown was seen as a draconian, horrifying measure that had no chance of ever being implemented. No one wants to shut everything down forever. But we could have saved so many lives if we had paid people to stay home for just two or three weeks.
It seems like more people are becoming aware of the social inequality since it has been SO blatant and in some ways inescapable, but I also worry that it is hardening peoples’ hearts. I feel in particular that service industry workers outside of the hospital and support staff in the hospital are being dehumanized and ignored more than ever before. We even had a hospital (not one of mine) in the Baltimore area get in trouble because they vaccinated their board members before any front-line workers.
Although it is difficult to see, I am hopeful that we are also seeing more solidarity among workers of all types, more people vocally questioning things, and more people unionizing or opting out of the system entirely if possible.
But we are seeing the same old tired union-busting tactics that companies have been utilizing forever writ large and applied to other things. For example, many hospital staff of all types would like to speak up more about things like work conditions, burnout, hazard pay, differential standards of pay (i.e., why does a doctor make so much but a janitor so little, when the janitor is probably exposed to more danger on a daily basis), but the threat of losing one’s job for doing so is always there, especially potent when we see people losing their jobs and their houses at such high rates.
EB: Regarding the disconnect between the war-zone-like environment in the hospital and the “return to normalcy” by many people, I think it’s important to understand this politically, as the outcome of relentless propaganda by the corporate media and politicians to push the vaccine-only approach and present the pandemic as being over. What are your thoughts on these deliberate efforts to say we have to “live with the virus,” with some even going so far as to say that everyone getting infected with Omicron would be a positive good?
HP: The efforts of some politicians (and “experts” paid by politicians) to essentially gaslight the public have been infuriating and frustrating. I think in particular it’s been very difficult for parents and immunocompromised individuals (obviously those categories can overlap), who CAN’T “return to normal,” and I think many people don’t realize that not every immunocompromised person is like Bubble Boy, and they don’t view their own lives as expendable or not important.
As far as “living with the virus,” I certainly do not think that everyone should simply get infected or leave themselves completely open to infection, particularly with Long COVID (which politicians rarely refer to as well). There is a way to “learn to live with the virus,” but that means moving forward and finding a new way, keeping some public health measures in place, leaving a lot of the new remote work or education measures in place, etc. It doesn’t mean “scrap every single public health measure and everyone never wear a mask again.”
EB: As a final question, can you comment on how the concept of “endemicity” is now being misused, and your thoughts on the interview we did with Boston University epidemiologist Eleanor Murray on this?
HP: The interview with Dr. Murray says it well—the POLITICAL framing of endemicity has been that “endemic” is essentially a “step down” from pandemic. In public health or immunology, we don’t use endemic that way, and the political connotation that endemic is less “serious” also doesn’t really mean anything in a scientific sense.
A good example of this is malaria, which is endemic to certain regions of the world, but which also causes untold suffering and is a leading cause of death in many of those same areas, especially pediatric death.
So, the framing of endemic as a sort of “junior” pandemic is extremely disingenuous and dangerous. Specificity of language means things. We’ve already been battling a huge disinformation campaign about how vaccines work (i.e., there are MANY MANY existing vaccines that don’t prevent infection but they DO prevent disease, which are DIFFERENT things), and we don’t need to add new layers to that.
I truly think we are doing a huge public disservice when we sort of throw terms around like endemicity and use them to mean whatever we want. I think the level of scientific literacy in this country is shockingly low, but I also don’t think that is because the majority of people are stupid or “don’t believe in science,” it’s just that science and in particular public health are not taught in schools and in general not presented in ways that invite curiosity and learning.
If I had not specifically learned these things in college-level courses, I would also not know them, and it’s not fair that we keep that knowledge behind numerous accessibility barriers and then complain that people don’t know it. But that is a whole other conversation of course!
EB: Thank you for your time and for sharing your thoughts and experiences. You’ve given a real depiction of what conditions are like at present after two years of the COVID-19 pandemic.
